General anesthesia is not associated with dementia in older adults with osteoarthritis for hip/knee replacements, a national population-based nested case-control study.

BACKGROUND: Dementia is a prevalent neurological condition, yet the relationship between dementia and general anesthesia remains uncertain. The study aimed to explore the association between general anesthesia and dementia using a nationwide population-based database. METHODS: The study extracted data from Taiwan's national health insurance, which encompassed the records of one million insured residents. A total of 59,817 patients aged 65 years and above, diagnosed with osteoarthritis between 2002 and 2010, were included. Among these patients, 3277 individuals with an initial diagnosis of dementia between 2004 and 2013 were matched with non-dementia patients based on age, gender, and the date of osteoarthritis diagnosis. Following a 1:2 random matching, the case group included 2171 patients with dementia, while the control group consisted of 4342 patients without dementia. The data was analyzed using conditional and unconditional logistic regressions. RESULTS: No significant differences in the odds of dementia were found between individuals exposed to general and regional anesthesia during hip/knee replacement surgeries (OR = 1.11; 95%CI: 0.73-1.70), after adjusting for age, sex, and co-morbidities. Similarly, there were no significant differences in the odds of dementia based on different durations of anesthesia exposure (General: <2 h: OR = 0.91, 95%CI = 0.43-1.92; 2-4 h: OR = 1.21, 95%CI = 0.82-1.79; >4 h: OR = 0.39, 95%CI = 0.15-1.01; compared to no exposure. Regional: <2 h: OR = 1.18, 95%CI = 0.85-1.62; 2-4 h: OR = 0.9, 95%CI = 0.64-1.27; >4 h: OR = 0.55, 95%CI = 0.15-1.96; compared to no exposure). Likewise, no significant differences were observed in the odds of dementia based on the number of replacement surgeries (twice: OR = 0.74, 95%CI = 0.44-1.23, compared to once). CONCLUSION: Neither general anesthesia nor regional anesthesia in hip/knee surgery was associated with dementia. Different numbers and durations of anesthesia exposure showed no significant differences in the odds for dementia.

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery.

BACKGROUND: Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models. RESULTS: The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05). CONCLUSION: There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Current practice of thoracic anaesthesia in Europe - a survey by the European Society of Anaesthesiology Part I - airway management and regional anaesthesia techniques.

BACKGROUND: The scientific working group for "Anaesthesia in thoracic surgery" of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) has performed an online survey to assess the current standards of care and structural properties of anaesthesia workstations in thoracic surgery. METHODS: All members of the European Society of Anaesthesiology (ESA) were invited to participate in the study. RESULTS: Thoracic anaesthesia was most commonly performed by specialists/board-certified anaesthetists and/or senior/attending physicians. Across Europe, the double lumen tube (DLT) was most commonly chosen as the primary device for lung separation (461/ 97.3%). Bronchial blockers were chosen less frequently (9/ 1.9%). Throughout Europe, bronchoscopy was not consistently used to confirm correct double lumen tube positioning. Respondents from Eastern Europe (32/ 57.1%) frequently stated that there were not enough bronchoscopes available for every intrathoracic operation. A specific algorithm for difficult airway management in thoracic anaesthesia was available to only 18.6% (n = 88) of the respondents. Thoracic epidural analgesia (TEA) is the most commonly used form of regional analgesia for thoracic surgery in Europe. Ultrasonography was widely available 93,8% (n = 412) throughout Europe and was predominantly used for central line placement and lung diagnostics. CONCLUSIONS: While certain "gold standards "are widely met, there are also aspects of care requiring substantial improvement in thoracic anaesthesia throughout Europe. Our data suggest that algorithms and standard operating procedures for difficult airway management in thoracic anaesthesia need to be established. A European recommendation for the basic requirements of an anaesthesia workstation for thoracic anaesthesia is expedient and desirable, to improve structural quality and patient safety.

Two types of anaesthesia and length of hospital stay in patients undergoing unilateral total knee arthroplasty (TKA): a secondary analysis based on a single-centre retrospective cohort study in Singapore.

BACKGROUND: Evidence regarding the relationship between the type of anaesthesia and length of hospital stay is controversial. Therefore, the objective of this research was to investigate whether the type of anaesthesia was independently related to the length of hospital stay in patients undergoing unilateral total knee arthroplasty (TKA) after adjusting for other covariates. METHODS: The present study was a cohort study. A total of 2622 participants underwent total knee arthroplasty (TKA) at a hospital in Singapore from 2013 to 1-1 to 2014-6-30. The target independent variable and the dependent variable were two types of anaesthesia and length of hospital stay, respectively. The covariates included age, BMI, hemoglobin (Hb), length of stay (LOS), duration of surgery, sex, ethnicity, American Society of Anesthesiologist (ASA) Status, smoking, obstructive sleep apnea (OSA), diabetes mellitus (DM), DM on insulin, ischemic heart disease (IHD), congestive cardiac failure (CCF), cerebrovascular accident (CVA), creatinine > 2 mg/dl, day of week of operation. Multivariate linear and logistic regression analyses were performed on the variables that might influence the choice of the two types of anaesthesia and the LOS. This association was then tested by subgroup analysis using hierarchical variables. RESULTS: The average age of 2366 selected participants was 66.57 ± 8.23 years old, and approximately 24.18% of them were male. The average LOS of all enrolled patients was 5.37 ± 4.87 days, 5.92 ± 6.20 days for patients receiving general anaesthesia (GA) and 5.09 ± 3.98 days for patients receiving regional anaesthesia (RA), P < 0.05. The results of fully adjusted linear regression showed that GA lasted 0.93 days longer than RA (ß = 0.93, 95% CI (0.54, 1.32)), P < 0.05. The results of fully adjusted logistic regression showed that LOS > 6 days was 45% higher for GA than for RA (OR = 1.45, 95% CI (1.15, 1.84)), P < 0.05. Through the subgroup analysis, the results were basically stable and reliable. CONCLUSION: Our study showed that GA increased the length of stay during unilateral TKA compared with RA. This finding needs to be validated in future studies.

The Impact of Transversus Abdominis Plane Block Within an Enhanced Recovery After Surgery Protocol on Length of Stay.

BACKGROUND: Multimodal, narcotic-sparing analgesic strategies are an important part of enhanced recovery after surgery protocols. Within such protocols, regional anesthetics have proven to be superior to narcotics. OBJECTIVE: This study aimed to evaluate the impact of the transversus abdominis plane block within an enhanced recovery after surgery protocol on length of stay. DESIGN: A retrospective analysis of patients who underwent colorectal surgery in 2015 to 2016 was completed. The primary end points for this analysis were total length of stay and total narcotics consumed during hospitalization. Length of stay and total narcotic use were compared for patients who received a transversus abdominis plane block versus those that did not. DATA SOURCE: The data were obtained from the data warehouse of a university teaching hospital. SETTINGS: This study took place at a university teaching hospital. PATIENTS: The patients were 18 years or older. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and the total narcotics used. RESULTS: A total of 347 patients underwent colorectal procedures under the enhanced recovery protocol. Among these, 186 (54%) received a transversus abdominis plane block. Overall, the mean length of stay was 5.8 days (SD ±5.6), and median length of stay was 4 days. These values compare to a mean length of stay of 9.6 days and median length of stay of 7 days before implementing the enhanced recovery protocol. Patients who received a transversus abdominis plane block had a mean length of stay of 5.1 days compared to 6.6 days for those who did not receive one (p < 0.01). Patients who received a transversus abdominis plane block consumed 736.5 morphine milligram equivalents of opioids compared to 1150.3 morphine milligram equivalents of opioid consumed by those without a transversus abdominis plane block (p < 0.05), a 36% decrease in opioid use. When comparing patients who had a mean length of stay of 4 days with those whose length of stay was >4 days, there was an 80% decrease in opioid use. The readmission rate was 7.8%. LIMITATIONS: The lack of randomization of patients was a limitation of this study. CONCLUSION: The use of transversus abdominis plane block in the setting of a well-structured enhanced recovery protocol was associated with a statistically significant decrease in length of stay by 1.5 days and a 36% decrease in narcotic use. See Video Abstract at http://links.lww.com/DCR/B432. IMPACTO DE LA ANESTESIA DEL PLANO MUSCULAR DE LOS TRANSVERSOS ABDOMINALES EN LA ESTADA DENTRO UN PROTOCOLO ERAS: ANTECEDENTES:La estrategia analgésica multimodal que consume poco medicamento de tipo narcótico es parte importante en los protocolos de recuperación mejorada postoperatoria. Dentro de dichos protocolos, los anestésicos regionales han demostrado ser superiores a la administración de medicamentos narcóticos.OBJETIVO:Estudiar el impacto del bloqueo del plano muscular de los transversos del abdomen sobre la duración de la estadía dentro de un protocolo de recuperación mejorada postoperatoria.DISEÑO:Se realizó un análisis retrospectivo de los pacientes que se sometieron a cirugía colorrectal entre 2015-2016. Los criterios principales de valoración en el presente análisis fueron la duración total de la estadía y el total de medicamentos narcóticos consumidos durante la hospitalización. Se comparó la duración de la estadía y el uso total de narcóticos en los pacientes que recibieron un bloqueo anestésico del plano muscular de los transversos del abdomen con los que no lo recibieron.FUENTE DE DATOS:Banco de datos de un hospital universitario docente.AMBIENTE:Hospital Universitario Docente.PACIENTES:Adultos desde los 18 años o mayores.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estadía, cantidad total de medicamentos narcóticos administrados.RESULTADOS:Un total de 347 pacientes se sometieron a procedimientos colorrectales bajo el protocolo ERAS. Entre ellos, 186 (54%) recibieron un bloqueo del plano muscular de los transversos del abdomen. En la globalidad, la duración media de la estadía fué de 5,8 días (DE ± 5,6) y la duración media de la estadía fué de 4 días. Estos resultados fueron comparados con la estadía media de 9,6 días y una estadía media de 7 días antes de implementar el protocolo ERAS. Los pacientes que recibieron un bloqueo del plano muscular de los transversos del abdomen tuvieron una estadía media de 5,1 días en comparación con los 6,6 días de los que no recibieron el mencionado bloqueo (p <0,01). Los pacientes que recibieron el bloqueo del plano muscular consumieron 736,5 miligramos de morfina o su equivalente en opioides, comparados con los 1150,3 de aquellos sin bloqueo del plano muscular (p <0,05) lo que significó una disminución del 36% en la administración de opioides. Al comparar los pacientes que tuvieron una estadía media de 4 días con aquellos cuya estadía fue mayor a 4 días, se evidenció una disminución en el 80% de la administración de opioides. La tasa de reingreso fue del 7,8%.LIMITACIONES:Estudio sin sin aleatorización de pacientes.CONCLUSIÓN:El bloqueo anestésico del plano muscular de los transversos del abdomen dentro un contexto protocolar tipo ERAS o de recuperación mejorada bien estructurada, se asoció con la disminución estadísticamente significativa de la duración de la estadía en 1,5 días y una disminución del 36% en la administración de medicamentos narcóticos. Consulte Video Resumen en http://links.lww.com/DCR/B432.

The Intersection of Regional Anesthesia and Cancer Progression: A Theoretical Framework.

The surgical stress and inflammatory response and volatile anesthetic agents have been shown to promote tumor metastasis in animal and in-vitro studies. Regional neuraxial anesthesia protects against these effects by decreasing the surgical stress and inflammatory response and associated changes in immune function in animals. However, evidence of a similar effect in humans remains equivocal due to the high variability and retrospective nature of clinical studies and difficulty in directly comparing regional versus general anesthesia in humans. We propose a theoretical framework to address the question of regional anesthesia as protective against metastasis.This theoretical construct views the immune system, circulating tumor cells, micrometastases, and inflammatory mediators as distinct populations in a highly connected system. In ecological theory, highly connected populations demonstrate more resilience to local perturbations but are prone to system-wide shifts compared with their poorly connected counterparts. Neuraxial anesthesia transforms the otherwise system-wide perturbations of the surgical stress and inflammatory response and volatile anesthesia into a comparatively local perturbation to which the system is more resilient. We propose this framework for experimental and mathematical models to help determine the impact of anesthetic choice on recurrence and metastasis and create therapeutic strategies to improve cancer outcomes after surgery.

Regional Anaesthesia Alone is Reasonable for Major Lower Extremity Amputation in High Risk Patients and May Initiate a More Efficacious Enhanced Recovery Programme.

OBJECTIVE: Major limb amputations are physiologically stressful and subject patients to peri-operative cardiovascular risk. Up to 90% of major lower extremity amputations (LEAMP) are being performed under general anaesthesia, despite regional anaesthesia being an acceptable option in most cases. Obtaining a better understanding of who would benefit from regional vs. general anaesthesia could reduce complications and help establish best evidence based practice. It was hypothesised that patients undergoing LEAMP with regional anaesthesia would have better post-operative outcomes than patients receiving general anaesthesia. METHODS: This retrospective cohort study used the U.S. Vascular Quality Initiative lower extremity amputation module to identify patients (≥18 years) who underwent LEAMP from 2013 to 2018. Outcomes included 30 day incidence of major adverse cardiac events (MACE) and all cause mortality. Multivariable logistic regression models were used to compute odds ratios (OR) and 95% confidence intervals (CI). Time to death was analysed using standard survival analysis. RESULTS: The final sample included 5 567 patients (median age: 65 years, 67% white, 65% male). Only 719 (13%) of patients received regional anaesthesia. Compared with patients undergoing general anaesthesia, patients in the regional group were older (67 vs. 65 years, p < .001) and more likely to have diabetes (78% vs. 69%; p < .001), end stage renal disease (26% vs. 18%; p < .001), congestive heart failure (33% vs. 27%; p < .01) and coronary artery disease (35% vs. 30%; p < .01). The overall incidence of MACE, death, and MACE or death was 5%, 6%, and 9%, respectively. There was no statistically significant difference by anaesthesia groups for MACE (OR 0.98, 95% CI 0.69-1.39) or mortality (HR 1.03, 95% CI 0.90-1.17). CONCLUSION: There was no difference in outcomes between regional or general anaesthesia techniques in patients undergoing LEAMP, despite the regional group having more comorbidities. Regional anaesthesia may be under used for high risk patients undergoing LEAMP. Further studies are needed to establish best practices in LEAMP procedures.

Environmental sustainability in neurointerventional procedures: a waste audit.

BACKGROUND: Operating rooms contribute between 20% to 70% of hospital waste. This study aimed to evaluate the waste burden of neurointerventional procedures performed in a radiology department, identify areas for waste reduction, and motivate new greening initiatives. METHODS: We performed a waste audit of 17 neurointerventional procedures at a tertiary-referral center over a 3-month period. Waste was categorized into five streams: general waste, clinical waste, recyclable plastic, recyclable paper, and sharps. Our radiology department started recycling soft plastics from 13 December 2019. Hence, an additional recyclable soft plastic waste stream was added from this time point. The weight of each waste stream was measured using a digital weighing scale. RESULTS: We measured the waste from seven cerebral digital subtraction angiograms (DSA), six mechanical thrombectomies (MT), two aneurysm-coiling procedures, one coiling with tumour embolization, and one dural arteriovenous fistula embolization procedure. In total, the 17 procedures generated 135.3 kg of waste: 85.5 kg (63.2%) clinical waste, 28.0 kg (20.7%) general waste, 14.7 kg (10.9%) recyclable paper, 3.5 kg (2.6%) recyclable plastic, 2.2 kg (1.6%) recyclable soft plastic, and 1.4 kg (1.0%) of sharps. An average of 8 kg of waste was generated per case. Coiling cases produced the greatest waste burden (13.1 kg), followed by embolization (10.3 kg), MT (8.8 kg), and DSA procedures (5.1 kg). CONCLUSION: Neurointerventional procedures generate a substantial amount of waste, an average of 8 kg per case. Targeted initiatives such as engaging with suppliers to revise procedure packs and reduce packaging, digitizing paper instructions, opening devices only when necessary, implementing additional recycling programs, and appropriate waste segregation have the potential to reduce the environmental impact of our specialty.

Regional anaesthesia practice for arteriovenous fistula formation surgery.

We conducted a survey and semi-structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty-five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill-mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as 'regional anaesthesia dominant' or 'local anaesthesia/mixed'; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians' beliefs and preferences, resource considerations and patients' treatment preferences; (4) anaesthetists' preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource-related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.

The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery.

BACKGROUND: Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population. METHODS: After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores. RESULTS: The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924). CONCLUSIONS: Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Emergency hysterectomy in a tertiary care hospital: indications, surgical outcomes and challenges: a 2-year retrospective descriptive cross-sectional study.

INTRODUCTION: emergency hysterectomy (EH) remains a life-saving procedure in cases of life-threatening obstetric hemorrhage and other gynaecological emergencies. We aim to determine the indications, surgical outcomes and challenges of EH in our tertiary centre. METHODS: an ethically approved retrospective descriptive cross-sectional study on all EHs performed at a tertiary hospital during the period of 1st January 2018 to 31st December 2019 was conducted. Medical records of eligible patients were retrieved, reviewed and analysed using frequencies and percentages and then summarized in tables. RESULTS: there were 146 EHs over the two year period. The age of participants ranged from 19 to 59 years, with a mean of 34.3 years (SD = 6.06). SD: standard deviation.The main indication for EH was primary postpartum haemorrhage (PPH): 73.28% (n = 110/146). The other indications were uterine perforation with necrosis: 8.9% (n = 13/146), secondary postpartum haemorrhage: 4.8% (n = 7/146), choriocarcinoma and pelvic abscess: 2.74% (n = 4/146) each and broad ligament haematoma: 2.06% (n = 3/146). There were 3.42% (n = 5/146) which were classified as 'others **': two cases of ovarian cyst torsion; one case of placental site tumour; one case of incomplete septic abortion; one case of bulky multinodular fibroid uterus with severe unremitting lower abdominal pain.The most common indication for the subgroup of hysterectomy due to PPH was uterine atony 54.20% (n = 60/110), followed by ruptured uterus20.56% (n = 23/110) and then, morbidly adherent placenta 14.95% (n = 16/110). Placenta accreta constituted 62.5% (n = 10/16) of the morbidly adherent placenta.There were 91.78% (n=134/146) total abdominal hysterectomies and 8.22% (n = 12/146) subtotalhysterectomies. About eighty percent 79.45% (n = 116/146) of the surgeries required general anaesthesia, 15.07% (n = 22/146) required regional anaesthesia whilst 5.48% (n = 8/146) were started as regional anaesthesia but were converted to general anaesthesia.There were no associated intraoperative complications in 96.60% (141/146) of the cases. The most frequent intraoperative complications included bowel injury 2.04% (3/146), bladder injury 0.68% (1/146) and maternal death 0.68% (1/146).Twoof the three bowel injuries required bowel resection and anastomosis. Most of the surgeries 89.73% (n = 131/146) were performed by skilled doctors above the level of a Specialist. Major challenges faced include delayed referral of patients to the tertiary centre for prompt management and lack of quick access to blood products. CONCLUSION: emergency hysterectomy is performed in women who are relatively young with primary postpartum haemorrhage as the commonest indication but there are other non-obstetric indications for this emergency surgery. Though a challenging procedure, it is safe in the hands of a skilled surgical team.

Mode of anesthesia and major perioperative outcomes associated with vaginal surgery.

INTRODUCTION AND HYPOTHESIS: The primary aim was to compare the incidence of major perioperative complications in women undergoing vaginal reconstructive surgery with general, regional, and monitored anesthesia care using a national database. The secondary aim was to compare length of hospital stay, 30-day readmission rates, urinary tract infections, and reoperation rates between anesthesia types. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was used to study women undergoing vaginal surgery for pelvic floor disorders from 2006 to 2015 via Current Procedural Terminology codes. Demographic and clinical variables were abstracted. The incidence of major perioperative complications was defined as the occurrence of any of the following within 30 days of surgery: death, surgical-site infection, pneumonia, venous thromboembolism, intensive care unit admission, stroke, transfusion, sepsis, and myocardial infarction. Regression analysis was used to estimate the relative risks (RR) associated with anesthesia type for each outcome. RESULTS: From the database, we gathered data on 37,426 women who underwent vaginal reconstructive surgery between 2006 and 2015; 87.2% (n = 32,623) underwent general, 6.9% (n = 2565) regional, and 5.9% (n = 2238) monitored anesthesia care. Major perioperative complications occurred in 560 women (1.5%). Relative to general anesthesia, the adjusted risk of major perioperative complications was not significantly different in those receiving monitored or regional anesthesia [monitored vs. general, adjusted RR 0.74, 95% confidence interval (CI) 0.45-1.20; regional vs. general, adjusted RR 1.23, 95% CI 0.92-1.65]. DISCUSSION: Major perioperative complications in vaginal reconstructive surgery were uncommon, and no differences were observed between monitored, regional, and general anesthesia outcomes.

Open inguinal hernia repair with self-gripping Parietex ProGrip mesh: a retrospective study of 204 cases.

Chronic pain and recurrence rates are the main challenge in modern inguinal hernia surgery. Several trials have investigated the role of self-adhesive mesh repair for inguinal hernia, with special attention to the incidence of chronic postoperative inguinal pain and recurrence. The purpose of our study was to retrospectively evaluate the early and long-term results using a self-gripping mesh (Parietex Progrip® , Covidien) in our institution. A total of 204 patients, mean age 50.3 standard deviation (SD) 15.3, was included in the study. The repair was performed under local anaesthesia in 159 (78%) cases and locoregional anaesthesia in remaining 45 (22%). Mean operative time was 39 ± 20 minutes. The time for self-gripping mesh placement ranged from 5 to 9 minutes (mean 7 ± 2 minutes). There were no intraoperative complications. Clinical follow-up was performed at 1 month, 1 year and 2 years and consisted in the evaluation of complications, discomfort/pain and recurrence. One case of cutaneous infection and three cases of seroma were observed at one-month follow-up and were all treated conservatively. 8 patients were lost at one year follow-up, and another 4 were lost at 2 years. 3 patients died for other causes during follow-up. At 1 year and 2 years follow-up no cases of seroma, testicular complications or mesh infection were observed. Two cases of recurrence were recorded at 2 years follow up. No patient reported VAS score > 2 at one month, 1 year and 2 years follow-up. There were no readmissions, systemic complications or death during 2 years follow-up. Lichtenstein open repair using Parietex Progrip® mesh is a simple, rapid, effective and safe method for inguinal hernia repair. The main advantage of self-fixing mesh is the reduced operative time. A suturless fixation seems to prevent the development of postoperative chronic pain, without increasing recurrence rate in the majority of the trials.

General or regional? Exploring patients' anaesthetic preferences and perception of regional anaesthesia. / ¿General o regional? Preferencias anestésicas de los pacientes y su percepción sobre la anestesia regional.

INTRODUCTION AND OBJECTIVES: Regional anaesthesia (RA) has gained popularity due to its numerous benefits and increasing safety. Yet, often patients refuse this procedure and prefer general anaesthesia (GA). This study aimed to investigate variables (demographic factors, safety perception of GA and RA, patients' fears, anxiety, and knowledge) related to patients' anaesthetic preference. MATERIAL AND METHODS: Participants were patients aged 18 years or more proposed to an anaesthesia appointment for preoperative assessment. Patients completed a written questionnaire before meeting the anaesthesiologist. The questionnaire asked about their preferences, fears and perceptions about RA. RESULTS: One hundred and 2patients agreed to participate. Mean age was 52.6±13.5 years, 57.8% were female and 44.5% had at least 12 years of education. Given the choice, 54.0% would prefer GA and 20.7% said they would refuse RA if proposed by the anaesthesiologist. Among patients who already experienced neuroaxial anaesthesia, 40.0% said they did not wish to repeat it. Patients who preferred GA over RA perceived GA to be safer than RA and expressed more anxiety towards being awake during surgery and more fear of feeling pain during surgery, of having back pain, and of needle puncture. Results also suggested that patients are unaware of RA's real risks and benefits. CONCLUSIONS: Knowing patients' fears is essential for the anaesthesiologist address their patients' needs. Anaesthesiologists should work on improving general population perspective and knowledge about RA.

Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists.

BACKGROUND: Fluid and pain management during liver surgery (eg, low central venous pressure) is a classic topic of controversy between anesthesiologists and surgeons. Little is known about practices worldwide. The aim of this study was to assess perioperative practices in liver surgery among and between surgeons and anesthesiologists worldwide that could guide the design of future international studies. METHODS: An online questionnaire was sent to 22 societies, including 4 international hepatopancreatobiliary societies, the American Society of Anesthesiologists, and 17 other (inter-)national societies. RESULTS: A total of 913 participants (495 surgeons and 418 anesthesiologists) from 66 countries were surveyed. A large heterogeneity in fluid management practices was identified, with 66% using low central venous pressure, 22% goal-directed fluid therapy, and 6% normovolemia. In addition, large heterogeneity was found regarding pain management practices, with 49% using epidural analgesia, 25% patient-controlled analgesia with opioids, and 12% regional techniques. Most participants assume that there is a relation between perioperative pain management and morbidity and mortality (78% of surgeons vs 89% of anesthesiologists; P < .001). Both surgeons and anesthesiologists have the highest expectations for minimally invasive surgery and enhanced recovery pathways for improving outcomes in liver surgery. No clear differences between continents were found. CONCLUSION: Worldwide there is a large heterogeneity in fluid and pain management practices in liver surgery. This survey identified several areas of interest for future international studies aiming to improve outcomes in liver surgery.

Transversus abdominis plane blocks with liposomal bupivacaine after open major hepatectomy is associated with reduced early patient-reported pain scores and opioid administration.

BACKGROUND: Opioid overprescription can contribute to suboptimal patient outcomes. Surgeon-performed transversus abdominis plane blocks appear to be associated with pain reduction. We compared the analgesic efficacy of surgeon-performed transversus abdominis plane blocks for major hepatectomy with or without concurrent neuraxial analgesia. METHODS: We performed a single-institution review, assessing surgeon-performed transversus abdominis plane blocks for major hepatectomy during 2013-2016. The primary outcome was patient-reported pain (11-point numeric pain-rating scale) and the secondary outcome was opioid consumption. Independent factors predictive of pain control were identified using logistic regression and reported as odds ratios with 95% confidence intervals. RESULTS: A total of 232 patients with a mean (± SD) age of 56.5 (±13.9) years; 51.7% were female. Operative duration, incision type, and American Society of Anesthesiologists score were similar between groups. The 24-hour pain score was decreased substantially in patients who received a transversus abdominis plane block compared with those who did not (3 [2-4] versus 5 [4-6], P = .001) and this decrease in pain sscore persisted at 48 hours (2 [1-2] versus 4 [4-5], P = .001). In patients who received a transversus abdominis plane block, there were decreasess in consumption of oral morphine equivalents at 24 hours (322 [± 18] versus 183 [± 15], P = .0001) and 48 hours (100 [± 11] versus 33 [± 9.4], P = .03) compared with those without transversus abdominis plane block respectively. CONCLUSION: In patients receiving a transversus abdominis plane block, early patient opioid consumption was decreased and utilization was predictive for improved pain control. Routine transversus abdominis plane block administration should be considered during major hepatectomy as a step toward curbing systematic reliance on opioids for pain management. A prospective study on the utility of transversus abdominis plane block in hepatectomy is warranted.

Use of Regional Anesthesia for Outpatient Surgery Within the United States: A Prevalence Study Using a Nationwide Database.

BACKGROUND: Regional anesthesia is of benefit for outpatient surgery given its demonstrated improvement in analgesia and decrease in complications, resulting in shorter average recovery room times and lower hospital readmission rates. Unfortunately, there are few epidemiological studies outlining the overall utilization of peripheral nerve blocks (PNBs) in this setting. Therefore, the primary objective of this study was to report the overall utilization of several types of PNBs among all candidate cases in the outpatient setting within the United States. METHODS: We identified all cases from the National Anesthesia Clinical Outcomes Registry that were performed as an outpatient surgery. We reported the frequency of various types of PNBs among all candidate cases, defined as cases that potentially could have received a PNB. Changes in prevalence of PNB utilization from 2010 to 2015 were analyzed by using logistic regression. RESULTS: Of the 12,911,056 outpatient surgeries in the National Anesthesia Clinical Outcomes Registry, 3,297,372 (25.5%) were amenable to a PNB. However, the overall PNB frequency was only 3.3% of the possible cases. The overall utilization for PNB of the brachial plexus, sciatic nerve, and femoral nerve were 6.1%, 1.5%, and 1.9%, respectively. The surgical procedures generating the highest volume of PNBs were shoulder arthroscopies and anterior cruciate ligament reconstruction, in which 41% and 32% received a PNB, respectively. During this time period, there was a significant increase in overall PNB utilization for both single-injection and continuous PNB (P < .0001). However, the proportion of continuous PNB to single-injection PNB did not increase significantly. CONCLUSIONS: While the overall frequency of PNB is relatively low, there was a significant increase in its prevalence during the study period. Regional anesthesia offers significant positive impact for perioperative outcomes and hospital efficiency metrics; however, it is not clear what is limiting its widespread use. Future studies are necessary to identify barriers and disparities in care to implement methods to increase regional anesthesia volume nationwide where beneficial and appropriate.

Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes: A Population-based Cohort Study.

BACKGROUND: There is consistent and significant variation in neuraxial anesthesia use for hip fracture surgery across jurisdictions. We measured the association of hospital-level utilization of neuraxial anesthesia, independent of patient-level use, with 30-day survival (primary outcome) and length of stay and costs (secondary outcomes). METHODS: We conducted a population-based cohort study using linked administrative data in Ontario, Canada. We identified all hip fracture patients more than 65 yr of age from 2002 to 2014. For each patient, we measured the proportion of hip fracture patients at their hospital who received neuraxial anesthesia in the year before their surgery. Multilevel, multivariable regression was used to measure the association of log-transformed hospital-level neuraxial anesthetic-use proportion with outcomes, controlling for patient-level anesthesia type and confounders. RESULTS: Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic; utilization varied from 0 to 100% between hospitals. In total, 9,122 (8.5%) of patients died within 30 days of surgery. Survival independently improved as hospital-level neuraxial use increased (P = 0.009). Primary and sensitivity analyses demonstrated that most of the survival benefit was realized with increase in hospital-level neuraxial use above 20 to 25%; there did not appear to be a substantial increase in survival above this point. No significant associations between hospital neuraxial anesthesia-use and other outcomes existed. CONCLUSIONS: Hip fracture surgery patients at hospitals that use more than 20 to 25% neuraxial anesthesia have improved survival independent of patient-level anesthesia type and other confounders. The underlying causal mechanism for this association requires a prospective study to guide improvements in perioperative care and outcomes of hip fracture patients. VISUAL ABSTRACT: An online visual overview is available for this article at http://links.lww.com/ALN/B634.

Use of Regional Anesthesia Techniques: Analysis of Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery.

INTRODUCTION: Principles of Enhanced Recovery After Surgery (ERAS®) protocols are well established, with the primary goal of optimizing perioperative care and recovery. The use of multimodal analgesia is a key component of these protocols, including regional analgesia techniques such as thoracic epidural analgesia (TEA), transversus abdominis plane (TAP), rectus sheath blocks or continuous wound infiltration (CWI)/catheters, and spinal anesthesia. We compare and contrast regional anesthesia approaches in different institutional colorectal surgery ERAS protocols. MATERIALS AND METHODS: ERAS protocols for open and laparoscopic colorectal surgery were obtained from 15 different healthcare facilities mostly located in North American and one in New Zealand. A comparison was then made with respect to regional anesthesia recommendations. RESULTS: The most commonly used regional technique among protocols was TEA. TAP blocks were the next most common, with rectus sheath blocks and continuous wound catheters only mentioned in one protocol each. CONCLUSION: There are both similarities and differences in regional anesthesia techniques, which may be due to institution- and provider-level factors. Most protocols advocate for TEA use, which has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use. Use of spinal anesthesia may lead to earlier mobilization compared to TEA, and lower doses of intrathecal morphine are recommended to reduce respiratory depression. TAP blocks were indicated for laparoscopic procedures. Rectus sheath blocks, which are listed in some protocols, may provide analgesia equivalent to epidural anesthesia, while avoiding complications of TEA. CWI has been effective in reducing postoperative pain, hastening recovery, and improving pulmonary function.

Increased resource utilization and overall morbidity are associated with general versus regional anesthesia for carotid endarterectomy in data collected by the Michigan Surgical Quality Collaborative.

OBJECTIVE: Advocates for performing carotid endarterectomy (CEA) under regional anesthesia (RA) cite reduction in hemodynamic instability and the ability for neurologic monitoring, but many still prefer general anesthesia (GA) as benefits of RA have not been clearly demonstrated, reliable RA may not be available in all centers, and a certain amount of movement by the patient during the procedure may not be uniformly tolerated. We evaluated the association of anesthesia type and perioperative morbidity and mortality as well as resource utilization in patients undergoing CEA using the Michigan Surgical Quality Collaborative (MSQC) database. METHODS: Between 2012 and 2014, 4558 patients underwent CEA among the MSQC participating hospitals. Of these patients, 4008 underwent CEA under GA and 550 underwent CEA under RA. Data points were collected for each procedure, and a review of 30-day perioperative outcomes was conducted using the χ2 test. Propensity score regression adjusted for case mix preoperative conditions as fixed effects, and a mixed model adjusted for site as a random effect. RESULTS: The two groups were similar in gender and incidence of hypertension, diabetes, congestive heart failure, and smoking history. The RA group tended to be of better functional status. After GA, there was a greater than twofold higher percentage of any morbidity (8.7% vs 4.2%). Further analysis demonstrated that patients undergoing GA had higher unadjusted rates for mortality (1.0% vs 0.0%), unplanned intubations (2.1% vs 0.6%), pneumonia (1.3% vs 0.0%), sepsis (0.8% vs 0.0%), and readmissions (9.2% vs 6.1%). Adjusting for case mix and random effect, there was statistically significantly higher overall morbidity (P = .0002), unplanned intubation (P = .0196), extended length of stay (P = .0007), emergency department visits (P = .0379), and readmissions (P = .0149) in the GA group. There was no statistically significant difference in incidence of myocardial infarction or cerebrovascular accident. CONCLUSIONS: Based on this analysis from the MSQC database, there is an associated increased morbidity and resource utilization with GA vs RA for CEA. This has implications for enterprise resource planning initiatives and the CEA value proposition in general, which is of special interest to both hospitals and payers.