The effect of ampule size of fentanyl on perioperative intravenous opioid dosing.

BACKGROUND AND AIMS: There are limited data on the effect of ampule size on drug dosing. The objective of this study is to determine the effect of ampule size on perioperative opioid dosing and post-anesthesia care unit (PACU) outcomes. MATERIAL AND METHODS: This was a retrospective review of patients undergoing robotically assisted laparoscopic radical prostatectomy before and after a 5-ml fentanyl ampule was discontinued. The primary outcome was intraoperative opioid administration divided into fentanyl at induction of anesthesia, total fentanyl, and total opioid. Secondary outcomes observed in PACU included the opioid administered, visual analog scale (VAS) pain scores, postoperative nausea and vomiting, and length of stay in PACU. RESULTS: A total of 100 patients (50 PRE and 50 POST) were included. In the intraoperative opioid administration, mean (SD) of fentanyl at induction was 117.0 (49.3) in PRE group and 85.0 (35.4) µg in POST group (P < 0.01). The total fentanyl requirement was 247.0 (31.0) in PRE group and 158.5 (85.1) µg in POST group (P < 0.01). The total opioid in intravenous morphine equivalents (IVME) was 34.1 (5.8) in PRE group and 23.2 (6.8) mg in POST group (P < 0.01). Among the secondary outcomes, mean (SD) of IVME of opioid was 7.7 (8.2) in PRE group and 9.9 (8.1) mg in POST group (P = 0.18). The VAS pain score on arrival was 0.7 (1.4) in PRE group and 3.8 (3.3) in POST group (P < 0.01). The cumulative VAS pain score was 2.3 (2.0) in PRE group and 3.3 (2.2) in POST group (P < 0.01). The length of stay was significantly more in POST group, 193.8 (75.8) minutes, as compared with PRE group, 138.6 (61.0) minutes (P < 0.01). CONCLUSIONS: A change in the ampule size significantly affected intraoperative dosing, PACU pain scores, and PACU length of stay in patients undergoing robotically assisted laparoscopic radical prostatectomy under general anesthesia. This was explained by clinician's desire to conserve the drug and avoid the complex process of narcotic waste disposal.

Insertion of intra-oral electrodes for cranial nerve monitoring using a Crowe-Davis retractor.

Acoustic neuroma resection is an example of a neurosurgical procedure where the brainstem and multiple cranial nerves are at risk for injury. Electrode placement for monitoring of the glossopharyngeal and hypoglossal nerves during acoustic neuroma resection can be challenging. The purpose of this report is to illustrate the use of a device for intra-oral electrode placement for intraoperative monitoring of the glossopharyngeal and hypoglossal nerves. A 60-year-old male presented for acoustic neuroma resection. Under general anesthesia, a Crowe-Davis retractor was used to open the mouth, providing access to the posterior pharynx. For glossopharyngeal monitoring, two bent subdermal needle electrodes were inserted just lateral to the uvula. Two additional electrodes were inserted on the lateral tongue to monitor the hypoglossal nerve. Cranial nerves monitoring was conducted utilizing both free running and triggered electromyography of the trigeminal and facial nerves in addition to the lower cranial nerves. The tumor was resected successfully. Monitoring of the cranial nerves (including the glossopharyngeal and hypoglossal nerves) revealed no concerning responses. The Crowe-Davis retractor and the technique described allowed insertion of electrodes for neural monitoring, contributing to neural preservation.

Findings of a Naloxone Database and its Utilization to Improve Safety and Education in a Tertiary Care Medical Center.

INTRODUCTION: Analyzing hospital naloxone use may assist in identification of areas for quality and safety improvement. Our primary objective is to quantitate the incidence of hospital naloxone use and to assess certain patient populations at risk. METHODS: During the years 2008 to 2011, each clinical scenario where naloxone was administered on an in-patient care ward was reviewed. The events were assessed to separate situations where naloxone rescue was effective in reversing opioid-induced intoxication vs. others. Further analysis was conducted to stratify patient populations at greatest risk. RESULTS: Naloxone was administered for well-defined opioid-induced respiratory depression and oversedation 61% of the time, the remainder used for patient deterioration of other etiology. Surgical populations are at risk with an incidence of 3.8/1,000 hospitalized patients, and this is the greatest within 24 hours of surgery. General surgical patients represent the highest surgical patient risk at 5.5/1,000. Medical patients represent lower risk at 2.0/1,000. Patients with patient-controlled analgesia and epidural opioid infusion are high risk at 12.1 and 13.1/1,000 patients, respectively. Many quality and safety interventions were gradually implemented in response to this data and are summarized. These include nursing and provider education, electronic medical record modification, and more stringent patient monitoring practices. CONCLUSION: Examination of naloxone use can assist in the identification and stratification of patients at risk for opioid-induced respiratory depression and oversedation and can serve as a driver for improvements in hospital patient safety. This information can also guide other institutions interested in similar improvements.

Current and emerging treatments for hypercholesterolemia: A focus on statins and proprotein convertase subtilisin/kexin Type 9 inhibitors for perioperative clinicians.

Statins are a mainstay of hyperlipidemia treatment. These drugs inhibit the enzyme 3-hydroxy-3-methylglutaryl coenzyme A reductase and have beneficial effects on atherosclerosis including plaque stabilization, reduction of platelet activation, and reduction of plaque proliferation and inflammation. Statins also have a benefit beyond atherosclerotic plaque, including anticoagulation, vasodilatation, antioxidant effects, and reduction of mediators of inflammation. In the perioperative period, statins appear to contribute to improved outcomes via these mechanisms. Both vascular and nonvascular surgery patients have been shown in prospective studies to have lower risk of adverse cardiac outcomes when initiated on statins preoperatively. However, not all patients can tolerate statins; the search for novel lipid-lowering therapies led to the discovery of the proprotein convertase subtilisin/kexin Type 9 (PCSK9) inhibitors. These drugs are fully-humanized, injectable monoclonal antibodies. With lower PCSK9 activity, low-density lipoprotein cholesterol (LDL-C) receptors are more likely to be recycled to the hepatocyte surface, where they serve to clear plasma LDL-C. Evidence from several prospective studies shows that these new agents can significantly lower LDL-C levels. While PCSK9 inhibitors offer hope of effective therapy for patients with familial hyperlipidemia or intolerance of statins, several important questions remain, including the results of long term cardiovascular outcome studies. The perioperative effects of new LDL-C-lowering drugs are unknown at present but are likely to be similar to the older agents.

Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study.

BACKGROUND: Recent studies evaluated short-term efficacy and safety of peripheral nerve stimulation (PNS) of the occipital nerves for managing chronic migraine. We present 52-week safety and efficacy results from an open-label extension of a randomized, sham-controlled trial. METHODS: In this institutional review board-approved, randomized, multicenter, double-blinded study, patients were implanted with a neurostimulation system, randomized to an active or control group for 12 weeks, and received open-label treatment for an additional 40 weeks. Outcomes collected included number of headache days, pain intensity, migraine disability assessment (MIDAS), Zung Pain and Distress (PAD), direct patient reports of headache pain relief, quality of life, satisfaction and adverse events. Statistical tests assessed change from baseline to 52 weeks using paired t-tests. Intent-to-treat (ITT) analyses of all patients (N = 157) and analyses of only patients who met criteria for intractable chronic migraine (ICM; N = 125) were performed. RESULTS: Headache days were significantly reduced by 6.7 (±8.4) days in the ITT population (p < 0.001) and by 7.7 (±8.7) days in the ICM population (p < 0.001). The percentages of patients who achieved a 30% and 50% reduction in headache days and/or pain intensity were 59.5% and 47.8%, respectively. MIDAS and Zung PAD scores were significantly reduced for both populations. Excellent or good headache relief was reported by 65.4% of the ITT population and 67.9% of the ICM population. More than half the patients in both cohorts were satisfied with the headache relief provided by the device. A total of 183 device/procedure-related adverse events occurred during the study, of which 18 (8.6%) required hospitalization and 85 (40.7%) required surgical intervention; 70% of patients experienced an adverse event. CONCLUSION: Our results support the 12-month efficacy of PNS of the occipital nerves for headache pain and disability associated with chronic migraine. More emphasis on adverse event mitigation is needed in future research. TRIAL REGISTRATION: Clinical trials.gov (NCT00615342).

Patient understanding of the importance of statin use in the perioperative period.

OBJECTIVE: Perioperative hydroxy-3-methyl glutaryl coenzyme A reductase inhibitors (statins) have been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to assess patient understanding of the potential benefits of perioperative statins in a select population already on chronic therapy. A secondary aim was to determine the frequency with which patients recalled having a discussion with their provider regarding perioperative statins. DESIGN: Survey. SETTING: Teaching hospital. PARTICIPANTS: Patients taking daily statins presenting to a preoperative medical evaluation clinic were offered a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients completed the questionnaire. The mean age was 68.3 years (standard deviation, 9.0); 42% were female. The most frequent surgical referral to the clinic was orthopedics, at 36%. The most common statin prescribed was atorvastatin, in 35% of patients. Twenty-seven percent of patients (n = 36) recognized that perioperative statins are beneficial; 44% of these patients (n = 14) cited decreased cholesterol during the procedure as the reason, representing 12% of the total sampled population. Twenty-two percent (n = 8) of those recognizing the benefit of perioperative statins identified a decrease in the risk of heart attack or death as the reason. This represented only 6% of the total sample. One percent of surgeons mentioned statins in relation to the planned surgery; 2% of primary or prescribing physicians mentioned the medication in relation to surgery. CONCLUSIONS: This study suggested low patient understanding of the potential importance and reasons for perioperative statins. In addition, this study also suggested that the information regarding the importance of perioperative statins is not being relayed to the patient at the level of the surgeon or primary care physician. All physicians involved in perioperative care can offer improved patient education to promote compliance with statin therapy in hopes of a favorable impact on perioperative outcomes.

Attributes associated with patient perceived outcome in an academic chronic pain clinic.

OBJECTIVES: Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient-provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health. METHODS: A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit. RESULTS: The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good. CONCLUSIONS: Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.

Long-term outcome in occipital nerve stimulation patients with medically intractable primary headache disorders.

INTRODUCTION: €‚ Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-€term ONS outcomes. METHODS: €‚ The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. RESULTS: €‚ Twenty-nine patients underwent a trial of ONS during the 8.5-€year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-€eight percent of patients required at least one lead revision. DISCUSSION: €‚ These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. CONCLUSIONS: €‚ Randomized controlled long-€term studies in specific, intractable, primary headache disorders are indicated.

Patient satisfaction in an academic chronic pain clinic.

OBJECTIVES: Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient-physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from "very good" to "excellent," and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking. METHODS: Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit. RESULTS: A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of "very good" vs. "excellent" patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making. CONCLUSIONS: These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.

The role of digital subtraction myelography in the diagnosis and localization of spontaneous spinal CSF leaks.

OBJECTIVE: The objective of our study was to review the clinical utility of digital subtraction myelography for the diagnosis of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH) and those with superficial siderosis. MATERIALS AND METHODS: Procedure logs from 2007 to 2011 were reviewed to identify cases in which digital subtraction myelography was performed to diagnose spinal CSF leaks. Electronic medical records were reviewed to obtain information regarding diagnosis and outcome. For patients to be included in the study, preprocedural spinal MRI had to show an extradural fluid collection spanning more than one vertebral level and postmyelographic CT had to confirm the presence of an active CSF leak. If digital subtraction myelography successfully showed the site of the CSF leak, the location was documented. RESULTS: Eleven patients (seven men and four women; mean age, 49.0 years) underwent digital subtraction myelography during the study period. Six patients had SIH and five patients had superficial siderosis. The extradural fluid collection on spinal MRI averaged a length of 15.5 vertebral levels. Digital subtraction myelography successfully showed the site of the CSF leak in nine of the 11 patients, and all of the dural tears were located in the thoracic spine between T3 and T11. CONCLUSION: Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.

Revision of occipital nerve stimulator leads: technical note of two techniques.

OBJECTIVE: Occipital nerve stimulation can be effective therapy for recalcitrant headache disorders. Lead migration remains the primary technical adverse event associated with this therapy. Revision surgery for occipital nerve stimulator leads sometimes requires exposure of all components including internal pulse generator, extension cables, connectors, and leads with multiple incisions. However, minimizing the invasiveness of revision surgery reduces the time, infection risk, and discomfort associated with the procedure. We describe two techniques that attempt to minimize the extent of revision surgery necessary for lead migration. MATERIALS AND METHODS: We describe two minimally invasive revision techniques. One uses a 14-gauge Tuohy needle converted to a slotted needle. The other uses a standard Tuohy needle inserted subcutaneously into the anchor site along the desired course of the lead. RESULTS: Both techniques allow replacement of a migrated occipital nerve stimulator lead while eliminating the need to access connector or battery sites with multiple incisions. CONCLUSIONS: When migration occurs, the techniques described can simplify lead revision while minimizing the invasiveness of the procedure.

A Plant-Based Dietary Intervention for Preoperative Glucose Optimization in Diabetic Patients Undergoing Total Joint Arthroplasty.

Purpose. The purpose of this study was to assess the feasibility and effectiveness of a whole food plant-based diet (WFPBD) to improve day of surgery fasting blood glucose (FBG) among patients with type 2 diabetes (T2D). Patients and Methods. Ten patients with T2D scheduled for a total hip or total knee replacement were recruited. For 3 weeks preceding their surgeries, subjects were asked to consume an entirely WFPBD. Frozen WFPBD meals were professionally prepared and delivered to each participant for the 3 weeks prior to surgery. FBG was reassessed on the morning of surgery and compared with preintervention values. Compliance with the diet was assessed. Results. Mean age of subjects and reported duration of diabetes was 65 and 8 years, respectively, average hemoglobin A1c (HbA1c) was 6.6%, and 6 were women. Mean FBG decreased from 127 to 116 mg/dL (P = .2). Five of the subjects experienced improvement in glycemic control, with an average decline of 11 mg/dL. Conclusion. A WFPBD is a potentially effective intervention to improve glycemic control among patients with T2D during the period leading up to surgery. Future controlled trials on a larger sample of patients to assess the impact of a WFPBD on glycemic control and surgical outcomes are warranted.

More hypotension in patients taking antihypertensives preoperatively during shoulder surgery in the beach chair position.

PURPOSE: Hypotension is common in patients undergoing surgery in the sitting position under general anesthesia, and the risk may be exacerbated by the use of antihypertensive drugs taken preoperatively. The purpose of this study was to compare hypotensive episodes in patients taking antihypertensive medications with normotensive patients during shoulder surgery in the beach chair position. METHODS: Medical records of all patients undergoing shoulder arthroscopy during a 44-month period were reviewed retrospectively. The primary endpoint was the number of moderate hypotensive episodes (systolic blood pressure ≤ 85 mmHg) during the intraoperative period. Secondary endpoints included the frequency of vasopressor administration, total dose of vasopressors, and fluid administered. Values are expressed as mean (standard deviation). RESULTS: Of 384 patients who underwent shoulder surgery, 185 patients were taking no antihypertensive medication, and 199 were on at least one antihypertensive drug. The antihypertensive medication group had more intraoperative hypotensive episodes [1.7 (2.2) vs 1.2 (1.8); P = 0.01] and vasopressor administrations. Total dose of vasopressors and volume of fluids administered were similar between groups. The timing of the administration of angiotensin-converting enzyme inhibitors and of angiotensin receptor antagonists (≤ 10 hr vs > 10 hr before surgery) had no impact on intraoperative hypotension. CONCLUSIONS: Preoperative use of antihypertensive medication was associated with an increased incidence of intraoperative hypotension. Compared with normotensive patients, patients taking antihypertensive drugs preoperatively are expected to require vasopressors more often to maintain normal blood pressure.

Sedation and analgesia in the cardiac electrophysiology laboratory: a national survey of electrophysiologists investigating the who, how, and why?

OBJECTIVE: To investigate sedation and anesthesia trends and practice patterns for procedures in the cardiac electrophysiology laboratory (EPL). DESIGN: A survey distributed by e-mail. SETTING: US teaching hospitals with a training program in cardiac electrophysiology. PARTICIPANTS: Cardiologists involved in procedures in the electrophysiology laboratory of academic electrophysiology programs. INTERVENTIONS: A survey was e-mailed to the selected programs. The survey questions included the use of anesthesia professional (MD/CRNA) and nonanesthesia professional (RN) services, medications administered, commonly performed airway interventions, satisfaction with anesthesia services, and reasons that anesthesia professionals are not used when RNs administer sedation. MEASUREMENTS AND MAIN RESULTS: Of the 95 academic electrophysiology programs surveyed, there were 38 responses (40%). The majority (71%) of respondents used a combined model of care with both anesthesia professional care and nonanesthesia professional (RN) sedation, although there were EPLs that had exclusively anesthesia professional (n = 6) and exclusively nonanesthesia professional coverage (n = 5); 26.3% of respondents answered that care by an anesthesia professional was warranted most (>50%) of the time regardless of their current care model. The main reasons cited for having RN-administered sedation were the lack of availability of anesthesia professionals, difficulty with scheduling, and increased operating room suite turnover times. Programs using exclusively RN sedation (13%) reported all levels of anesthesia including general anesthesia (patient unarousable to repeated deep stimulation). CONCLUSIONS: This survey suggested that sedation for EPL procedures was sometimes allowed to progress to deep sedation and general anesthesia and that selection of anesthesia provider frequently was made based on availability, operating room efficiency, and economic reasons before patient safety issues. The implications of the survey must be explored further in a larger-scale sample population before more definitive statements can be made, but results suggested that sedation in the EPL is an area that would benefit from updated guidelines specific to the current practice as well as attention from the anesthesia community to address the deficiency in provision of anesthesia care.

Adoption of anesthesia information management systems by US anesthesiologists.

OBJECTIVE: Electronic medical records (EMR) may increase the safety and efficiency of healthcare. Anesthesia care is a significant component of the perioperative period, yet little is known about the adoption of anesthesia information management systems (AIMS) by US anesthesiologists, particularly in non-academic settings. Herein, we report the results of a survey of US anesthesiologists regarding adoption of AIMS and anesthesiologist-perceived advantages and barriers to AIMS adoption. METHODS: Using the e-mail database of the American Society of Anesthesiologists, we solicited randomly selected US anesthesiologists to participate in a survey of their AIMS adoption, perceived advantages and barriers to AIMS. Two and then 3 weeks after the initial mailing, a follow-up e-mail was sent to each anesthesiologist. The study was closed 4 weeks after the initial mailing. RESULTS: Five thousand anesthesiologists were solicited; 615 (12.3%) responses were received. Twenty-four percent of respondents had installed an AIMS, while 13% were either installing a system now or had selected one, and an additional 13% were actively searching. Larger anesthesiology groups with large case loads, urban settings, and government affiliated or academic institutions were more likely to have adopted AIMS. Initial cost was the most frequently cited AIMS barrier. The most commonly cited benefit was more accurate clinical documentation (79%), while unanticipated need for ongoing information technology support (49%) and difficult integration of AIMS with an existing EMR (61%) were the most commonly cited problems. There were no barriers cited significantly more often by non-adopters than adopters. CONCLUSIONS: At least 50% of our survey respondents were currently using, installing, planning to install, or searching for an AIMS. However, the strength of any conclusion is undermined by a low survey response rate and potential bias as respondents using or searching for an AIMS may be more likely to participate. Nonetheless, challenges exist for anesthesiologists considering AIMS adoption including cost. Furthermore, important questions remain regarding payment for anesthesia services and the relationship of AIMS and "meaningful use" as defined by the Centers for Medicare & Medicaid Services.

Occipital nerve stimulator placement via a retromastoid to infraclavicular approach: a technical report.

Occipital nerve stimulation is a form of peripheral nerve stimulation used to treat refractory headache disorders. Various techniques have been described for occipital nerve stimulator implantation; these include midline cervical or retromastoid lead insertion with internal pulse generator placement in the infraclavicular, gluteal or low abdominal regions. Lead migration is one of the most common complications of occipital nerve stimulators. Implantation approaches that include remote battery sites may contribute to mechanical stress on the components, as the leads or extensions may traverse highly mobile body regions. In this technical report, we describe an occipital stimulator implantation technique that may be advantageous in terms of patient positioning, ease of surgical approach and minimization of mechanical stress on components.

Occipital nerve stimulator lead pathway length changes with volunteer movement: an in vitro study.

BACKGROUND: Occipital nerve stimulation is a modality reserved for refractory headache disorders. Leads (wires) are inserted subcutaneously in the occipital region to stimulate the distal C1-3 nerves; lead migration may result from repeated mechanical forces on the lead associated with patient movement. The primary aim of this study was to determine implantation pathways associated with the least pathway length change secondary to body movement in an in vitro model of an occipital stimulator system. METHODS: After institutional review board approval, 10 volunteers were recruited. The expected pathway of an occipital stimulator system was identified and measured externally, and then changes in pathway length were measured during various volunteer movements, including neck and low back flexion, extension, rotation, and lateral flexion. The pathways studied included those that connect internal pulse generators in the gluteal, low abdominal, and infraclavicular regions to occipital leads inserted via a cervical or retromastoid approach. RESULTS: The flexion/extension pathway length changes associated with midline occipital and retromastoid sites to the infraclavicular site were significantly less than those pathways to the periscapular site. Also, the abdominal site was associated with less pathway length change during flexion/extension than the gluteal site. CONCLUSIONS: Internal pulse generators in sites other than the buttock, including infraclavicular or low abdomen, may be associated with lower lead migration risk. There are many considerations when selecting insertion sites and lead pathways for occipital nerve stimulation. Implanters and patients may consider these results when contemplating surgical approaches to this challenging form of peripheral nerve stimulation.

Randomized non-inferiority trial of the vitalHEAT temperature management system vs the Bair Hugger warmer during total knee arthroplasty.

PURPOSE: Intraoperative and postoperative hypothermia occur commonly; mild hypothermia (34-36 degrees C) is associated with adverse events. The use of perioperative warming devices has become routine, but currently available active warming devices may be limited in certain circumstances. The vitalHEAT Temperature Management System provides conductive warming (circulating warm water) around a single extremity together with a vacuum that is applied to the limb. In this randomized trial, we tested the hypothesis that the vitalHEAT system is non-inferior to the Bair Hugger during unilateral total knee arthroplasty. METHODS: Physical status I-III patients who were >or=18 yr-old were eligible to participate. The patients were randomly assigned to the vitalHEAT system (n = 30) or to Bair Hugger (n = 25) warming. Intraoperative and first recovery room temperatures were recorded in both groups. RESULTS: The baseline characteristics of the groups were similar. In terms of the primary outcome measure, i.e., sublingual temperature measured within 10 min of recovery room arrival, the vitalHEAT system did not meet the criterion for non-inferiority. Specifically, the confidence interval for the difference between means included the non-inferiority margin (-0.5 degrees C). In terms of the secondary measures, i.e., intraoperative esophageal temperatures, the vitalHEAT system also underperformed compared with the Bair Hugger. CONCLUSIONS: The vitalHEAT system may have advantages over convective warming systems because it requires a much smaller body surface area; however, in this study of warming during total knee arthroplasty, it underperformed when compared with the Bair Hugger, especially around and after the time of tourniquet release. CLINICAL TRIAL REGISTRATION NUMBER: NCT00711867.

Airway interventions in the cardiac electrophysiology laboratory: a retrospective review.

OBJECTIVE: To quantify the incidence of airway interventions during cardiac electrophysiology laboratory procedures. DESIGN: A retrospective chart review. SETTING: A tertiary care teaching hospital. PARTICIPANTS: Two-hundred eight adult patients undergoing cardiac electrophysiology laboratory procedures during a 2-year period, March 2006 to March 2008. The patients underwent the following procedures: supraventricular tachycardia ablation, atrial tachycardia ablation, atrial flutter ablation, premature ventricular contraction ablation, and ventricular tachycardia ablation. Patients who were intubated (in the intensive care unit or emergency department) before the ablation began, patients with ventricular assist devices or intra-aortic balloon pumps, and patients receiving inotropic support before the procedure were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The data were summarized by using the mean and standard deviation. Of the 208 patients, 186 were planned monitored anesthesia care, and 22 were planned general anesthetics. Of the monitored anesthesia care cases, 20 were converted to general anesthesia, and 54 received some type of airway intervention including oral-pharyngeal airway or nasal airway insertion. Therefore, 40% (74/186) of the non-general anesthesia cases required an airway intervention. CONCLUSIONS: These results suggest that a significant proportion of the authors' patients undergoing cardiac electrophysiology laboratory procedures required deep sedation if not general anesthesia, although a non-general anesthetic was planned. The issue of depth of sedation has implications for patient safety, privileging, and regulatory compliance. Based on the present results, the authors believe sedation for these procedures is best given by anesthesia providers; furthermore, caregivers should be aware that these procedures are likely to require deep sedation if not general anesthesia.

Vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections.

OBJECTIVE: To document the per patient rate of vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections. BACKGROUND: Anecdotal observations at our institution suggested that vasovagal reactions are much more common during cervical epidural steroid injections than lumbar injections, and more frequent than previously reported. METHODS: Records of 249 patients undergoing their first cervical epidural steroid injection were reviewed for vasovagal reactions and other adverse events. For comparison, a first lumbar epidural steroid injection performed by the same staff physician was matched to each cervical procedure and reviewed for complications. RESULTS: The incidence of vasovagal reaction was 7 points more common (P < 0.001, 95% confidence interval 0.04-0.12) in the cervical group (8%) than in the lumbar group (1%). This correlates to an additional vasovagal reaction for every 14 patients who were treated with cervical injection in comparison with those treated with lumbar injection. DISCUSSION: The risk of vasovagal reaction is significantly higher for cervical translaminar epidural steroid injections than for lumbar injections. The risk of vasovagal reaction remained higher for cervical injection even when adjusting for differences between the two populations. The higher rate of cervical vasovagal reactions may result from a combination of anxiety, the prone position with neck flexed, head drapes, and stimulus from a neck procedure. CONCLUSION: Increased vigilance for patients undergoing translaminar cervical epidural steroid injections may be warranted. Clinicians may choose to consider these results when counseling patients regarding risk and the need for conscious sedation during the procedure.