Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study.

BACKGROUND: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization. METHODS: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported. RESULTS: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used. CONCLUSIONS: While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

Do Hospitals Performing Frequent Neuraxial Anesthesia for Hip and Knee Replacements Have Better Outcomes?

BACKGROUND: Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes. METHODS: National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported. RESULTS: Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively. CONCLUSIONS: Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality.

Intravenous Acetaminophen Does Not Reduce Inpatient Opioid Prescription or Opioid-Related Adverse Events Among Patients Undergoing Spine Surgery.

BACKGROUND: Having entered the US market relatively recently, the perioperative role of intravenous acetaminophen (ivAPAP) remains to be established for several surgeries. Using national data, we therefore assessed current utilization and whether it reduces inpatient opioid prescription and opioid-related side effects in a procedure with relatively high opioid utilization. METHODS: Patients undergoing a lumbar/lumbosacral spinal fusion (n = 117,269; 2011-2014) were retrospectively identified in a nationwide database and categorized by the amount and timing of ivAPAP administration (1 or >1 dose on postoperative day [POD] 0, 1, or 1+). Multivariable models measured associations between ivAPAP utilization categories and opioid prescription and perioperative complications; odds ratios (or % change) and 95% confidence intervals are reported. RESULTS: Overall, ivAPAP was used in 18.9% (n = 22,208) of cases of which 1 dose on POD 0 was the most common (73.6%; n = 16,335). After covariate adjustment, use of ivAPAP on POD 0 and 1 was associated with minimal changes in opioid prescription, length and cost of hospitalization particularly favoring >1 ivAPAP dose with a modestly (-5.2%, confidence interval, -7.2% to -3.1%; P < .0001) decreased length of stay. Use of ivAPAP did not coincide with a consistent pattern of significantly reduced odds for complications. In comparison, the most commonly used nonopioid analgesic, pregabalin/gabapentin, did demonstrate reduced opioid prescription combined with lower complication risk. CONCLUSIONS: We could not show that perioperative ivAPAP reduces inpatient opioid prescription with subsequent reduced odds for adverse outcomes. It remains to be determined if and under what circumstances ivAPAP has a meaningful clinical role in everyday practice.

Association of opioid prescription and perioperative complications in obstructive sleep apnea patients undergoing total joint arthroplasties.

PURPOSE: Obstructive sleep apnea (OSA) has been linked to higher rates of perioperative complications. Practice guidelines recommend minimizing opioids in this cohort to reduce complications. However, a paucity of evidence exists relating different levels of opioid prescription to perioperative complications. Our aim was to investigate if different levels of opioid prescription are related to perioperative complication risk in patients with OSA. METHODS: A total of 107,610 OSA patients undergoing total knee or hip arthroplasty between 2006 and 2013 were identified in a nationwide database and divided into subgroups according to the amount of opioids prescribed. We then compared those subgroups for odds of perioperative complications using multilevel multivariable logistic regression models. RESULTS: OSA patients with higher levels of opioid prescription had increased odds for gastrointestinal complications (OR 1.90, 95% CI 1.47-2.46), prolonged length of stay (OR 1.64, 95% CI 1.57-1.72), and increased cost of care (OR 1.48, 95% CI 1.40-1.57). However, we found lower odds for pulmonary complications (OR 0.85, 95% CI 0.74-0.96) for the high-prescription group. CONCLUSIONS: Higher levels of opioid prescription were associated with higher odds for gastrointestinal complications and adverse effects on cost and length of stay but lower odds for pulmonary complications in OSA patients undergoing joint arthroplasties. The latter finding is unlikely causal but may represent more preventive measures and early interventions among those patients. Attempts to reduce opioid prescription should be undertaken to improve quality and safety of care in this challenging cohort in the perioperative setting.

Patient preference survey: are patients willing to delay surgery if obstructive sleep apnea is suspected?

BACKGROUND: Screening and optimizing patients for OSA in the perioperative period may reduce postoperative complications. However, sleep studies can be difficult to obtain before surgery. Previous surveys reported that the majority of sleep physicians would delay surgery to diagnose and manage OSA, but most anesthesiologists would not. While disagreements exist, the importance of shared decision making and patient preferences have never been studied on this topic. It is unknown whether patients with suspected OSA, when given information about OSA, would be willing to delay surgery to diagnose and manage their condition preoperatively. METHODS: This study consisted of a self-administered questionnaire that surveyed patients, patient relatives, or any accompanying members. The survey was conducted in the preoperative clinic or in the perioperative patient and family waiting area at two hospitals in Canada and in the United States. A hypothetical scenario was used: participants were given information about OSA, and asked about their preferences regarding preoperative management should they be at risk for OSA in the setting of pending elective surgery. The objective of this study was to determine whether respondents preferred to 1) proceed with surgery as planned, 2) delay surgery to ensure the medical condition of OSA is diagnosed and optimized, or 3) let his/her physician decide. RESULTS: The final survey contained 19 questions and the survey was conducted from June 2016 to September 2016. Four hundred and seventy-three surveys were collected. Forty-four percent of respondents, when given information about OSA, preferred to delay surgery pending a sleep study and treatment. Forty percent of respondents who preferred to delay surgery would tolerate delaying up to two months. CONCLUSION: Increasing emphasis and significant value has been placed on shared-decision making between patients and physicians. Educating patients about the risks of OSA and incorporating patient preferences into the perioperative management of OSA may be warranted.

Changes in the augmentation index and postoperative orthostatic intolerance in orthopedic surgery: a prospective cohort study.

BACKGROUND: Postoperative orthostatic intolerance (OI) can be a major obstacle to early ambulation and its determinants are poorly understood. We aimed to study postoperative changes in vascular tone and their potential association with OI in various orthopedic surgical settings. METHODS: In this prospective cohort study, 350 patients undergoing total joint arthroplasty under neuraxial anesthesia or spine surgery under general anesthesia were enrolled. We determined the augmentation index (AI) as a measure of vascular tone and studied symptoms of OI using a validated questionnaire at various postoperative time points. RESULTS: The AI was significantly reduced postoperatively (at spinal resolution in patients with neuraxial anesthesia or two hours postoperatively in general anesthesia) compared with baseline values in all procedures and did not subsequently return to baseline throughout the postoperative period in the majority of patients [252/335 (75.2%); P < 0.001]. The majority [260/342 (76.0%); P < 0.001] of patients had postoperative symptoms of OI. Nevertheless, no association was found between postoperative change in AI from baseline and postoperative symptoms of OI. CONCLUSIONS: A significantly prolonged decrease in AI and symptoms of OI are common after orthopedic surgery. Nevertheless, an association between the two measures was not observed. While compensatory mechanisms may limit the influence of an AI decrease on symptoms of OI, more research is needed to understand the contributing factors and aid in the identification of patients at risk of OI.

Trends in Perioperative Practice and Resource Utilization in Patients With Obstructive Sleep Apnea Undergoing Joint Arthroplasty.

BACKGROUND: Emerging evidence associating obstructive sleep apnea (OSA) with adverse perioperative outcomes has recently heightened the level of awareness among perioperative physicians. In particular, estimates projecting the high prevalence of this condition in the surgical population highlight the necessity of the development and adherence to "best clinical practices." In this context, a number of expert panels have generated recommendations in an effort to provide guidance for perioperative decision-making. However, given the paucity of insights into the status of the implementation of recommended practices on a national level, we sought to investigate current utilization, trends, and the penetration of OSA care-related interventions in the perioperative management of patients undergoing lower joint arthroplasties. METHODS: In this population-based analysis, we identified 1,107,438 (Premier Perspective database; 2006-2013) cases of total hip and knee arthroplasties and investigated utilization and temporal trends in the perioperative use of regional anesthetic techniques, blood oxygen saturation monitoring (oximetry), supplemental oxygen administration, positive airway pressure therapy, advanced monitoring environments, and opioid prescription among patients with and without OSA. RESULTS: The utilization of regional anesthetic techniques did not differ by OSA status and overall <25% and 15% received neuraxial anesthesia and peripheral nerve blocks, respectively. Trend analysis showed a significant increase in peripheral nerve block use by >50% and a concurrent decrease in opioid prescription. Interestingly, while the absolute number of patients with OSA receiving perioperative oximetry, supplemental oxygen, and positive airway pressure therapy significantly increased over time, the proportional use significantly decreased by approximately 28%, 36%, and 14%, respectively. A shift from utilization of intensive care to telemetry and stepdown units was seen. CONCLUSIONS: On a population-based level, the implementation of OSA-targeted interventions seems to be limited with some of the current trends virtually in contrast to practice guidelines. Reasons for these findings need to be further elucidated, but observations of a dramatic increase in absolute utilization with a proportional decrease may suggest possible resource constraints as a contributor.

Impact of obstructive sleep apnea on perioperative complications among patients undergoing hysterectomy: a population-based analysis.

INTRODUCTION: Although obstructive sleep apnea (OSA) is a known risk factor for perioperative complications in various patient cohorts data is lacking for patients undergoing hysterectomies, one of the most frequently performed surgeries among women. Using national data we therefore aimed to assess the risk in this patient group. MATERIALS AND METHODS: We extracted data on patients who underwent a hysterectomy between 2006 and 2014 from a large nationwide database (n = 459,508). OSA patients (identified by ICD-9 CM codes) were compared to non-OSA patients regarding perioperative outcomes: cardiac, central-nervous, gastrointestinal, genitourinary, renal, respiratory, and thromboembolic complications; as well as opioid prescription, need for blood transfusion, cost of hospitalization, length of stay and ICU admission. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Overall, 2.67% (n = 11,936) of patients were identified as having OSA. Compared to non-OSA patients, OSA was particularly associated with higher odds for renal (OR 1.98; 95% CI 1.70-2.32) and respiratory complications (OR 3.25; 95% CI 2.97-3.56), and ICU admission (OR 2.28; 95% CI 1.77-2.94). Further, while significant, OSA was associated with modestly increased cost of hospitalization (+6.24%; P < 0.0001) and length of stay (+2.58%; P < 0.0001). CONCLUSIONS: In patients undergoing hysterectomies, OSA was associated with substantially increased risk of complications and modestly increased resource utilization. Further research is needed to assess currently used perioperative care strategies for OSA patients undergoing hysterectomies, with the goal to improve outcomes.

The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017.

The American Society of Regional Anesthesia and Pain Medicine's Third Practice Advisory on local anesthetic systemic toxicity is an interim update from its 2010 advisory. The advisory focuses on new information regarding the mechanisms of lipid resuscitation, updated frequency estimates, the preventative role of ultrasound guidance, changes to case presentation patterns, and limited information related to local infiltration anesthesia and liposomal bupivacaine. In addition to emerging information, the advisory updates recommendations pertaining to prevention, recognition, and treatment of local anesthetic systemic toxicity. WHAT'S NEW IN THIS UPDATE?: This interim update summarizes recent scientific findings that have enhanced our understanding of the mechanisms that lead to lipid emulsion reversal of LAST, including rapid partitioning, direct inotropy, and post-conditioning. Since the previous practice advisory, epidemiological data have emerged that suggest a lower frequency of LAST as reported by single institutions and some registries, nevertheless a considerable number of events still occur within the general community. Contemporary case reports suggest a trend toward delayed presentation, which may mirror the increased use of ultrasound guidance (fewer intravascular injections), local infiltration techniques (slower systemic uptake), and continuous local anesthetic infusions. Small patient size and sarcopenia are additional factors that increase potential risk for LAST. An increasing number of reported events occur outside of the traditional hospital setting and involve non-anesthesiologists.

Incidence of Local Anesthetic Systemic Toxicity in Orthopedic Patients Receiving Peripheral Nerve Blocks.

BACKGROUND AND OBJECTIVES: Peripheral nerve blocks are increasingly used. However, despite low complication rates, concerns regarding local anesthetic systemic toxicity remain. Although recent studies suggest that this severe complication has decreased considerably, there is a paucity of data about it on a national level. We sought to elucidate the incidence of local anesthetic systemic toxicity on a national level and therefore provide guidance toward the need for preparedness in daily anesthetic practice. METHODS: We searched a large administrative database for patients who received peripheral nerve blocks for total joint arthroplasties from 2006 to 2014. Their discharge and billing data were analyzed for International Classification of Diseases, Ninth Revision, Clinical Modification codes coding for local anesthetic systemic toxicity or surrogate outcomes including cardiac arrest, seizures, and use of lipid emulsion on the day of surgery. Rates for these outcomes were determined cumulatively and over time. RESULTS: We identified 238,473 patients who received a peripheral nerve block within the study period. The cumulative rate of outcomes among these patients in the study period was 0.18%. There was a significant decrease of overall outcome rates between 2006 and 2014. Use of lipid emulsion on the day of surgery increased significantly in total knee replacement from 0.02% 2006 to 0.26% in 2014. CONCLUSIONS: The incidence of local anesthetic systemic toxicity is low but should be considered clinically significant. Since it may cause substantial harm to the patient, appropriate resources and awareness to identify and treat local anesthetic systemic toxicity should be available wherever regional anesthesia is performed.

Opioid prescription levels and postoperative outcomes in orthopedic surgery.

Given the basic need for opioids in the perioperative setting, we investigated associations between opioid prescription levels and postoperative outcomes using population-based data of orthopedic surgery patients. We hypothesized that increased opioid amounts would be associated with higher risk for postoperative complications. Data were extracted from the national Premier Perspective database (2006-2013); N = 1,035,578 lower joint arthroplasties and N = 220,953 spine fusions. Multilevel multivariable logistic regression models measured associations between opioid dose prescription and postoperative outcomes, studied by quartile of dispensed opioid dose. Compared to the lowest quartile of opioid dosing, high opioid prescription was associated with significantly increased odds for deep venous thrombosis and postoperative infections by approx. 50%, while odds were increased by 23% for urinary and more than 15% for gastrointestinal and respiratory complications (P < 0.001 respectively). Furthermore, higher opioid prescription was associated with a significant increase in length of stay (LOS) and cost by 12% and 6%, P < 0.001 respectively. Cerebrovascular complications risk was decreased by 25% with higher opioid dose (P = 0.004), while odds for myocardial infarction remained unaltered. In spine cases, opioid prescription was generally higher, with stronger effects observed for increase in LOS and cost as well as gastrointestinal and urinary complications. Other outcomes were less pronounced, possibly because of smaller sample size. Overall, higher opioid prescription was associated with an increase in most postoperative complications with the strongest effect observed in thromboembolic, infectious and gastrointestinal complications, cost, and LOS. Increase in complication risk occurred stepwise, suggesting a dose-response gradient.