My anesthesia Choice-HF: development and preliminary testing of a tool to facilitate conversations about anesthesia for hip fracture surgery.

BACKGROUND: Patients often desire involvement in anesthesia decisions, yet clinicians rarely explain anesthesia options or elicit preferences. We developed My Anesthesia Choice-Hip Fracture, a conversation aid about anesthesia options for hip fracture surgery and tested its preliminary efficacy and acceptability. METHODS: We developed a 1-page, tabular format, plain-language conversation aid with feedback from anesthesiologists, decision scientists, and community advisors. We conducted an online survey of English-speaking adults aged 50 and older. Participants imagined choosing between spinal and general anesthesia for hip fracture surgery. Before and after viewing the aid, participants answered a series of questions regarding key outcomes, including decisional conflict, knowledge about anesthesia options, and acceptability of the aid. RESULTS: Of 364/409 valid respondents, mean age was 64 (SD 8.9) and 59% were female. The proportion indicating decisional conflict decreased after reviewing the aid (63-34%, P < 0.001). Median knowledge scores increased from 50% correct to 67% correct (P < 0.001). 83% agreed that the aid would help them discuss options and preferences. 76.4% would approve of doctors using it. CONCLUSION: My Anesthesia Choice-Hip Fracture decreased decisional conflict and increased knowledge about anesthesia choices for hip fracture surgery. Respondents assessed it as acceptable for use in clinical settings. PRACTICE IMPLICATIONS: Use of clinical decision aids may increase shared decision-making; further testing is warranted.

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty.

BACKGROUND: Calls to better involve patients in decisions about anesthesia-e.g., through shared decision-making-are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia. METHODS: This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia. RESULTS: The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences. CONCLUSIONS: Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists' attention away from important humanistic aspects of communication such as decreasing patients' anxiety.

An Investigation of Patient Preferences for Music Played Before Electroconvulsive Therapy.

OBJECTIVE: Patients often feel anxious before electroconvulsive therapy (ECT), which can lead to avoidance of treatments. Music is a noninvasive safe option to reduce anxiety in the preoperative setting. Therefore, we examined patients' preferences of listening to music while receiving ECT by providing music-by way of headphones or speakers-to participants before treatment. METHODS: Patients receiving ECT were recruited for this study. Patients served as their own controls in 3 separate music intervention sessions: 1) randomization to music via headphones or speakers, 2) no music, 3) the remaining music intervention. Patients completed a questionnaire related to satisfaction and preferences of music being played before ECT. Patients received a final questionnaire at the end of the study asking which intervention they preferred. RESULTS: Thirty patients completed the study. Ninety percent enjoyed listening to music through speakers. Eighty percent liked listening to music through headphones. Seventeen percent preferred not having any music. The difference in preference between speakers and headphones was not significant (P = 0.563; McNemar-Bowker test). There was no association between preference at the end of the study and the initial assignment of speakers or headphones (P = 0.542 and P = 0.752, respectively; Pearson χ tests). No adverse events were reported. CONCLUSIONS: Music is a low-cost intervention with virtually no side effects that could be offered as an adjunctive therapy for patients receiving ECT. A significant proportion of patients liked hearing music before treatment.

Cost of sterility: probe covers should not be mandated for single-shot peripheral nerve blocks.

Ultrasound guidance has become ubiquitous with regional anesthesia, but little consistency exists on necessary ultrasound probe hygiene and sterility barriers. Fear of possible infection has led to calls for universal use of sterile ultrasound probe covers. Available data seems to suggest that single-shot peripheral nerve blocks have a low infectious risk. The widespread use of single-use disposable probe covers would carry an associated cost, increased environmental impact, and little evidence to suggest that they are effective at preventing infection if proper technique is used. While various parties have labeled single-shot nerve blocks as a sterile procedure, in practice, it is a clean technique. In this article, we argue that mandating the use of probe covers is unnecessary and that it should be left to the anesthesiologist to determine what type of anti-infection equipment is necessary for single-shot nerve blocks based on their practice situation and expertize.

Analgesic efficacy of adding the IPACK block to a multimodal analgesia protocol for primary total knee arthroplasty.

BACKGROUND AND OBJECTIVES: Peripheral nerve blocks have been integrated into most multimodal analgesia protocols for total knee arthroplasty (TKA). The adductor canal block (ACB) has gained popularity because of its quadriceps muscle sparing. Similarly, local anesthetic injection between the popliteal artery and the posterior capsule of the knee, IPACK block, has been described to provide analgesia to the posterior capsule of the knee with motor-sparing qualities. This prospective randomized controlled trial aimed to assess the analgesic efficacy of adding the IPACK block to our current multimodal analgesic regimen, including the ACB, in patients undergoing primary TKA. METHODS: 119 patients were randomized to receive either an IPACK or a sham block in addition to multimodal analgesia and an ACB. We were set to assess pain in the back of the knee 6 hours after surgery. Other end points included quality of recovery after surgery, pain scores, opioid requirements, and functional measures. RESULTS: Patients who received the IPACK block had less pain in the back of the knee 6 hours after surgery when compared with the sham block: 21.7% vs 45.8%, p<0.01. There was marginal improvement in other pain measures in the first 24 hours after surgery. However, opioid requirements, quality of recovery and functional measures were similar between the two groups. CONCLUSION: The IPACK block reduced the incidence of posterior knee pain 6 hours postoperatively.

Music versus midazolam during preoperative nerve block placements: a prospective randomized controlled study.

BACKGROUND AND OBJECTIVES: Music medicine is a non-pharmacologic intervention that is virtually harm-free, relatively inexpensive and has been shown to significantly decrease preoperative anxiety. In this study we aim to compare the use of music to midazolam as a preoperative anxiolytic prior to the administration of an ultrasound-guided single-injection peripheral nerve block. METHODS: In this randomized controlled study we compared the anxiolytic effects of intravenous midazolam (1-2 mg) with noise-canceling headphone-delivered music medicine. All patients received a preoperative ultrasound-guided single-injection peripheral nerve block indicated for a primary regional anesthetic or postoperative analgesia. RESULTS: The change in the State Trait Anxiety Inventory-6 (STAI-6) anxiety scores from after to before the procedure were similar in both groups (music group -1.6 (SD 10.7); midazolam group -4.2 (SD 11); p=0.14; mean difference between groups -2.5 (95% CI -5.9 to 0.9), p=0.1). Patient satisfaction scores with their procedure experience were higher in the midazolam group (p=0.01); however, there were no differences in physician satisfaction scores of their procedure experience between groups (p=0.07). Both patient and physician perceptions on difficulties in communication were higher in the music group than in the midazolam group (p=0.005 and p=0.0007, respectively). CONCLUSIONS: Music medicine may be offered as an alternative to midazolam administration prior to peripheral regional anesthesia. However, further studies are warranted to evaluate whether or not the type of music, as well as how it is delivered, offers advantages over midazolam that outweigh the increase in communication barriers. CLINICAL TRIAL REGISTRY: Clinicaltrials.gov #NCT03069677.