Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial.

BACKGROUND: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING: 46 U.S. and Canadian hospitals. PARTICIPANTS: Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION: Spinal or general anesthesia. MEASUREMENTS: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION: Missing outcome data and multiple outcomes assessed. CONCLUSION: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Human Factors Applied to Perioperative Process Improvement.

This article discusses some of the major theories of the science of human factors/ergonomics (HF/E) in relation to perioperative medicine, with a focus on safety and errors within these systems. The discussion begins with human limitations based in cognition, decision making, stress, and fatigue. Given these limitations, the importance of measuring human performance is discussed. Finally, using the HF/E perspective on safety, high-level recommendations are provided for increasing safety within the perioperative environment.

Effect of preoperative intravenous methocarbamol and intravenous acetaminophen on opioid use after primary total hip and knee replacement.

Between 2010 and 2011, a perioperative pain protocol for primary total hip and knee replacement at one Florida medical center replaced preoperative oral analgesics with intravenous methocarbamol and intravenous acetaminophen. This is a retrospective cohort study of 300 patients, with 150 patients using the new pain protocol and 150 patients using a 2008 pain protocol that did not include these medications. The 2 cohorts were similar in patient gender, age, and body mass index. Opioid consumption was evaluated for a period of 48 hours after incision and was divided into 3 separate time intervals, as well as total 48-hour consumption. Mean opiate use decreased significantly from 2008 to 2011 in all time intervals and total consumption (7.5±3.4 mg to 6.1±3.0 mg; P<.01). Subgroup analysis suggested that changes to the hip protocol were responsible for decreased opioid use in the operating room and the postanesthesia care unit, and changes to the knee protocol were responsible for decreased opioid use on the hospital floor and total consumption. The difference between the 2 protocol groups was not due to differences in individual surgeon practice patterns. Physical therapy progress of knee flexion, average walking distance, and maximum walking distance were significantly improved. Hospital discharge was shorter in the 2011 group (4.0±1.1 days in 2008 group and 3.6±1.0 days in 2011 group). This study shows significant improvement in patient care from 2008 to 2011 that is at least partially due to the change to the use of preoperative intravenous methocarbamol and intravenous acetaminophen.

Effects of milrinone versus epinephrine on left ventricular relaxation after cardiopulmonary bypass following myocardial revascularization: assessment by color m-mode and tissue Doppler.

OBJECTIVE: The purpose of this study was to evaluate the left ventricular lusitropic effects of epinephrine versus milrinone after cardiopulmonary bypass. DESIGN: Prospective randomized study. SETTING: Single institution, university teaching hospital. PARTICIPANTS: Adult patients undergoing coronary artery bypass grafting under cardiopulmonary bypass. INTERVENTIONS: After separation from cardiopulmonary bypass, patients were randomized to receive intravenous epinephrine by continuous infusion (0.03 microg/kg/min) or milrinone (50 microg/kg followed by 0.5 microg/kg/min). Transesophageal echocardiographic evaluation of left ventricular diastolic function, with emphasis on relaxation, was performed before and after bypass and after the administration of either epinephrine or milrinone. MEASUREMENTS AND MAIN RESULTS: Measurements included pulse-wave Doppler analysis of mitral inflow and pulmonary vein and left ventricular outflow tract velocities. Left ventricular inflow velocity of propagation measured with color M-mode and tissue Doppler assessment of early mitral annulus velocity were used to evaluate left ventricular relaxation. Values of velocity of propagation and mitral annulus velocity improved significantly after bypass, suggesting improved relaxation. The administration of either epinephrine or milrinone did not result in further improvement in left ventricular relaxation. CONCLUSIONS: After cardiopulmonary bypass, left ventricular relaxation was significantly improved. Neither epinephrine nor milrinone exhibited favorable lusitropic effects after bypass.