Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

BACKGROUND: Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS: In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS: Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS: These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Lean methodology in quality improvement.

Measurement of quality and improvement in medicine has existed since Florence Nightingale's time. In modern times, medicine has sought to learn from other high-reliability industries such as aviation and nuclear power, where errors can result in catastrophic outcomes. Lean is a unique quality improvement strategy that seeks to improve both quality and safety by driving out waste and, where possible, standardizing work practices. It is a visual system with work aids and signals built into the workspace. An important tenet is that ideas come from the workers and that there is an iterative improvement. The improvement efforts are always viewed from the perspective of the customer, our patients, families, and coworkers. This paper describes the evolution of Lean in healthcare and highlights core principles of Lean. Examples are used to describe how various Lean tools can be applied by pediatric anesthesiologists to solve clinical problems.

Perioperative acute kidney injury: impact and recent update.

PURPOSE OF REVIEW: Acute kidney injury (AKI) is common in hospitalized patients and is a major risk factor for increased length of stay, morbidity, and mortality in postoperative patients. There are multiple barriers to reducing perioperative AKI - the etiology is multi-factorial and the diagnosis is fraught with issues. We review the recent literature on perioperative AKI and some considerations for anesthesiologists that examine the far-reaching effects of AKI on multiple organ systems. RECENT FINDINGS: This review will discuss recent literature that addresses the epidemiology, use of novel biomarkers in risk stratification, and therapeutic modalities for AKI in burn, pediatrics, sepsis, trauma, cardiac, and liver disease, contrast-induced AKI, as well as the evidence assessing goal-directed fluid therapy. SUMMARY: Recent studies address the use of risk stratification models and biomarkers, more sensitive than creatinine, in the preoperative identification of patients at risk for AKI. Although exciting, these scores and models need validation. There is a need for research assessing whether early AKI detection improves outcomes. Enhanced recovery after surgery utilizing goal-directed fluid therapy has not been shown to make an appreciable difference in the incidence of AKI. Reducing perioperative AKI requires a multi-pronged and possibly disease-specific approach.

A Comparison of the Minimal-Touch Technique and the Eversion Technique for Microvascular Anastomosis in a Rat Model.

Background During microvascular anastomosis, needle placement is facilitated by inserting the tips of the forceps into the lumen of the vessel, rather than grasping and everting the luminal wall, to minimize trauma to the vessel. This study examines whether the vessel wall can be grasped and everted during microvascular anastomosis without compromising surgical outcomes. Methods A total of 20 Sprague-Dawley rats weighing between 252 and 483 g were used. Bilateral anastomoses of the animals' femoral arteries (mean size: 0.90 mm) were performed using two different techniques: the classic minimal-touch approach and the eversion technique. The first 10 animals were survived for 48 hours and the second 10 animals were survived for 2 weeks. Patency was assessed immediately after surgery and just before sacrifice. Hematoxylin and eosin stains were performed and each anastomosis scored according to a grading rubric assessing endothelial cell loss, neointimal proliferation, medial necrosis, adventitial inflammation, and inflammation thickness. Results The patency rates of both techniques were identical (100%). There was no difference in the patency rates of anastomoses evaluated 48 hours after surgery (100%) and 2 weeks after surgery (100%). Histological outcomes between the minimal-touch technique and the eversion method were similar. The thickness of adventitial inflammation at 2 weeks was the only outcome found to be statistically different (p = 0.046) between the two treatments and this difference favored the eversion technique (i.e., less inflammation thickness). Conclusion The eversion method of performing microvascular anastomosis provides comparable results to the classic minimal-touch approach in rat femoral artery anastomoses.

Effect of white adipose tissue flap and insulin-like growth factor-1 on nerve regeneration in rats.

Adipose tissue-derived stem cells and insulin-like growth factor-1 (IGF-1) have shown potential to enhance peripheral nerve regeneration. The purpose of this study was to investigate the effect of an in vivo biologic scaffold, consisting of white adipose tissue flap (WATF) and/or IGF-1 on nerve regeneration in a crush injury model. Forty rats all underwent a sciatic nerve crush injury and then received: a pedicled WATF, a controlled local release of IGF-1, both treatments, or no treatment at the injury site. Outcomes were the normalized maximum isometric tetanic force (ITF) of the tibialis anterior muscle and histomorphometric measurements. At 4 weeks, groups with WATF had a statistically significant improvement in maximum ITF recovery, as compared to those without (P < 0.05), and there was an increase in myelin thickness and total axon count in the WATF-only group versus control (P < 0.01). Functional and histomorphometric data suggest that IGF-1 suppressed the effect of the WATF. Use of a pedicled WATF improved the functional and histomorphometrical results after axonotmesis in a rat model. IGF-1 does not appear to enhance nerve regeneration in this model. Utilizing the WATF may have a beneficial therapeutic role in peripheral nerve injuries.

Palliative surgery for head and neck cancer with extensive skin involvement.

OBJECTIVES/HYPOTHESIS: To evaluate the role of regional and free tissue transfer for the palliative management of head and neck cancer with extensive skin involvement. STUDY DESIGN: Case Series. METHODS: A retrospective review was performed of patients treated for head and neck cancer with involvement of the skin at the Mount Sinai Medical Center over a 5-year period (2006-2010). Only patients with extensive skin involvement and unresectable tumors who underwent palliative resection and reconstruction were included in the review. Subjects were analyzed for age, gender, performance status, primary site, tumor histology, extent of invasion, type of reconstruction, hospital course, wound complications, adjuvant therapy, survival, and cause of death. RESULTS: Twenty-five patients met the inclusion criteria for the review. Fourteen patients (56%) underwent regional flap reconstruction, and 11 patients (44%) underwent free flap reconstruction. The average length of stay was 7 days. Twenty-four patients (96%) had a medically uncomplicated postoperative hospital course. Nineteen patients (76%) were treated with adjuvant palliative radiotherapy and/or chemotherapy. Long-term follow-up was achieved for 19 patients. The median follow up in this group was 9.5 months. Eleven of the 21 patients (52%) developed wound complications postoperatively. Eight of these were minor wound dehiscences, while three developed major wound complications. Four patients (16%) had distant metastasis at the time of surgery, and the median time to develop distant metastases after surgery was 6 months. Median survival time was 9.5 months. Twenty-two patients (88%) were discharged in the care of their families with appropriate pain management and without the need for extensive wound care. CONCLUSIONS: For unresectable tumors with extensive skin involvement, palliative resection and reconstruction is a reasonable treatment option. Although survival may not be affected, addressing the odor, bleeding, pain, and infection associated with skin involvement has the potential to improve a patient's quality of life. LEVEL OF EVIDENCE: 4.

Incentive spirometry for the tracheostomy patient.

OBJECTIVE: To determine the feasibility of developing and using a customized incentive spirometer device for patients who have undergone a tracheostomy procedure. STUDY DESIGN: The authors performed a prospective case series approved by the institutional review board. SETTING: Academic medical center. SUBJECTS AND METHODS: Patients were eligible for participation if they were older than 18 years and had a new tracheostomy. Spirometry exercises were performed using a protocol adapted from the American Academy of Respiratory Care guidelines. Patient data were recorded, including age, sex, tobacco use, surgical procedure, time under general anesthesia, length of hospital stay, and time until ambulation. The details of the spirometry exercises were also recorded along with any complications that occurred. RESULTS: An incentive spirometer was adapted for use with tracheostomy patients and received an investigational device exemption from the Food and Drug Administration. A total of 10 patients were enrolled (mean age 60 years). Sixty percent were current or former tobacco users, the mean anesthesia time was 9 hours, and 70% underwent a microvascular free flap reconstruction. Patients used the incentive spirometer for a mean of 1.6 days during the postoperative period, averaging 3.3 sessions per day and 6.8 breaths per session. The device was well tolerated by patients, and there were no complications associated with its use. CONCLUSION: This study supports the feasibility of using a customized incentive spirometer for tracheostomy patients and establishes a safety profile for the device to be used in future studies.

A systematic review of head and neck cancer quality of life assessment instruments.

Although quality of life (QOL) is an important treatment outcome in head and neck cancer (HNC), cross-study comparisons have been hampered by the heterogeneity of measures used and the fact that reviews of HNC QOL instruments have not been comprehensive to date. We performed a systematic review of the published literature on HNC QOL instruments from 1990 to 2010, categorized, and reviewed the properties of the instruments using international guidelines as reference. Of the 2766 articles retrieved, 710 met the inclusion criteria and used 57 different head and neck-specific instruments to assess QOL. A review of the properties of these utilized measures and identification of areas in need of further research is presented. Given the volume and heterogeneity of QOL measures, there is no gold standard questionnaire. Therefore, when selecting instruments, researchers should consider not only psychometric properties but also research objectives, study design, and the pitfalls and benefits of combining different measures. Although great strides have been made in the assessment of QOL in HNC and researchers now have a plethora of quality instruments to choose from, more work is needed to improve the clinical utility of these measures in order to link QOL research to clinical practice. This review provides a platform for head and neck-specific instrument comparisons, with suggestions of important factors to consider in the systematic selection of QOL instruments, and is a first step towards translation of QOL assessment into the clinical scene.