Opioid- and Motor-sparing with Proximal, Mid-, and Distal Locations for Adductor Canal Block in Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial.

BACKGROUND: The ideal location for single-injection adductor canal block that maximizes analgesia while minimizing quadriceps weakness after painful knee surgery is unclear. This triple-blind trial compares ultrasound-guided adductor canal block injection locations with the femoral artery positioned medial (proximal adductor canal), inferior (mid-adductor canal), and lateral (distal adductor canal) to the sartorius muscle to determine the location that optimizes postoperative analgesia and motor function. The hypothesis was that distal adductor block has (1) a superior opioid-sparing effect and (2) preserved quadriceps strength, compared with proximal and mid-locations for anterior cruciate ligament reconstruction. METHODS: For the study, 108 patients were randomized to proximal, mid-, or distal adductor canal injection locations for adductor canal block. Cumulative 24-h oral morphine equivalent consumption and percentage quadriceps strength decrease (maximum voluntary isometric contraction) at 30 min postinjection were coprimary outcomes. The time to first analgesic request, pain scores, postoperative nausea/vomiting at least once within the first 24 h, and block-related complications at 2 weeks were also evaluated. RESULTS: All patients completed the study. Contrary to the hypothesis, proximal adductor canal block decreased 24-h morphine consumption to a mean ± SD of 34.3 ± 19.1 mg, (P < 0.0001) compared to 64.0 ± 33.6 and 65.7 ± 22.9 mg for the mid- and distal locations, respectively, with differences [95% CI] of 29.7 mg [17.2, 42.2] and 31.4 mg [21.5, 41.3], respectively, mostly in the postanesthesia care unit. Quadriceps strength was similar, with 16.7%:13.4%:15.3% decreases for proximal:mid:distal adductor canal blocks. The nausea/vomiting risk was also lower with proximal adductor canal block (10 of 34, 29.4%) compared to distal location (23 of 36, 63.9%; P = 0.005). The time to first analgesic request was longer, and postoperative pain was improved up to 6 h for proximal adductor canal block, compared to mid- and distal locations. CONCLUSIONS: A proximal adductor canal injection location decreases opioid consumption and opioid-related side effects without compromising quadriceps strength compared to mid- and distal locations for adductor canal block in patients undergoing anterior cruciate ligament reconstruction.

Patient function and caregiver burden after ambulatory surgery: a cohort study of patients older than 65.

PURPOSE: The primary objective of this prospective cohort study was to assess the impact of ambulatory surgery on patient function one week and one month following surgery among surgical patients ≥ 65 yr of age. Secondary objectives were to determine whether changes in patient function were correlated with increased burden of care in the patient's primary caregiver and with patient assessments of postoperative pain and quality of life. METHODS: Following Research Ethics Board approval, patients aged ≥ 65 yr undergoing elective ambulatory surgery and their caregivers were recruited. Patients completed the système de mesure de l'autonomie fonctionnelle (SMAF) and the Brief Pain Inventory. Primary caregivers completed the Zarit Burden Interview (ZBI). All measurements were obtained preoperatively and on postoperative days (POD) 7 and 30. RESULTS: Patient function decreased on POD 7 and had not returned to baseline on POD 30 (mean change in SMAF 6.9; 95% confidence interval (CI) 5.3 to 8.4 on POD 7 and mean change in SMAF 2.6; 95% CI 1.3 to 4.0 on POD 30). Interval changes in caregiver burden were not significant (mean change in ZBI -0.4; 95% CI -1.8 to 0.96 on POD 7 and mean change in ZBI -0.6; 95% CI -2.1 to 0.8 on POD 30). Decreased patient function was associated with increased caregiver burden at all time points (P < 0.001). Decreased caregiver function at baseline was also associated with higher ZBI (linear association 0.71; P = 0.02). CONCLUSIONS: Patients exhibited reduced function seven days following ambulatory surgery. Patient function largely recovered by POD 30. Caregiver burden was variable and influenced by both patient and caregiver function. This trial was registered with Clinical Trials.gov (NCT01382251).

Perioperative Considerations in a Patient with Kleine-Levin Syndrome Undergoing a Neurosurgical Procedure under General Anesthesia.

Kleine-Levin syndrome (KLS) is a rare central disorder of daytime hypersomnolence and is often characterized by a relapsing and remitting course, recurrent episodes of excessive sleep lasting from 12 to 20 hours a day, and symptoms including hyperphagia, hallucinations, derealization, disorientation, and hypersexuality. There are numerous perioperative considerations in dealing with KLS that include challenges during induction of anesthesia, delayed emergence, postoperative sleep disorders, and delirium. However, due to its rare occurrence, the anesthetic considerations of KLS remain poorly described. This case report outlines the anesthetic considerations and management of a young female patient with KLS who underwent transnasal excision of a trigeminal schwannoma under general anesthesia.

Assessment of caregiver burden in patients undergoing in- and out-patient neurosurgery.

The objective of this study is to describe the caregiver burden, as well as the financial burden among caregivers after inpatient and outpatient neurosurgical patients. In this single center, observational study, adult patients undergoing elective inpatient or outpatient neurosurgery (supratentorial tumor resection or lumbar microdiscectomy) and his/her caregiver were recruited for the study. Bakas Caregiving Outcome Scale (BCOS) was used to assess caregiver burden and data was collected from preoperative period until post-operative day (POD) 30. Cost burden was assessed by a cost diary from day of surgery till POD 7. Forty-eight patient-caregiver pairs (21 inpatient craniotomies, 7 outpatient craniotomies, and 20 outpatient microdiscectomies) completed the study. BCOS values were in the negative impact range (<60) on POD1 in craniotomy group and improved to positive impact range (>60) after POD3. Median BCOS score remained at 60 in outpatient microdiscectomy. 56% of caregiver had at least 1 day of loss of income and 20% lost income throughout first 8 days. Median Cost (in Canadian dollars) associated with caregiving ranged from C$57 to C$250 amongst different groups. We concluded that caring for patients after craniotomy is psychologically demanding which leads to an increase in caregiver burden. In addition, there is a cost burden for the care givers in the form of missed workdays and additional direct expenses. Further studies are needed to recognize this problem and address the burden among the caregivers in the neurosurgical population.

Failed videolaryngoscope intubation in a patient with diffuse idiopathic skeletal hyperostosis and spinal cord injury.

PURPOSE: A case of difficult intubation in a patient with cervical spinal cord injury with diffuse idiopathic skeletal hyperostosis (DISH) is described. The trachea could not be intubated with a videolaryngoscope, and successful intubation was achieved with a laryngeal mask airway device (LMAD) and a fibreoptic bronchoscope (FOB). CLINICAL FEATURES: A 65-yr-old male developed sudden tetraplegia after a fall. Initial attempts at securing his airway were unsuccessful with a videolaryngoscope, but success was achieved with a LMAD and a FOB. Diagnostic imaging revealed no cervical spine fracture but demonstrated severe airway distortion from DISH and a spinal cord contusion accounting for his tetraplegia. Subcutaneous neck emphysema likely secondary to difficult intubation was also identified, but it did not result in additional morbidity. CONCLUSIONS: Although often considered to be a benign entity, DISH can predispose patients to catastrophic cervical injury and difficult airway management. Careful review of plain radiographs in the spinal cord injury patient may assist with appropriate selection of airway interventions. The videolaryngoscope is useful for difficult airways, but its effectiveness may be compromised with an anteriorly displaced airway in combination with restricted cervical movement and limited oropharyngeal airspace.

Total Hip Replacement in a Patient With a Fontan Circulation: A Case Report.

Anesthetic management of the adult patient with a Fontan circulation is complex and requires understanding of the specific physiology of the individual patient. Long-term survival in this cohort has increased to the point where patients are presenting for noncardiac surgery related to degenerative diseases of aging. We describe the perioperative management of a patient with a Fontan circulation undergoing total hip arthroplasty using combined spinal-epidural anesthesia and discuss the issues requiring special consideration for this surgical procedure in this group of patients.

Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.

BACKGROUND: With increasing fiscal restraints on health care systems, procedural cost-effectiveness has become an important metric for evaluating surgical procedures. While outpatient craniotomy has been shown to be safe and effective, the economic implications of this procedure has yet to be examined. Here, we present the first cost analysis comparing inpatient versus outpatient awake craniotomy for tumor resection/biopsy. METHODS: We conducted a retrospective chart review on consecutive patients undergoing awake craniotomy for tumor resection/biopsy at a publicly funded tertiary care center from Sept 2014 to Aug 2015. Patient demographics, comorbidities and surgical factors were recorded. Direct and indirect costs for each patient visit were calculated based on institutional records. RESULTS: A total of 50 consecutive patients undergoing awake craniotomy for tumor resection were included in this study (29 outpatients, 21 inpatients). Rates of complications and 30-day readmission were similar between groups. The total costs associated with inpatient surgery were nearly double that of outpatient surgery ($10649 versus $5242, P < 0.001). In-patient surgery resulted in a nearly 6-fold increase in unit/bed costs compared to out-patient surgery ($4142 versus $758, P < 0.001). There were no differences in the costs incurred from the operating room, laboratory, or anesthesia departments. CONCLUSIONS: Costs associated with outpatient craniotomy are nearly half compared to inpatient craniotomy and this is largely driven by reductions in bed resource utilization and allied health services. Outpatient neurosurgery for tumor resection is therefore a safe and feasible option for appropriately selected patients and confers an overall cost reduction.

Airway adverse events following posterior occipito-cervical spinal fusion.

Management of the airway may be challenging in patients undergoing occipito-cervical spine fusions (OCF). Changes in the occipito-cervical angle (dOC2A) of fusion after surgery may result in acute airway obstruction, dyspnea and/or dysphagia. Objectives of the study were to review the airway management of patients during posterior OCF, determine the incidence, nature and risk factors for postoperative airway adverse events (AEs), and to determine the relationship between airway AEs and the change in dOC2A. In this retrospective cohort of 59 patients, following extubation in the operating room (OR), there were no complications in 43 (73%) patients (Group 1). Sixteen (27%) patients (Group 2) had airway complications; 4 requiring reintubation and 12 having delayed extubation. The number of vertebral levels fused (>6), presence of difficult intubation and duration of surgery (>5h) were significantly associated with AEs. There was no significant difference in the dOC2A between the groups (-1.070±5.527 versus -4.375±10.788, p=0.127). Airway management in patients undergoing OCF poses a challenge for the anesthesiology and surgical teams. The incidence of AEs was 27%. The decision to extubate immediately after surgery needs to be individualized. Factors such as difficult intubation, number of vertebral levels fused and duration of surgery have to be considered. A significant correlation between dOC2A and postoperative AEs could not be established. Risk factors for postoperative AEs are multifactorial and prospective evaluation of these factors is indicated.