Total Intravenous Anesthesia with Propofol Reduces Discharge Times Compared with Inhaled General Anesthesia in Shoulder Arthroscopy: A Randomized Controlled Trial.

BACKGROUND: Shoulder arthroscopy is commonly performed at ambulatory surgical centers (ASCs) with use of an interscalene block and inhaled general anesthesia (IGA). However, an alternative option known as total intravenous anesthesia with propofol (TIVA-P) has shown promising results in reducing recovery time for other surgeries. The objective of this study was to assess whether there is a clinically meaningful difference in post-anesthesia care unit phase-I (PACU-I) time following shoulder arthroscopy between patients receiving an interscalene block with IGA and those receiving an interscalene block with TIVA-P. METHODS: Patients who underwent shoulder arthroscopy performed by a single surgeon at the ASC of our institution between 2020 and 2023 were enrolled. Enrollment was conducted in blocks, with up to 3 planned interim analyses. After 2 blocks, enrollment was halted because the study arms demonstrated a significant difference in the primary outcome measure, PACU-I time. A total of 96 patients were randomized into the TIVA-P and IGA groups; after patient withdrawals, the groups comprised 42 and 40 patients, respectively. Patients underwent shoulder arthroscopy with use of the anesthesia method corresponding to their assigned group. Pain, satisfaction, antiemetic use, perioperative interventions, surgical time, PACU-II time, postoperative care time, and total time until discharge were recorded and were analyzed with use of chi-square and Mann-Whitney U tests with a significance cutoff of 0.0167 to account for the interim analyses. RESULTS: Across groups, 81.7% of patients were non-Hispanic White and 58.5% were male. Significant differences were observed between the TIVA-P and IGA groups with respect to median PACU-I time (0.0 minutes [interquartile range (IQR), 0.0 to 6.0 minutes] versus 25.5 minutes [IQR, 20.5 to 32.5 minutes]; p < 0.001) and median total time until discharge (135.5 minutes [IQR, 118.5 to 156.8 minutes] versus 148.5 minutes [IQR, 133.8 to 168.8 minutes]; p = 0.0104). The TIVA-P group had a 9.1% quicker discharge time, primarily as a result of bypassing PACU-I (66.7% of patients) and spending 25.5 fewer minutes there overall. The TIVA-P group also had a lower rate of antiemetic use than the IGA group (59.5% versus 92.5% of patients; p = 0.0013). No significant differences were detected between the TIVA-P and IGA groups in terms of median pain improvement (1.0 [IQR, 0.0 to 2.0] versus 1.0 [IQR, 0.0 to 2.0]; p = 0.6734), perioperative interventions (78.6% versus 77.5% of patients, p = 1.0000), or median patient satisfaction (4.0 [IQR, 4.0 to 4.0] versus 4.0 [IQR, 3.8 to 4.0]; p = 0.4148). CONCLUSIONS: TIVA-P showed potential to improve both PACU-I time and the total time until discharge while reducing antiemetic use without impacting pain or satisfaction. TIVA-P thus warrants consideration by orthopaedic surgeons for use in shoulder arthroscopy performed at ASCs. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Enhancement of anesthesiology in-training exam performance with institution of an academic improvement policy.

BACKGROUND: Anesthesiology resident physicians across the United States complete an annual in-training examination (ITE). The ITE evaluates resident knowledge and provides personalized feedback to guide future study in low scoring sections(1). Performance on the ITE correlates with outcomes on the American Board of Anesthesiology (ABA) written board examination(2). Over the last several years, declining ITE scores were observed at the University of North Carolina (UNC). In response to this decline, our department reprioritized the ITE by instituting an academic improvement policy (AIP). The AIP employed both reward for satisfactory achievement and consequence for under-performance to elevate the ITE as a "high stakes" examination. Our hypothesis was that implementation of this AIP would improve ITE scores. METHODS: ITE scores were compiled from 150 residents in the Department of Anesthesiology at UNC for graduating classes from 2004-2015. Data is presented as the number of residents scoring below the 20th percentile when compared to the national distribution before and after the AIP. In addition, average USMLE Step 1 three-digit scores for each graduating class were compared to average ITE percentile scores of the corresponding graduating class (USMLE does not provide percentile scores). RESULTS: Between 2009 and 2013, the number of residents who scored below the 20th percentile on the ITE increased steadily to a peak of 10 in 2011. After implementation of the AIP in July 2011, there was an 80% decrease in those scoring below the 20th percentile, from 10 to 2 residents (p<0.05). CONCLUSIONS: Anesthesiology resident ITE scores improved after implementation of an academic improvement policy.