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.

Preemptive analgesia for postoperative pain relief in thoracolumbosacral spine operations: a double-blind, placebo-controlled randomized trial.

OBJECTIVEPreemptive administration of analgesic medication is more effective than medication given after the onset of the painful stimulus. The efficacy of preoperative or preemptive pain relief after thoracolumbosacral spine surgery has not been well studied. The present study was a double-blind, placebo-controlled randomized trial of preemptive analgesia with a single-shot epidural injection in adult patients undergoing spine surgery.METHODSNinety-nine adult patients undergoing thoracolumbosacral operations via a posterior approach were randomized to receive a single shot of either epidural placebo (group 1), hydromorphone alone (group 2), or bupivacaine with hydromorphone (group 3) before surgery at the preoperative holding area. The primary outcome was the presence of opioid sparing and rescue time-defined as the time interval from when a patient was extubated to the time pain medication was first demanded during the postoperative period. Secondary outcomes include length of stay at the postanesthesia care unit (PACU), pain score at the PACU, opioid dose, and hospital length of stay.RESULTSOf the 99 patients, 32 were randomized to the epidural placebo group, 33 to the hydromorphone-alone group, and 34 to the bupivacaine with hydromorphone group. No significant difference was seen across the demographics and surgical complexities for all 3 groups. Compared to the control group, opioid sparing was significantly higher in group 2 (57.6% vs 15.6%, p = 0.0007) and group 3 (52.9% vs 15.6%, p = 0.0045) in the first demand of intravenous hydromorphone as a supplemental analgesic medication. Compared to placebo, the rescue time was significantly higher in group 2 (187 minutes vs 51.5 minutes, p = 0.0014) and group 3 (204.5 minutes vs 51. minutes, p = 0.0045). There were no significant differences in secondary outcomes.CONCLUSIONSThe authors' study demonstrated that preemptive analgesia in thoracolumbosacral surgeries can significantly reduce analgesia requirements in the immediate postoperative period as evidenced by reduced request for opioid medication in both analgesia study groups who received a preoperative analgesic epidural. Nonetheless, the lack of differences in pain score and opioid dose at the PACU brings into question the role of preemptive epidural opioids in spine surgery patients. Further work is necessary to investigate the long-term effectiveness of preemptive epidural opioids and their role in pain reduction and patient satisfaction.Clinical trial registration no.: NCT02968862 (clinicaltrials.gov).

Linshom thermodynamic sensor is a reliable alternative to capnography for monitoring respiratory rate.

Monitoring ventilation accurately is a technically challenging, yet indispensable aspect of patient care in the intra- and post-procedural settings. A new prototypical device known as the Linshom Respiratory Monitoring Device (LRMD) has been recently designed to non-invasively, inexpensively, and portably measure respiratory rate. The purpose of this study was to measure the accuracy and variability of LRMD measurements of respiratory rate relative to the measurement of capnography. In this prospective study, participants were enrolled and individually fitted with a face mask monitored by the LRMD and capnography. With a baseline oxygen flow rate and digital metronome to pace their respiratory rate, the participants were instructed to breathe at 10 breaths per minute (bpm) for 3 min, 20 bpm for 3 min, 30 bpm for 3 min, 0 bpm for 30 s, and resume regular breathing for 30 s. Both sensors were connected to a computer for continuous temperature and carbon dioxide waveform recordings. The data were then retrospectively analyzed. Twenty-six healthy volunteers, mean (range) age 27.8 (23-37) and mean (range) BMI 23.1 (18.8-29.2) kg/m2 were recruited. There were 15 males (57.7%) and 11 females (42.3%). After excluding 3 subjects for technical reasons, 13,800 s of breathing and 4,140 expiratory breaths were recorded. Throughout the protocol, the average standard deviation (SD) for the LRMD and capnography was 1.11 and 1.81 bpm, respectively. The overall mean bias (±2SD) between LRMD and capnography was -0.33 (±0.1.56) bpm. At the lowest and intermediate breathing rates reflective of hypoventilation and normal ventilation, the LRMD variance was 0.55 and 1.23 respectively, compared to capnography with 5.54 and 7.47, respectively. At higher breathing rates indicative of hyperventilation, the variance of the test device was 4.52, still less than that of capnography at 5.73. This study demonstrated a promising correlation between the LRMD and capnography for use as a respiratory rate monitor. The LRMD technology may be a significant addition to monitoring vital signs because it offers a minimally intrusive opportunity to detect respiratory rate and apnea, without expensive or complex anesthetic equipment, before the need for life-saving resuscitation arises.

A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial to Evaluate Intravenous Acetaminophen Versus Placebo in Patients Undergoing Robotic-Assisted Laparoscopic Prostatectomy.

Radical prostatectomy for prostate cancer is one of the most commonly performed operations in men. The objective of this study was to determine the impact of intravenous (IV) acetaminophen when added to the perioperative analgesic regimen for robotic-assisted laparoscopic prostatectomy (RALP) on hospital length of stay (LOS), postoperative pain scores, and opioid consumption. In this prospective, randomized, double-blind, placebo-controlled trial, a total of 86 patients undergoing RALP were prospectively enrolled and randomly assigned to receive either 1 g IV acetaminophen (study group; n = 43) or IV placebo (n = 43) within 15 minutes following the induction of anesthesia and prior to surgical incision. Seventy-five records were completed and included for analysis. Pain scores were recorded every 30 minutes for 2 hours in the postanesthesia care unit (PACU) and then 16 distinct time points for 48 hours after PACU discharge. Repeat doses of IV acetaminophen or placebo was given every 6 hours for a total of four doses. Median average pain scores after PACU discharge between the treatment and placebo groups were 0.62 vs. 0.88, respectively (P = .055), over the first 24 hours and 1.28 vs. 2.25, respectively (P = .13), over the second 24 hours. Hospital LOS was shorter in the IV acetaminophen group compared with placebo by 32% (P = .006). Median intraoperative opioid use in the IV acetaminophen group was 42 mg morphine equivalents compared with 50 mg in placebo (P = .64) and 8 mg in both groups postoperatively (P = .16). Overall, use of perioperative IV acetaminophen decreased hospital LOS without a significant difference in PACU LOS, pain scores, or opioid use.

The effects of dynamic airway photographs on preoperative airway planning among a panel of anesthetists.

STUDY OBJECTIVE: To determine whether having preoperative airway photographs will change the preanesthetic airway plan. DESIGN: Questionnaire. SETTING: American academic medical center (Brigham and Women's Hospital, Boston MA). SUBJECTS: Twenty-five test subjects (American Society of Anesthesiologists 1-4) were enrolled to have their preoperative airway photographs taken as well as to have a customary preoperative history and physical examination. In addition, 15 anesthetists were enrolled to review the subjects' preoperative history, physical examination, and preoperative airway photographs. MEASUREMENTS: All 15 anesthetists were asked to fill out a survey for airway management for each test subject. MAIN RESULTS: All 15 anesthetists completed the survey. Across all providers, plans were changed a median of 24% (95% confidence interval [CI], 12.7-38.6). Among attending anesthesiologists, airway management plans were changed 30% of the time (95% CI, 12.4-40.0), whereas among nonattending level providers, plans changed 24% of the time (95% CI, 12.0-38.8). χ2 Tests found no difference between the percent change of airway plans between attending and nonattending level providers (P=.306). CONCLUSIONS: Our findings suggest that the addition of dynamic airway photographs to preoperative airway reports affects airway management plans among a variety of anesthesia care providers. In general, dynamic airway photographs can aid preoperative airway management planning.