Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Trends in Comorbidities and Complications Among Patients Undergoing Hip Fracture Repair.

BACKGROUND: Hip fracture patients represent various perioperative challenges related to their significant comorbidity burden and the high incidence of morbidity and mortality. As population trend data remain rare, we aimed to investigate nationwide trends in the United States in patient demographics and outcomes in patients after hip fracture repair surgery. METHODS: After Institutional Review Board (IRB) approval (IRB#2012-050), data covering hip fracture repair surgeries were extracted from the Premier Healthcare Database (2006-2016). Patient demographics, comorbidities, and complications, as well as anesthesia and surgical details, were analyzed over time. Cochran-Armitage trend tests and simple linear regression assessed significance of (linear) trends. RESULTS: Among N = 507,274 hip fracture cases, we observed significant increases in the incidence in preexisting comorbid conditions, particularly the proportion of patients with >3 comorbid conditions (33.9% to 43.4%, respectively; P < .0001). The greatest increase for individual comorbidities was seen for sleep apnea, drug abuse, weight loss, and obesity. Regarding complications, increased rates over time were seen for acute renal failure (from 6.9 to 11.1 per 1000 inpatient days; P < .0001), while significant decreasing trends for mortality, pneumonia, hemorrhage/hematoma, and acute myocardial infarction were recorded. In addition, decreasing trends were observed for the use of neuraxial anesthesia either used as sole anesthetic or combined with general anesthesia (7.3% to 3.6% and 6.3% to 3.4%, respectively; P < .0001). Significantly more patients (31.9% vs 41.3%; P < .0001) were operated on in small rather than medium- and large-sized hospitals. CONCLUSIONS: From 2006 to 2016, the overall comorbidity burden increased among patients undergoing hip fracture repair surgery. Throughout this same time period, incidence of postoperative complications either remained constant or declined with the only significant increase observed in acute renal failure. Moreover, use of regional anesthesia decreased over time. This more comorbid patient population represents an increasing burden on the health care system; however, existing preventative measures appear to be effective in minimizing complication rates. Although, given the proposed benefits of regional anesthesia, decreased utilization may be of concern.

Trends and Outcomes in Pediatric Patients Undergoing Scoliosis Repair: A Population-Based Study.

BACKGROUND: Although surgery represents the only definitive treatment for congenital scoliosis, comprehensive information regarding trends in perioperative complications, particularly in the pediatric setting, is lacking. We sought to identify trends in and factors associated with perioperative complications following pediatric scoliosis surgery. METHODS: In this retrospective cohort study, patients below the age of 21 years undergoing a scoliosis repair procedure were identified from the Premier Healthcare database (2006-2016). The primary outcomes of interest were any complication, cardiopulmonary complications, blood transfusions, intensive care unit (ICU) admission, length of stay (LOS), and cost of hospitalization. Trends in these outcomes over time were analyzed. Multivariable logistic regression models were run to identify factors associated with each of the perioperative outcomes. RESULTS: In the full cohort of 9351 scoliosis patients, 17% experienced any complication, 12% of which were cardiopulmonary in nature, 42% required blood transfusions, and 62% were admitted to the ICU. Median LOS was 5 days (interquartile range [IQR], 4-6) and median cost was $56,375 (IQR, $40,053-$76,311). Annual incidence of complications and blood transfusions as well as LOS and cost decreased significantly throughout the study period. The most consistently observed factors associated with complications were younger age, high comorbidity burden, low institutional case volume, and hospital teaching status. CONCLUSIONS: Although the incidence of the studied adverse outcomes in scoliosis surgery has decreased over time, this study shows it remains relatively high (17%). The associations demonstrated help clarify factors associated with complications and may be useful in guiding interventions to improve outcomes.

Modifiable Analgesia-/Anesthesia-Related Factors and Risk of Severe Gastrointestinal Complications After Lower Extremity Total Joint Arthroplasty: A Nationwide Analysis.

BACKGROUND: Severe gastrointestinal (GI) complications after elective hip and knee arthroplasty (THA/TKA) are rare. Some of them can be life-threatening and/or require emergency abdominal surgery. We studied the epidemiology of severe GI complications after THA/TKA and associations with anesthesia- and/or analgesia-related factors. METHODS: We included 591,865 THA and 1,139,616 TKA cases (Premier Healthcare claims database; 2006-2016). Main outcomes were GI complications and related emergency surgeries within 30 days after THA/TKA. Anesthesia- and analgesia-related factors were anesthesia type (neuraxial, general), use of peripheral nerve block, patient-controlled analgesia, nonopioid analgesics (acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, ketamine), and opioids (in oral morphine equivalents, categorized into low, medium, and high use based on the interquartile range). Mixed-effects models measured associations between anesthesia- and analgesia-related factors and outcomes, which were reported using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Among THA patients, GI complications were observed in 1.03% (n = 6103), with 0.08% (n = 450) requiring emergency surgery; this was 0.79% (n = 8971) and 0.05% (n = 540), respectively, for TKA patients. After adjustment for relevant covariates (including opioid use), almost all anesthesia-/analgesia-related factors were associated with significantly decreased odds of GI complications, specifically use of cyclooxygenase-2 inhibitors (OR 0.72 CI 0.67-0.76/OR 0.82 CI 0.78-0.86), nonsteroidal anti-inflammatory drugs (OR 0.81 CI 0.77-0.85/OR 0.90 CI 0.86-0.94), and peripheral nerve blocks (OR 0.77 CI 0.69-0.87/OR 0.91 CI 0.85-0.97); all for THA and TKA, respectively (all P < .01). CONCLUSION: Rare, but devastating, acute GI complications (requiring surgery) after THA/TKA may be positively impacted by a variety of modifiable anesthesia-/analgesia-related interventions.

Enhanced Recovery Implementation and Perioperative Outcomes in Posterior Fusion Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: We sought to determine if there was an association between enhanced recovery after surgery (ERAS) implementation level and complication risk, length of stay, and cost of hospitalization. SUMMARY OF BACKGROUND DATA: ERAS protocols aim to minimize the stress response of surgery by promoting early mobilization, oral intake, as well as improvement of analgesia. Implementation of ERAS protocols in spine surgeries has been limited to mostly single-institution studies, and no population-based data exist on the impact of the level of implementation of various ERAS components on outcomes. METHODS: In this study we identified 265,576 posterior lumbar fusion surgeries from 2006 to 2016. The main effect was the application of eight ERAS-related practices: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics, (4) steroids, (5) early physical therapy, (6) avoidance of urinary catheters, (7) avoidance of patient-controlled analgesia, (8) avoidance of wound drains. Patients were classified by levels of ERAS implementation: "High," "Medium," and "Low" ERAS implementation if they received more than five, three to five, or less than three ERAS components, respectively. Mixed-effects models measured associations between ERAS implementation categories and complications, length and cost of hospitalization; odds ratios (OR, or average ratios for continuous outcomes), and 99.4% confidence intervals (CI) were reported. RESULTS: Overall, 13.3%, 62.8%, and 24.4% of cases were categorized as "High," "Medium," and "Low" ERAS implementation, respectively. After adjusting for study variables, "Medium" and "High" (compared with "Low") ERAS implementation levels were significantly associated with incrementally improved outcomes regarding "any complication" (OR 0.84 CI 0.80-0.88 and OR 0.77 CI 0.71-0.84), cardiopulmonary complications (OR 0.75 CI 0.68-0.73 and OR 0.69 CI 0.59-0.80), length of stay (average ratio 0. 94 CI 0.93-0.94 and average ratio 0.91 CI 0.90-0.91), and hospitalization cost (average ratio 0.99 CI 0.98-0.99 and average ratio OR 0.95 0.95-0.96). CONCLUSION: In a cohort undergoing posterior lumbar spine fusion the level of utilization of ERAS protocol components was independently associated with incrementally improved complication odds as well as reduced length of stay and a small decrease in overall hospitalization cost. LEVEL OF EVIDENCE: 3.

New Onset Depression and Anxiety After Spinal Fusion Surgery: Incidence and Risk Factors.

STUDY DESIGN: Retrospective database study. OBJECTIVE: We sought to investigate trends and risk factors for new-onset anxiety and/or depression within 6 months after elective spine surgery. SUMMARY OF BACKGROUND DATA: Surgery represents a stressful experience associated with a number of physiological and psychological consequences. A subset of patients develop clinically significant symptoms of new-onset anxiety or depression. However, the incidence of and risk factors for these adverse outcomes after spine surgery remain ill-defined. METHODS: We performed a retrospective analysis including anterior cervical discectomy and fusion and posterior lumbar fusion cases from 2012 to 2015, utilizing the Truven MarketScan database. Primary outcomes were new-onset depression, new-onset anxiety, and new-onset depression and/or anxiety after surgery. Potential risk factors included patient demographics, comorbidities, hospital and procedural characteristics as well as perioperative opioid regimens. Multivariable logistic regression models measured associations between risk factors and outcomes. Odds ratios (OR) were reported and results with P < 0.0167 were considered statistically significant. RESULTS: Among 39,495 unique patients, overall incidence of new-onset depression and anxiety was 6% and 11.2%, respectively. In adjusted analyses, significant risk factors across all three outcomes included chronic opioid use (ORs ranging from 1.31 to 2.93; P < 0.01), female sex (ORs ranging from 1.25 to 1.67; P < 0.01), longer length of stay (ORs ranging from 1.05 to 1.08; P < 0.01), and readmission within 6 months of surgery (OR ranging from 1.31 to 1.68; P < 0.01). CONCLUSION: We identified several risk factors contributing to increased odds of new-onset depression and/or anxiety after spine fusion surgery. These data may aid the implementation of preventative measures among identified high-risk patients. LEVEL OF EVIDENCE: 3.

Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been shown to benefit recovery after several operations. However, large-scale data on the association between the level of ERAS use and perioperative complications are scarce, particularly in surgeries with increasing ERAS uptake, including total hip (THA) and knee arthroplasty (TKA). Using US national data, we examined the relationship between the number of ERAS components implemented ('level') and perioperative outcomes. METHODS: After ethics approval, we included 1 540 462 elective THA/TKA procedures (2006-2016, as recorded in the Premier Healthcare claims database) in this retrospective cohort study. Main outcomes were any complication, cardiopulmonary complications, mortality, blood transfusions, and length of stay. Eight commonly used ERAS components were included. Mixed-effects models measured associations between ERAS level and outcomes, with odds ratios (OR) and confidence intervals (CI) reported. RESULTS: ERAS use increased over time; overall, 21.6% (n=324 437), 62.7% (n=965 953), and 18.0% (n=250 072) of cases were classified as 'High', 'Medium', or 'Low' ERAS. 'High ERAS', 'Medium ERAS', and 'Low ERAS' level of use were defined as such if they received either >6, 5-6, or <5 ERAS components, respectively. After adjustment for relevant covariates, higher levels of ERAS use were associated with incremental reductions in 'any complication': 'Medium' vs 'Low' (OR=0.84; CI, 0.82-0.86) and 'High' vs 'Low' (OR=0.71; CI, 0.68-0.74). Similar patterns were found for the other study outcomes. Individual ERAS components with the strongest effect estimates were early physical therapy, avoidance of a urinary catheter, and tranexamic acid administration. CONCLUSIONS: ERAS components were used more frequently over time, and the level of utilisation was independently associated with incrementally improved complication odds and reduced length of stay during the primary admission. Possible indication bias limits the certainty of these findings.

Risk factors for reintubation after anterior cervical discectomy and fusion surgery: evaluation of three observational data sets.

PURPOSE: Postoperative loss of airway requiring reintubation is a rare but potentially catastrophic complication following anterior cervical discectomy and fusion (ACDF). We sought to identify risk factors asscociated with reintubation within one day following ACDF. Attention was focused on patient demographics, comorbidities, and factors potentially linked to soft tissue swelling and hematoma formation that could compromise the upper airway. METHODS: We performed a retrospective cohort study of patients who underwent ACDF procedures at a high-volume institution from 2005 to 2014 (n = 3,041), participating hospitals in the National Surgical Quality Improvement Program (NSQIP) (n = 47,425), and Premier Healthcare (n = 233,633) databases from 2006 to 2016. Separate multivariable logistic regression models using the NSQIP and Premier samples were used to identify risk factors for reintubation within one day of ACDF. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Incidence of reintubation within one day of ACDF was 0.19% in the institutional database and 0.21% in NSQIP and Premier databases. Risk factors for reintubation included older age, male sex, high comorbidity burden, procedures performed at large hospitals, non-elective procedures, Medicaid insurance, and use of heparin or more than one anticoagulant. Intravenous or oral steroid use (OR, 0.45; 95% CI, 0.36 to 0.56; P < 0.001) and delayed extubation (OR, 0.28 95% CI, 0.16 to 0.49; P < 0.001) were found to decrease risk of reintubation. CONCLUSIONS: Across three complementary data sets, incidence of reintubation within one day of ACDF was approximately 0.20%. Increased risk of reintubation associated with anticoagulant administration suggests upper airway hematoma as an underlying etiology. Steroid administration and delayed extubation may be useful in patients considered to be at higher risk for reintubation.

Trends in Comorbidities and Complications Among Patients Undergoing Inpatient Spine Surgery.

STUDY DESIGN: Retrospective database study. OBJECTIVE: We sought to identify trends in demographics, comorbidities, and postoperative complications among patients undergoing ACDF and PLF. SUMMARY OF BACKGROUND DATA: As demand for anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) surgery continues to increase, it is important to understand changes in the healthcare system and patient populations undergoing these procedures. METHODS: We identified 220,520 ACDF and 151,547 PLF surgeries (2006-2016; Premier Healthcare database). Annual proportions or medians were calculated for patient and hospital characteristics, and (Elixhauser) comorbidities. Postoperative complications, including blood transfusions, cardiovascular, pulmonary, renal, or wound complications, hemorrhage, stroke, sepsis, thromboembolism, delirium, inpatient falls, and mortality, were reported per 1000 inpatient days. Trends were assessed by Cochran-Armitage tests and linear regression for binary and continuous variables, respectively. RESULTS: The median age of patients undergoing ACDF and PLF increased significantly from 2006 to 2016 (50 to 57 yr and 58 to 61 yr, respectively; P < 0.001) coinciding with an increasing comorbidity burden (30.2% to 47.9% and 44.9% to 55.7%, respectively representing the share of patients with ≥2 Elixhauser comorbidities; P < 0.001). Overall rate of any complication experienced a significant decline after both ACDF (24.5 to 20.8 per 1000 inpatient days; P = 0.002) and PLF (30.5 to 23.1 per 1000 inpatient days; P < 0.001). CONCLUSIONS: The comorbidity burden of patients undergoing ACDF and PLF increased substantially from 2006 to 2016, however without a corresponding increase in overall complication rate. Understanding these changes can help guide future practice, advise in the allocation of resources, and inform future areas of research. LEVEL OF EVIDENCE: 3.

Multimodal Pain Management and Postoperative Outcomes in Lumbar Spine Fusion Surgery: A Population-based Cohort Study.

STUDY DESIGN: Retrospective population-based cohort analysis. OBJECTIVE: Given the lack of large-scale data on the use and efficacy of multimodal analgesia in spine fusion surgery, we conducted a population-based analysis utilizing the nationwide claims-based Premier Healthcare database. SUMMARY OF BACKGROUND DATA: Multimodal analgesia, combining different pain signaling pathways to achieve additive and synergistic effects, is increasingly emerging as the standard of care. METHODS: Cases of posterior lumbar fusion surgery were extracted (2006-2016). Opioid-only analgesia was compared to multimodal analgesia, that is, systemic opioid analgesia + either acetaminophen, steroids, gabapentinoids, ketamine, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, or neuraxial anesthesia (categorized into 1, 2, or >2 additional analgesic modes). Mixed-effects models measured associations between multimodal analgesia categories and outcomes, including opioid prescription dose, cost/length of hospitalization, and opioid-related complications. Odds ratios (ORs, or % change) and 95% confidence intervals (CIs) are reported. RESULTS: Among 265,538 patients the incidence of multimodal analgesia was 61.1% (162,156); multimodal pain management-specifically when adding NSAIDs/COX-2 inhibitors to opioids-was associated with reduced opioid prescription (-13.3% CI -16.7 to -9.7%), cost (-2.9% CI -3.9 to -1.8%) and length of hospitalization (-7.3% CI -8.5 to -6.1%). Multimodal analgesia in general was associated with stepwise decreased odds for gastrointestinal complications (OR 0.95, 95% CI 0.88-1.04; OR 0.84, CI 0.75-0.95; OR 0.78, 95% CI 0.64-0.96), whereas odds were increased for postoperative delirium (OR 1.14, 95% CI 1.00-1.32; OR 1.33, 95% CI 1.11-1.59; OR 1.31, 95% CI 0.99-1.74), and counterintuitively- naloxone administration (OR 1.25, 95% CI 1.13-1.38; OR 1.56, 95% CI 1.37-1.77; OR 1.84, 95% CI 1.52-2.23) with increasing analgesic modes used: one, two, or more additional analgesic modes, respectively. Post-hoc analysis revealed that specifically gabapentinoid use increased odds of naloxone requirement by about 50%, regardless of concurrent opioid dose (P < 0.001). CONCLUSION: Although multimodal analgesia was not consistently implemented in spine fusion surgery, particularly NSAIDs and COX-2 inhibitors demonstrated opioid sparing effects. Moreover, results suggest a synergistic interaction between gabapentinoids and opioids, the former potentiating opioid effects resulting in greater naloxone requirement. LEVEL OF EVIDENCE: 3.

Risk factors for new-onset depression or anxiety following total joint arthroplasty: the role of chronic opioid use.

BACKGROUND: Several studies have evaluated the impact of preoperative depression on outcomes following total joint arthroplasty (TJA), however few have studied new-onset depression or anxiety after TJA. We aimed to identify the incidence of and risk factors for new-onset depression/anxiety after TJA, specifically focusing on the role of chronic opioid use. METHODS: Patients who underwent total hip (THA) or total knee (TKA) arthroplasty from 2012 to 2015 were identified from the Truven MarketScan database. The main outcomes were new-onset depression or anxiety. The main risk factor of interest was chronic opioid use as a proxy for chronic pain; this was classified into three groups: isolated preoperative use, isolated postoperative use, and preoperative use that continued postoperatively. Multivariable logistic regression models were used to obtain ORs and 95% CIs. RESULTS: Overall, 106 260 TJA procedures were included (34.3% THA/65.7% TKA); new-onset depression and anxiety were observed in 3.6% and 4.8% of patients, respectively. Preoperative chronic opioid use (6.3%; OR 1.88, 95% CI 1.47 to 2.40), isolated postoperative use (10%; OR 2.61, 95% CI 2.08 to 3.28), and continued postoperative use (7.8%; OR 2.08, 95% CI 1.74 to 2.49) were all associated with significantly increased odds of new-onset depression. Additional risk factors included female gender, younger age, comorbid psychological conditions, and hospital readmission within 6 months of surgery. Similar patterns were seen for new-onset anxiety. DISCUSSION: Given the observed relationship between chronic opioid use and adverse psychological outcomes following TJA, the relationship between these two entities requires further evaluation, specifically to identify if there is a causal relationship.

Anaesthesia provider volume and perioperative outcomes in total joint arthroplasty surgery.

BACKGROUND: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties. METHODS: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported. RESULTS: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95). CONCLUSIONS: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings.

Cost of Care for Patients With Pre-Existing Comorbidities Undergoing Total Joint Arthroplasty: A Retrospective Cohort Study Evaluating Disease-Specific Perioperative Care.

BACKGROUND: Investigations suggest a relationship between increased resource utilization with disease burden and advanced age. However, it remains unknown the degree increased resource utilization is associated with pre-existing conditions, before complications occur. METHODS: This retrospective study identified total hip/knee arthroplasty cases in the Premier Database from 2006 to 2016 (N = 1,613,744), with hospitalization cost as the primary outcome. With a variable combining the conditions and complication, generalized linear models measured associations between condition/complication interaction groups and hospitalization cost. Estimates of percent cost increase by variable were obtained. RESULTS: Across all conditions, an increase in cost ranging from 0.38% to 4.28% was found in the absence of a complication. The "Condition = No, Complication = Yes" group was associated with a range of 11.50%-12.40% increase in average hospitalization cost, and the range was 14.43%-30.85% for the "Condition = Yes, Complication = Yes" group. CONCLUSION: We found that having a high-risk condition without a complication accounted only for a modest hospitalization cost increase.

Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis.

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935.

Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study.

BACKGROUND AND OBJECTIVES: The significance of intravenous over oral acetaminophen (APAP) as part of multimodal analgesic protocols is contested, particularly when considering its relatively high price and use in a surgical cohort such as total hip or knee arthroplasty (THA/TKA), which generally tolerates oral medications. This study aims to elucidate APAP's effectiveness in a large, population-based patient sample. METHODS: 1 039 647 THA/TKA procedures were sampled from the Premier Healthcare claims database 2011-2016. APAP use was categorized by intravenous/oral and use on the day of surgery, postoperative day 1 and thereafter. Outcomes were opioid utilization (in oral morphine equivalents), length and cost of hospitalization, and opioid-related adverse effects (respiratory, gastrointestinal, and naloxone use as a proxy). Mixed-effects models measured the associations between intravenous/oral APAP use and outcomes. Percent (%) change and 95% CIs are reported. RESULTS: Overall, 23.6% (n=245 454) of patients received intravenous APAP; of these, 56.3% (n=138 180) received just one dose on the day of surgery. After adjustment for relevant covariates, particularly use of >1 dose of intravenous APAP (compared with no use) on postoperative day 1 was associated with -6.0% (CI -7.2% to -4.7%) reduced opioid utilization; this was -10.7% (CI -11.4% to -9.9%) for use of > 1 dose oral APAP on postoperative day 1. Further comparisons regarding other outcomes also favored oral (over intravenous) APAP. CONCLUSIONS: These results do not support the routine use of intravenous APAP in patients undergoing lower joint arthroplasty, especially since oral APAP shows more beneficial outcome patterns.