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Introduction Quadratus lumborum (QL) block has previously been shown to provide improved analgesia in patients undergoing primary total hip arthroplasty (THA) under spinal anesthesia when compared to spinal anesthesia alone. Additionally, recent studies have shown the addition of intrathecal morphine (ITM) to provide superior postoperative analgesia in patients undergoing various surgical interventions including total knee arthroplasty under spinal anesthesia with peripheral nerve blockade. At this time, however, there has not been a study evaluating the effects of intrathecal morphine in patients undergoing THA under spinal anesthesia with QL block. This study aims to assess if the addition of intrathecal morphine can provide adequate or even superior postoperative analgesia in patients undergoing primary THA. Methods This retrospective study included 26 patients in the spinal/QL block/intrathecal morphine (SA+QLB+ITM) group, 31 patients in the spinal/QL block group (SA+QLB), and 28 patients in the spinal only (SA or control) group. Twenty-six patients undergoing primary THA under a combination of spinal anesthesia and peripheral nerve blockade (quadratus lumborum block) were given a dose of 100 mcg of intrathecal morphine. Various parameters were evaluated including Post-Anesthesia Care Unit (PACU) and 24-hour visual analog scale (VAS) scores, time to first opioid use, 24- and 48-hour total opioid use as oral morphine equivalents (OME), 24-hour ambulation distance, and time from block placement to hospital discharge. The results were analyzed and compared to patients undergoing primary THA under spinal anesthesia with QL block (no intrathecal morphine) and compared to a control group of patients undergoing primary THA under spinal anesthesia only. Results The study analysis included 26 patients in the SA+QLB+ITM group, 31 patients in the SA+QLB group, and 28 patients in the SA (control) group. When compared with the control group, the SA+QLB+ITM had lower 24-hour total opioid usage (mean difference 20.80 OME, CI 6.454 to 35.15, p-value 0.0025), longer time to 1st opioid use (mean difference -20.51 hours later, p-value .0052), lower 24-hr VAS (difference 2.421, p-value 0.0012, CI 0.8559 to 3.987), and faster time to discharge (16.00 hr earlier, p-value 0.0459). When compared to the SA+QLB group, the SA+QLB+ITM group only showed a statistically significant difference in faster time to discharge (19.46 hr earlier, p-value 0.0068). However, while there was no statistically significant difference in time to 1st opioid use between the control and SA+QLB group, the difference did become significant when comparing the control to the SA+QLB+ITM group (mean difference -20.51 hours later (p-value .0052). There was no significant difference in either of the three groups in ambulation distance at 24 hours, PACU VAS, or 48-hour total opioid use. Conclusion Our study concludes that the addition of 100 mcg ITM for total hip arthroplasty under spinal anesthesia improved postoperative analgesia compared to the control group. Also, the ITM group did better with respect to delay in first opioid use and decreased hospital stay compared to the control and block-only groups. Our study warrants no more concerns of PONV, pruritus, or respiratory depression with this dose of ITM and requires standard postoperative care.
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BACKGROUND: Non-OR Anesthesia (NORA) is rapidly becoming standard in many high-volume institutions and efficiency in these spaces has yet to be optimized. On-time first start percentage has been suggested to correlate with more efficient flow, and this correlation is established within the surgical space. PURPOSE: To investigate the effects of timetable targets on first case on-time first start percentage within a NORA setting. MATERIALS AND METHODS: A retrospective study of anesthesia-supported first start cases from October 2022 to April 2023 was performed to analyze the effect of timetable targets on on-time first-case starts for planned cases. Statistical analysis was calculated using Student's t-tests with statistical significance defined as p < 0.05. Additionally, analysis of variance was used to compare three or more groups, and Tukey Kramer was used to evaluate groups pairwise. RESULTS: One hundred twenty-four first start cases were included in the evaluation. After intervention with timetable targets, average patient arrival to the room time improved from 7:49 AM to 7:40 AM (p < 0.05) and procedure start time improved from 8:31 AM to 8:20 AM (p < 0.01). The percentage of procedure start times occurring prior to the goal time increased from 35 % to 58 % after the implementation (p < 0.05). With exception of Tuesdays (Anesthesia Late Start Day), on-time starts improved from 17 % to 48 % (p < 0.01) and sustained this improvement throughout the post-implementation period. CONCLUSION: Implementation of novel timetable targets yielded statistically significant improvement in first case start times. This improvement in efficiency and throughput results in increased room utilization, improved case throughput, and decreased block overrun times, all of which contribute toward increased revenues, decreased costs, and thus improved return on investment.
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Background and purpose of the study Intrathecal morphine (ITM) provides effective postoperative analgesia in patients undergoing total knee arthroplasty (TKA) under spinal anesthesia. However, the ideal dose at which maximal analgesic effects can be delivered with minimal side effects is not clearly known. This retrospective study is aimed to compare two different doses of ITM with respect to analgesia benefits and side effects. Methods This is a retrospective, descriptive, single-center study approved by the Institutional Review Board (IRB) at the University of Alabama at Birmingham. Three patient groups were selected: a control group receiving continuous adductor canal block (CCACB) under spinal anesthesia, and two experimental groups receiving single-dose adductor canal block (SSACB) under spinal anesthesia with either 100 mcg or 150 mcg of ITM. The sample size included 75 patients (25 per group) who were 18 years and older, American Society of Anesthesiology (ASA) class 1-3 who were undergoing primary TKA. Patients with chronic pain or opioid use exceeding 30 days and those undergoing surgeries other than primary TKA were excluded. Outcome data, including opioid use (from which post-operative oral morphine equivalents (OME) were calculated), antiemetic use, visual analog pain scale (VAS) scores, distance ambulated at 24 hours, and length of hospital stay, were extracted by chart review. Results In the post-anesthesia care unit (PACU), patients in both ITM groups experienced significantly lower opioid consumption and pain scores compared to the control group (p<.001). Furthermore, cumulative OME at 24 hours was significantly less in the ITM groups compared to the control, but there was no difference between ITM doses (p=0.004; mean cumulative OME for control was 77.2 OME vs 43.4 OME for 100 mcg ITM vs 42.6 OME for 150 mcg ITM). Antiemetic usage did not increase in the ITM groups. Although there was no statistically significant difference in ambulation at 24 hours, both ITM groups exhibited a trend toward greater average ambulation distance compared to the control group (p=0.095; mean distance walked for control was 67.6 feet, 76.6 feet for 100 mcg ITM vs 98.8 feet for 150 mcg ITM). Hospital length of stay did not significantly differ between the groups. Conclusion ITM doses of 100 mcg and 150 mcg provide effective analgesia for patients undergoing lower extremity total knee arthroplasty under spinal anesthesia. Patients receiving ITM had better pain scores in the immediate post-operative period and had overall less oral morphine equivalent consumption when compared to control. In addition, the safety and side effect profile for ITM is similar for both doses as there was no incidence of respiratory depression and antiemetic usage did not differ between all study arms. Future studies should explore the use of higher ITM doses and consider a broader patient population to further understand the advantages and potential drawbacks of ITM in TKA surgery.
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PURPOSE: Second victimhood, a phenomenon experienced by about half of health care providers, occurs when an individual experiences negative physical, psychological, or emotional effects after an adverse event, such as patient-related near miss, harm, or death. The stress of anesthesia practice increases the incidence of this phenomenon among anesthesia providers. Second victimhood increases turnover, absenteeism, and risk of medical error. This project aimed to decrease second victim distress among certified registered nurse anesthetists (CRNAs) by implementing a peer support program - second victims are more likely to use peer support over commonly offered support services. DESIGN: A quality improvement project. METHODS: Eight volunteer CRNAs were trained to provide peer support 24-hours a day. CRNAs needing peer support could self-identify or be identified by a colleague, peer supporter, or lead CRNA, and could locate the peer supporter on call in the electronic anesthesia dashboard. Pre- and post-implementation second victim distress were assessed using the Second Victim Experience and Support Tool, a validated survey that measures distress symptoms and perceived institutional support. FINDINGS: Although differences in pre- and post-implementation survey scores were statistically insignificant, the program was welcomed by leadership and staff. CONCLUSIONS: The program experienced higher utilization compared to similar launch studies, with eight encounters in the first month. Impact on staff morale is expected to increase; long-term peer support can improve provider well-being and patient outcomes.
