RESUMEN
Background: Patients with autism spectrum disorders (ASD) experience higher rates of perioperative anxiety and are likely to receive premedication. Little is known about nonpharmaceutical interventions which may decrease anxiety. This study aims to evaluate the use of an adaptive sensory environment (ASE) to reduce ASD patient anxiety during the perioperative process. Methods: Our feasibility study (ClinicalTrials.govNCT04994613) enrolled 60 patients in two parallel groups randomized to a control (no ASE) or intervention group (ASE). We included all surgical patients aged three to twelve years, with a formal diagnosis of ASD, Asperger's Syndrome, or pervasive developmental disorder not otherwise specified. Preoperative behaviors were recorded by an unblinded nurse utilizing the validated Modified Yale Preoperative Anxiety Scale (mYPAS). The difference in score on the mYPAS was the primary outcome, and an intention-to-treat analysis was employed. A generalized estimating equations model was used to compare mYPAS scores controlling for significant independent variables. Findings: 58 patients were analyzed after 1:1 randomization of 30 patients to each group. Groups were balanced except the median number of intraoperative pain medications was significantly lower in the ASE group (1 vs. 3, p = 0.012). Mean (SD) age for all patients was 7.2 (2.9) years, range 2.6-12.7. 72.4% (42/58) were White and all were Non-Hispanic or Latino. 74% were Male (21/30 ASE and 22/28 Control) and 26% were Female (9/30 ASE and 6/28 Control). No differences were found in mYPAS scores between groups at three time periods (43.5 vs. 42, p = 0.88, 47.8 vs. 48.4, p = 0.76, and 36.4 vs. 43.8, p = 0.15, ASE vs. control group, respectively). The ASE group had a significant within-group decrease in mYPAS scores from nursing intake to transition (p = 0.030). Interpretation: An ASE did not significantly reduce perioperative anxiety. However, the promising results deserve further investigation. Funding: Dayton Children's Hospital Foundation Robert C. Cohn Memorial Research Grant.
RESUMEN
BACKGROUND: Adductor canal block (ACB) has emerged as an appealing alternative to femoral nerve block (FNB) that produces a predominantly sensory nerve block by anesthetizing the saphenous nerve. Studies have shown greater quadriceps strength preservation with ACB compared with FNB, but no advantage has yet been shown in terms of fall risk. The Tinetti scale is used by physical therapists to assess gait and balance, and total score can estimate a patient's fall risk. We designed this study to test the primary hypothesis that FNB results in a greater proportion of "high fall risk" patients postoperatively using the Tinetti score compared with ACB. METHODS: After institutional review board approval, informed written consent to participate in the study was obtained. Patients undergoing primary unilateral total knee arthroplasty were eligible for enrollment in this double-blind, randomized trial. Patients received either an ACB or FNB (20 mL of 0.5% ropivacaine) with catheter placement (8 mL/h of 0.2% ropivacaine) in the setting of multimodal analgesia. Continuous infusion was stopped in the morning of postoperative day (POD)1 before starting physical therapy (PT). On POD1, PT assessed the primary outcome using the Tinetti score for gait and balance. Patients were considered to be at high risk of falling if they scored <19. Secondary outcomes included manual muscle testing of the quadriceps muscle strength, Timed Up and Go (TUG) test, and ambulation distance on POD1 and POD2. The quality of postoperative analgesia and the quality of recovery were assessed with American Pain Society Patient Outcome Questionnaire Revised and Quality of Recovery-9 questionnaire, respectively. RESULTS: Sixty-two patients were enrolled in the study (31 ACB and 31 FNB). No difference was found in the proportion of "high fall risk" patients on POD1 (21/31 in the ACB group versus 24/31 in the FNB group [P = 0.7]; relative risk, 1.14 [95% confidence interval, 0.84-1.56]) or POD2 (7/31 in the ACB versus 14/31 in the FNB group [P = 0.06]; relative risk, 2.0 [95% confidence interval, 0.94-4.27]). The average distance of ambulation during PT and time to up and go were similar on POD1 and POD2. Manual muscle testing grades were significantly higher on POD1 in the ACB group when compared with that in the FNB (P = 0.001) (Wilcoxon-Mann-Whitney odds, 2.25 [95% confidence interval, 1.35-4.26]). There were no other differences in postoperative outcomes. CONCLUSIONS: ACB results in greater preservation of quadriceps muscle strength. Although we did not detect a significant reduction in fall risk when compared with FNB, based on the upper limit of the relative risk, it may very well be present. Further study is needed with a larger sample size.
