Comparison of transversus abdominis plane catheters with thoracic epidurals for cost and length of stay in open colorectal surgeries: a cohort study.

BACKGROUND: Thoracic epidural analgesia has long been a common method of postoperative analgesia for major open abdominal surgeries and is frequently used within enhanced recovery after surgery programs. An alternative postoperative analgesia method is the single shot transversus abdominis plane block, which has shown promising outcomes with respect to total length of stay, cost, pain scores, and decreased opioid usage. However, far less is known regarding continuous transversus abdominis plane analgesia using catheters. We evaluated the total cost-effectiveness of transversus abdominis plane catheter analgesia compared to thoracic epidural analgesia for patients undergoing open colorectal surgeries within the enhanced recovery after surgery program at our institution. METHODS: This cohort study included patients booked under the colorectal surgery enhanced recovery after surgery program from November 2016 through March 2018 who received either bilateral transversus abdominis plane catheters (n = 52) or thoracic epidural analgesia (n = 24). RESULTS: There was no difference in total direct cost (p = 0.660) and indirect cost (p = 0.220), and median length of stay (p = 0.664) in the transversus abdominis plane catheter group compared to the thoracic epidural group. Additionally, the transversus abdominis plane catheter group received significantly less morphine equivalents compared to the thoracic epidural group (p = 0.008) and had a lower mean body mass index (p = 0.019). There was no significant difference between the two groups for age (p = 0.820), or sex (p = 0.330). CONCLUSIONS: Transversus abdominis plane catheter analgesia is not associated with increased cost or longer hospital stays when compared to thoracic epidural analgesia in patients undergoing open colorectal surgery within an enhanced recovery after surgery program. Furthermore, transversus abdominis plane catheter analgesia led to decreased opioid consumption while maintaining similar pain scores, suggesting similar pain control between the two modalities.

Enhanced Recovery after Partial and Radical Nephrectomy Reduces Length of Stay, Opioid Use and Cost.

INTRODUCTION: Enhanced recovery after surgery pathways are multidisciplinary, multimodal approaches to perioperative care that aim to improve patient outcomes. In this study we evaluate the outcomes of the implementation of enhanced recovery after surgery pathways in patients undergoing nephrectomy. METHODS: A retrospective analysis was performed comparing patients who underwent renal surgery before vs after implementation of enhanced recovery after surgery pathways. Data analyzed included length of stay, opioid use, cost and complications before and after the enhanced recovery after surgery protocol was implemented. RESULTS: There were 76 patients in the pre-enhanced recovery after surgery group and 42 in the enhanced recovery after surgery group. Median length of stay in the pre-enhanced vs enhanced recovery after surgery group was 3 days vs 2 days (p <0.005). For open procedures median length of stay was 5 days vs 2 days (p <0.001). For robotic procedures median length of stay decreased from 3 days to 2 days (p <0.001). Median length of stay was lower in the enhanced recovery after surgery group independent of age, sex, body mass index, American Society of Anesthesiologists® score and anesthesia time. Median total morphine equivalents decreased from 4 mg to 0 mg (p <0.005) while median total oxycodone went from 52.5 mg to 8.75 mg (p <0.005). Direct cost per patient decreased from $13,036 pre-enhanced recovery after surgery to $9,779 (p <0.001) in the enhanced recovery after surgery group, representing a 25% decrease. The 30-day readmission rates did not change after implementation of enhanced recovery after surgery protocol, and a National Surgical Quality Improvement Program sampling showed similar rates in complications, although this was not amenable to statistical analysis. CONCLUSIONS: Enhanced recovery after surgery improves the care of patients undergoing renal surgery. It significantly decreased length of stay, opioid use and hospital cost without having a significant effect on complications.

Use of jet ventilation in thoracoscopic tracheo-esophageal fistula repair-can both surgeons and anesthesiologists be happy?

Laparoscopic and open thoracic surgery in the neonate typically results in hypercapnea and low cardiac output with often poor surgical visualization as the anesthesiologist attempts to correct the respiratory derangements usually seen. We describe three cases in which jet ventilation provided not only superior ventilation with a return to normocapnea but also ideal operating conditions. In addition, jet ventilation utilizes lower mean airway pressures which typically results in improved cardiac output.