Chronic Subdural Hematoma Drainage Under Local Anesthesia with Sedation versus General Anesthesia and Its Outcome.

BACKGROUND: Burr hole drainage is the criterion standard treatment for chronic subdural hematoma (CSDH), a common neurosurgical condition. However, apart from the surgical technique, the method of anesthesia also has a significant impact on postoperative patient outcome. Currently, there are limited studies comparing the use of local anesthesia with sedation (LA sedation) versus general anesthesia (GA) in the drainage of CSDH. The objective of this study was to compare the morbidity and mortality outcomes of using LA sedation versus GA in CSDH burr hole drainage. METHODS: This retrospective study presents a total of 257 operations in 243 patients from 2 hospitals. A total of 130 cases were operated under LA sedation in hospital 1 and 127 cases under GA in hospital 2. Patient demographics and presenting features were similar at baseline. RESULTS: Values are shown as LA sedation versus GA. Postoperatively, most patients recovered well in both groups with Glasgow Outcome Scale scores of 4-5 (96.2% vs. 88.2%, respectively). The postoperative morbidity was significantly increased by an odds ratio of 5.44 in the GA group compared with the LA sedation group (P = 0.005). The mortality was also significantly higher in the GA group (n = 5, 3.9%) than the LA sedation group (n = 0, 0.0%; P = 0.028). The CSDH recurrence rate was 4.6% in the LA sedation group versus 6.3% in the GA group. No intraoperative conversion from LA sedation to GA was reported. CONCLUSIONS: This study demonstrates that CSDH drainage under LA sedation is safe and efficacious, with a significantly lower risk of postoperative mortality and morbidity when compared with GA.

Investigation of Asleep versus Awake Motor Mapping in Resective Brain Surgery.

OBJECTIVE: To develop an asleep motor mapping paradigm for accurate detection of the corticospinal tract during glioma surgery and compare outcomes with awake patients undergoing glioma resection. METHODS: A consecutive cohort of adult patients undergoing craniotomy for suspected diffuse glioma with tumor in a perirolandic location who had awake or asleep cortical and subcortical motor mapping with positive areas of motor stimulation were assessed for postoperative extent of resection (EOR), permanent neurological deficit, and proximity of stimulation to diffusion tensor imaging-based corticospinal tract depiction on preoperative magnetic resonance imaging. Outcome data were compared between asleep and awake groups. RESULTS: In the asleep group, all 16 patients had improved or no change in motor function at last follow-up (minimum 3 months of follow-up). In the awake group, all 23 patients had improved function or no change at last follow-up. EOR was greater in the asleep group (mean [SD] EOR 88.71% [17.56%]) versus the awake group (mean [SD] EOR 80.62% [24.44%]), although this difference was not statistically significant (P = 0.3802). Linear regression comparing distance from stimulation to corticospinal tract in asleep (n = 14) and awake (n = 4) patients was r = -0.3759, R2 = 0.1413, P = 0.1853, and 95% confidence interval = -0.4453 to 0.09611 and r = 0.7326, R2 = 0.5367, P = 0.2674, and 95% confidence interval = -7.042 to 14.75, respectively. CONCLUSION: In this small patient series, asleep motor mapping using commonly available motor evoked potential hardware appears to be safe and efficacious in regard to EOR and functional outcomes.

Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018.

BACKGROUND: Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. METHODS: A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. RESULTS: Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years). CONCLUSIONS: The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.

Improving Care and Outcomes for Pediatric Musculoskeletal Infections.

BACKGROUND: Pediatric musculoskeletal infection (MSKI) is a common cause of hospitalization with associated morbidity. To improve the care of pediatric MSKI, our objectives were to achieve 3 specific aims within 24 months of our quality improvement (QI) interventions: (1) 50% reduction in peripherally inserted central catheter (PICC) use, (2) 25% reduction in sedations per patient, and (3) 50% reduction in empirical vancomycin administration. METHODS: We implemented 4 prospective QI interventions at our tertiary children's hospital: (1) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) implementation of an MSKI infection algorithm and order set. We included patients 6 months to 18 years of age with acute osteomyelitis, septic arthritis, or pyomyositis and excluded patients with complex chronic conditions or ICU admission. We used statistical process control charts to analyze outcomes over 2 general periods: baseline (January 2015-October 17, 2016) and implementation (October 18, 2016-April 2019). RESULTS: In total, 224 patients were included. The mean age was 6.1 years, and there were no substantive demographic or clinical differences between baseline and implementation groups. There was an 81% relative reduction in PICC use (centerline shift 54%-11%; 95% confidence interval 70-92) and 33% relative reduction in sedations per patient (centerline shift 1.8-1.2; 95% confidence interval 21-46). Empirical vancomycin use did not change (centerline 20%). CONCLUSIONS: Our multidisciplinary MSKI QI interventions were associated with a significant decrease in the use of PICCs and sedations per patient but not empirical vancomycin administration.

[Palliative Sedation at the End of Life: A Comparative Study of Chronic Obstructive Pulmonary Disease and Lung Cancer Patients].

BACKGROUND: Although patients with chronic obstructive pulmonary disease (COPD) receive poor-quality palliative care, information about the use of palliative sedation (PS) in the last days of life is very scarce. OBJECTIVES: To compare the use of PS in hospitalized patients who died from COPD or lung cancer and identify factors correlating with PS application. METHODS: In a retrospective observational cohort study, from 1,675 patients died at a teaching hospital between 2013 and 2015, 109 patients who died from COPD and 85 from lung cancer were compared. Sociodemographic data, clinical characteristics, health care resource utilization, application of PS and prescribed drugs were recorded. RESULTS: In the last 6 months of life, patients who died from COPD had more hospital admissions due to respiratory causes and less frequent support by a palliative home care team (PHCT). Meanwhile, during their last hospitalization, patients who died from COPD had fewer do-not-resuscitate orders and were subjected to more intensive care unit admissions and cardiopulmonary resuscitation maneuvers. PS was applied less frequently in patients who died from COPD than in those who died from lung cancer (31 vs. 53%, p = 0.002). Overall, previous use of opioid drugs, support by a PHCT, and a diagnosis of COPD (adjusted odds ratio 0.48, 95% CI: 0.26-0.89, p = 0.020) were retained as factors independently related to PS. In COPD patients, only previous use of opioid drugs was identified as a PS-related factor. CONCLUSION: During their last days of life, hospitalized COPD patients receive PS less frequently than patients with lung cancer.

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology.

PURPOSE: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. MATERIALS AND METHODS: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). RESULTS: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. CONCLUSIONS: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.

Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Variation in Practice and Outcomes.

OBJECTIVES: The aims of this study were to examine variation in the use of conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) across hospitals and over time and to evaluate outcomes of CS compared with general anesthesia (GA) using instrumental variable analysis, a quasi-experimental method to control for unmeasured confounding. BACKGROUND: Despite increasing use of CS for TAVR, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding. METHODS: Among 120,080 patients in the TVT (Transcatheter Valve Therapy) Registry who underwent transfemoral TAVR between January 2016 and March 2019, the relationship between anesthesia choice and TAVR outcomes was evaluated using hospital proportional use of CS as an instrumental variable. RESULTS: Over the study period, the proportion of TAVR performed using CS increased from 33% to 64%, and CS was used in a median of 0% and 91% of cases in the lowest and highest quartiles of hospital CS use, respectively. On the basis of instrumental variable analysis, CS was associated with decreases in in-hospital mortality (adjusted risk difference: 0.2%; p = 0.010) and 30-day mortality (adjusted risk difference: 0.5%; p < 0.001), shorter length of hospital stay (adjusted difference: 0.8 days; p < 0.001), and more frequent discharge to home (adjusted risk difference: 2.8%; p < 0.001) compared with GA. The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach, however. CONCLUSIONS: In contemporary U.S. practice, the use of CS for TAVR continues to increase, although there remains wide variation across hospitals. The use of CS for TAVR is associated with improved outcomes (including reduced mortality) compared with GA, although the magnitude of benefit appears to be less than in previous studies.

Trends in Outpatient Procedural Sedation: 2007-2018.

BACKGROUND: Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. METHODS: Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. RESULTS: A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). CONCLUSIONS: We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes.

BACKGROUND: Mechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens. METHODS: Patients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3. RESULTS: 371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions. CONCLUSION: In this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question.

Lack of recall after sedation for cataract surgery and its effect on the validity of measuring patient satisfaction.

BACKGROUND: We evaluated the validity of assessing patient satisfaction with the sedation regimen among patients being discharged 45 min after receiving midazolam. If most patients do not have recall, then the sedation cannot be considered complete at the time of evaluation. METHODS: In this prospective cohort study, 20 patients underwent cataract surgery with nurse-administered midazolam and fentanyl. The 11-item Iowa Satisfaction with Anesthesia Scale was administered  30 min after sedation in the recovery room. Recalled items were evaluated the next morning. RESULTS: Eleven patients recalled 0 themes, 4 recalled 1, 4 recalled 2, and 1 recalled 3 themes. Thus, 15/20 patients (75%) recalled 0 or 1 of the 11 themes (P = 0.021 versus half the patients). The 95% one-sided lower confidence limit for 0, 1, or 2 themes was 80% of patients (P < 0.001 versus half). Patients who received less midazolam recalled more themes (Kendall's τb = 0.43, P = 0.039). CONCLUSIONS: Evaluating patient satisfaction with sedation shortly after admission to the post-anesthesia care unit is invalid because of a lack of recall; the sedation/amnesia is ongoing. Patient comfort may be assessed, but comfort is not synonymous with satisfaction; 'satisfaction' implies presence of recall. Because we studied sedation with low doses of midazolam and fentanyl, the same conclusion reliably would apply to larger doses of anxiolytics administered intraoperatively. The results match previous findings that when patients receive preoperative midazolam prior to meeting the anesthesiologist, even if the patient fully answers questions, they may have negligible recall of having met the anesthesiologist.

The rise, fall, and future direction of computer-assisted personalized sedation.

PURPOSE OF REVIEW: The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. RECENT FINDINGS: CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. SUMMARY: Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model.

A national survey on routines regarding sedation in Swedish intensive care units.

Background: Previous studies concerning sedation in Swedish intensive care units (ICU) have shown variability in drug choices and strategies. Currently, there are no national guidelines on this topic. As an update to a Nordic survey from 2004, and as a follow-up to a recently introduced quality indicator from the Swedish Intensive Care Registry, we performed a national survey. Methods: A digital survey was sent to the ICUs in Sweden, asking for sedation routines regarding hypnosedatives, analgosedatives, protocols, sedation scales, etc. Results: Fifty out of 80 ICUs responded to the survey. All units used sedation scales, and 88% used the RASS scale; 80% used written guidelines for sedation. Propofol and dexmedetomidine were the preferred short-term hypnosedatives. Propofol, dexmedetomidine, and midazolam were preferred for long-term hypnosedation. Remifentanil, morphine, and fentanyl were the most frequently used agents for analgosedation. Conclusions: All ICUs used a sedation scale, an increase compared with previous studies. Concerning the choice of hypno- and analgosedatives, the use of dexmedetomidine, clonidine, and remifentanil has increased, and the use of benzodiazepines has decreased since the Nordic survey in 2004.

Outcomes of general anesthesia versus conscious sedation for Stroke undergoing endovascular treatment: a meta-analysis.

BACKGROUND: The impact of anesthesia strategy on the outcomes of acute ischemic stroke (AIS) patients undergoing endovascular treatment is currently controversy. Thus, we performed this meta-analysis to compare the differences of clinical and angiographic outcomes between general anesthesia (GA) and conscious sedation (CS). METHODS: A literature search in PubMed, Embase, and Web of Knowledge databases through February 2019 was conducted for related records on GA and CS of AIS undergoing endovascular treatment. The results of the studies were pooled and meta-analyzed with fixed- or random-effect model based on heterogeneity test in total and subgroup analyses. RESULTS: Twenty-three studies including 6703 patients were analyzed in this meta-analysis. We found that patients in the GA group have lower odds of favorable functional outcome (mRS scores ≤2) compared with the CS group (odds ratio [OR] = 0.62, 95% confidence interval [CI]: 0.49-0.77), and higher risk of mortality (OR = 1.68, 95% CI: 1.49-1.90), pneumonia (OR = 1.78, 95% CI: 1.40-2.26), symptomatic intracranial hemorrhage (OR = 1.64, 95% CI: 1.13-2.37). However, no significant differences were seen between the groups in the rate of recanalization (OR = 1.07, 95% CI: 0.89-1.28), vessel dissection or perforation (OR = 1.00, 95% CI: 0.98-1.03) and asymptomatic intracranial hemorrhage (OR = 1.19, 95% CI: 0.96-1.47). While in the RCT subgroup analysis, we found patients in the GA group does not show lower rate of favorable functional outcome compared with the CS group (OR = 1.84, 95% CI: 1.17-2.89). And there was no significant difference in the rate of mortality between GA and CS groups during RCT subgroup analysis (OR = 0.74, 95% CI: 0.43-1.27). CONCLUSIONS: AIS patients performed endovascular treatment under GA compared with CS was associated with worse functional outcome and increased rate of mortality, but differences in worsened outcomes do not exist when one looks into the GA vs. CS RCTs. Moreover, these findings are mainly based on the retrospective studies and additional multi-center randomized controlled trials to definitively address these issues is warranted.

Future of paediatric sedation: towards a unified goal of improving practice.

This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.

Ideal sedation for stroke thrombectomy: a prospective pilot single-center observational study.

OBJECTIVESeveral retrospective studies have supported the use of conscious sedation (CS) over general anesthesia (GA) as the preferred methods of sedation for stroke thrombectomy, but a recent randomized controlled trial showed no difference in outcomes after CS or GA. The purpose of the Ideal Sedation for Stroke Thrombectomy (ISST) study was to evaluate the difference in time and outcomes in the reperfusion of anterior circulation in ischemic stroke using GA and monitored anesthesia care (MAC).METHODSThe ISST study was a prospective, open-label registry. A total of 40 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke were enrolled. Informed consent was obtained from each patient before enrollment. The primary endpoint included the interval between the patient's arrival to the interventional radiology room and reperfusion time. Secondary endpoints were evaluated to estimate the effects on the outcome of patients between the 2 sedation methods.RESULTSOf the 40 patients, 32 received thrombectomy under MAC and 8 patients under GA. The male-to-female ratio was 18:14 in the MAC group and 4:4 in the GA group. The mean time from interventional radiology room arrival to reperfusion in the GA group was 2 times higher than that in the MAC group. Complete reperfusion (TICI grade 3) was achieved in more than 50% of patients in both groups. The mean modified Rankin Scale score at 3 months was < 2 in the MAC group and > 3 in the GA group (p = 0.021).CONCLUSIONSThe findings from the pilot study showed a significantly shorter time interval between IR arrival and reperfusion and better outcomes in patients undergoing reperfusion for ischemic stroke in the anterior circulation using MAC compared with GA.Clinical trial registration no.: NCT03036631 (clinicaltrials.gov).

Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide.

BACKGROUND AND AIMS: The use of anesthesia assistance (AA) for outpatient colonoscopy has been increasing over the past decade, raising concern over its effects on procedure safety, quality, and cost. We performed a nationwide claims-based study to determine regional, patient-related, and facility-related patterns of anesthesia use as well as cost implications of AA for payers. METHODS: We analyzed the Premier Perspective database to identify patients undergoing outpatient colonoscopy at over 600 acute-care hospitals throughout the United States from 2006 through 2015, with or without AA. We used multivariable analysis to identify factors associated with AA and cost. RESULTS: We identified 4,623,218 patients who underwent outpatient colonoscopy. Of these, 1,671,755 (36.2%) had AA; the proportion increased from 16.7% in 2006 to 58.1% in 2015 (P < .001). Factors associated with AA included younger age (odds ratios [ORs], compared to patients 18-39 years old: 0.94, 0.82, 0.77, 0.72, and 0.77 for age groups 40-49 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years, respectively); and female sex (OR, 0.96 for male patients compared to female patients; 95% CI, 0.95-0.96). Black patients were less likely to receive AA than white patients (OR, 0.81; 95% CI, 0.81-0.82), although this difference decreased with time. The median cost of outpatient colonoscopy with AA was higher among all payers, ranging from $182.43 (95% CI, $180.80-$184.06) higher for patients with commercial insurance to $232.62 (95% CI, $222.58-$242.67) higher for uninsured patients. CONCLUSIONS: In an analysis of a database of patients undergoing outpatient colonoscopy throughout the United States, we found that the use of AA during outpatient colonoscopy increased significantly from 2006 through 2015, associated with increased cost for all payers. The increase in anesthesia use mandates evaluation of its safety and effectiveness in colorectal cancer screening programs.

Sedación paliativa en hemorragia digestiva alta masiva (hematemesis) / Palliative sedation in massive upper gastrointestinal bleeding (haematemesis)

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Arthroscopic knotless anterior labral stabilization using labral tape and wide awake anaesthesia-short term results.

BACKGROUND: The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 20%. There is a lack of evidence in the literature regarding use of labral tape and anchors for anterior stabilization despite the growing market for this product. We describe the outcomes of 67 patients who underwent knotless arthroscopic anterior stabilisation under awake anaesthesia using 1.5 mm LabralTape with 2.9 mm Pushlock anchors for primary anterior instability by a single surgeon. METHODS: This was a retrospective analysis of prospectively collected outcome data for adult patients undergoing anterior stabilisation for primary traumatic anterior shoulder instability between 2013 and 2016 at two centres. Patients with > 25% glenoid bone loss, engaging Hill Sach's, and multidirectional instability were excluded. All cases underwent surgery using awake anaesthetic technique. The surgical technique and post-operative physiotherapy was standardized. Outcomes were measured at 6 months and 12 months. RESULTS: Of the 74 patients in our study, 7 were lost to follow up. Outcomes were measured using the Oxford Instability Shoulder Score (OISS) and clinical assessment including the range of motion. The OISS showed statistically significant improvement from a mean score and standard deviation (SD) of 24.72 ± 2.8 pre-surgery to 43.09 ± 3.5 after the procedure at 12 months with good to excellent outcomes in 66 cases (98.5%). The mean abduction was 134.2 ± 6.32 and external rotation was 72.55 ± 5.42 at 60-90 position at 12 months. We report no failures due to knot slippage or anchor pull-out. CONCLUSION: Our case series using the above technique has distinct advantages of combining a small non-absorbable implant with flat, braided, and high-strength polyethylene tape. This technique demonstrates superior medium term results to conventional suture knot techniques for labral stabilization thereby validating its use.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures.

PURPOSE OF REVIEW: To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. RECENT FINDINGS: The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.