Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery.

BACKGROUND: Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models. RESULTS: The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05). CONCLUSION: There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Factors Associated With Same Day Discharge Post-Spinal Cord Stimulator Placement.

BACKGROUND: Spinal cord stimulator (SCS) surgeries, whether performed using the open or percutaneous approach, are becoming increasingly common for a range of neuropathic pain conditions, including post-laminectomy syndrome and complex regional pain syndrome. However, there is limited knowledge regarding the factors linked to same-day discharge patterns following SCS. OBJECTIVE: The purpose of this study was to identify factors associated with same-day discharge after SCS placement. The primary outcome was same-day discharge. STUDY DESIGN: Retrospective, cohort study using a nationwide database. METHODS: Inclusion criteria included patients who underwent percutaneous or open SCS from January 1, 2014 through December 31, 2021. Exclusion criteria included patients with missing data (n = 178) and those with SCS implants for unlisted indications (n = 1,817). A multivariable analysis was conducted on the outcome data and co-variates associated with same-day discharge after SCS. RESULTS: After applying inclusion and exclusion criteria, a total of 18,058 patients remained in the final data set, including 7,339 patients who underwent percutaneous SCS and 10,719 patients who underwent open SCS procedures. After analysis, factors associated with increased rates of same-day discharge after SCS included men (odds ratio [OR] 1.16; 95% CI, 1.09 -1.24;  P < 0.001), patients on Medicaid (OR 1.64; 95% CI, 0.1.34 - 2.01; P < 0.001), and hospitals in the US Midwest (OR 1.66; 95% CI, 1.45 - 1.90; P < 0.001) and hospitals in the US West (OR 1.32; 95% CI, 1.20 - 1.46; P < 0.001). Factors associated with decreased rates of same-day discharge after SCS included the open approach (OR 0.21; 95% CI, 0.19 - 0.23; P < 0.001), Hispanic ethnicity (OR 0.61; 95% CI, 0.54 - 0.69; P < 0.001) and increased age (OR 0.99; 95% CI, 0.98 - 0.99; P < 0.001). LIMITATIONS: Since our study is retrospective, the data are subject to various biases, including variable confounding, human error in data entry, and generalizability of the results. CONCLUSION: These results can be used to help determine hospital bed needs post-SCS surgery. Future research should focus on identifying the specific reasons certain demographic and geographic factors might influence same-day discharge rates. Our study provides important insights into the factors associated with same-day discharge rates post open and percutaneous SCS implant and highlights the need for patient-centered, evidence-based approaches to health care delivery.

Racial Differences in 30-Day Reintubation After Head and Neck Surgery.

Background This study aimed to examine the association of race and ethnicity with 30-day unplanned reintubation following head and neck surgery. Methodology A retrospective analysis of head and neck surgery patients aged greater than or equal to 18 years was extracted from the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020. Patient demographics, comorbidities, and 30-day reintubation were included in the analysis. Pearson's chi-square and independent samples t-test were used to compare reintubation cohorts. Multivariable logistic regression was used to identify the association of race and ethnicity with 30-day reintubation. Results Of the total 108,442 head and neck surgery cases included, 74.9% of patients were non-Hispanic White, 17.3% were non-Hispanic Black, and 7.7% were Hispanic. The overall 30-day reintubation rate was 0.33%. After adjusting for age, body mass index, sex, and comorbidities, non-Hispanic Black patients had increased 30-day reintubation compared to non-Hispanic White patients (odds ratio [OR] = 2.14, 95% confidence interval [CI] 1.70-2.69, and P < 0.0001). There was no difference in 30-day reintubation for Hispanic patients compared to non-Hispanic White patients (OR = 1.08, 95% CI 0.67-1.65, and P = 0.747). Conclusions This analysis showed that non-Hispanic Black patients disproportionately had higher odds of 30-day reintubation following head and neck surgery. Hispanic ethnicity was not associated with increased odds of 30-day reintubation. More studies are needed to investigate the reasons for these racial differences.

Racial and Ethnic Differences in the Receipt of Regional Anesthesia Among Patients Undergoing Thoracic Surgery.

OBJECTIVES: The objective of this study was to assess differences in the use of perioperative regional anesthesia for thoracic surgery based on race and ethnicity. DESIGN: This retrospective cohort study used data from the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2020. The study authors applied a multivariate logistic regression in which the dependent variable was the primary endpoint (regional versus no regional anesthesia). The primary independent variables were race and ethnicity. SETTING: Multiple healthcare systems in the United States. PARTICIPANTS: Participants were ≥18 years of age and undergoing thoracic surgery. INTERVENTIONS: Regional anesthesia. MEASUREMENTS AND MAIN RESULTS: On adjusted multivariate analysis, Hispanic patients had lower odds (odds ratio [OR] 0.61, 95% CI 0.46-0.80, p = 0.0003) of receiving regional anesthesia for postoperative pain control compared to non-Hispanic patients. There was no significant difference in the odds of regional anesthesia when comparing racial cohorts (ie, White, Black, Asian, or other). CONCLUSIONS: There were differences observed in the provision of regional anesthesia for thoracic surgery among ethnic groups. Although the results of this study should not be taken as evidence for healthcare disparities, it could be used to support hypotheses for future studies that aim to investigate causes of disparities and corresponding patient outcomes.

Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy.

STUDY OBJECTIVE: The primary aim of this study is to understand how intraoperative medication administration patterns change in response to ERAS® protocol implementation for patients who underwent laparoscopic donor nephrectomy. DESIGN: Single-center, retrospective analysis of laparoscopic donor nephrectomy patients. SETTING: Large tertiary academic medical center. PATIENTS: We divided all cases of laparoscopic donor nephrectomies (n = 929) over seven years into three approximately equal time periods: Pre-ERAS 1 (n = 317), Pre-ERAS 2 (n = 297) and Post-ERAS (n = 315). MEASUREMENTS: We examined patient demographics, intraoperative opioid and non-opioid pain adjuvant administration, Post Anesthesia Recovery Unit (PACU) pain scores and opioid use as well as PACU and hospital lengths of stay (LOS). MAIN RESULTS: Segmented regression analysis of interrupted time series was utilized to evaluate the association of ERAS protocol implementation with the amount of intraoperative opioid and non-opioid pain adjuvant use. In adherence to our institutional ERAS protocol, there was a significant reduction in intraoperative fentanyl use after ERAS protocol of -70.2µg (95% CI -106.0, -34.2, p < 0.001) and a significant increase in intraoperative hydromorphone use of 0.47 mg (95% CI 0.284, 0.655, p < 0.001). However, in contrary to our ERAS protocol, we found no significant change in odds of receiving IV acetaminophen OR 1.31 (95% CI 0.450, 3.76, p = 0.613) or IV ketorolac OR 1.65 (95% CI 0.804, 3.41, p = 0.172) after ERAS protocol implementation. We found a significant reduction in PACU opioid use of -9.68 Morphine Milligram Equivalents (MME) (95% CI -17.1, -2.31, p = 0.010) but no significant change in PACU initial pain score, PACU LOS and hospital LOS. CONCLUSIONS: We examined intraoperative practice pattern changes by anesthesiologists in response to ERAS protocol implementation for laparoscopic donor nephrectomies. Our results suggest that there was a variable uptake of recommendations from ERAS protocol. While ERAS protocols are often studied as a bundle of best practice recommendations, understanding the variability of provider adherence represents an important future research direction for the ERAS initiative.

The Association of Preoperative Hematocrit With Adverse Events Following Exploratory Laparotomy in Septic Patients: A Retrospective Analysis.

BACKGROUND: Sepsis continues to be the leading cause of death in intensive care units and surgical patients comprise almost one third of all sepsis patients. Anemia is a modifiable risk factor for worse postoperative outcomes in sepsis patients. Here we aim to evaluate the association of preoperative anemia and postoperative mortality in sepsis patients undergoing exploratory laparotomy. METHODS: The National Surgical Quality Improvement Program registry was used to query for preoperative sepsis patients undergoing exploratory laparotomy between 2014 and 2016. Preoperative hematocrit was stratified into 4 categories: ≥30% to polycythemia, <21%, 21 and less than 30%, and polycythemia. The primary outcome was 30-day mortality. Multivariable logistic regression was used to evaluate the association of preoperative hematocrit with primary and secondary endpoints. The multivariable analysis included preoperative hematocrit, gender, age, BMI, smoking status, functional status, hypertension, steroid use, bleeding disorder, and sepsis. The odds ratio (OR) with associated 95% confidence interval (CI) is reported for all outcomes. A p-value of less than <0.05 was considered statistically significant. RESULTS: The unadjusted 30-day death rate was the highest for patients with preoperative hematocrit <21% (p < 0.001) compared to the other hematocrit cohorts. The odds of 30-day death was significantly increased for patients with preoperative hematocrit <21% (OR 2.39 95% CI: 1.28-4.49, p = 0.006) and 21-30% (OR 1.35, 95% CI: 1.05 -1.72, p = 0.017) compared to patients with preoperative hematocrit of ≥30% and less than polycythemic ranges (reference cohort). CONCLUSION: Preoperative anemia in sepsis patients undergoing surgery can lead to increased mortality, postoperative complications, and length of hospital stay. Diagnosing sepsis early in the hospital course can allow physicians more time to titrate anticoagulation medications and treat preoperative anemia.

An Update on Racial and Ethnic Differences in Neuraxial Anesthesia for Cesarean Delivery.

Background Racial and ethnic differences in the use of neuraxial anesthesia compared with general anesthesia are less studied, particularly in obstetrical anesthesia. Here, we aimed to provide an update on the association between race and ethnicity, and the use of neuraxial anesthesia for cesarean delivery in the United States (US). Methods We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File 2019. We extracted cases that had a primary surgery defined with Current Procedural Terminology (CPT) code for cesarean delivery (59510, 59514, and 59515) and cesarean after attempted vaginal delivery in parturients with a prior history of cesarean (59618, 59620, and 59622). Multivariable logistic regression was used to report the association of race and ethnicity with primary anesthetic technique. Results There were 12,876 parturients included in the study. Compared with White parturients, Black (adjusted odds ratio (aOR) = 0.71, 95% confidence interval (CI): 0.57-0.88, p = 0.001) and American Indian or Alaska Native (aOR = 0.22, 95% CI: 0.12-0.40, p < 0.001) parturients had lower odds of receiving neuraxial compared with general anesthesia. There were no significant differences in the odds of neuraxial anesthesia between non-Hispanic and Hispanic cohorts. Conclusions While we do observe racial differences in anesthetic technique, Hispanic patients did not have significantly lower odds of neuraxial anesthesia. This study highlights the importance of an update to prior studies, as the current study suggests a lack of disparity between non-Hispanic and Hispanic parturients. While the results here are encouraging, a multidisciplinary approach is necessary to further address racial disparities.

The Influence of Hospital Urbanicity on Mortality in Patients With Acute Respiratory Failure: A National Cohort Retrospective Analysis.

BACKGROUND: The primary objective of this study was to employ a national database to evaluate the association of hospital urbanicity, urban versus rural, on mortality and length of hospital stay in patients hospitalized with acute respiratory failure. METHODS: We used the 2014 National Inpatient Sample database to evaluate the association of hospital urbanicity with (1) mortality and (2) prolonged hospital stay, defined as ≥ 75th percentile of the study population. We conducted a mixed-effects logistic regression analysis adjusting for sociodemographic variables and medical comorbidities. The random effect was hospital identification number (a unique value assigned in the NIS database for a specific institution). The odds ratio (OR), 95% CI, and P values were reported for each independent variable. RESULTS: The odds of inpatient mortality were significantly higher among urban teaching (OR 1.39, 95% CI 1.39-1.66, P < .001) and urban nonteaching hospitals (OR = 1.39, 95% CI 1.26-1.52, P < .001) compared to rural hospitals. The odds of prolonged hospital stay were significantly higher among urban teaching (OR = 1.82, 95% CI 1.66-2.0, P < .001) and urban nonteaching compared to rural hospitals (OR = 1.50, 95% CI 1.36-1.65, P < .001). CONCLUSIONS: This study supports the current body of literature that there are significant differences in patient populations among hospital type. Differences in health outcomes among different types of hospitals should be considered when designing policies to address health equity as these are unique populations with specific needs.

Class 3 obesity is not associated with same-day admission in obese patients undergoing parathyroidectomy.

IMPORTANCE: Rising rates of obesity and outpatient performance of parathyroidectomies are making it increasingly crucial to investigate the association of obesity with post-operative complications. OBJECTIVE: To determine whether Class 3 obesity is associated with increased same-day admission compared to lower obesity classes following outpatient parathyroidectomy. DESIGN: Retrospective cohort study. SETTING: Outpatient surgery. PATIENTS: 12,973 patients ≥18 years old who underwent outpatient parathyroidectomy between 2014 and 2016, per the American College of Surgeons National Surgical Quality Improvement Program registry. INTERVENTIONS: Primary exposure variable: body mass index (BMI), with patients assigned to one of six cohorts. MEASUREMENTS: Primary outcome measure: same-day admission. Secondary outcome measure: 30-day readmission. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). MAIN RESULTS: There was a final sample size of 12,973 adult patients who underwent parathyroidectomy from 2014 to 2016. The admission rate for BMI ≥30 and < 40 kg/m2 (reference cohort) was 42.6%. The admission rates for Class 3 obesity categories were 46.2%, 56.2%, and 52.6% for those in the BMI range of ≥40 kg/m2 and < 50 kg/m2, ≥50 kg/m2 and < 60 kg/m2, and ≥ 60 kg/m2, respectively. On multivariable logistic regression, there were no difference in the odds of 30-day hospital admission or readmission rate with any of the BMI cohorts when compared to the reference group. CONCLUSIONS: There is no significant difference in rates of same-day admission or 30-day readmission between any Class 3 (BMI ≥40 kg/m2) obesity cohort and the Class 1 and 2 (BMI ≥30 and < 40 kg/m2) reference cohort following outpatient parathyroidectomy. This corroborates the notion that BMI classes cannot be used in a vacuum to determine eligibility for outpatient parathyroidectomy - a concept that can guide safe and cost-effective institutional practices.

Should there be a body mass index eligibility cutoff for elective airway cases in an ambulatory surgery center? A retrospective analysis of adult patients undergoing outpatient tonsillectomy.

STUDY OBJECTIVE: It is unclear what the body mass index (BMI) should be when performing surgery involving the airway at an outpatient surgery facility. The objective of this study was to evaluate the association of Class 3 obesity versus a composite cohort of Class 1 and 2 obesity with same-day hospital admission following outpatient tonsillectomy in adults. DESIGN: Retrospective cohort study. SETTING: Multi-institutional. PATIENTS: Patients undergoing outpatient tonsillectomy. INTERVENTION: None. MEASUREMENTS: We used the National Surgical Quality Improvement Program (NSQIP) to analyze association of BMI to same-day admission and 30-day readmission following outpatient tonsillectomy from 2017 to 2019. We looked at six BMI cohorts: 1) ≥30 and < 40 kg/m2 (reference cohort), 2) ≥20 and < 30 kg/m2, 3) <20 kg/m2, 4) ≥40 and < 50 kg/m2, 5) ≥50 and < 60 kg/m2, and 6) ≥60 kg/m2. We used multivariable Poisson regression with robust standard errors and controlled for various confounders to calculate risk ratios (RR) and 99% confidence intervals (CI). MAIN RESULTS: There were 12,287 patients included in the final analysis, at which 697 (5.7%) and 283 (2.3%) had a same-day admission or 30-day readmission, respectively. On Poisson regression with robust standard errors, the relative risks for BMI ≥40 kg/m2 and < 50 kg/m2, ≥50 kg/m2 and < 60 kg/m2, and ≥ 60 kg/m2 (BMI ≥30 kg/m2 and < 40 kg/m2 was the reference group) were 1.31 (99% CI 1.03-1.65, p = 0.03), 1.99 (99% CI 1.43-2.78, p = 0.002), and 1.80 (99% CI 1.00-3.25, p = 0.07), respectively. Furthermore, Class 3 obesity was not associated with 30-day readmission. CONCLUSION: These results contribute data that may help practices - especially freestanding ambulatory surgery centers - decide appropriate BMI cutoffs for surgery involving the airway. Whether this is considered clinically significant enough to rule out eligibility will differ from practice-to-practice and will depend on surgical volume, resources available and financial interests.

The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery.

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m2 underweight, ≥20 to <25 kg/m2 normal weight, ≥25 to <30 kg/m2 overweight, ≥30 to <40 kg/m2 obese, ≥40 kg/m2to <50 kg/m2 severely obese, and ≥50 kg/m2 extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.

Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence.

PURPOSE OF REVIEW: In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD). RECENT FINDINGS: Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.

Monitored Anesthesia Care Versus General Anesthesia as the Primary Anesthetic for Ankle Amputations.

OBJECTIVES: The authors hypothesized that monitored anesthesia care (MAC)-either by local sedation or regional anesthesia (RA)-compared with general anesthesia (GA), would be associated with lower odds of significant 30-day postoperative complications and mortality in patients undergoing an ankle amputation. DESIGN: Retrospective cohort study. SETTING: Inpatient. PARTICIPANTS: The authors used data from patients who underwent ankle amputation from the American College of Surgeons National Surgical Quality Improvement Program registry. INTERVENTION: RA as primary anesthetic. MEASUREMENTS AND MAIN RESULTS: A multivariate logistic regression was used to evaluate the association of primary anesthesia type with the outcomes. The regression analysis included all covariates to test the association of the primary exposure variable (anesthesia type) with each outcome of interest. The odds ratio (OR), with associated 95% confidence interval (CI), was reported for each covariate. There were a total of 3,368 patients undergoing guillotine amputation through the tibia/fibula (n = 2,935) or ankle disarticulation (n = 433). Among these patients, 15.5% (n = 491) received MAC as their primary anesthetic. Among all patients, 11.4% (n = 363) experienced a significant postoperative complication. On multivariate logistic regression, MAC was found to decrease odds of postoperative complications (OR 0.57, 95% CI 0.40-0.82, p = 0.002), but not mortality (OR 1.26, 95% CI 0.87-1.84, p = 0.22). CONCLUSION: This study showed that MAC was associated with improved outcomes, as opposed to GA, as the primary anesthetic in ankle amputations.

Geriatric Patients Undergoing Outpatient Surgery in the United States: A Retrospective Cohort Analysis on the Rates of Hospital Admission and Complications.

INTRODUCTION:  This study is a retrospective cohort analysis that describes key clinical outcomes in elderly individuals who undergo outpatient surgical procedures. In particular, we report same-day admission, 30-day mortality, 30-day complications, and 30-day readmission rates for three separate age groups undergoing frequent outpatient, general surgical procedures. METHODS: Patients ≥18 years old who underwent the 10 most common outpatient surgical procedures in the National Surgical Quality Improvement Program database from 2017 to 2019 and who underwent general anesthesia were included in the study. The primary outcome of interest was hospital admission, defined as hospital length of stay >0 days. Secondary outcomes of interest included 30-day readmission, 30-day mortality, and 30-day postoperative complications. The primary exposure variable of interest was age, which was divided into <65 years of age (reference cohort), 65-79 years of age, and ≥80 years of age. For univariate analysis, to measure differences in the outcomes and patient characteristics, we used chi-squared tests. Our primary method of analysis was multivariable logistic regression. RESULTS: Those who were ≥80 and 65-79 years of age compared to <65 years of age had higher odds of same-day admission, 30-day mortality, composite postoperative complications, and readmission. Patients who were ≥80 years old had higher odds of same-day admission for laparoscopic cholecystectomy, partial mastectomy, laparoscopic inguinal hernia repair, inguinal hernia repair, umbilical hernia repair, laparoscopic removal of adnexal structures, and lumbar laminotomy. CONCLUSION: Increasing age, particularly greater than 80 years or older and 65-79 years of age group, is associated with an increased rate of same-day hospital admissions and complications after ambulatory surgery.