Outpatient compared to inpatient thyroidectomy on 30-day postoperative outcomes: a national propensity matched analysis.

BACKGROUND: To address the postoperative outcomes between outpatient and inpatient neck surgery involving thyroidectomy procedures. METHODS: A cohort analysis of surgical patients undergoing primary, elective, total thyroidectomy from multiple United States medical institutions who were registered with the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2018. The primary outcome was a composite score that included any 30-day postoperative adverse event. RESULTS: A total of 55,381 patients who underwent a total thyroidectomy were identified comprising of 14,055 inpatient and 41,326 outpatient procedures. A cohort of 13,496 patients who underwent outpatient surgery were propensity matched for covariates with corresponding number of patients who underwent inpatient thyroidectomies. In the propensity matched cohort, the occurrence of any 30-day after surgery complications were greater in the inpatient group, 424 out of 13,496 (3.1%) compared to the outpatient group, 150 out of 13,496 (1.1%), P < 0.001. Moreover, death rates were greater in the inpatient group, 22 out 13,496 (0.16%) compared to the outpatient group, 2 out of 13,496 (0.01%), P < 0.001. Similarly, hospital readmissions occurred with greater frequency in the inpatient group, 438 out of 13,496 (3.2%) compared to the outpatient group, 310 out of 13,496 (2.3%), P < 0.001. CONCLUSION: Thyroidectomy procedures performed in the outpatient setting had less rates of adverse events, including serious postoperative complications (e.g., surgical site infection, pneumonia, progressive renal insufficiency). In addition, patients who had thyroidectomy in the outpatient setting had less 30-day readmissions and mortality. Surgeons should recognize the benefits of outpatient thyroidectomy when selecting disposition of patients undergoing neck surgery.

Burnout and depression among anesthesiology trainees in the United States: An updated National Survey.

STUDY OBJECTIVE: A high prevalence of burnout, depression and suicidal ideation has been reported among anesthesiology trainees. Over the last decade, there has been a significant emphasis on the development of wellness programs in academic departments to mitigate the prevalence and effects of burnout during anesthesiology training. Therefore, we aimed to reevaluate the prevalence of burnout and depression in anesthesiology trainees in the United States. DESIGN: Cross-sectional survey. SETTING: Anesthesiology Department. PATIENTS: A nationally representative sample of 1000 anesthesiology trainees in the United States. MEASUREMENTS: A 33-item questionnaire consisting of 1) burnout, 2) depression, 3) job satisfaction, 4) family support, 5) work characteristics, 6) demographic factors, 7) self-reported errors, and 8) impact of COVID-19 pandemic. RESULTS: We received 384 responses. Twenty-four percent (91/384) of the respondents met the criteria for high burnout risk and 58/384 (15%) of the respondents screened positive for depression. Multivariable analysis revealed that: (1) hours per week > 70, (odds ratio [OR; 95% confidence interval {CI}] = 3.1 [1.4-6.8], P=0.005 and (2) overnight calls per month > 7 (OR [95% CI] = 2.5 [1.0- 6.0], P=0.03 were independent factors for increased odds of burnout whereas the presence of (3) married/domestic partnership (OR [95% CI} = 0.52 [0.32-0.85], P=0.01 was associated with lower odds of burnout and/or depression. Ten percent (4/40) of high burnout/depression residents reported that they often times fall short in the quality of care provided to patients compared to 0.36% (1/275) residents with low burnout/depression scores, P < 0.001. Similarly, 22% (9/40) of high burnout/depression residents reported that they often times did not have enough attention to their patients compared to 4% (11/275) residents with low burnout/depression scores, P < 0.001. CONCLUSIONS: We report a still concerning but significantly lower rate of burnout and depression in anesthesiology trainees than previously reported a decade ago. This suggests that efforts on wellness implemented by academic programs have positively impacted the work experience of anesthesia trainees.

Thromboelastometry Predicts Thromboembolic Events, Hospital Length of Stay, and Mortality in Patients with COVID-19 Infection and Mild Hypoxemia: A Prospective Observational Study.

Background: The aim of this study was to assess changes in hemostasis and associated outcome of hospitalized patients with COVID-19 infection and mild hypoxemia. Methods: Adult patients with COVID-19 infection and hypoxemia admitted to ICU were included in this prospective observational study. The primary outcome was defined as an unfavorable course of the disease if a patient: (1) developed a thromboembolic event while receiving anticoagulation prophylaxis, (2) had prolonged ICU stay, or (3) died. Demographic data, laboratory parameters and thromboelastometry (ROTEM) test results were collected. Results: Twenty-five patients were recruited into the study. There were 16 patients with an unfavorable course of the disease. Compared to the 9 patients in the favorable course group, patients with an unfavorable course had a lower platelet count, median difference of 154 (95% CI, 26 to 223 x109/L), P = 0.012, and lower clot firmness parameters in EXTEM assay: amplitude at 20 minutes (A20), median difference of 7 (95% CI, 2 to 11) P = 0.006, maximum clot firmness (MCF), median difference of 6 (95% CI, 3 to 10) P = 0.006 and area under the curve (AUC) with a median difference of 671 (95% CI, 244 to 1029) P = 0.005. They also demonstrated suppression of fibrinolysis: higher lysis index 60, median difference of -3 (95% CI, -6 to 0), P = 0.023. Results of functional fibrinogen (FIBTEM) assay were similar between the groups. Conclusion: The platelet count and the results of EXTEM assay, but not FIBTEM assay, were associated with the difference in clinical outcome among patients with COVID-19 infection and hypoxemia. The role of platelets in the outcome of COVID-19 infection calls for further investigation. Future studies on adjusting anticoagulant therapy based on the results of viscoelastic testing may be beneficial.

The impact of hypoalbuminemia on postoperative outcomes after outpatient surgery: a national analysis of the NSQIP database.

PURPOSE: Hypoalbuminemia has been described as a modifiable factor to optimize postoperative outcomes after major inpatient surgeries. Nevertheless, the role of hypoalbuminemia on outpatient procedures is not well defined. The purpose of this study was to examine the impact of hypoalbuminemia on postoperative outcomes of patients undergoing low-risk outpatient surgery. METHODS: Patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program database who had outpatient surgery from 2018 and recorded preoperative albumin levels. The primary outcome was a composite of any major complications including: 1) unplanned intubation, 2) pulmonary embolism, 3) ventilator use > 48 hr, 4) progressive renal failure, 5) acute renal failure, 6) stroke/cerebrovascular accident, 7) cardiac arrest, 8) myocardial infarction, 9) sepsis, 10) septic shock, 11) deep venous thrombosis, and 12) transfusion. Death, any infection, and readmissions were secondary outcomes. RESULTS: A total of 65,192 (21%) surgical outpatients had albumin collected preoperatively and 3,704 (1.2%) patients had levels below 3.5 g⋅dL-1. In the albumin cohort, 394/65,192 (0.6%) patients had a major medical complication and 68/65,192 (0.1%) patients died within 30 days after surgery. Albumin values < 3.5 g⋅dL-1 were associated with major complications (adjusted odds ratio [aOR], 1.92; 95% confidence interval [CI], 1.44 to 2.57; P < 0.001; death-adjusted OR, 3.03; 95% CI, 1.72 to 5.34; P < 0.001); any infection (aOR, 1.49; 95% CI, 1.23 to 1.82; P < 0.001); and readmissions (aOR, 1.82; 95% CI, 1.56 to 2.14; P < 0.001). In addition, when evaluated as a continuous variable in a multivariate analysis, for each increase in albumin of 0.10 g⋅dL-1, there was an associated reduction of major complications (aOR, 0.94; 95% CI, 0.92 to 0.96; P < 0.001). CONCLUSIONS: Hypoalbuminemia is associated with major complications and death in outpatient surgery. Since hypoalbuminemia is a potential modifiable intervention, future clinical trials to evaluate the impact of optimizing preoperative albumin levels before outpatient surgery are warranted.

RéSUMé: OBJECTIF: L'hypoalbuminémie a été décrite comme un facteur modifiable pour optimiser les issues postopératoires après des chirurgies hospitalières majeures. Néanmoins, le rôle de l'hypoalbuminémie dans les interventions ambulatoires n'est pas bien défini. L'objectif de cette étude était d'examiner l'impact de l'hypoalbuminémie sur les issues postopératoires des patients bénéficiant d'une chirurgie ambulatoire à faible risque. MéTHODE: Les patients ayant bénéficié d'une chirurgie ambulatoire à partir de 2018 et pour lesquels les taux d'albumine préopératoire ont été enregistrés ont été extraits de la base de données américaine du programme national d'amélioration de la qualité chirurgicale (NSQIP) de l'American College of Surgeons. Le critère d'évaluation principal était un composite de toutes les complications majeures, y compris : 1) intubation non planifiée, 2) embolie pulmonaire, 3) utilisation d'un ventilateur > 48 h, 4) insuffisance rénale progressive, 5) insuffisance rénale aiguë, 6) accident vasculaire cérébral, 7) arrêt cardiaque, 8) infarctus du myocarde, 9) sepsis, 10) choc septique, 11) thrombose veineuse profonde, et 12) transfusion. Les décès, infections et réadmissions constituaient des critères d'évaluation secondaires. RéSULTATS: Au total, les taux d'albumine ont été prélevés chez 65 192 (21 %) patients chirurgicaux ambulatoires avant l'opération et 3704 (1,2 %) patients avaient des taux inférieurs à 3,5 g⋅dL-1. Dans la cohorte albumine, 394 / 65 192 (0,6 %) patients ont eu une complication médicale majeure et 68 / 65 192 (0,1%) patients sont décédés dans les 30 jours suivant la chirurgie. Des valeurs d'albumine < 3,5 g⋅dL-1 étaient associées à des complications majeures (rapport de cotes ajusté [RCA]), 1,92 ; intervalle de confiance [IC] à 95 %, 1,44 à 2,57; P < 0,001; RC ajusté en fonction du décès, 3,03; IC 95 %, 1,72 à 5,34; P < 0,001); infections (RCA, 1,49; IC 95 %, 1,23 à 1,82; P < 0,001); et réadmissions (RCA, 1,82; IC 95 %, 1,56 à 2,14; P < 0,001). De plus, lorsque le taux d'albumine était évalué comme variable continue dans une analyse multivariée, pour chaque augmentation de l'albumine de 0,10 g⋅dL-1, il y avait une réduction associée des complications majeures (RCA, 0,94; IC 95 %, 0,92 à 0,96; P < 0,001). CONCLUSION: L'hypoalbuminémie est associée à des complications majeures et au décès en chirurgie ambulatoire. Étant donné que l'hypoalbuminémie est une intervention potentiellement modifiable, de futures études cliniques visant à évaluer l'impact de l'optimisation des taux préopératoires d'albumine avant une chirurgie ambulatoire sont nécessaires.

Utility of preoperative laboratory testing in ASA 1 & ASA 2 patients undergoing outpatient surgery in the United States.

STUDY OBJECTIVE: To assess the utility of preoperative testing in ASA physical status 1 and 2 patients undergoing outpatient surgery across several surgical specialties. DESIGN: Retrospective cohort study. PATIENTS: The American College of Surgeons National Surgical Quality Improvement Program database from 2017 to 2018 was queried to extract patients defined as ASA 1 and 2 who underwent outpatient surgeries. A total of 352,775 adult patients underwent outpatient surgery with 186,954 patients had at least one lab drawn within 30 days prior to the surgery. INTERVENTIONS: ASA physical status 1 and 2 patients who underwent outpatient surgeries. MEASUREMENTS: The primary independent variable was the utilization of preoperative laboratory testing. The primary outcomes were the occurrence of any medical or surgical complication adverse events within 30 days of discharge. In addition, we also examined hospital readmissions. A P value of 0.025 was used to avoid type I error for each primary outcome. MAIN RESULTS: In the overall cohort, 186,954 out of 352,775 (53%) of patients had at least one lab test. Hematology was the most common lab test ordered, 172,903 out of 352,755 patients (49%), followed by chemistry (43%), liver function (23%), and coagulation tests (11%). After adjusting for confounding factors, the use preoperative testing was not associated with overall medical complications, OR (95%CI) of 1.09 (1.00 to 1.18), P = 0.05 and overall surgical complications, 1.00 (0.92 to 1.08), P = 0.96 [Bonferroni corrected: medical complications OR (97.5% CI) of 1.09 (0.989 to 1.202), P = 0.0950 and overall surgical complications, 1.00 (0.918 to 1.093), P = 1.00. CONCLUSION: We detected a low utility of preoperative tests for ASA 1 and 2 patients undergoing a large variety of outpatient procedures. Our results support the elimination of preoperative laboratory test for ASA 1 and 2 undergoing ambulatory surgery.

Early Postoperative Outcomes of Super Morbid Obese Compared to Morbid Obese Patients After Ambulatory Surgery Under General Anesthesia: A Propensity-Matched Analysis of a National Database.

BACKGROUND: Patients with body mass index (BMI) ≥50 kg/m2, defined as super morbid obesity, represent the fastest growing segment of patients with obesity in the United States. It is currently unknown if super morbid obese patients are at greater odds than morbid obese patients for poor outcomes after outpatient surgery. The main objective of the current investigation is to assess if super morbid obese patients are at increased odds for postoperative complications after outpatient surgery when compared to morbid obese patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2018 was queried to extract and compare patients who underwent outpatient surgery and were defined as either morbidly obese (BMI >40 and <50 kg/m2) or super morbidly obese (BMI ≥50 kg/m2). The primary outcome was the occurrence of medical adverse events within 72 hours of discharge. In addition, we also examine death and readmissions as secondary outcomes. A propensity-matched analysis was used to evaluate the association of BMI ≥50 kg/m2 versus BMI between 40 and 50 kg/m2 and the outcomes. RESULTS: A total of 661,729 outpatient surgeries were included in the 2017-2018 NSQIP database. Of those, 7160 with a BMI ≥50 kg/m2 were successfully matched to 7160 with a BMI <50 and ≥40 kg/m2. After matching, 17 of 7160 (0.24%) super morbid obese patients had 3-day medical complications compared to 15 of 7160 (0.21%) morbid obese patients (odds ratio [OR; 95% confidence interval {CI}] = 1.13 [0.57-2.27], P = .72). The rate of 3-day surgical complications in super morbid obese patients was also not different from morbid obese patients. Thirty-five of 7160 (0.48%) super morbid obese patients were readmitted within 3 days, compared to 33 of 7160 (0.46%) morbid obese patients (OR [95% CI] = 1.06 [0.66-1.71], P = .80). When evaluated in a multivariable analysis as a continuous variable (1 unit increase in BMI) in all patients, BMI ≥40 kg/m2 was not significantly associated with overall medical complications (OR [95% CI] = 1.00 [0.98-1.04], P = .87), overall surgical complication (OR [95% CI] = 1.02 [0.98-1.06], P = .23), or readmissions (OR [95% CI] = 0.99 [0.97-1.02], P = .8). CONCLUSIONS: Super morbid obesity is not associated with higher rates of early postoperative complications when compared to morbid obese patients. Specifically, early pulmonary complications were very low after outpatient surgery. Super morbid obese patients should not be excluded from outpatient procedures based on a BMI cutoff alone.

Spinal versus general anesthesia for patients undergoing outpatient total knee arthroplasty: a national propensity matched analysis of early postoperative outcomes.

BACKGROUND: A comparison of different anesthetic techniques to evaluate short term outcomes has yet to be performed for patients undergoing outpatient knee replacements. The aim of this investigation was to compare short term outcomes of spinal (SA) versus general anesthesia (GA) in patients undergoing outpatient total knee replacements. METHODS: The ACS NSQIP datasets were queried to extract patients who underwent primary, elective, unilateral total knee arthroplasty (TKA) between 2005 and 2018 performed as an outpatient procedure. The primary outcome was a composite score of serious adverse events (SAE). The primary independent variable was the type of anesthesia (e.g., general vs. spinal). RESULTS: A total of 353,970 patients who underwent TKA procedures were identified comprising of 6,339 primary, elective outpatient TKA procedures. Of these, 2,034 patients received GA and 3,540 received SA. A cohort of 1,962 patients who underwent outpatient TKA under GA were propensity matched for covariates with patients who underwent outpatient TKA under SA. SAE rates at 72 h after surgery were not greater in patients receiving GA compared to SA (0.92%, 0.66%, P = 0.369). In contrast, minor adverse events were greater in the GA group compared to SA (2.09%, 0.51%), P < 0.001. The rate of postoperative transfusion was greater in the patients receiving GA. CONCLUSIONS: The type of anesthetic technique, general or spinal anesthesia does not alter short term SAEs, readmissions and failure to rescue in patients undergoing outpatient TKR surgery. Recognizing the benefits of SA tailored to the anesthetic management may maximize the clinical benefits in this patient population.

An evaluation of impact factor bias of clinical trials published in pain journals.

BACKGROUND AND OBJECTIVE: Studies with nonsignificant results are less likely to be published or published in lower impact factor journals. To determine whether a similar phenomenon occurs in pain literature, we explored impact factor bias in peer-reviewed pain journals. METHODS: A PubMed search involving randomized controlled trials in pain journals during 2012 through 2018 was performed. The primary outcome was the publication impact factor. Exclusion criteria included commentaries, editorials, meta-analyses, reviews, and animal studies. The average impact factor for each journal was determined. The primary independent variable was a study with a positive outcome. RESULTS: Of the 9 journals evaluated, 1108 articles met our inclusion criteria and were included in our analysis. The quartiles for the impact factor for the journals included were 2.5, 2.9, and 3.6. A multivariate analysis identified sample size greater than 100, description of a sample size calculation, presence of a stated hypothesis, and presence of sponsorship funding as independent predictors of publication in a journal with greater impact factor. In contrast, positive results were not associated with publication in a greater impact factor journal, even when forced into the model, P = 0.49. CONCLUSIONS: After adjusting for study factors associated with publication, there is no evidence of impact factor bias within the pain literature. The lack of impact factor bias in the pain literature is a positive finding for the field and should benefit scientific development and the clinical care of patients.

American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: an analysis of 2,089,830 ACS-NSQIP outpatient cases.

BACKGROUND: Seventy percent of surgical procedures are currently performed in the outpatient setting. Although the American Society of Anesthesiologists (ASA) Physical Classification ability to predict risk has been evaluated for in-patient surgeries, an evaluation in outpatient surgeries has yet to be performed. The major goal of the current study is to determine if the ASA classification is an independent predictor for morbidity and mortality for outpatient surgeries. METHODS: The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. ASA PS class was the primary independent variable of interest. The primary outcome was 30-day medical complications, defined as having one or more of the following postoperative outcomes: (1) deep vein thrombosis, (2) pulmonary embolism, (3) reintubation, (4) failure to wean from ventilator, (5) renal insufficiency, (6) renal failure, (7) stroke, (8) cardiac arrest, (9) myocardial infarction, (10) pneumonia, (11) urinary tract infection, (12) systemic sepsis or septic shock. Mortality was also evaluated as a separate outcome. RESULTS: A total of 2,089,830 cases were included in the study. 24,777 (1.19%) patients had medical complications and 1,701 (0.08%) died within 30 days. ASA PS IV patients had a much greater chance of dying when compared to healthy patients, OR (95%CI) of 89 (55 to 143), P < 0.001. Nonetheless, over 30,000 ASA PS IV patients had surgery in the outpatient setting. Multivariable analysis demonstrated a stepwise independent association between ASA PS class and medical complications (C statistic = 0.70), mortality (C statistic = 0.74) and readmissions (C statistic = 0.67). Risk stratifying ability was maintained across surgical procedures and anesthesia techniques. CONCLUSIONS: ASA PS class is a simple risk stratification tool for surgeries in the outpatient setting. Patients with higher ASA PS classes subsequently developed medical complications or mortality at a greater frequency than patients with lower ASA PS class after outpatient surgery. Our results suggest that the ambulatory setting may not be able to match the needs of high-risk patients.

The effect of systemic lidocaine on post-operative opioid consumption in ambulatory surgical patients: a meta-analysis of randomized controlled trials.

BACKGROUND: Ambulatory surgical procedures continue to grow in relevance to perioperative medicine. Clinical studies have examined the use of systemic lidocaine as a component of multimodal analgesia in various surgeries with mixed results. A quantitative review of the opioid-sparing effects of systemic lidocaine in ambulatory surgery has not been investigated. The primary objective of this study was to systematically review the effectiveness of systemic lidocaine on postoperative analgesic outcomes in patients undergoing ambulatory surgery. METHODS: We performed a quantitative systematic review of randomized controlled trials in electronic databases (Cochrane Library, Embase, PubMed, and Google Scholar) from their inception through February 2019. Included trials investigated the effects of intraoperative systemic lidocaine on postoperative analgesic outcomes, time to hospital discharge, and adverse events. Methodological quality was evaluated using Cochrane Collaboration's tool and the level of evidence was assessed using GRADE criteria. Data was combined in a meta-analysis using random-effects models. RESULTS: Five trials evaluating 297 patients were included in the analysis. The pooled effect of systemic lidocaine on postoperative opioid consumption at post-anesthesia care unit revealed a significant effect, weighted mean difference (95% CI) of - 4.23 (- 7.3 to 1.2, P = 0.007), and, at 24 h, weighted mean difference (95% CI) of - 1.91 (- 3.80 to - 0.03, P = 0.04) mg intravenous morphine equivalents. Postoperative pain control during both time intervals, postoperative nausea and vomiting reported at post anesthesia care unit, and time to hospital discharge were not different between groups. The incidence rate of self-limiting adverse events of the included studies is 0.007 (2/297). CONCLUSION: Our results suggest that intraoperative systemic lidocaine as treatment for postoperative pain has a moderate opioid-sparing effect in post anesthesia care unit with limited effect at 24 h after ambulatory surgery. Moreover, the opioid-sparing effect did not impact the analgesia or the presence of nausea and vomiting immediately or 24 h after surgery. Clinical trials with larger sample sizes are necessary to further confirm the short-term analgesic benefit of systemic lidocaine following ambulatory surgery. TRIAL REGISTRATION: PROSPERO ( CRD42019142229 ).

An appraisal of published clinical guidelines in anesthesiology practice using the AGREE II instrument.

PURPOSE: Clinical practice guidelines are developed to provide physicians with appraised scientific evidence and enhance their medical decision-making process. Poorly developed guidelines can have a negative impact on patient care, but the quality of clinical guidelines has not been evaluated in anesthesiology practice. METHODS: We evaluated the quality of clinical practice guidelines in anesthesiology retrieved from PubMed, Scopus, Cochrane Library, and Embase databases from August 2013 to August 2018 using a validated appraisal instrument. Exclusion criteria excluded consensus statements, editorials, non-clinical/legal-themed manuscripts, institutional protocols, research methods, and chronic pain and surgical technique guidelines. PRINCIPAL FINDINGS: A total of 96 clinical practice guidelines were included in the analysis. Seventy-one out of 96 (74%; 95% confidence interval, 65 to 83) guidelines had overall quality scores lower or equal to 5 and could not be recommended as published. Higher quality guidelines (overall score greater than 5) were published in journals with higher median [interquartile range] impact factors than lower quality guidelines (4.0 [3.5-6.5] vs 3.8 [2.3-4.7]; P = 0.02). The publication of a higher quality guideline was not associated with the year that the guideline was published or if the guideline was published by a society. CONCLUSIONS: The overall quality of most guidelines relevant to the practice of anesthesiology were poor, and the domains applicability and rigor of development rated particularly low. Future groups developing clinical guidelines should consider using methodological support to improve the quality of guidelines relevant to the practice of anesthesiology.

RéSUMé: OBJECTIF: Les lignes directrices de pratique clinique sont élaborées afin de fournir aux médecins des données probantes et d'améliorer leur processus de prise de décision médicale. Des lignes directrices mal élaborées peuvent avoir un impact négatif sur les soins aux patients, mais la qualité des lignes directrices cliniques n'a pas été évaluée en anesthésiologie. MéTHODE: Nous avons évalué la qualité des directives pour la pratique clinique de l'anesthésiologie extraites des bases de données PubMed, Scopus, Cochrane Library et Embase entre le mois d'août 2013 et le mois d'août 2018 à l'aide d'un instrument d'évaluation validé. Étaient exclus selon nos critères les déclarations de consensus, les éditoriaux, les manuscrits non cliniques/juridiques, les protocoles institutionnels, les méthodes de recherche et les lignes directrices sur la douleur chronique et les techniques chirurgicales. CONSTATATIONS PRINCIPALES: Au total, 96 lignes directrices sur la pratique clinique ont été incluses dans notre analyse. Soixante et onze lignes directrices sur 96 (74 %; intervalle de confiance de 95 %, 65 à 83) avaient des scores de qualité globaux inférieurs ou égaux à 5 et ne pouvaient pas être recommandées telles que publiées. Les lignes directrices de meilleure qualité (score global supérieur à 5) ont été publiées dans des revues ayant des facteurs d'impact médians [écart interquartile] plus élevés que les lignes directrices de qualité inférieure (4,0 [3,5-6,5] vs 3,8 [2,3­4,7]; P = 0,02). La publication d'une ligne directrice de meilleure qualité n'a pas été associée à l'année de publication de la ligne directrice ni à sa publication par une société. CONCLUSION: La qualité globale de la plupart des lignes directrices pertinentes à la pratique de l'anesthésiologie était médiocre, et les domaines d'applicabilité et de la rigueur de mise au point ont été évalués comme étant particulièrement faibles. Les futurs groupes élaborant des lignes directrices cliniques devraient envisager d'utiliser un soutien méthodologique pour améliorer la qualité des lignes directrices pertinentes à la pratique de l'anesthésiologie.

Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Health-Care Resources Utilization After Transitions of Care: A Meta-analysis of Randomized Controlled Trials.

OBJECTIVES: Medication errors are common during transitions of care. The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition of care interventions on the reduction of medication errors after hospital discharge. METHODS: A systematic search was conducted to detect published reports of randomized trials using the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews, and Google Scholar inclusive to July 1, 2015. Search terms included pharmacist, medication, errors, readmission, transition, and discharge. A priori main outcomes included medication errors and health-care resources utilization (hospital readmission and/or emergency room visits). Quantitative analysis was performed using a random effect method. RESULTS: Thirteen randomized trials examining 3503 patients were included in the final analysis. The aggregate effect of the 10 studies evaluating the effect of pharmacists intervention on the incidence of medication errors during transitions of care favored pharmacist over control with an odds ratio (95% confidence interval [CI]) of 0.44 (0.31-0.63). The overall effect of 4 studies evaluating the effect of a pharmacist intervention on the incidence of emergency room visits compared with control favored the pharmacist intervention, odds ratio (95% CI) of 0.42 (0.22-0.78), number needed to treat (95% CI) of 6.2 (3.4-31.4). CONCLUSIONS: Pharmacist transition of care intervention is an effective strategy to reduce medication errors after hospital discharge. In addition, a pharmacist intervention also reduces subsequent emergency room visits. Hospitals should consider implementing this intervention to improve patient safety and quality during transitions of care.

Safety and outcomes of outpatient compared to inpatient total knee arthroplasty: a national retrospective cohort study.

BACKGROUND: Many factors are driving total knee arthroplasty to be performed more commonly as an outpatient (<24 hour discharge) procedure. Nonetheless, the safety of total knee replacements performed in the outpatient setting is not well established when compared with inpatient setting. The purpose of this study is to compare the postoperative outcomes of outpatient and inpatient total knee arthroplasties. METHODS: The 2015 and 2016 American College of Surgeons National Surgical Quality Improvement Program data sets were queried to extract patients who underwent primary, elective, unilateral total knee arthroplasty. The primary outcome was serious adverse events defined by a composite outcome including: return to operating room, wound-related infection, thromboembolic event, renal failure, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, cerebrovascular accident, use of ventilator >48 hours, unplanned intubation, sepsis/septic shock, and death. Propensity matched analysis was used to adjust for potential confounding covariates. RESULTS: 1099 patients undergoing outpatient total knee arthroplasty (1% of total cases) were successfully matched to 1099 patients undergoing inpatient surgeries. The composite rate of serious adverse events was greater in outpatient procedures compared with inpatient procedures (3.18% vs 1.36%, p=0.005). In contrast, failure to rescue and readmission rates were not different between groups. CONCLUSIONS: Outpatient total knee arthroplasty is associated with a higher composite risk of serious adverse events than inpatient procedures. Anesthesiologists and surgeons should inform patients and discuss this information when obtaining consent for surgery and planning for discharge timing.

The association between surgical duration and venous thromboembolism in outpatient surgery: A propensity score adjusted prospective cohort study.

BACKGROUND: Outpatient surgeries account for 60-70% of all procedures. Increased surgical duration has been demonstrated to be an independent risk factor for the development of venous thromboembolism (VTEs) after inpatient surgeries. In contrast, it is currently unknown if surgical duration increases the risk of VTEs for outpatient surgeries. MATERIALS AND METHODS: The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. A z-score for surgical duration was calculated for each procedure to allow for standardization across surgeries of expected shorter or longer duration. The primary outcome measured was incidence of VTEs within 30 days of surgery. RESULTS: A total of 3474 patients out of 1,863,523 (0.19%) had a VTE. After adjusting for confounding factors, the first and fifth quintiles compared to the middle quintile had odds ratios (ORs) of 0.75 (95% CI 0.68, 0.80) and 1.43 (95% CI, 1.35%-1.52%), respectively, P < 0.001. Patients who developed VTEs were more likely to be readmitted to the hospital, OR (95%CI) of 51.9 (48.0-56.2), C statistic = 0.67. CONCLUSION: Surgical duration is associated with the development of VTEs after outpatient surgery. While the overall incidence of VTE is low and does not require generalized prophylaxis, clinical practitioners should consider prophylaxis for patients undergoing outpatient surgery performed with excessive time compared to the average surgical procedure duration.

The effect of ultrasound-guided erector spinae plane block on postsurgical pain: a meta-analysis of randomized controlled trials.

BACKGROUND: The effect of erector spinae plane block has been evaluated by clinical trials leading to a diversity of results. The main objective of the current investigation is to compare the analgesic efficacy of erector spinae plane block to no block intervention in patients undergoing surgical procedures. METHODS: We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases from their inception through July 2019. Included trials reported either on opioid consumption or pain scores as postoperative pain outcomes. Methodological quality of included studies was evaluated using Cochrane Collaboration's tool. RESULTS: Thirteen randomized controlled trials evaluating 679 patients across different surgical procedures were included. The aggregated effect of erector spinae plane block on postoperative opioid consumption revealed a significant effect, weighted mean difference of - 8.84 (95% CI: - 12.54 to - 5.14), (P < 0.001) IV mg morphine equivalents. The effect of erector spinae plane block on post surgical pain at 6 h compared to control revealed a significant effect weighted mean difference of - 1.31 (95% CI: - 2.40 to - 0.23), P < 0.02. At 12 h, the weighted mean difference was of - 0.46 (95% CI: - 1.01 to 0.09), P = 0.10. No block related complications were reported. CONCLUSIONS: Our results provide moderate quality evidence that erector spinae plane block is an effective strategy to improve postsurgical analgesia.

The association between labor epidural analgesia and postpartum depression: a systematic review and meta-analysis.

BACKGROUND: Previous studies have demonstrated that appropriate treatment for postoperative pain can lead to improvement in depressive symptoms, however the association between adequate intrapartum pain control and the development of postpartum depression is not clear. The purpose of the study was to examine the effects of labor epidural analgesia and postpartum depression. METHODS: We performed a quantitative systematic review in compliance with the PRISMA statement. We conducted a search of PubMed, Embase, the Cochrane Database of Systematic Reviews and Google Scholar databases. The primary outcome was a positive screen of postpartum depression among women who received labor epidural analgesia up to 3 months into the postpartum period. Meta-analysis was performed using the random effect model. RESULTS: Of the 148 studies available, 9 studies with 4442 patients were included in the analysis. The use of labor analgesia on positive depression screen compared to control revealed no significant effect, OR (95% CI) of 1.02 (0.62 to 1.66, P = 0.94). CONCLUSION: Based on current literature, the use of epidural analgesia for pain relief during labor doesn't appear to affect the likelihood of postpartum depression. Future studies are warranted to further investigate these findings and identity other possible preventative interventions that reduce postpartum depression.

The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials.

METHODS: We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases. Meta-analysis was performed using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals, and sample size. Methodological quality was evaluated using Cochrane Collaboration's tool. RESULTS: Seven randomized controlled trials evaluating 337 patients across different surgical procedures were included. The aggregated effect of intraoperative methadone on postoperative opioid consumption did not reveal a significant effect, WMD (95% CI) of -0.51 (-1.79 to 0.76), (P=0.43) IV morphine equivalents. In contrast, the effect of methadone on postoperative pain demonstrated a significant effect in the postanesthesia care unit, WMD (95% CI) of -1.11 (-1.88 to -0.33), P=0.005, and at 24 hours, WMD (95% CI) of -1.35 (-2.03 to -0.67), P < 0.001. CONCLUSIONS: The use of intraoperative methadone reduces postoperative pain when compared to morphine. In addition, the beneficial effect of methadone on postoperative pain is not attributable to an increase in postsurgical opioid consumption. Our results suggest that intraoperative methadone may be a viable strategy to reduce acute pain in surgical patients.