Perioperative adverse events in adult patients with obstructive sleep apnea undergoing ambulatory surgery: An updated systematic review and meta-analysis.

BACKGROUND: The suitability of ambulatory surgery for patients with obstructive sleep apnea (OSA) remains controversial. This systematic review and meta-analysis aimed to evaluate the odds of perioperative adverse events in patients with OSA undergoing ambulatory surgery, compared to patients without OSA. METHODS: Four electronic databases were searched for studies published between January 1, 2011 and July 11, 2023. The inclusion criteria were: adult patients with diagnosed or high-risk of OSA undergoing ambulatory surgery; perioperative adverse events; control group included; general and/or regional anesthesia; and publication on/after February 1, 2011. We calculated effect sizes as odds ratios using a random effects model, and additional sensitivity analyses were conducted. RESULTS: Seventeen studies (375,389 patients) were included. OSA was associated with an increased odds of same-day admission amongst all surgery types (OR 1.94, 95% CI 1.46-2.59, I2:79%, P < 0.00001, 11 studies, n = 347,342), as well as when only orthopedic surgery was considered (OR 2.68, 95% CI 2.05-3.48, I2:41%, P < 0.00001, 6 studies, n = 132,473). Three studies reported that OSA was strongly associated with prolonged post anesthesia care unit (PACU) length of stay (LOS), while one study reported that the association was not statistically significant. In addition, four studies reported that OSA was associated with postoperative respiratory depression/hypoxia, with one large study on shoulder arthroscopy reporting an almost 5-fold increased odds of pulmonary compromise, 5-fold of myocardial infarction, 3-fold of acute renal failure, and 5-fold of intensive care unit (ICU) admission. CONCLUSIONS: Ambulatory surgical patients with OSA had almost two-fold higher odds of same-day admission compared to non-OSA patients. Multiple large studies also reported an association of OSA with prolonged PACU LOS, respiratory complications, and/or ICU admission. Clinicians should screen preoperatively for OSA, optimize comorbidities, adhere to clinical algorithm-based management perioperatively, and maintain a high degree of vigilance in the postoperative period.

Noninferiority trials in acute pain research: a valid approach or a slippery slope?

The conduct and reporting of studies with a noninferiority hypothesis is challenging because of the complexity involved in their design and interpretation. However, studies with a noninferiority design have increased in popularity. A recently published trial reported on the noninferiority of lidocaine infusion to epidural analgesia in major abdominal surgeries. Apart from needing a critical appraisal, this draws attention to improve our understanding of noninferiority study framework and its unique features. Given the increasing focus on using various analgesic adjuncts and multiple approaches to fascial plane blocks to avoid more definitive and standard approaches, it is imperative that particular attention is paid to appropriate execution and reporting of noninferiority studies.

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery.

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC: Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES: Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management.

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy.

PURPOSE: Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy. METHODS: Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay. RESULTS: Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min). CONCLUSIONS: Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA. METHODS: In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME). RESULTS: There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0-25] mg vs 16 [0-30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05). CONCLUSIONS: In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids. CLINICAL TRIAL REGISTRATION: NCT0507270.

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns.

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

Basic analgesic use in randomised trials assessing local and regional analgesic interventions for mastectomy: a critical appraisal and clinical implications.

Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n=82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate.

Rational Multimodal Analgesia for Perioperative Pain Management.

PURPOSE OF REVIEW: A multimodal analgesic approach improves postoperative pain relief and reduces opioid use; however, it is not universally implemented. This review presents the evidence assessing multimodal analgesic regimens and recommends optimal analgesic combinations. RECENT FINDINGS: The evidence for best combinations of individual patients undergoing specific procedures is lacking. Nevertheless, an optimal multimodal regimen may be determined based on identifying efficacious, safe, and inexpensive analgesics interventions. Key components of an optimal multimodal analgesic regimen include the preoperative identification of patients at high risk for postoperative pain in addition to patient and caregiver education. Unless contraindicated, all patients should receive a combination of acetaminophen, non-steroidal anti-inflammatory drug or cycoxygenase-2-specific inhibitor, dexamethasone, and procedure-specific regional analgesic technique and/or surgical site local anesthetic infiltration. Opioids should be administered as rescue adjuncts. Non-pharmacological interventions are important components of an optimal multimodal analgesic technique. It is imperative to integrate multimodal analgesia regimens within a multidisciplinary enhanced recovery pathway.

Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations.

BACKGROUND: Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain. OBJECTIVES: To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy. DESIGN: A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology. ELIGIBILITY CRITERIA: Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions. DATA SOURCES: PubMed, Embase and Cochrane Databases. RESULTS: Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration. CONCLUSIONS: The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.

Enhanced recovery and same-day discharge hospital stay: speed versus safety?

Same-day ambulatory major surgery is evolving, but requires more study regarding patient selection and safety.

Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations.

BACKGROUND: Pain after craniotomy can be intense and its management is often suboptimal. OBJECTIVES: We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy. DESIGN: A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. DATA SOURCES: Randomised controlled trials and systematic reviews published in English from 1 January 2010 to 30 June 2021 assessing pain after craniotomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. ELIGIBILITY CRITERIA: Each randomised controlled trial (RCT) and systematic review was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and NSAIDs, and current clinical relevance. RESULTS: Out of 126 eligible studies identified, 53 RCTs and seven systematic review or meta-analyses met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture. Limited evidence was found for flupirtine, intra-operative magnesium sulphate infusion, intra-operative lidocaine infusion, infiltration adjuvants (hyaluronidase, dexamethasone and α-adrenergic agonist added to local anaesthetic solution). No evidence was found for metamizole, postoperative subcutaneous sumatriptan, pre-operative oral vitamin D, bilateral maxillary block or superficial cervical plexus block. CONCLUSIONS: The analgesic regimen for craniotomy should include paracetamol, NSAIDs, intravenous dexmedetomidine infusion and a regional analgesic technique (either incision-site infiltration or scalp nerve block), with opioids as rescue analgesics. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.