Association Between Naloxone Coprescription Mandates and Postoperative Outcomes.

INTRODUCTION: The opioid epidemic is a public health issue in the United States. The objective of this study was to evaluate the association between naloxone coprescription mandates and postoperative outcomes. BACKGROUND: Data on naloxone coprescription mandates show mixed evidence for fatal overdoses in the broader population. How these mandates have impacted surgical patients has not been fully explored. METHODS: Healthcare claims data were used to identify all patients undergoing 1 of 50 common procedures between January 1, 2004, and June 30, 2019, and categorized as high risk for opioid overdose. The primary outcomes were an emergency department visit or hospital admission within 30 postoperative days. To reduce confounding, the association between this outcome and the implementation of naloxone coprescription mandates was estimated using a difference-in-differences approach. RESULTS: The study included 429,878 surgical patients with an average age of 54.8 years (SD=15.9 years) and with 257,728 females (60.0%). There was no significant association between naloxone prescribing mandates and the primary outcomes. After adjustment for potential confounders, the incidence of hospital admission was 3.26% after implementation of a naloxone coprescription mandate compared with 3.33% before (difference change: -0.08%, 95% CI: -0.44% to 0.29%, P =0.68). The incidence of an emergency department visit was 7.06% after implementation of a naloxone coprescription mandate compared with 7.73% before (difference: -0.67%, 95% CI: -1.39% to 0.05%, P =0.07). These results were robust to a variety of sensitivity and subgroup analyses. CONCLUSIONS: Naloxone coprescription mandates were not associated with a statistically or clinically significant change in emergency department visits or hospital admissions within 30 postoperative days.

Is Obesity Associated With Better Liver Transplant Outcomes? A Retrospective Study of Hospital Length of Stay and Mortality Following Liver Transplantation.

BACKGROUND: The rise in obesity in the United States, along with improvements in antiviral therapies, has led to an increase in the number of obese patients receiving liver transplants. Currently, obesity is a relative contraindication for liver transplant, although exact body mass index (BMI) limits continue to be debated. Studies conflict regarding outcomes in obese patients, while some argue that BMI should not be used as an exclusion criterion at all. Therefore, this retrospective study-utilizing a large national database-seeks to elucidate the association between recipient BMI and hospital length of stay and mortality following liver transplant. METHODS: A retrospective study was conducted using the United Network for Organ Sharing Standard Transplant Analysis and Research database. Fine-Gray competing risk regressions were used to explore the association between BMI and rate of discharge, which varies inversely with length of stay. In our model, subdistribution hazard ratio (SHR) represented the relative change in discharge rate compared to normal BMI, with in-hospital death was considered as a competing event for live discharge. Cox proportional hazard models were built to assess the association of BMI category on all-cause mortality after liver transplantation. Cluster-robust standard errors were used in all analyses to construct confidence intervals. RESULTS: Within the final sample (n = 47,038), overweight (≥25 and <30 kg/m2) patients comprised the largest BMI group (34.7%). The competing risk regression model showed an association for increased length of stay among underweight (SHR = 0.82, 95% confidence interval [CI], 0.77-0.89; P < .001) and class 3 obesity patients (SHR = 0.88, 95% CI, 0.83-0.94; P < .001), while overweight (SHR = 1.05, 95% CI, 1.03-1.08; P < .001) and class 1 obesity (SHR = 1.04, 95% CI, 1.01-1.07; P = .01) were associated with decreased length of stay. When the sample excluded patients with low pretransplant functional status, however, length of stay was not significantly shorter for overweight and obesity class 1 patients. Cox proportional hazard models demonstrated increased survival among overweight, class 1 and class 2 obesity patients and decreased survival among underweight patients. CONCLUSIONS: Our results provide evidence that overweight and obesity class 1 are associated with decreased length of stay and mortality following liver transplant, while underweight and obesity class 3 are associated with prolonged length of stay. Pretransplant functional status may contribute to outcomes for overweight and class 1 obese patients, which necessitates continued investigation of the isolated impact of BMI in those who have had a liver transplant.

Frameworks for trainee education in the nonoperating room setting.

PURPOSE OF REVIEW: As the volume and types of procedures requiring anesthesiologist involvement in the nonoperating room anesthesia (NORA) setting continue to grow, it is important to create a formal curriculum and clearly define educational goals. RECENT FINDINGS: A NORA rotation should be accompanied by a dedicated curriculum that should include topics such as education objectives, information about different interventional procedures, anesthesia techniques and equipment, and safety principles. NORA environment may be unfamiliar to anesthesia residents. The trainees must also learn the principles of efficiency, rapid recovery from anesthesia, and timely room turnover. Resident education in NORA should be an essential component of their training. The goals and objectives of the NORA educational experience should include not only developing the clinical knowledge necessary to implement the specific type of anesthetic desired for each procedure, but also the practical knowledge of care coordination needed to safely and efficiently work in the NORA setting. SUMMARY: As educators, we must foster and grow a resident's resilience by continually challenging them with new clinical scenarios and giving them appropriate autonomy to take risks and move outside of their comfort zone. Residents should understand that exposure to such unique and demanding environment can be transformative.

National trends in nonoperating room anesthesia: procedures, facilities, and patient characteristics.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) continues to increase in popularity and scope. This article reviews current and new trends in NORA, trends in anesthesia management in nonoperating room settings, and the evolving debates surrounding these trends. RECENT FINDINGS: National data suggests that NORA cases will continue to rise relative to operating room (OR) anesthesia and there will continue to be a shift towards performing more interventional procedures outside of the OR. These trends have important implications for the safety of interventional procedures as they become increasingly more complex and patients continue to be older and more frail. In order for anesthesia providers and proceduralists to be prepared for this future, rigorous standards must be set for safe anesthetic care outside of the OR.Although the overall association between NORA and patient morbidity and mortality remains unclear, focused studies point toward trends specific to each non-OR procedure type. Given increasing patient and procedure complexity, anesthesiology teams may see a larger role in the interventional suite. However, the ideal setting and placement of anesthesia staff for interventional procedures remain controversial. Also, the impact of COVID-19 on the growth and utilization of non-OR anesthesia remains unclear, and it remains to be seen how the pandemic will influence the delivery of NORA procedures in postpandemic settings. SUMMARY: NORA is a rapidly growing field of anesthesia. Continuing discussions of complication rates and mortality in different subspecialty areas will determine the need for anesthesia care and quality improvement efforts in each setting. As new noninvasive procedures are developed, new data will continue to shape debates surrounding anesthesia care outside of the operating room.

Association of race and ethnicity with pediatric burn outcomes: A population study of the Kids' Inpatient Database.

BACKGROUND: While most studies on burn outcomes have focused on adults, it is unclear if the same socioeconomic and environmental inequalities affect paediatric patients. This study aims to investigate the impact of race and ethnicity on outcomes in paediatric burn patients. METHODS: The Kids' Inpatient Database is released by Agency for Healthcare Research and Quality, and is the largest publicly available database for the United States inpatient paediatric population. All paediatric burned patients in 2016 and 2019 were identified. Race and/or ethnicity was the primary exposure variable, and the primary outcome was a composite of several in-hospital morbidities. Secondary outcomes included death, non-routine disposition, and length of stay. Fine-Gray competing risks regression and multivariable logistic regression were used to analyze length of stay and all other outcomes, respectively. Analysis also isolated subgroups related to socioeconomic status and case severity. RESULTS: We included12,582 pediatric burn patients in this study. No difference was found in composite morbidity between White patients and those of other race or ethnicity groups. Hispanic ethnicity was associated with longer lengths of stay and increased odds of routine (i.e. home) discharge. Black patients had increased length of stay compared to White patients only in severe burn cases. CONCLUSIONS: Our study implies that race- or ethnicity-associated mechanisms driving outcome disparities in adults does not necessarily apply in paediatric burn patients.

Outcomes Following Distal Nerve Blocks for Open Carpal Tunnel Release: A Single-Institution Retrospective Study.

Background Severe cases of carpal tunnel syndrome (CTS) are treated with surgical decompression, for which regional nerve blocks are often administered. There is little data about complications associated with these regional techniques for this surgery. The primary objective was to assess the association of ultrasound-guided regional anesthesia nerve blocks in patients undergoing carpal tunnel release with symptom resolution. Methods This single-institution, retrospective study analyzed all patients undergoing open carpal tunnel release from March 2018 to November 2020. Primary exposure was either regional anesthesia (median and ulnar nerve blocks) or non-regional anesthesia (general anesthesia or local infiltration by surgeon). The primary outcome measurement was symptom resolution at postoperative follow-up at 30-60 days. Secondary outcomes were postoperative surgical site infection, time in operating room (minutes), and post-anesthesia care unit (PACU) length of stay (min). The primary outcome was analyzed using multivariable logistic regression. Results A total of 417 patients were included in this study. Of these, 269 (64.5%) subjects received regional anesthesia as their primary anesthetic. When adjusting for confounders, the use of regional anesthesia was not associated with symptoms not improving at postoperative visit (OR 0.52, 95% CI 0.22 - 1.26, P = 0.15), postoperative surgical site infection (OR 1.47, 95% CI 0.44 - 4.85, p = 0.53), or operating room time duration (p = 0.09). However, the use of regional anesthesia was associated with an approximately 15-minute decrease in PACU length of stay (p < 0.001). Conclusions Regional anesthesia is a safe, effective, and time-efficient method for anesthesia in patients undergoing open carpal tunnel release.

Association of thoracic epidural analgesia and hospital length of stay for patients undergoing thoracotomy: a retrospective cohort analysis.

INTRODUCTION: Regional anesthesia has been shown to be efficacious for analgesia in patients who underwent thoracotomies. The objective of this study was to analyze the association of epidurals and peripheral regional anesthesia with time to hospital discharge for these patients. METHODS: This was a retrospective cohort study using National Surgical Quality Improvement Program dataset from 2014 to 2020. Propensity-matched cohorts were assembled based on use of regional anesthesia, peripheral regional anesthesia, or epidural. Fine-Gray competing risk regressions were used to explore the association between regional anesthesia use and rate of discharge. The subdistribution hazard ratio (HR) represented relative discharge rates, and in-hospital death was a competing event. A sensitivity analysis was subsequently performed in which patients with American Society of Anesthesiologists score ≥4 were removed. RESULTS: There were 4350 patients included in this analysis, in which 472 (10.8%) received a peripheral regional anesthesia nerve block and 565 (13.0%) received thoracic epidural analgesia. The subdistribution HR for rate of discharge in the epidural versus non-epidural cohort was 1.09 (95% CI 1.01 to 1.18), thus epidurals were associated with an increased rate of discharge over time. However, this benefit was no longer apparent with the sensitivity analysis. The subdistribution HR for rate of discharge in the peripheral regional anesthesia versus no regional anesthesia cohort was 1.26 (95% CI 1.15 to 1.39), thus peripheral regional anesthesia was associated with an increased rate of discharge over time. This benefit remained even with the sensitivity analysis. CONCLUSIONS: Thoracic epidural use when compared with no regional anesthesia was associated with decreased length of stay following thoracotomy in our primary analysis. The difference was no longer apparent with the sensitivity analysis. Peripheral regional anesthesia was associated with decreased length of stay even after sensitivity analysis.

The Association of Primary Anesthesia Type With Postoperative Transfusion in Anemic Patients Undergoing Primary Total Joint Arthroplasty.

Background and objective A high rate of preoperative anemia has been observed in patients undergoing knee and hip arthroplasty. The type of anesthesia that patients receive may play a role in preventing or minimizing adverse outcomes in these patients. In this study, we aimed to examine the complication rates in patients with severe anemia undergoing this surgery. In addition, we explore whether neuraxial anesthesia is associated with better outcomes compared to general anesthesia. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) registry was used to extract data related to patients who underwent total hip or knee arthroplasty from 2014 to 2016. Only those patients with a hematocrit level <30% were included, and they were classified into two groups based on primary anesthesia type received: neuraxial versus general anesthesia. The primary outcome of interest was postoperative transfusion. Secondary outcomes included 30-day hospital readmission and postoperative complications. Multivariable logistic regression was used to model primary anesthesia type to outcomes while controlling for various confounders. The odds ratio (OR) and their 95% confidence intervals (CI) were reported. Results There were 1,723 patients with severe anemia included in our analysis, of which 41.2% received neuraxial anesthesia. Among patients that received neuraxial versus general anesthesia, 170 (31.08%) and 486 (41.33%), respectively, received a postoperative blood transfusion (p<0.001). On multivariable regression analysis, neuraxial anesthesia was associated with 40% decreased odds of postoperative transfusion (OR: 0.63, 95% CI: 0.51-0.79, p<0.0001), but it was not associated with any other outcomes. Conclusion Neuraxial anesthesia can reduce the risk of postoperative transfusion in severely anemic patients undergoing total joint arthroplasty (TJA), ultimately leading to reduced discomfort, hospital expenditure, and adverse outcomes.

Body Mass Index Is Not an Independent Factor Associated With Recovery Room Length of Stay for Patients Undergoing Outpatient Surgery.

OBJECTIVES: Prolonged recovery time in the postanesthesia care unit (PACU) increases cost and administrative burden of outpatient surgical staff. The primary aim of this study was to determine whether body mass index (BMI) is associated with prolonged recovery in the PACU after outpatient surgery in a freestanding ambulatory surgery center. METHODS: We retrospectively studied 3 years of surgeries performed at a freestanding ambulatory surgery center. Mixed-effects logistic (for binary outcomes) and linear (for continuous outcomes) regressions were performed, in which the random effect was the surgical procedure. Prolonged PACU length of stay was modeled as a binary variable, that is, stay greater than the third quartile, and as a continuous variable, that is, actual duration of stay in minutes. We reported odds ratio and 95% confidence interval from the logistic regression and estimates with standard errors from the linear regression. RESULTS: Patients with obesity (BMI ≥ 30 kg/m 2 ) did not demonstrate increased odds for prolonged PACU length of stay (all P > 0.05). Furthermore, BMI-represented as a continuous variable-was not associated with actual PACU length of stay (estimate = 0.05, standard error = 0.06, P = 0.41). No association was found between obesity and PACU length of stay on a subgroup analysis where only patients with obstructive sleep apnea were analyzed. CONCLUSIONS: There was no association between BMI and PACU length of stay among patients who received outpatient surgery at a freestanding ambulatory surgery center.

Obesity and outcomes in patients undergoing upper airway surgery for obstructive sleep apnea.

OBJECTIVE: Obesity is frequently debated as a factor associated with increased postoperative complications. Specifically, upper airway surgeries for obstructive sleep apnea (OSA), a common comorbidity among obese patients, may be complicated by obesity's impact on intraoperative ventilation. The aim of this retrospective study was to analyze the association of various degrees of obesity with postoperative outcomes in patients undergoing surgery for OSA. METHODS: The American College of Surgeons National Surgical Quality Improvement database between 2015 and 2019 was used to create a sample of patients diagnosed with OSA who underwent uvulopalatopharyngoplasty, tracheotomy, and surgeries at the base of tongue, maxilla, palate, or nose/turbinate. Inverse probability-weighted logistic regression and unadjusted multivariable logistic regression were used to compare outcomes of non-obese and obesity class 1, class 2, and class 3 groups (World Health Organization classification). Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications, and a secondary outcome was all-cause same-day hospital admission. RESULTS: There were 1929 airway surgeries identified. The inverse probability-weighted regression comparing class 1, class 2, and class 3 obesity groups to non-obese patients showed no association between obesity and composite outcome and no association between obesity and hospital admission (all p-values > 0.05). CONCLUSION: These results do not provide evidence that obesity is associated with poorer outcomes or hospital admission surrounding upper airway surgery for OSA. While these data points towards the safety of upper airway surgery in obese patients with OSA, larger prospective studies will aid in elucidating the impact of obesity.

Caffeine: What Is Its Role in Pain Medicine?

Caffeine is the world's most widely used psychoactive legal substance. The involvement of caffeine in pain management has gotten minimal attention in the past, but it is getting more attention now. This article provides a brief assessment of the literature to clarify the role of caffeine as a pain reliever and stimulate the interest of researchers. Caffeine affects adenosine receptors, which are involved in nociception, and plays a significant role in pain regulation. Caffeine's usage as an adjuvant therapy has been extensively documented in the literature, and it is now accessible in certain over-the-counter drugs. The mixture of coffee and morphine for pain reduction in individuals with terminal cancer has shown mixed outcomes in studies. Caffeine can be utilized for hypnic headaches and post-dural puncture headaches since it is crucial in pain regulation. Caffeine has the potential to help in pain management. Caffeine's usage for migraines and end-stage cancer disease is not well acknowledged. Further research is essential to focus on caffeine's potential role in various forms of pain, including dosage escalation and outcome assessment standardization.

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.

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.