Gregory P. Giambrone

Anesthesia for the patient undergoing total knee replacement: current status and future prospects

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation.

Variability in Anesthetic Care for Total Knee Arthroplasty An Analysis From the Anesthesia Quality Institute

Anesthetic practice utilization and related characteristics of total knee arthroplasties (TKAs) are understudied. The research team sought to characterize anesthesia practice patterns by utilizing National Anesthesia Clinical Outcomes Registry data of the Anesthesia Quality Institute. The proportions of primary TKAs performed between January 2010 and June 2013 using general anesthesia (GA), neuraxial anesthesia (NA), and regional anesthesia (RA) were determined. Utilization of anesthesia types was analyzed using anesthesiologist and patient characteristics and facility type. In all, 108 625 eligible TKAs were identified; 10.9%, 31.3%, and 57.9% were performed under RA, NA, and GA, respectively. Patients receiving RA had higher median age and higher frequency of American Society of Anesthesiology score ≥3 compared with those receiving other anesthesia types under study. Relative to GA (45.0%), when NA or RA were used, the anesthesiologist was more frequently board certified (75.5% and 62.1%, respectively; P < .0001). Anesthetic technique differences for TKAs exist, with variability associated with patient and provider characteristics.

Efficacy of methylnaltrexone for the treatment of opiod-induced constipation: a meta-analysis and systematic review.

ABSTRACT Objective: Constipation is a common adverse effect in patients requiring long-term opioid therapy for pain control. Methylnaltrexone, a quaternary peripheral mu-opioid receptor antagonist, is an effective treatment of opioid induced constipation (OIC) without affecting centrally mediated analgesia. Our objective was to conduct a review and meta-analysis to evaluate the efficacy of methylnaltrexone for treatment of OIC, as well as to provide a clinical discussion regarding newly developed alternatives and provide the current treatment algorithm utilized at our institution. Methods: We performed a systematic review and meta-analysis of randomized control trials using Cochrane Collaboration Databases and MEDLINE from 2007-present. Literature related to methylnaltrexone, opioids, opioid receptors, opioid antagonists, opioid-induced constipation were reviewed. A meta-analysis was completed with the primary outcome of rescue-free bowel movement (RFBM) within four hours of administration. All pooled analyses were based on random-effects models. Results: 1239 patients were analyzed; 599 received methylnaltrexone and 640 received placebo. With a 95% CI calculated, the true risk difference is between 0.267 and 0.385, demonstrating a statistically significant difference in RFBM between treatment and placebo groups (p < 0.0001). Both the 0.15 mg/kg, 0.30 mg/kg doses every other day, and 12 mg/day dose were found to have increased risk of RFBM compared to placebo. Conclusion: Results support the use of methylnaltrexone. Furthermore, the use of methylnaltrexone to induce laxation may decrease use of health care resources, increase work productivity, and improve cost utilization. New treatments have been made available; however, controlled clinical studies are needed to demonstrate long–term efficacy, safety and cost–effectiveness. Possible limitations of this study include the relatively small number of randomized, placebo-controlled trials investigating the efficacy of methylnaltrexone versus placebo. There is also the possibility of publication bias, which may lead to overestimating the efficacy of methylnaltrexone in treating OIC.

Information technology innovation: the power and perils of big data

The global health-care system is consistently under tremendous pressure to lower health-care costs, maintain high efficiency and quality of care, and remain up-to-date technologically in an era of instantaneous information exchange. In the UK, around 8.4% of the gross domestic product is spent on health care (approximately 0.19 trillion GBP). In the USA, this number is 17.9% of gross domestic product, or 2.7 trillion USD. With the introduction of health-care reform and a shift in payment structure to pay-forperformance, further pressure has been placed on the health-care system to reduce costs and increase health-care quality. Additionally, a shift in patient characteristics to an ageing population and improved access to care have increased the number of patients seeking care. Compounding the situation is a shortage of key practitioners, including nursing staff, in the medical workforce. 4 As a result of staff shortage and external pressure and regulations fromgovernment agencies to reduce costs, the health-care system must find away to improve the quality of patient care formore patients with fewer resources. With these difficulties in mind, and the additional challenges that lie ahead, the health-care system, including anaesthetists, must continue to use innovative medical technologies and becomemore efficient in the collection and analysis of this information to drive cost-effective clinical practice. As discussed in the article by Simpao and colleagues, technological advancements in health care have led to an explosion in data collection, increasing storage and analysis needs. In 2011, there were 1.8 zettabytes of data created globally. In the same year, it was estimated that data from the US health-care system reached 150 exabytes. 7 This number will continue to grow to reach zettabyte (10 gigabytes) followed by yottabyte (10 gigabytes) levels over time. Data of this magnitude are known as ‘big data,’ defined as electronic data sets so large and complex that they are difficult or impossible to manage with traditional software, hardware, or both; nor can they be easilymanagedwith traditional or common data-management tools and methods. There are three primary characteristics of big data: volume (the amount of data generated by organizations, individuals, or machines), variety (data in all forms; structured, unstructured, and semistructured), and velocity (the speed of data generation, delivery, or processing). The creation of these massive data sets with varying formats is a result of the proliferation of electronic health records (EHRs). The EHRs have vastly improved the maintenance of health information and have promoted the collection and sharing of information among providers across all health-care disciplines, leading to a more collaborative approach to patient care. In thefield of anaesthesia, the EHRs, also knownasAnaesthesia Information Management Systems (AIMS) or Anaesthesia Information Systems (AIS), have decreased inaccuracies, incompleteness, biases, and inherent errors. However, implementation of these EHRs has created data sets that can be difficult to analyse for quality control or research purposes. In one study of AIMS, event recording dependent on user input can have a low sensitivity (38%), leading to under-reporting of key clinical events, demonstrating that EHR systems are in need of improvements and analytics to identify issues. Further adding to the predicament of using big data in health care is the development and use of low-cost, non-invasive, wearable health-monitoring systems that allow for continuous monitoring of patients’ vital signs and mobility from external locations rather than the traditional approach of hardwired equipment. These devices, along with EHRs and existing clinical monitoring technologies, have challenged the health-care industry in the storage and analysis of this big data. Additionally, such data can be collected in systems that do not communicate, and datamight not be collected in a structured format, further confounding analyses. There are several systems that have been developed to overcome structural and analytical data issues. Themost popular system at this time is the open-source distributed data processing platform, Hadoop (Apache platform). Initially, Hadoop was developed as a platform toaggregateWeb search indexes. Usingnumerous servers, known as nodes, Hadoop has the potential to store and process extremely large amounts of data by allocating partitioned data sets to each node. An analysis request in Hadoop (a Map Reduce request) is allocated to each node and each data set, and executed at the data level in parallel (the Map process), and the results are integrated and aggregated for the final result (the Reduce process). Hadoop has the ability to analyse unstructured, semi-structured, and structured data. As a data-protection method, Hadoop maintains redundant data sets in different nodes to protect the data and analyses from system crashes. If a node becomes unusable, an additional node will be used to continue the requested analyses. 9 Therefore, Hadoop is structured to serve dual roles, namely the ability to store massive amounts of data

Incidence and implications of postoperative supraventricular tachycardia after pulmonary lobectomy

OBJECTIVE We sought to determine the rate of postoperative supraventricular tachycardia (POSVT) in patients undergoing pulmonary lobectomy, and its association with adverse outcomes. METHODS Using the State Inpatient Database, from the Healthcare Cost and Utilization Project, we reviewed lobectomies performed (2009-2011) in California, Florida, and New York, to determine POSVT incidence. Patients were grouped by presence or absence of POSVT, with or without other complications. Stroke rates were analyzed independently from other complications. Multivariable regression analysis was used to determine factors associated with POSVT. RESULTS Among 20,695 lobectomies performed, 2449 (11.8%) patients had POSVT, including 1116 (5.4%) with isolated POSVT and 1333 (6.4%) with POSVT with other complications. Clinical predictors of POSVT included age ≥75 years, male gender, white race, chronic obstructive pulmonary disease, congestive heart failure, thoracotomy surgical approach, and pulmonary complications. POSVT was associated with an increase of: stroke (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.03-2.94); in-hospital death (OR 1.85; 95% CI 1.45-2.35); LOS (OR 1.33; 95% CI 1.29-1.37); and readmission (OR 1.29; 95% CI 1.04-1.60). The stroke rate was <1% in patients who had isolated POSVT, and 1.5% in patients with POSVT with other complications. Patients with isolated POSVT had increased readmission and LOS, and a marginal increase in stroke rate, compared with patients with an uncomplicated course. CONCLUSIONS POSVT is common in patients undergoing pulmonary lobectomy and is associated with adverse outcomes. Comparative studies are needed to determine whether strict adherence to recently published guidelines will decrease the rate of stroke, readmission, and death after POSVT in thoracic surgical patients.

Provider Board Certification Status and Practice Patterns in Total Knee Arthroplasty.

Purpose The presumption that board certification directly affects the quality of clinical care is a topic of ongoing discussion in medical literature. Recent studies have demonstrated disparities in patient outcomes associated with type of anesthesia provided for total knee arthroplasty (TKA); improved outcomes are associated with neuraxial (or regional) versus general anesthesia. Whether board-certified (BC) and non-board-certified (nBC) anesthesiologists make different choices in the anesthetic they administer is unknown. The authors sought to study potential associations of board certification status with anesthesia practice patterns for TKA. Method The authors accessed records of anesthetics provided from 2010 to 2013 from the National Anesthesia Clinical Outcomes Registry database. They identified TKA cases using Clinical Classifications Software and Current Procedural Terminology codes. The authors divided practitioners into two groups: those who were BC and those who were nBC. For each of these groups, the authors compared the following: their patient populations, the hospitals in which they worked, the nature of their practices, and the anesthetics they administered to their patients. Results BC anesthesiologists provided care for 81.7% of 97,508 patients having TKA; 18.3% were treated by nBC anesthesiologists. BC anesthesiologists administered neuraxial/regional anesthesia more frequently than nBC anesthesiologists (41.4% versus 21.2%; P < .001). Conclusions The rates at which regional/neuraxial anesthesia were administered for TKA were relatively low, and there were significant differences in practice patterns of BC and nBC anesthesiologists providing care for patients undergoing TKA. More research is necessary to understand the causes of these disparities.

Acute Pain Management/Regional Anesthesia

Effective and efficient acute pain management strategies have the potential to improve medical outcomes, enhance patient satisfaction, and reduce costs. Pain management records are having an increasing influence on patient choice of health care providers and will affect future financial reimbursement. Dedicated acute pain and regional anesthesia services are invaluable in improving acute pain management. In addition, nonpharmacologic and alternative therapies, as well as information technology, should be viewed as complimentary to traditional pharmacologic treatments commonly used in the management of acute pain. The use of innovative technologies to improve acute pain management may be worthwhile for health care institutions.