Jose Soliz

Epidural Versus ON-Q Local Anesthetic-Infiltrating Catheter for Post-Thoracotomy Pain Control

OBJECTIVE The authors compared thoracic epidural with ON-Q infiltrating catheters in patients having open thoracotomy to determine whether one method better relieves postoperative pain and would allow earlier discharge from the hospital and, hence, cost savings. DESIGN Retrospective chart review. SETTING University hospital. PARTICIPANTS Fifty adult patients (24 to 81 years old) undergoing open thoracotomy by one surgeon. INTERVENTIONS One group had thoracic epidural catheters placed by an anesthesiologist and then managed by the acute pain service. The other group had intraoperative ON-Q (ON-Q; I-Flow; Lake Forest, California) infiltrating catheters placed by the surgeon, wound infiltration with a local anesthetic, plus patient-controlled analgesia with an intravenous opioid. MEASUREMENTS AND MAIN RESULTS The authors measured and compared average daily pain rating, maximum pain rating, time to discharge from the hospital, and total bill for hospital stay. Patients who received epidural analgesia had lower average pain scores on day 2 than did patients in the ON-Q group. Patients in the ON-Q group reported higher maximum pain scores on days 1 and 2 and at the time of discharge. Patients in the ON-Q group were discharged an average of 1 day earlier; hence, their average total bill was lower. CONCLUSIONS Even though the maximum pain score was higher in the ON-Q group, patients were comfortable enough to be discharged earlier, resulting in cost savings. ON-Q infiltrating catheters present a good option for providing postoperative analgesia to patients having an open thoracotomy.

A Randomized Controlled Trial of Postoperative Thoracic Epidural Analgesia Versus Intravenous Patient-controlled Analgesia after Major Hepatopancreatobiliary Surgery

Objectives: The primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient-controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization, and complications. Background: Although adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial. Methods: Using a 2.5:1 randomization strategy, 140 patients were randomized to TEA (N = 106) or intravenous patient-controlled analgesia (N = 34). Patient-reported pain was measured on a Likert scale (0–10) at standard time intervals. Cumulative pain area under the curve was determined using the trapezoidal method. Results: Between the study groups key demographic, comorbidity, clinical, and operative variables were equivalently distributed. The median area under the curve of the postoperative time 0- to 48-hour pain scores was lower in the TEA group (78.6 vs 105.2 pain-hours, P = 0.032) with a 35% reduction in patients experiencing ≥7/10 pain (43% vs 62%, P = 0.07). Patient-reported outcomes and total opiate use further supported the benefit of TEA on patient experience. Anesthesia-related events requiring change in analgesic therapy were comparable (12.2% vs 2.9%, respectively, P = 0.187). Grade 3 or higher surgical complications (6.6% vs 9.4%), median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the operating room (0.9% vs 3.1%) were similar (all P > 0.05). There were no mortalities in either group. Conclusions: In major HPB surgery, TEA provides a superior patient experience through improved pain control and less narcotic use, without increased length of stay or complications.

Anesthetic and operative considerations for laparoscopic liver resection

We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.

Assessing the impact of perioperative blood transfusions on the survival of adults undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for appendiceal carcinomatosis

Perioperative red blood cell transfusions (PBT) may be associated with worse survival. In this study of adults undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS‐HIPEC), we investigated whether there was an association between PBT and survival.

Impact of Regional Anesthesia on Recurrence, Metastasis, and Immune Response in Breast Cancer Surgery: A Systematic Review of the Literature

Background and Objectives The perioperative period is critical in the long-term prognosis of breast cancer patients. The use of regional anesthesia, such as paravertebral block (PVB), could be associated with improvements in long-term survival after breast cancer surgery by modulating the inflammatory and immune response associated with the surgical trauma, reducing opioid and general anesthetic consumption, and promoting cancer cells death by a direct effect of local anesthetics. Methods A systematic literature search was conducted for studies of patients who received PVB for breast cancer surgery. The Jadad score and Ottawa-Newcastle scale were used to assess the methodological quality of randomized controlled trial and observational retrospective studies, respectively. Only high-quality studies were considered for meta-analysis. The selected studies were divided into 3 groups to determine the impact of PVB on (a) recurrence and survival, (b) humoral response, and (c) cellular immune response. Results We identified 467 relevant studies; 121 of them underwent title and abstract review, 107 were excluded, and 15 studies were selected for full text reading and quality assessment. A meta-analysis was not conducted because of low-quality studies and lack of uniform definition among primary outcomes. Thus, a systematic review of the current evidence was performed. Conclusions Our study indicates that there are no data to support or refute the use of PVB for reduction of cancer recurrence or improvement in cancer-related survival. However, PVB use is associated with lower levels of inflammation and a better immune response in comparison with general anesthesia and opioid-based analgesia.

Using computed tomography scans and patient demographic data to estimate thoracic epidural space depth.

Background and Objectives. Previous studies have used varying methods to estimate the depth of the epidural space prior to placement of an epidural catheter. We aim to use computed tomography scans, patient demographics, and vertebral level to estimate the depth of the loss of resistance for placement of thoracic epidural catheters. Methods. The records of consecutive patients who received a thoracic epidural catheter were reviewed. Patient demographics, epidural placement site, and technique were collected. Preoperative computed tomography scans were reviewed to measure the skin to epidural space distance. Linear regression was used for a multivariate analysis. Results. The records of 218 patients were reviewed. The mean loss of resistance measurement was significantly larger than the mean computed tomography epidural space depth measurement by 0.79 cm (p < 0.001). Our final multivariate model, adjusted for demographic and epidural technique, showed a positive correlation between the loss of resistance and the computed tomography epidural space depth measurement (R 2 = 0.5692, p < 0.0001). Conclusions. The measured loss of resistance is positively correlated with the computed tomography epidural space depth measurement and patient demographics. For patients undergoing thoracic or abdominal surgery, estimating the loss of resistance can be a valuable tool.

Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy

Background: Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs. Study Design: Three unique risk‐stratified pancreatectomy clinical pathways—low‐risk pancreatoduodenectomy, high‐risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk‐stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated. Results: The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk‐stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low‐risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high‐risk pancreatoduodenectomy. The rates of 90‐day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation. Conclusion: Implementation of risk‐stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low‐risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high‐risk pancreatoduodenectomy.

Identification of risk factors associated with postoperative acute kidney injury after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a retrospective study

Abstract Background: Acute kidney injury (AKI) is a postoperative complication associated with significant morbidity and mortality. The incidence and risks factors for AKI after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been fully studied. The purpose of this study was to identify perioperative risk factors predictive of AKI after CRS-HIPEC. Methods: This retrospective study collected demographic, tumour-related, intraoperative and postoperative data from 475 patients who underwent CRS-HIPECs. AKI was defined using the acute kidney injury network criteria and calculated on postoperative days 1, 2, 3, 7 and day of hospital discharge. We conducted univariate and multivariate analyses to assess the association between variables of interest and AKI. A p value of <0.05 was considered statistically significant. Results: The incidence of AKI was 21.3%. The multivariate analysis identified six predictor factors independently associated with the development of AKI (OR: [95%CI]); age: 1.16 (1.05–1.29, p < 0.005), BMI (overweight: 1.97 [1.00–3.88], p = 0.05) and obesity: 2.88 (1.47–5.63), p < 0.002)), preoperative pregabalin: 3.04 (1.71–5.39, p < 0.037), platinum-based infusion: 3.04 (1.71–5.39, p < 0.001) and EBL: 1.77 (1.27–2.47, p < 0.001). Splenectomy had a protective effect (OR: 0.44 (0.25–0.76, p < 0.003). Conclusions: Our study demonstrates that the incidence of AKI is high. While other studies have reported that AKI is associated with platinum-based infusion, age and obesity, we report for the first time a negative association between pregabalin use and AKI. More studies are needed to confirm our results.

What Is the Best Pain Control After Major Hepatopancreatobiliary Surgery

Currently, EA is supported by high-level evidence, specifically in liver surgery, to be the most effective analgesic modality for pain control after HPB surgery. Additional high-level evidence for superior analgesic modalities after pancreatectomies is required. Subsequent randomized controlled trials are required to elucidate the effectiveness and safety of new strategies such as a TAP block compared to EA for both hepatectomies and pancreatectomies in the setting of ER. Beyond adequate pain control and total opiate consumption, PRO tools and the ability to RIOT in cancer patients should be secondary outcome measure in all future studies.

39 Safe culture? – a burning question answered by fire safety awareness

Background A variety tools are used by hospitals to evaluate their culture of safety. Although a rare occurrence, surgical fires occur as a result of breakdowns in the safety culture. Causes of these fires are related to lack of communication; lack of formal education related to surgical fires; and not adhering to advisories from professional societies and regulatory agencies. Theoretically, surgical fire prevention could be an ideal measure of safety for the following: No debate exists that fires are “never events”; the occurrence can realistically approach zero; prevention is based upon education and team communication; prevention is multi-disciplinary; and effective measures are cost-free. Methods A survey was sent to 120 healthcare facilities across the US. 82 (68.3%) surveys were answered electronically. The results were subsequently analysed using multivariate linear regression. Results The strongest correlation was to linking the question regarding use of fire risk assessment and planning pre-procedure to perceptions of safety, 79 respondents answered positively and 62 of these also answered a positive or strongly positive response to questions regarding safety culture (p=<0.001). All those who rated their facility indicating a poor safety culture did not experience fire prevention education and also included the 3 facilities who never evaluate OR fire risk. Conclusions This survey suggested a correlation between the perception of a safe culture and surgical fire education and risk assessment. We realise that questionnaire return rate could skew the conclusions of this survey and analysis. Further evaluation should be pursued to ascertain if surgical fire prevention education improves the culture of safety or if facilities with an emphasis placed on safety educate their staff on surgical fire prevention. In either case, surgical fire prevention seems to be a preliminary marker for safety culture in surgical facilities.