Meg A. Rosenblatt

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.

To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

Meta-analyses of ultrasound-guided versus traditional peripheral nerve block techniques—are we comparing apples and oranges?

The beginning of ultrasound-guided regional anesthesia (UGRA) dates back to the late 1970s and early 1980s, when sound effect Doppler was used to locate the axillary artery for supraclavicular and axillary brachial plexus blocks [1,2]. The use of ultrasound (US) for lumbar epidural space localization, celiac plexus, stellate ganglion, and upper and lower extremity nerve blocks also dates to the 1980s and 1990s [3-7]. Despite growing interest in the ability to visualize anatomy, needle placement, and local anesthetic spread, expensive equipment and lack of guidelines limited the routine clinical use of UGRA. During the past decade, however, well described techniques and the greater availability of US have led to a dramatic rise in UGRA. Whereas many large academic institutions may not have practiced UGRA 5 years ago, both private facilities and teaching centers are now avidly obtaining US equipment, and physicians are eagerly acquiring the necessary skills. Indeed, UGRA workshops are in high demand and integral parts of many regional, national, and international meetings and congresses. Although UGRA is still in its infancy, its growing popularity has allowed for numerous randomized controlled studies that compare it with other nerve block techniques such as superficial landmark, paresthesia, nerve stimulation (NS), or NS plus US guidance. Even more recently, meta-analyses of these studies have attempted to further elucidate the advantages of UGRA. In this issue of the Journal of Clinical Anesthesia, Gelfand et al. performed a meta-analysis of 16 randomized controlled trials that compared the analgesic efficacy of UGRA with non-US techniques [8]. Their primary outcome for assessment was the success rate of single-shot peripheral nerve blocks. Success was defined as anesthesia sufficient for surgery without the need for supplementation with additional nerve blocks or general anesthesia. Studies were excluded if the purpose of the nerve block was not for

Positive perceptions on safety and satisfaction during a patient-centered timeout before peripheral nerve blockade

OBJECTIVESnTo determine the psychometric outcomes of patients participating in an extensive patient-centered verification process before receiving sedation for regional anesthesia.nnnDESIGNnSurvey.nnnSETTINGnPerioperative areas of university-affiliated hospital.nnnPATIENTSnTwo hundred eligible patients scheduled for elective orthopedic surgery undergoing peripheral nerve blockade.nnnINTERVENTIONSnPostoperative survey evaluating patient perception, experience, and satisfaction with the anesthetic timeout before regional anesthesia.nnnMEASUREMENTSnMeasures using numeric rating scales were obtained on patient perceptions of safety, confidence in anesthesia provider, anxiety, and positive sentiments during participation in block timeout. These variables were analyzed using logistic regression models to correlate with reported pain and satisfaction perioperatively.nnnMAIN RESULTSnOne hundred seventy-five patients (93% enrollment) completed the study. More than 90% of patients reported agreeing strongly to feeling safe, confident, relaxed, and positive about their participation in the block timeout. These sentiments are associated with less reported perioperative pain and higher overall satisfaction.nnnCONCLUSIONSnPatient perceptions of confidence and safety in regional anesthesia providers were enhanced by a preprocedural timeout process. These positive attitudes are associated with a superior perioperative experience and patient satisfaction.

Anesthesia for patients undergoing orthopedic oncologic surgeries

When planning an anesthetic for patients undergoing orthopedic oncologic surgeries, numerous factors must be considered. Preoperative evaluation may elucidate significant co-morbidities or side effects secondary to chemotherapy or radiation, which can affect anesthetic choices. Procedures vary in length and complexity and pose challenges in both positioning and in planning to minimize blood loss. Many anesthetic techniques are available to provide both intraoperative anesthesia and postoperative analgesia, while the type of thromboprophylaxis and analgesic adjuvants that will be administered needs to be defined. This review focuses on approaches to use when caring for patients undergoing orthopedic oncologic procedures.

Perioperative care map improves compliance with best practices for the morbidly obese

BACKGROUNDnMorbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients.nnnMETHODSnA care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines.nnnRESULTSnIn the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices.nnnCONCLUSIONnAfter care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Preoperative evaluation and preparation of patients for orthopedic surgery.

Orthopedic patients frequently have multiple comorbidities when they present for surgery. This article discusses risk stratification of this population and the preoperative work-up for patients with specific underlying conditions who often require orthopedic procedures. Preoperative strategies to decrease exposure to allogeneic blood and advantages of the Perioperative Surgical Home model in this unique population are discussed.

Considerations When Performing Ultrasound-Guided Supraclavicular Perineural Catheter Placement

To the Editor: Drs Heil et al have presented an interesting case series describing ultrasound-guided supraclavicular perineural catheters for perioperative analgesia.1 Ultrasound guidance has increased the popularity and success rate, as well as decreased the complication rate, of supraclavicular brachial plexus blocks and perineural catheters.2–7 In this series, 1 of 10 catheters (10%) was inadvertently dislodged on the first postoperative day. Over the last few years, many of our supraclavicular catheters have become unintentionally dislodged before the intended date of removal. We attribute this to the curved contour of the location of supraclavicular catheter placement and the difficulty in securing the catheter on this nonflat surface. Both the shallow nature of this block, much like the interscalene block, and using a catheter-through-needle technique lead to leakage around the catheter and also contribute to dislodgement. We have also found that it can be difficult to pass the catheter using the lateral-to-medial approach described in this article. A medial-to-lateral needle direction provides a more anatomic approach to catheter threading along the brachial plexus, and the catheters usually pass easily without complication. The authors describe the use of minimal sedation for the placement of supraclavicular catheters compared to past studies, which have described heavy procedural sedation for infraclavicular catheters.8,9 We have performed both supraclavicular and infraclavicular catheter placements and found that they both require similar minimal sedation to prevent patient discomfort. Further studies may be necessary to confirm the use of less procedural sedation for placement of infraclavicular catheters over amounts used for similar procedures. Our preference for continuous brachial plexus anesthesia for the elbow, forearm, and hand remains the infraclavicular approach. Not only is catheter affixed on a “flat” surface, but this approach also has the advantage of the catheter being secured by the pectoral muscles, and the added depth decreases leakage of local anesthetic to the surface. Last, in young women (and men), using an infraclavicular approach may also be preferable because the scar from needle insertion is not as apparent. Whichever approach chosen, we have found that affixing catheters with 2-octyl cyanoacrylate (Dermabond topical skin adhesive; Ethicon, Inc, West Somerville, NJ) and a transparent adhesive dressing with an integrated gel pad containing chlorhexidine gluconate (Tegaderm chlorhexidine gluconate dressing; 3M Health Care, St Paul, MN) have contributed to our increased success in providing continuous postoperative analgesia.

Statin therapy: the new perioperative “magic bullet” for all surgical procedures?

Statins are highly effective, well tolerated lipid-lowering agents. Through their inhibition of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, statins decrease the production of cholesterol intermediaries and, ultimately, LDL, by 25% to 50% [1]. Independent of their lipid-lowering properties, statins offer protection via plaque stabilization and antiinflammatory, antiplatelet aggregration, vasodilatory, profibrinolytic, and antithrombotic effects [2]. Numerous randomized clinical trials have shown that statins increase long-term survival and reduce the incidence of stroke and adverse cardiovascular events, including myocardial infarction and death in patients with cardiovascular disease [3]. The observation that patients with normal lipid levels benefit from stroke reduction with statin therapy highlights the importance of the non-lipid-lowering effects of statins [1]. Despite encouraging findings, controversy exists over whether to start, stop, or continue statins perioperatively. The prevalence of statin-related myopathy and, rarely, rhabdomyolysis, remains an important concern because between 5% and 10% of patients who take statins develop myalgias (muscle pain or weakness without elevated creatine kinase) [4]. These adverse reactions play a major role in statin intolerance and discontinuation, and the percentage of adverse events secondary to statin therapy may be underestimated. In this issue of the Journal of Clinical Anesthesia, Laisalmi-Kokki et al. [5] look at the prevalence and severity of myopathy and hepatic deterioration in patients receiving statin therapy who undergo elective lower extremity arthroplasty. Twenty-four patients having total knee arthroplasty (TKA) and 24 patients undergoing total hip arthroplasty (THA) were enrolled in their study. Half of the TKA patients and half of the THA patients were receiving chronic statin therapy for at least one month. The presence of preoperative and postoperative myalgias was documented via questionnaire. Serum creatinine kinase (SCK), serum myoglobin, and urine myoglobin, among other laboratory values, were also measured preoperatively and postoperatively. Ultimately, they found no increase in the number of muscular complaints after surgery. All patients

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery

BackgroundFew guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting.MethodsProviders from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: >u200915xa0years vs. ≤15xa0years in practice, and attending vs. resident physicians.ResultsA total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (pu2009=u20090.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (pu2009=u20090.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (pu2009<u20090.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with >u200915xa0years in practice vs. 86 (74.5%) with ≤15xa0years (pu2009=u20090.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (pu2009=u20090.002).ConclusionsWhile there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

A perioperative care map improves outcomes in patients with morbid obesity undergoing major surgery

Background The surgical management of patients with morbid obesity (body mass index ≥ 40) is notable for a relatively high risk of complications. To address this problem, a perioperative care map was developed using precautions and best practices commonly employed in bariatric surgery. It requires additional medical assessments, sleep apnea surveillance, more stringent guidelines for anesthetic management, and readily available bariatric operating room equipment, among other items. This care map was implemented in 2013 at 4 major urban teaching hospitals for use in patients undergoing all types of nonambulatory surgery with a body mass index greater than 40 kg/m2. The impact on patient outcomes was evaluated. Methods The American College of Surgeons National Surgical Quality Improvement Program database was used to compare 30‐day outcomes of morbidly obese patients before the year 2013 and after the years 2015 care‐map implementation. In addition, trends in 30‐day outcomes for morbidly obese patients were compared with those for non‐obese patients. Results Morbidly obese patients, between 2013 and 2015, saw an adjusted decrease in the rate of unplanned return to the operating room (OR = 0.49; P = .039), unplanned readmission (OR = 0.57; P = .006), total duration of stay (−0.87 days; P = .009), and postoperative duration of stay (−0.69 days; P = .007). Of these, total duration of stay (−0.86 days; P = .015), and postoperative duration of stay (−0.69 days; P = .012) improved significantly more for morbidly obese patients than for nonmorbidly obese patients. Conclusion Outcomes in morbidly obese patients improved from 2013 to 2015. Implementation of a perioperative care map may have contributed to these improvements. The care map should be further investigated and considered for more widespread use.