Spencer S. Kee

Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery.

BACKGROUND The goal of the current study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery. METHODS Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed. RESULTS Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 vs 3, P = .006) and 3 hours (0 vs 2, P = .001) but not at later time points. The overall worst pain experienced was lower with PVB (3 vs 5, P = .02). More patients were pain-free in the PVB group at 1 hour (44% vs 17%, P = .014) and 3 hours (54% vs 17%, P = .005) postoperatively. CONCLUSIONS PVB significantly decreases postoperative pain up to 3 hours after breast cancer surgery.

Ongoing provision of individual clinician performance data improves practice behavior

BACKGROUND: Clinical practice guidelines summarize evidence from science and attempt to translate those findings into clinical practice. Pervasive and consistent adoption of these guidelines into daily provider practice has proven slow. METHODS: Using postoperative nausea and vomiting (PONV) prophylaxis guideline compliance as our metric, we compared the effects of continuing medical education (CME) alone (I), CME with a single snapshot of provider compliance (II), and ongoing reporting of provider compliance data without further CME (III). We retrospectively analyzed guideline compliance of 23,279 anesthetics at the University of Texas M.D. Anderson Cancer Center. Compliance was defined as a patient with 1 risk factor for PONV receiving at least 1 antiemetic, 2 risk factors receiving at least 2 antiemetics, and 3 risk factors receiving at least 3 antiemetics. Drugs of the same class were counted as single antiemetic administration. Propofol-based anesthetic techniques were counted as receiving 1 antiemetic. Patients with 0 risk factors for PONV were not included. We estimated the compliance rates for each of the 4 time periods of the study adjusting for multiple observations on the same clinician. Individual performance feedback was given once at 6 months after intervention I coincident with a refresher presentation on PONV (start of intervention II) and on an ongoing quarterly basis during intervention III. RESULTS: Compliance rates were not significantly influenced with CME (intervention I) compared with baseline behavior (54.5% vs 54.4%, P = 0.9140). Significant improvement occurred during the time period when CME was paired with performance data (intervention II) compared with intervention I (59.2% vs 54.4%, P = 0.0002). Further significant improvement occurred when data alone were presented (intervention III) compared with intervention II (65.1% vs 59.2%, P < 0.0001). For patients with 3 risk factors, we saw significant improvement in compliance rates during intervention III (P = 0.0002). In post hoc analysis of overtreatment, the percentage differences between the baseline and time period III decreased as the number of risk factors increased. CONCLUSIONS: We observed the greatest improvement in guideline compliance with ongoing personal performance feedback. Provider feedback can be an effective tool to modify clinical practice but can have unanticipated consequences.

Improved Postoperative Pain Control using Thoracic Paravertebral Block for Breast Operations

Abstract:  Thoracic paravertebral block (PVB) in breast surgery can provide regional anesthesia during and after surgery with the potential advantage of decreasing postoperative pain. We report our institutional experience with PVB over the initial 8 months of use. All patients undergoing breast operations at the ambulatory care building from September 09, 2005 to June 28, 2005 were reviewed. Comparison was performed between patients receiving PVB and those who did not. Pain scores were assessed immediately, 4 hours, 8 hours and the morning after surgery. 178 patients received PVB and 135 patients did not. Patients were subdivided into three groups: Group A–segmental mastectomy only (n = 89), Group B–segmental mastectomy and sentinel node surgery (n = 111) and Group C–more extensive breast surgery (n = 113). Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery PVB patients were significantly less likely to report pain than controls. Patients in Group C who received PVB were significantly less likely to require overnight stay. The average immediate pain scores were significantly lower in PVB patients than controls in both Group B and Group C and approached significance in Group A. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients that required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery.

A Novel Nomenclature to Classify Parathyroid Adenomas

BackgroundA uniform and reliable description of the exact locations of adenomatous parathyroid glands is necessary for accurate communications between surgeons and other specialists. We developed a nomenclature that provides a precise means of communicating the most frequently encountered parathyroid adenoma locations.MethodsThis classification scheme is based on the anatomic detail provided by imaging and can be used in radiology reports, operative records, and pathology reports. It is based on quadrants and anterior-posterior depth relative to the course of the recurrent laryngeal nerve and the thyroid parenchyma. The system uses the letters A-G to describe exact gland locations.ResultsA type A parathyroid gland is a gland that originates from a superior pedicle, lateral to the recurrent laryngeal nerve compressed within the capsule of the thyroid parenchyma. A type B gland is a superior gland that has fallen posteriorly into the tracheoesophageal groove and is in the same cross-sectional plane as the superior portion of the thyroid parenchyma. A type C gland is a gland that has fallen posteriorly into the tracheoesophageal groove and on a cross-sectional view lies at the level of or below the inferior pole of the thyroid gland. A type D gland lies in the midregion of the posterior surface of the thyroid parenchyma, near the junction of the recurrent laryngeal nerve and the inferior thyroid artery or middle thyroidal vein; because of this location, dissection is difficult. A type E gland is an inferior gland close to the inferior pole of the thyroid parenchyma, lying in the lateral plane with the thyroid parenchyma and anterior half of the trachea. A type F gland is an inferior gland that has descended (fallen) into the thyrothymic ligament or superior thymus; it may appear to be “ectopic” or within the superior mediastinum. An anterior-posterior view shows the type F gland to be anterior to the trachea. A type G gland is a rare, truly intrathyroidal parathyroid gland.ConclusionsA reproducible nomenclature can provide a means of consistent communication about parathyroid adenoma location. If uniformly adopted, it has the potential to reliably communicate exact gland location without lengthy descriptions. This system may be beneficial for surgical planning as well as operative and pathology reporting.

The effect of an anatomically classified procedure on antiemetic administration in the postanesthesia care unit.

BACKGROUND: The effect of the type of surgical procedure on postoperative nausea and vomiting (PONV) rate has been debated in the literature. Our goal in this retrospective database study was to investigate the effect the type of surgical procedure (categorized and compared anatomically) has on antiemetic therapy within 2 h of admission to the postanesthesia care unit (PACU). METHODS: We retrospectively analyzed data for oncology surgeries (n = 18,109), from our automated anesthesia information system database. We classified the types of surgical procedures anatomically into seven categories, with the integumentary musculoskeletal and the superficial surgeries chosen as the referent group. Our analysis included nine other risk factors for each patient, such as gender, smoking status, history of PONV or motion sickness, duration of anesthesia, number of prophylactic antiemetics administered, intraoperative opioids, ketorolac, epidural use, and postoperative opioids. Multivariate logistic regression was used to assess the effect of the type of surgery on antiemetic administration within the first 2 h of PACU admission, while adjusting for the other risk factors. RESULTS: Compared with integumentary musculoskeletal and superficial surgeries, patients undergoing neurological (P < 0.0001), head or neck (P < 0.0001), and abdominal (P < 0.0001) surgeries were administered PACU antiemetic significantly more often, whereas patients undergoing thoracic surgeries were administered PACU antiemetic significantly less often (P = 0.02). Breast or axilla (P = 0.74) and endoscopic (P = 0.28) procedures did not differ from the referent category. Female, nonsmoker, history of PONV or motion sickness, anesthesia duration, and intraoperative and postoperative opioid administration were significantly associated with antiemetic administration during early PACU admission. CONCLUSIONS: Using our automated anesthesia information system database, we found that the type of surgery, when categorized anatomically, was associated with an increased frequency of early PACU antiemetic administration in our population.

Outpatient Minimally Invasive Parathyroidectomy Is Safe for Elderly Patients

BACKGROUND Elderly patients with primary hyperparathyroidism (PHPT) are often not referred for surgical intervention because of concern of comorbid conditions that may increase perioperative complications. Because PHPT is more common in the elderly, we sought to compare indications and complications of minimally invasive parathyroidectomy in patients 70 years of age and older (elderly) with their younger counterparts. STUDY DESIGN A review was conducted of a prospectively collected database of all patients undergoing parathyroidectomy on our endocrine surgery service. Data collected included patient demographic, biochemical pathologic, and operative findings. Wilcoxon rank sum and chi-square tests were used for comparisons. RESULTS Three hundred eighty-eight patients with PHPT recently underwent parathyroidectomy over a 3-year period (elderly, n=101; younger, n=287). The elderly cohort had significantly higher median preoperative creatinine (elderly, 2.0 mg/dL; younger,1.0 mg/dL; p=0.002) and parathyroid hormone (elderly, 145 pg/mL; younger, 123 pg/mL; p=0.026) levels. The elderly cohort also had more severe osteoporosis, with a significantly worse median bone mineral density T-score (elderly, -2.5; younger, -1.8; p<0.001). The rate of postoperative complications was similarly low in both groups (elderly, 5.9%; younger, 3.5%; p=0.38). CONCLUSIONS Minimally invasive parathyroidectomy for PHPT can be performed as safely in elderly patients as in their younger counterparts. Elderly patients with PHPT are more likely to have osteoporosis and higher creatinine levels at the time of surgical referral. Additional study of the role of earlier intervention is warranted.

Innate immune function after breast, lung, and colorectal cancer surgery

BACKGROUND The cytotoxic activity and count of natural killer (NK) cells appear to be reduced after surgery; however, it is unknown whether the magnitude of this immune suppression is similar among different types of oncological surgery. In this study, we compared the innate immune function of patients undergoing three different oncological surgeries. METHODS We compared the number and function of NK cells obtained from patients who had undergone mastectomies (n = 17), thoracotomies (n = 21), or liver resections for cancer (n = 22). Cytotoxicity assays were performed to measure the function of NK cells. We also determined the plasma concentrations of interleukins (IL) 2 and 4, interferon-γ, granzyme B, perforin, soluble major histocompatibility complex class I-related chain A, and epinephrine, both before and 24 h after surgery. Differences in immunologic parameters were compared preoperatively and postoperatively and by type of surgery. P values <0.05 were considered statistically significant. RESULTS The preoperative NK cell count differed statistically (P < 0.006) among all three types of surgeries; however, within surgery postoperative counts and changes compared with baseline did not. The postoperative function of NK cells was similar among types of surgeries, but was significantly reduced compared with preoperative levels (mastectomy P < 0.0001, thoracotomy P = 0.001, and liver resections P = 0.002). We observed a significant increase in the postoperative plasma concentrations of epinephrine, whereas the concentrations of major histocompatibility class I polypeptide-related sequence A and the IL-2 and/or IL-4 ratio remained unchanged before and after surgery. CONCLUSIONS The magnitude of innate immune suppression is similar among different oncological procedures. More studies are needed to better understand this complex phenomenon.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction.

Background: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. Methods: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. Results: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). Conclusions: Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction—with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A case series of thoracic paravertebral blocks using a combination of ropivacaine, clonidine, epinephrine, and dexamethasone

Five patients who underwent surgery for breast cancer were followed for 6 days after placement of a multiple-injection, one-time paravertebral block. Data were collected on patient satisfaction, analgesic consumption, side effects, and complications. Ropivacaine as a sole agent in paravertebral blocks has a clinical duration of up to 6 hours. The addition of epinephrine, clonidine, and dexamethasone prolonged the clinical duration considerably.

Adaptation of the OODA Loop to Reduce Postoperative Nausea and Vomiting in a High-Risk Outpatient Oncology Population

Postoperative nausea and vomiting (PONV) remains a ubiquitous concern for surgical outpatients with published rates ranging from 14% to 80%. An evidence-based approach was used to reduce PONV in a high-risk adult outpatient oncology population. The Observe, Orient, Decide, and Act (OODA) Loop, a rapid cycle management strategy, was adapted for use in an outpatient surgery center with six ORs. A PONV prophylaxis protocol was developed and adapted until a stable PONV rate was achieved. A combination of dexamethasone, promethazine, and ondansetron was used in patients with one to three PONV risk factors. Patients with four major risk factors received an additional intervention. The PONV rate for the final protocol stabilized below 4% by 46 weeks and remained stable through 79 weeks. The OODA paradigm provides an effective technique for interfacing health care research with clinical practice. In this case, an effective PONV prophylaxis plan was developed from within a collaborative nursing and medical setting.