For elective surgery, a joint statement from the American Society of Anesthesiologists and Anesthesia Patient Safety Foundation recommends a recovery period of four to twelve weeks depending on the ...severity of infection and treatment intensity 1. The patient was already one month post-injury, and there was concern that further delay would decrease the likelihood of successful repair and functional recovery 2. ...the decision was made to proceed with urgent scheduling. After placement, the patient reported numbness only on the medial thigh and knee. ...the regional anesthesia team performed a supplemental ultrasound-guided lateral femoral cutaneous nerve block with 10 ml of mepivacaine 1.5% injected around the nerve, caudal to the anterior superior iliac spine.
•Perioperative eye injury (PEI) can be a serious surgical complication.•No large-scale studies have assessed PEI in the Veterans Affairs (VA) population.•We conducted a 6-year review of all ...consecutive surgical inpatients.•The incidence of new PEI among our veteran patients was 0.24%.•Nearly all PEI cases were treated empirically as corneal abrasions.
Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the ...Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.
Long-term sustainability of clinical practice changes in anesthesia has not been previously reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change to ...favor spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA) which did not undergo clinical pathway change as well as the utilization of regional analgesia.
We identified all primary unilateral TKA and THA cases performed from January 2013 through December 2018 to include data from one-year pre-implementation and 5-years post-implementation of the clinical pathway change. Our primary outcome was the overall rate of spinal anesthesia usage. Secondary outcomes included rate of nerve block utilization, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.
The sample consisted of 1859 cases (1250 TKAs, 609 THAs). In the first year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) in the year before implementation (p<0.001). In the subsequent 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (p=0.532 vs. year 1). For THA, 78/124 (62.9%) received spinal anesthesia in the year after implementation compared to 48/116 (41.4%) pre-implementation (p=0.001), but this rate decreased in the subsequent 4-year period to 193/369 (52.3%) (p=0.040 vs. year 1). Utilization of regional analgesia was high in both groups, and there were no differences in other outcomes.
A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.
Perioperative peripheral nerve injury (PNI) is a known complication in patients undergoing surgery with or without regional anesthesia. The incidence of new PNI in a Veterans Affairs (VA) inpatient ...surgical population has not been previously described; therefore, the incidence, risk factors, and clinical course of new PNI in this cohort are unknown. We hypothesized that peripheral nerve blocks do not increase PNI incidence.
We conducted a 5-year review of a Perioperative Surgical Home database including all consecutive surgical inpatients. The primary outcome was new PNI between groups that did or did not have peripheral nerve blockade. Potential confounders were first examined individually using logistic regression, and then included simultaneously together within a mixed-effects logistic regression model. Electronic records of patients with new PNI were reviewed for up to a year postoperatively.
The incidence of new PNI was 1.2% (114/9558 cases); 30 of 3380 patients with nerve block experienced new PNI (0.9%) compared with 84 of 6178 non-block patients (1.4%; p=0.053). General anesthesia alone, younger age, and American Society of Anesthesiologists physical status <3 were associated with higher incidence of new PNI. Patients who received transversus abdominis plane blocks had increased odds for PNI (OR, 3.20, 95% CI 1.34 to 7.63), but these cases correlated with minimally invasive general and urologic surgery. One hundred PNI cases had 1-year follow-up: 82% resolved by 3 months and only one patient did not recover in a year.
The incidence of new perioperative PNI for VA surgical inpatients is 1.2% and the use of peripheral nerve blocks is not an independent risk factor.
Multimodal analgesic clinical pathways for joint replacement patients often include perineural catheters, but long-term adherence to these pathways has not yet been investigated. Our primary aim was ...to determine adherence rate to a knee arthroplasty clinical pathway for patients undergoing staged bilateral procedures.
This study was performed at a hospital with a Perioperative Surgical Home program and knee arthroplasty clinical pathway using multimodal analgesia and adductor canal catheters. Data were examined for all orthopedic surgery patients over a 4-year period. We included patients who had staged bilateral knee arthroplasty electively scheduled on 2 separate dates. The primary outcome was rate of adductor canal catheter utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major perioperative complications.
We analyzed data for 103 unique patients. The interval between surgeries was a median of 261 days (10th-90th percentile, 138-534 days). All 103 patients had adductor canal catheters for both the first and second surgeries (P > 0.999). Forty-one percent of patients had the same surgeon for both surgeries, but only 2% had the same anesthesiologist (P < 0.001). From the first to the second surgery, utilization of neuraxial anesthesia increased from 51% to 68%, respectively (P = 0.005). There were no differences in minor or major complications.
For staged bilateral knee arthroplasty patients, 100% clinical pathway adherence including perineural catheters and multimodal analgesia is feasible despite multiple variables. We believe that patient-centered acute pain management requires consistent and reliable delivery of care.
Objectives
Using a through‐the‐needle local anesthetic bolus technique, ultrasound‐guided infraclavicular perineural catheters have been shown to provide greater analgesia compared to supraclavicular ...catheters. A through‐the‐catheter bolus technique, which arguably “tests” the anesthetic efficacy of the catheter before initiating an infusion, has been validated for infraclavicular catheters but not supraclavicular catheters. This study investigated the through‐the‐catheter bolus technique for supraclavicular catheters and tested the hypothesis that infraclavicular catheters provide faster onset of brachial plexus anesthesia.
Methods
Preoperatively, patients were randomly assigned to receive either a supraclavicular or an infraclavicular catheter using an ultrasound‐guided nonstimulating catheter insertion technique with a mepivacaine bolus via the catheter and ropivacaine perineural infusion initiated postoperatively. The primary outcome was time to achieve complete sensory anesthesia in the ulnar and median nerve distributions. Secondary outcomes included procedural time, procedure‐related pain and complications, and postoperative pain, opioid consumption, sleep disturbances, and motor weakness.
Results
Fifty patients were enrolled in the study; all but 2 perineural catheters were successfully placed per protocol. Twenty‐one of 24 (88%) and 24 of 24 (100%) patients in the supraclavicular and infraclavicular groups, respectively, achieved complete sensory anesthesia by 30 minutes (P= .088). There was no difference in the time to achieve complete sensory anesthesia. Supraclavicular patients reported more sleep disturbances postoperatively, but there were no statistically significant differences in other outcomes.
Conclusions
Both supraclavicular and infraclavicular perineural catheters using a through‐the‐catheter bolus technique provide effective brachial plexus anesthesia.
For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to ...on-campus rehabilitation. We retrospectively examined whether this ‘fast track’ pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost median (10th–90th percentiles) was US$30,755 (US$23,066–38,444) for ward patients compared to US$17,620 (US$13,215–33,918) for rehabilitation patients (
P
= 0.006). This difference mean (95% CI) was US$10,143 (US$2174–18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.
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