Anesthetic Modality Research Articles

Is Epinephrine Safe for Infant Digit Excision? A Retrospective Review of 402 Polydactyly Excisions in Patients Younger than 6 Months.

Conventional dogma suggests that the use of local anesthetic with epinephrine is contraindicated in the digits because of fear of ischemia and necrosis. Although several reports have refuted this notion, the precept is still propagated in many clinical forums. For many years, the authors have used lidocaine with epinephrine to perform removal of postaxial polydactyly in infants and have observed few complications and no cases of digital ischemia or necrosis. This investigation details the authors' outcomes with this anesthetic modality in neonates and supports the growing body of literature documenting the safety of using lidocaine with epinephrine in the digits. A retrospective review of all infants younger than 6 months who underwent preaxial and postaxial polydactyly excision and removal of their sequelae of the hand or foot under local anesthesia, from 2011 to 2017, was completed. All demographic characteristics, frequency of complications, and descriptive statistics of the sample clinical group were documented. In the 215 patients who met inclusion criteria, a total of 402 procedures were performed. Mean follow-up was 19.9 months for 140 patients, or 264 procedures (65.7 percent). The total complication rate was 2.6 percent. There were two cases of minor bleeding, one wound dehiscence, and four surgical-site infections. In 402 procedures of surgical excision of polydactyly in infants, there were few short-term complications, none of which were necrosis or any vascular complication related to the use of epinephrine. The authors believe that, with the use of a low-dose epinephrine injection (1:200,000), the risk for digital infarction is low in this population. Therapeutic, IV.

Hemodynamic Management of Patients During Endovascular Treatment of Acute Ischemic Stroke Under Conscious Sedation: A Retrospective Cohort Study.

Anesthetic modality and hemodynamic management during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are potential contributors to the success of revascularization. The aims of our study were to review the hemodynamic management by anesthesiologists and clinical outcomes in patients undergoing MT under conscious sedation. Retrospective cohort study of patients with anterior circulation AIS from January 2012 to March 2016. Primary outcome was hemodynamic intervention, defined as administration of vasoactive drugs to maintain systolic blood pressure (BP) between 140 and 180 mm Hg. The secondary outcome was poor hemodynamic control, defined as BP outside target for >15 minutes despite hemodynamic intervention. We performed regression analysis to determine the predictors of hemodynamic intervention and poor hemodynamic control. A total of 126 patients were included in this study; 92% (116) receiving conscious sedation and 8% (10) no sedation. Upon arrival to the neuroradiology suite, systolic BP was <140 mm Hg in 30.2% of the patients and >180 mm Hg in 14.3%. Hemodynamic intervention was required in 38.9% of patients; 15.1% for hypotension and 19.8% for hypertension. In the multivariate analysis, systolic BP on hospital admission (odds ratio, 1.02; 95% confidence interval, 1.00-1.04; P=0.019) constituted a predictor for hemodynamic intervention. Poor hemodynamic control occurred in 12.7% of patients, with lower baseline systolic BP being associated with higher risk of intraprocedural hypotension (odds ratio, 0.92; 95% confidence interval, 0.89-0.96; P<0.001). In-hospital mortality was 13.6%. Hemodynamic intervention is frequent during MT under conscious sedation. The routine presence of anesthesiologists during MT may be helpful in maintaining hemodynamic stability and allow rapid treatment of emergent complications. An individualized approach with tailored hemodynamic targets is required during management of patients undergoing MT for AIS.

Is there a benefit to additional neuroaxial anesthesia in open nephrectomy? A prospective NSQIP propensity score analysis.

Neuroaxial (i.e., spinal, regional, epidural) anesthesia has been shown to be associated with reduced readmission rate, decreased hospital stay, and decreased overall complication rate in orthopedic and gynecologic surgery. Our aim was to identify differences in intra- and postoperative complications, length of stay and readmission rates in open nephrectomy patients managed with neuroaxial anesthesia. Utilizing National Surgical Quality Inpatient Program (NSQIP) database, we identified patients who have undergone an open nephrectomy between 2014 and 2017. Patients were further subdivided based on anesthesia modality. We used the propensity score-matching (PSM) method to adjust for baseline differences among patients who received general anesthesia alone and those with additional neuroaxial anesthesia. Using step-wise multivariable logistic regression, we identified preoperative and intraoperative predictors associated with 30-day procedure-related readmission, complications, and postoperative length of stay. Out of 3,633 patients identified, 2346 patients met our inclusion and exclusion criteria. There was no difference in baseline characteristics after propensity score matching between general and additional neuroaxial anesthesia. Postoperative outcomes including: procedure-related readmission, rate of reoperation, operative time, all complications were similar between the groups. Adjuvant neuroaxial anesthesia group did experience a prolonged postoperative hospital stay that was statistically significant as compared to patients with general anesthesia alone [5.3 (3.5) days vs 4.8 (2.9) days, p = 0.007]. Compared to GA alone after multivariable logistic regression, neuroaxial anesthesia was not statistically significant for readmission (p = 0.909), any complication (p = 0.505), but did showed increased odds ratio of prolonged postoperative stay [aOR 1.107, 95% CI 1.042-1.176, p = 0.001] after adjusting for multiple factors. Using 2014-2017 NSQIP database, we were able to demonstrate no additional reduction in complication or readmission rate in patients with neuroaxial anesthesia as compared to general anesthesia alone. Furthermore, patients who did receive neuroaxial anesthesia experienced a longer postoperative course.

Pulmonary Impacts of Anaesthetic Modalities Evaluated by Ultrasound

Pulmonary Impacts of Anaesthetic Modalities Evaluated by Ultrasound

Locoregional anesthesia is associated with lower 30-day mortality than general anesthesia in patients undergoing endovascular repair of ruptured abdominal aortic aneurysm

ObjectiveThe objective of this study was to compare 30-day postoperative mortality for patients undergoing endovascular repair of ruptured abdominal aortic aneurysm (rAAA) using locoregional vs general anesthesia. Unlike the open approach, endovascular repair of rAAA can be performed using either locoregional or general anesthesia. We hypothesize that mortality after endovascular repair of rAAA is lower when locoregional rather than general anesthesia is used. MethodsPropensity score matching techniques were used to compare the 30-day postoperative outcomes of patients from the 2007 to 2015 American College of Surgeons National Surgical Quality Improvement Program database who underwent endovascular repair of rAAA under locoregional vs general anesthesia. ResultsOf the 1382 endovascular rAAA repair procedures in our overall study population, 132 (9.5%) were performed using locoregional anesthesia. Our propensity score matching algorithm yielded a cohort of 130 general anesthesia patients who were well matched with their locoregional anesthesia counterparts for known patient and procedure characteristics. The 30-day postoperative mortality rates for patients in the matched cohort were 14.6% for patients in the locoregional anesthesia group compared with 29.2% for patients in the general anesthesia group (P = .002). ConclusionsLocoregional rather than general anesthesia is associated with a significantly lower 30-day mortality after endovascular repair of rAAA. The designs of future trials comparing endovascular and open rAAA repair should include stratification of endovascular procedures by anesthesia modality.

Frequency, variation and cost of dental extractions for adults in secondary care in Great Britain.

Aims We have conducted a survey of administrative data, aiming to investigate the reported provision of dental extraction under general anaesthesia in the NHS for adults in secondary care in the following aspects: 1) anaesthetic data accessibility by NHS organisations; 2) the number and proportion of dental extraction episodes by anaesthetic modality and procedure type; 3) the economic cost of dental general anaesthesia (DGA) for adults; 4) variations in the anaesthetic provision between commissioning regions and organisation types. Methods We collected data from individual secondary care NHS organisations that provide dental extraction services in England, Wales and Scotland. A data collection form was devised to capture the number of episodes of dental extraction under each relevant oral surgery procedure code per anaesthetic modality per institution from October 2015 to September 2016. Results The majority (64.0%, n = 96,659) of the episodes were categorised into an anaesthetic modality; 39.2% (n = 37,902) under general anaesthesia, 18.7% (n = 18,050) under sedation, and 42.1% (n = 40,707) under local anaesthesia. The majority of sedation provision (84.9%) derived from dental hospitals. A substantial proportion (37.0%) of the episodes could not be assigned an anaesthetic modality. Variations in dental general anaesthesia activity were observed with respect to the commissioning regions and organisation types. The annual cost of adult DGA from 81 out of 150 organisations that provided DGA data was estimated to be over £19 million, based on the NHS payment by results tariff 2015-2016. Conclusion Our data suggest that the number of adult DGA episodes and the associated cost are considerable, and highlights the scope for improving the quality of data for commissioners and providers to support discussions over patient pathways.

Use of non-contrast-enhanced computed tomography to identify deep digital flexor tendinopathy in horses with lameness: 28 cases (2014-2016).

To describe the use of non-contrast-enhanced CT to identify deep digital flexor (DDF) tendinopathy in horses with lameness attributed to pain in regions distal to the metatarsophalangeal or metacarpophalangeal joints. Retrospective case series. 28 client-owned horses. Medical records were searched to identify horses that underwent non-contrast-enhanced CT with or without high-field MRI as part of an evaluation for lameness localized to areas distal to the metacarpophalangeal or metatarsophalangeal joint in ≥ 1 limb. Horses were included in the study if they had ≥ 1 DDF tendon lesion (DDF tendinopathy) identified. Signalment, lameness examination findings and response to perineural anesthesia, imaging modality, anesthetic agents and duration of anesthesia, and imaging findings were recorded. Data were summarized descriptively. Bilateral imaging was performed for all horses, irrespective of unilateral or bilateral lameness. Nine of 28 horses underwent both CT and MRI, and all DDF tendon lesions identified by one modality were identified by the other. Of 48 limbs with DDF tendinopathy, 46 (96%) had core lesions and 35 (73%) had dorsal border irregularities. Median anesthesia time for CT and CT followed by MRI was 15 and 110 minutes, respectively. Results suggested that non-contrast-enhanced CT was useful for identifying DDF tendinopathy in horses with lameness localized to the phalangeal regions, and this was supported by consistency of findings in a subset of horses that underwent MRI. Further research is needed to confirm these results.

Abstract WP47: Efficacy and Safety of Nimodipin During Mechanical Thrombectomy

Background: Randomized controlled trials for calcium antagonists therapy in patients with acute ischemic stroke have failed to show a benefit as a stand-alone therapy, due largely to the reduction of blood pressure, especially in the absence of early recanalization. Since mechanical thrombectomy (MT) has led to high successful recanalization rates, the effect of nimodipin as an adjuvant therapy during MT has not been evaluated. Materials and Methods: We retrospectively reviewed all consecutive cases of MT for which Nimodipin was used as an adjuvant therapy after at least one pass of any device. Clinical and angiographic characteristics, as well as immediate vessel caliber modifications, reperfusion status and early neurological improvement were collected between January 2016 and December 2017. Results: Procedural intra-arterial nimodipin infusion was administered in 10.3 % (58/559; 95%CI 7.8-12.8 %) of patients, after at least one pass of MT device. In 52/58 patients, &lt; 3 manoeuvers of MT were performed. Angiographic vasospasm was identified on the carotid artery in 17/58 (29.3%) cases, on the middle cerebral artery in 35/58 (60.4%) cases and in vertebro-basilar artery in 6/58 (10.3%) cases. The vasospasm was responsible for an immediate reocclusion in 12% of the patients. Angiographic effect of nimodipin with the restauration of a normal vessel caliber and the improvement of the reperfusion without supplementary maneuver was observed in 77.5% % of the cases. Successful recanalization TICI 2b/3 was reached in 81% patients. Significant drop of blood pressure (BP) with need for additional vasopressive drugs was observed in 6 cases. Symptomatic hemorrhage occurred in 3 patients (5%). Concomitant fibrinolytic therapy did not influence the rate of intracranial hemorrhage rate after procedural nimodipin infusion (p=0.912). Early neurological improvement was reached in 46% and was not associated with a high initial systolic and diastolic BP at the admission (p=0.89) or with the modality of anesthesia (p =0.76). Conclusion: Nimodipin can be an efficient and safe adjuvant therapy in the setting of vasospasm due to MT, by normalizing the caliber of the recanalized artery and then, improving the reperfusion status without supplementary maneuver of MT.

Abstract TMP5: Social Media Campaign with Traditional Community Consultation for Successful Exception from Informed Consent Approval - the SEGA Trial Experience

Introduction/Background: Patients with severe stroke deficits due to large vessel occlusion are unable to provide consent and thus routinely excluded from emergency research participation – breaching the ethical principle of justice. The Food and Drug Administration has issued regulations for Exception from Informed Consent (EFIC) to facilitate research on potentially life-saving interventions in emergencies. We describe our novel approach to EFIC approval for an ongoing randomized trial that compares two anesthetic modalities for endovascular therapy (EVT) – sedation versus general anesthesia – the SEGA trial (Clinicaltrials.gov NCT-03263117). Methods: Partnering with our Institutional Review Board (IRB), we used a multifaceted approach to inform the Houston, Texas metropolitan area about EFIC in SEGA. In addition to in-person community consultations and surveys with focus groups (stroke survivors, advisory councils, etc.), we created a novel social media campaign on Facebook to users ≥ 25 years old within a 50-mile radius from the Texas Medical Center. Advertisements linked to a university-created SEGA trial website that included details on EFIC regulations, trial aims, survey questions, and opt-out procedures. A press release was issued with information about the trial and links to the webpage. Results: Between 6/17-9/17, we held 7 community consultations, placed Facebook ads, and issued a press release with trial information and website. Total of 193 individuals (65% female; average age 46.7 ± 16.6) participated in focus group community consultations. Of the 144 (75%) that completed surveys, 98% agreed to have themselves or a family member enrolled in SEGA under EFIC. Facebook ads had 134,481 views (52% female; 60% ≥ 45 years old) followed by 1,630 clicks to learn more and 1,130 website views (56% regional and 44% national). Users spent an average of 3 minutes and 51 seconds on the webpage. The IRB received zero emails requesting additional information or to opt-out. Conclusion: Our novel community consultation method reached far more potential stroke patients than traditional in-person EFIC focus groups. We propose this method as a standard practice for trials seeking such approval.

Spinal Anaesthesia for Infra-umbilical Surgeries - A Prospective Randomized Study to evaluate the effectiveness of Dexmedetomidine as an adjuvant to Bupivacaine.

Background: Spinal anesthesia is commonly used anesthetic modality worldwide but with the limitation of relatively short duration of action and complain of post-operative pain. However, the addition of adjuvants have intensified and increased the duration of sensory block with concommitent prolongation of the duration of postoperative analgesia.&#x0D; Study design and settings: This prospective randomized study was conducted in the Department of Anesthesia, Pain and Critical Care at the University Teaching Hospital.&#x0D; Methods: 60 patients irrespective of their age and gender were randomized equally into two groups, and received 3ml of total drug volume intrathecally (IT) viz 2.5 ml of hyperbaric bupivacaine 0.5% mixed with 0.5 ml of normal saline in Group I and 0.5 ml of 5 mcg of Dexmedetomidine in Group II respectively.&#x0D; Results: The maximum height of sensory block achieved were dermatomes T 6.5 ± 1.43 in Group I, and T 6.20 ± 1.28 in Group II (P value, 0.794 &gt; 0.05) with time required to reach T10 sensory block level was 6.70 ± 0.98 min. in Group I and 5.50 ± 1.00 min. in Group II (P value, 0.001) The time to reach Bromage scale 3 was 15.70 ± 2.56 min. in Group I and 8.55 ± 1.67min. in Group II (P value, &lt; 0.001) The time of first rescue dose requested by patient was 196.75 ± 15.16 min. in Group I, and 359.50 ± 49.79 min. in Group II (P value, 0.01) &#x0D; Conclusions: Dexmedetomidine in doses of 5 µg as adjuvants to hyperbaric 0.5% bupivacaine intrathecally produced a significantly quick onset and longer duration of motor and sensory block with benefit prolonged postoperative analgesia. JMS 2018: 21 (2):95-100

Decreased mortality with local versus general anesthesia in endovascular aneurysm repair for ruptured abdominal aortic aneurysm in the Vascular Quality Initiative database

BackgroundEndovascular aneurysm repair (EVAR) is an accepted approach for patients presenting with ruptured abdominal aortic aneurysm (rAAA) and suitable anatomy. The effect of anesthesia modality on mortality outcomes in rAAA has not been well described. Using the Vascular Quality Initiative database, this study compares local anesthesia (LA) vs general anesthesia (GA) in EVAR for rAAA. MethodsThe Vascular Quality Initiative database was queried for patients presenting with rAAA managed with open surgical repair, EVAR under LA (rEVAR-LA), and EVAR under GA (rEVAR-GA) between 2003 and 2017. Patients were observed until the earlier end point of either death or 1-year follow-up. Kaplan-Meier event rates are presented at 30 days and 1 year. Cox proportional hazards regression was used to model risk of death, with adjustment for demographic and clinical factors. Additional multivariate Cox hazards analyses were used to assess effect modifiers for 1-year mortality for the different repair methods. ResultsA total of 3330 patients (77.4% male) met the inclusion criteria (1594 [47.9%] open surgical repair, 226 [6.8%] rEVAR-LA, and 1510 [45.3%] rEVAR-GA). Patients treated with rEVAR-LA compared with rEVAR-GA had decreased intraoperative time, number of intraoperative blood transfusions, intraoperative crystalloid administration, intensive care unit length of stay, and postoperative pulmonary complications. Mortality rates with rEVAR-LA were lower compared with rEVAR-GA at 30 days (15.5% vs 23.3%; adjusted hazard ratio [AHR], 0.70; 95% confidence interval [CI], 0.49-0.99; P = .04) and at 1 year (22.5% vs 32.3%; AHR, 0.71; 95% CI, 0.53-0.96; P = .02). Patients undergoing EVAR who were <75 years old and those without preoperative hypotension had the greatest survival benefit from LA compared with GA (both factors: AHR, 0.14 [95% CI, 0.03-0.57]; single factor: AHR, 0.57 [95% CI, 0.36-0.91]). ConclusionsThis study demonstrates that rEVAR-LA for rAAA may be a safe alternative to rEVAR-GA for certain patients, with lower morbidity and improved mortality. Further prospective study is warranted to confirm mortality benefit in rEVAR-LA for rAAA.

Choosing anesthesia options for cataract surgery in patients with dementia

Background and Aims:Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of “Choosing Wisely” initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery.Material and Methods:A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the “Choosing Wisely” based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed.Results:One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6–7, and regional anesthesia (RA) for GDS stages 1–5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA.Conclusions:The authors found a reduced requirement for GA when “Choosing Wisely’ initiative was used based on the GDS stage.

The Effect of Spinal versus General Anesthesia on Quality of Life in Women Undergoing Cesarean Delivery on Maternal Request.

IntroductionThe proportion of women electing for cesarean delivery has increased in both developed and developing countries. Cesarean delivery on maternal request (CDMR) refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications.Several studies compared anesthesia modalities in cesarean section regarding clinical outcomes such as maternal mortality, post-operative pain and bleeding, but only a few compared health-related quality of life (HRQoL) of women undergoing general anesthesia versus spinal anesthesia. The aim of this study was to determine whether pregnant women who undergo general anesthesia (GA) for cesarean delivery compared with spinal anesthesia (SA) differ regarding their perceived HRQoL.MethodologyWe enrolled 160 pregnant women with American Society of Anesthesiologists (ASA) class II, scheduled for CDMR with GA or SA. Anesthesia modality was based on patient’s preference. Participants assessed their state of health with the EuroQoL-5 Dimensions-3 Levels (EQ-5D-3L) self-administered questionnaire at four time points: six hours before cesarean delivery, 24 hours after cesarean delivery, one week and one month after cesarean delivery. Patients also rated their health on the EQ visual analog scale (EQ-VAS) from 100 mm “best imaginable health state” to 0 mm “worst imaginable health state”.ResultsMore women who underwent spinal anesthesia reported “no problem” with regards to “mobility’ (64% vs. 30%, p = 0.00), “usual activities” (90% vs. 38%, p = 0.00), and “pain/discomfort” (20% vs. 5%, p = 0.007). Repeated measurement analysis showed that the two groups started off with the same EQ-VAS score, however, both decreased over time with different slope resulting in different scores at 24 hours after CS. Then the scores increased in both groups over time and ended up being rather close at one month after CS.DiscussionUnless there is a contraindication, neuraxial anesthesia is the anesthetic technique of choice for cesarean delivery in all parturient in general. This concept is based on more mortality and morbidity that have been seen with general anesthesia in this particular population. Our study demonstrated significant advantages of spinal anesthesia compared to general anesthesia in cesarean section regarding postoperatively perceived HRQoL. We showed that more pregnant women who chose spinal anesthesia as their anesthesia modality reported “no problem” with respect to “mobility” and “Self-care” 24 hours after cesarean section. On the top of that, more women in this group had “no problem” in their “usual activities” at one week and one month after cesarean delivery time points. Moreover, EQ-5D general health score was higher 24 hours after cesarean delivery with regional anesthesia comparing to general anesthesia.ConclusionWe determined that compared to general anesthesia, spinal anesthesia is the technique of choice for cesarean section because not only it avoids a general anesthetic and the risk of failed intubation, but also because it provides effective pain control, mobility and fast return back to daily activities for new mothers and increase their quality of life.

Tumescent Local Infiltration Anesthesia for Mini Abdominoplasty with Liposuction.

AIM:To evaluate the feasibility and safety of mini abdominoplasty with liposuction under local tumescent anaesthesia (LA) as the sole anaesthetic modality.METHODS:The study included 60 female patients with a mean age of 33.3 ± 5.6 years. Local infiltration using a mixture of 1:1000 epinephrine (1 ml), 2% lidocaine (100 ml) and 0.5% Levobupivacaine (50 ml) in 2500 ml saline was started with Local infiltration started with the abdomen, outer thigh, hips, back, inner thighs and knees. After Mini Abdominoplasty with supplemental liposuction was conducted and application of suction drains wound closure was performed, and the tight bandage was applied. Pain during injection, incision and surgical manipulations was determined. Duration of postoperative analgesia, till oral intake and return home, patients and surgeon satisfaction scores were determined.RESULTS:All surgeries were conducted completely without conversion to general anaesthesia. Injection pain was mild in 46 patients, moderate in 10 and hardly tolerated in 4 patients. Incision pain was mild in 16 patients, while 44 patients reported no sensation. During the surgical procedure, 6 patients required an additional dose of LA. Meantime till resumption of oral intake was 1.6 ± 0.9 hours. Meantime till home return was 5.6 ± 2.4 hours. Twelve patients were highly satisfied, 18 patients were satisfied, and these 42 patients were willing to repeat the trial if required. Eight patients found the trial is good and only one patient refused to repeat the trial and was dissatisfied, for a mean total satisfaction score of 3.1 ± 0.9.CONCLUSION:Mini Abdominoplasty with liposuction could be conducted safely under tumescent LA with mostly pain-free intraoperative and PO courses and allowed such surgical procedure to be managed as an office procedure. The applied anaesthetic procedure provided patients’ satisfaction with varying degrees in about 97% of studied patients.

The influence of anesthetic techniques on postoperative cognitive function in elderly patients undergoing hip fracture surgery: General vs spinal anesthesia

BackgroundHip fracture is common and morbid in elderly patients. Postoperative cognitive dysfunction (POCD) is also very common in these subjects undergoing surgery with an incidence which exceeds 40% in some reports. To date, the evidence is ambiguous as to whether anesthetic technique may affect the patients’ outcome as far as postoperative cognitive function is concerned. ObjectiveThe aim of this study was to compare the effect of general and subarachnoid (spinal) anesthesia on the development of POCD up to 30 days after surgery in elderly patients undergoing hip fracture surgery.Methods Subjects over 65 years with hip fracture undergoing surgery were recruited for this study. They were enrolled and randomized to receive either general anesthesia (GA group) or subarachnoid (spinal) anesthesia (S group). Cognitive function was assessed using a battery of neuropsychological tests undertaken preoperatively and at 30 days postoperatively. The incidence of delirium was examined during the same period and their functional status, in terms of activities of daily living was also recorded. ResultsA total of seventy patients, 33 men and 37 females, mean age of 76 years were analyzed. Thirty-three patients received general anesthesia (GA group) and 37 subarachnoid (spinal) anesthesia (S group). The two groups of patients were similar with respect to baseline characteristics, comorbidities and perioperative data. The results of neuropsychological testing showed that there were no significant differences between the groups in eight out of ten neurocognitive tests at baseline and 30 days after surgery. There was a statistically significant decline of the Instrumental Activities of Daily Living Scale score in S group compared with group GA on the 30th postoperative day (p = 0.043). A significant decline was also present in Color-Word Task test in S group compared with group GA at baseline (p = 0.014) and 30 days postoperatively (p = 0.003). Postoperative delirium was present in four patients (12%) for the GA group, and in 10 patients (27%) for the group receiving subarachnoid anesthesia. ConclusionWe concluded that the choice of anesthesia modality does not appear to influence the emergence of postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgery.

Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty

In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Interventional Pain Management: 32. Spinal anesthesia and thoracolumbar interfascial plane block provide optimum analgesia for lumbar fusion surgery

BACKGROUND CONTEXT Spinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies and discectomies. In particular, lower postoperative pain has been consistently demonstrated with SA. However, very few spine surgeons have extended the use of SA to lumbar fusion surgery, and few studies to date have documented its use in the literature. The authors posit that SA may lead to lower postoperative pain than GA, and have implemented use of a novel thoracolumbar interfascial plane (TLIP) block for additional long-lasting analgesia. PURPOSE The purpose of this study is to compare the use of GA and SA in lumbar fusion surgery in terms of acute postoperative outcomes, and to determine the analgesic value of the TLIP block. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 82 consecutive patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion by a single surgeon from 2015 to 2018. OUTCOME MEASURES A review of demographic information and postoperative records was conducted for the following outcome measures: pain (VAS score), opioid requirement, nausea/vomiting, PACU time, days of admission, adverse hospital event (PE, MI, COPD exacerbation, etc), ambulation during initial PT evaluation, discharge status, 30-day return to ED, 30-day readmission. METHODS The authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. TLIP block consisted of injection of a long-acting local anesthetic agent in liposomal suspension into the fascial plane between the multifidus and longissimus muscles. Patients were placed into 1 of 3 groups based on anesthetic modality: (1) GA; (2) SA; (3) SA+TLIP block. RESULTS A total of 29 patients received SA, 46 received GA, and seven received SA+TLIP block. All groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and ASA physical score. Both the SA and SA+TLIP groups experienced significantly lower max postoperative pain scores (3.31±1.65/10 and 1.71±2.71/10, respectively) than the GA group (5.96±0.84/10, p CONCLUSIONS To our knowledge, SA is almost never used in lumbar fusion and the use of the preoperative TLIP block is a novel concept in spine surgery. In this retrospective study, we demonstrate that use of SA in TLIF surgery can lead to lower pain scores and opioid usage in the PACU, while producing similar postoperative outcomes. Addition of the TLIP block may lead to even lower pain and opioid usage over SA alone, though our sample size was not large enough to achieve significance. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Saturday, September 29, 2018 9:00 am–10:00 am A Fresh Look at Opioids: 272. Spinal anesthesia is a cost-effective alternative to general anesthesia in lumbar fusion surgery

BACKGROUND CONTEXT Spinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost. PURPOSE The purpose of this study is to determine the relative cost-effectiveness of general and spinal anesthesia in lumbar fusion surgery. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 75 consecutive patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion by a single surgeon from 2015 to 2017. OUTCOME MEASURES A review of pre- and postoperative records was conducted for the following outcome measures: demographic information, operating room (OR), time presurgery OR time (time from entering OR to incision), postsurgery OR time (time from closure to exiting OR), anesthesia time, PACU time Postoperative pain (VAS score) and analgesic requirement Postoperative nausea or vomiting incidence Days of admission. In addition, an estimate of operative or recovery costs was created using the following hospital expense components:OR cost postanesthesia care unit (PACU) cost Ambulatory recovery room cost Anesthesia cost METHODS The authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2017. Data collected included demographics, operative and recovery times, nausea or vomiting, postoperative pain, and opioid requirement. If the following costs were included in analysis: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs, and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality. RESULTS A total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86±10.41 vs. 195.63±11.27 minutes, p CONCLUSIONS To our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain or opioids, and slight cost savings over GA. We conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Infraorbital foramen location in the pediatric population: A guide for infraorbital nerve block.

Infraorbital nerve blocks are often performed for the management of postoperative pain associated with cleft lip correction. Infraorbital nerve block procedures depend on the identification of the infraorbital foramen; however, there is little information regarding the infraorbital foramen location in the pediatric population. The aim of this study was to identify the location of the infraorbital foramen in the pediatric population relative to a midpoint between the nasospinale and jugale. The study assessed the location of 152 infraorbital foramina relative to a midpoint between the nasospinale and J on dry crania. Crania were from individuals ranging in age-at-death from 6-month fetal to 18years. The population was subdivided into fetal/infant (≥6months fetal age-<2years), child (≥2-<12years), and adolescent (≥12-≤18years) groups for comparison. The average distance of the infraorbital foramen from the nasospinale-to-jugale midpoint was 1.55±0.78mm (Mean±SD) in the fetal/infant group, 0.80±0.91mm in the child group, and 1.31±1.68mm in the adolescent group. Furthermore, infraorbital foramina tended to be located medial to the nasospinale-to-jugale midpoint in the fetal/infant population, directly upon or superomedial to the nasospinale-to-jugale midpoint in the child population, and directly upon or superior/superolateral to the nasospinale-to-jugale midpoint in the adolescent population. The infraorbital foramen was located within 2mm, on average, from the nasospinale-to-jugale midpoint regardless of age group. Therefore, the nasospinale-to-jugale midpoint may serve as useful means of identifying the location of the infraorbital foramen in the pediatric population and aid in optimizing infraorbital nerve block procedures. The information in this report is valuable in general, but may be particularly useful in developing countries where there is a lack of ultrasound training and availability for health care providers; or places where infraorbital nerve block may be the sole anesthetic modality for cleft lip surgery, even among adolescent patients.

Ultrasound-guided left lateral transversus abdominis plane block combined with rectus sheath block in peritoneal dialysis catheter placement.

This study assessed the utility of ultrasound-guided lateral transversus abdominis plane (TAP) block combined with rectus sheath (RS) block for peritoneal dialysis catheter placement surgery. Thirty consecutive patients with end-stage renal disease scheduled to have peritoneal dialysis catheter placement received a left lateral TAP block combined with RS block performed under ultrasound guidance. The TAP and RS blocks were, respectively, conducted with 15ml of 0.5% ropivacaine and 10ml of 0.5% ropivacaine. Pain intensity was evaluated by verbal rating scale during operation, and the degree of patient and surgeon satisfaction was qualified by a categorical scale. Twenty-nine patients received successful blocks without any other adjuvant anesthetic drugs. One patient required rescue analgesia with lidocaine infiltration. No complications related to regional anesthesia were noted. Ultrasound-guided left lateral TAP block combined with RS block can serve as the primary anesthetic modality for peritoneal dialysis catheter placement surgery.