Postanesthesia Care Unit Pain Scores Research Articles

Examining Disparities in Regional Anesthesia Utilization, Opioid Prescriptions, and Pain Scores Among Patients Who Received Primary or Revision Total Knee Arthroplasty at a Veterans Affairs Medical Center: A Retrospective Cohort Study.

Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores. This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest. Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort. Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the need for continuous investigation and focused mitigation efforts among Veterans.

Perioperative Risk Factors for Postoperative Delirium in Non-Dementia Older Patients after Non-Cardiac Surgery and Anesthesia: A Prospective Study.

To investigate the incidence and perioperative risk factors for postoperative delirium (POD) in non-dementia older patients who underwent anesthesia for non-cardiac surgery. This prospective cohort study was conducted on 195 non-dementia older patients, aged 60 years or older, who were hospitalized after non-cardiac surgery and anesthesia. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to evaluate the occurrence of POD. Incidence of POD was reported. We conducted univariate and multivariate logistic regression to identify the risk factors associated with POD. 195 patients were enrolled; 172 completed the study. POD occurred in seven patients within three days after anesthesia, which is a 4.1% incidence of POD. Multivariate logistic analysis showed arrhythmia, coagulopathy, urinary comorbidity, minimum intraoperative heart rate, and minimum post-anesthesia care unit (PACU) pain score as independent risk factors for POD. A minimum PACU pain score > 1 is the optimum cutoff pain score for developing POD, with a sensitivity of 85.7% and a specificity of 69.1%. The postoperative complication rate and in-hospital mortality were significantly higher for patients with POD compared to those without POD. The incidence of POD in the study population is 4.1%. Arrhythmia, coagulopathy, urinary comorbidity, minimum intraoperative heart rate, and minimum PACU pain score were independent risk factors for POD. The minimum PACU pain score is the strongest independent risk factor of POD. POD is associated with increased postoperative complications and in-hospital mortality rates in non-dementia older patients.

A Retrospective Study Establishing a Nomogram Predictive Model for Postoperative High-Activity Delirium After Non-Cardiac Surgery.

Postoperative high-activity delirium (PDHA) manifests as a high alertness, restlessness, hallucinations, and delusions. Occurrence of PDHA represents an increased risk of poor prognosis for patients. To establish and validate a nomogram prediction model for high-activity delirium after non-cardiac surgery in a post-anesthesia care unit (PACU). This study retrospectively enrolled adult patients who underwent non-cardiac surgery and were observed in the PACU as training data. Patients were divided into PDHA (199 patients) and non-PDHA (396 patients) groups. Patients' general data, preoperative indicators, intraoperative conditions, and postoperative PACU conditions were collected. The risk factors for PDHA were identified using univariate and multivariate logistic regression analyses. A predictive column chart was created using R language. Adult patients who underwent non-cardiac surgery and entered the PACU for observation were randomly selected as the validation set data (198 cases) for model performance validation. The incidence rate of adult PDHA in the PACU was 0.275%. Sex, age, smoking history, low preoperative albumin level, Society of Anesthesiologists (ASA) classification, anesthesia duration, and postoperative PACU pain score were independent risk factors for hyperactive delirium in PACU adults. In this study, an adult PACU PDHA nomogram prediction model was developed. The training dataset verified that the ROC curve (area under the curve) and 95% confidence interval (95% CI) were 0.936 (0.917-0.955). The ROC curve of the validation data row showed that the area under the curve and 95% CI were 0.926 (0.885-0.967). The nomogram predictive model for PACU adult high-activity delirium constructed in this study showed good predictive performance. This model could enable the visualization and graphical prediction of adult high-activity delirium occurrence after PACU, which has clinical value.

Perioperative Buprenorphine Management and Postoperative Pain Outcomes: A Retrospective Study with Evidence-Based Recommendations

The prevalence of patients on buprenorphine therapy presenting for elective surgery has increased. Buprenorphine is a widely used medication for the management of patients with chronic pain. It is also used as maintenance therapy for patients with a history of opioid use disorder (OUD). Due to the lack of a standardized protocol for managing patients on buprenorphine perioperatively, we performed a retrospective analysis to compare pain score outcomes and postoperative opiate requirements between patients who continued buprenorphine versus patients who discontinued buprenorphine. We identified 35 patients: 11 continued buprenorphine and 24 discontinued buprenorphine. The average Post-Anesthesia Care Unit (PACU) pain score was 5.59 for those who continued buprenorphine and 7.54 for those who discontinued preoperative buprenorphine (p value 0.0339). The average postoperative morphine milligram equivalent (MME) use was 86.13 for those who continued preoperative buprenorphine and 107.70 for those who discontinued buprenorphine (p value 0.6439). The results from our study correlate with several previous studies, which showed lower PACU pain scores in patients who continued buprenorphine. There is a benefit of decreased postoperative pain when preoperative buprenorphine is continued, and a decreased possibility for relapse in those with a history of OUD.

Use of regional anesthesia within a pediatric interventional radiology suite reduced periprocedural opioid use without delaying the overall workflow: a retrospective study

BackgroundNerve block utility has been extensively described in the operating room, however, there is a paucity of evidence regarding blocks in the interventional radiology (IR) suite, with no studies examining...

A Mobile Post Anesthesia Care Unit Order Reminder System Improves Timely Order Entry

Transition to the postanesthesia care unit (PACU) requires timely order placement by anesthesia providers. Computerized ordering enables automated order reminder systems, but their value is not fully understood. We performed a single-center, retrospective cohort study to estimate the association between automated PACU order reminders and primary outcomes (1) on-time order placement and (2) the degree of delay in placement. As a secondary post-hoc analysis, we studied the association between late order placement and PACU outcomes. We included patients with a qualifying postprocedure order from January 1, 2019, to May 31, 2023. We excluded cases transferred directly to the ICU, whose anesthesia provider was involved in the pilot testing of the reminder system, or those with missing covariate data. Order reminder system usage was defined by the primary attending anesthesiologist’s receipt of a push notification reminder on the day of surgery. We estimated the association between reminder system usage and timely order placement using a logistic regression. For patients with late orders, we performed a survival analysis of order placement. The significance level was 0.05. Patient (e.g., age, race), procedural (e.g., anesthesia duration), and provider-based (e.g., ordering privileges) variables were used as covariates within the analyses. Reminders were associated with 51% increased odds of order placement prior to PACU admission (Odds Ratio: 1.51; 95% Confidence Interval: 1.43, 1.58; p ≤ 0.001), reducing the incidence of late PACU orders from 17.5% to 12.6% (p ≤ 0.001). In patients with late orders, the reminders were associated with 10% quicker placement (Hazard Ratio: 1.10; 95% CI 1.05, 1.15; p < 0.001). On-time order placement was associated with decreased PACU duration (p < 0.001), decreased odds of peak PACU pain score (p < 0.001), and decreased odds of multiple administration of antiemetics (p = 0.02). An order reminder system was associated with an increase in order placement prior to PACU arrival and a reduction in delay in order placement after arrival.

Is a Failed Spinal Attempt Associated With a Worse Clinical Course Following Primary Total Hip and Knee Arthroplasty?

BackgroundSpinal anesthesia (SA) is the preferred anesthesia modality for total joint arthroplasty (TJA). However, studies establishing SA as preferential may be subject to selection bias given that general anesthesia (GA) is often selectively utilized on more difficult, higher-risk operations. The optimal comparison group, therefore, is the patient converted to GA due to a failed attempt at SA. The purpose of this study was to determine risk factors and outcomes following failed SA with conversion to GA during primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). MethodsA consecutive cohort of 4,483 patients who underwent primary TJA at our institution was identified (2,004 THA and 2,479 TKA). Of these patients, 3,307 underwent GA (73.8%), 1,056 underwent SA (23.3%), and 130 patients failed SA with conversion to GA (2.90%). Primary outcomes included rescue analgesia requirement in the postanesthesia care unit (PACU), time to ambulation, pain scores in the PACU, estimated blood loss, and 90-day complications. ResultsRisk factors for SA failure included older age and a higher comorbidity burden. Failure of SA was associated with increased estimated blood loss, rescue intravenous opioid use, and time to ambulation when compared to the successful SA group in both THA and TKA patients (P < .001). The anesthesia modality was not associated with significant differences in PACU pain scores. The 90-day complication rate was similar between the failed SA and GA groups. There was a higher incidence of postoperative pain prompting unplanned visits and thromboembolism when comparing failed SA to successful SA in both THA and TKA patients (P < .05). ConclusionsIn our series, patients who had failed SA demonstrated inferior outcomes to patients receiving successful SA and similar outcomes to patients receiving GA who did not have an SA attempt. This emphasizes the importance of success in the initial attempt at SA for optimizing outcomes following TJA.

Improving perioperative acetaminophen administration for safer and cost-effective multimodal analgesia in pediatric surgery: A QI initiative.

The use of acetaminophen in the perioperative period has emerged as an attractive option for providing safer and cost-effective analgesia in children. The primary aim of our project was to increase the use of acetaminophen (both oral and intravenous) in the perioperative period from a baseline of 39.5% to 50% for all surgical patients within 24 months. The secondary aim was to increase the use of enteral acetaminophen from 10% to 52.5% during the same period. A multidisciplinary team was formed, and model for improvement was chosen as the QI methodology. The primary measure was the total percentage of surgical patients receiving any form of perioperative acetaminophen, while our secondary measure was the percentage use of oral acetaminophen administration. We also tracked the average maximum PACU (Post Anesthesia Care Unit) pain scores and the percentage of patients receiving IV opioids. Multiple interventions were conducted, including education, increasing the availability of acetaminophen, and optimizing the electronic medical record (EMR). Monthly data was collected using an automated report in the EMR. We successfully achieved our goal, increasing the use of acetaminophen from 39.5% to 70% within four months. Despite some fluctuations, by the end of 24 months, we not only met but surpassed our goal, with 63% of patients receiving perioperative acetaminophen. Similarly, the usage of oral acetaminophen increased from a baseline of 10% to 78%. Our average maximum PACU pain scores improved from 5.4 to 5.2, and the percentage of patients receiving rescue opioids decreased from 15.4 to 13.1. We successfully achieved and sustained our goals of improving acetaminophen use for our surgical patients without worsening pain scores or worsening use of intravenous opioids. Future directions include further refining our strategies and exploring additional opportunities to optimize pain management in pediatric perioperative settings.

Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience

ABSTRACT Duration, intensity, and management of pain and discomfort may all be affected by experience, personality, and medical and psychosocial comorbidities. A negative cognitive-affective response to actual or anticipated pain, which impacts the pain experience, is called pain catastrophizing. The scale utilized for identifying individuals who magnify, feel helpless to manage, anticipate, or ruminate on pain is known as the Pain Catastrophizing Scale (PCS) and is composed of a 13-question validated measure and 3 subscales. The scale's score ranges from 0 to 52, where scores of 30 and greater indicate pain catastrophizing (30 points is the 75th percentile for PCS score distribution in patients with chronic pain). Pain catastrophizing is associated with increased pain severity, pain persistence, and opioid consumption following surgery, as well as poorer response to endometriosis treatments. Approximately 300,000 prolapse surgical procedures are performed in the United States annually, and because little is known about pain catastrophizing on perioperative pain, pelvic floor symptom distress/impact, and voiding trial (VT) performance following urogynecologic surgery, the authors' primary aim was to assess baseline pain catastrophizing on preoperative pelvic floor symptom impact and distress. The secondary aims included assessing the impact of pain catastrophizing on voiding function and postoperative pain following pelvic floor surgery. The patients for this prospective cohort study included self-identifying female patients undergoing surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse from March 2020 to December 2021. Inclusion came following completion of appropriate surveys and subsequent surgery. Exclusion was merited through surgery for reasons besides SUI or prolapse. At the baseline patient visit, a PCS score of 30 or greater was defined as pain catastrophizing. The initial visit also included recording data such as body mass index, age, benzodiazepine use, chronic opioid use, anxiety and depression diagnoses, postoperative prolapse stage, bothersome urgency urinary incontinence, and preoperative postvoid residual volume. Charts were used for abstracting surgical data, such as operative time, estimated blood loss, type of pelvic reconstructive surgery performed, and midurethral sling placement. Surgeries were all performed by fellowship-trained reconstructive pelvic surgery providers. Postanesthesia care unit (PACU) nurses and clinic staff were masked to preoperative PCS scores obtained in the PACU and postoperative clinic visits. A standardized void trial was performed. Of 320 participants in this cohort, 46 had a pain catastrophizing score of ≥30. Mean age was 60.0 ± 12.8 years. Bivariate analysis indicated that the pain catastrophizing group had higher average body mass index and greater preoperative use of benzodiazepines. Variants such as SUI rates, urgency urinary incontinence, or prolapse stage had no significant differences between groups, yet preoperative pelvic floor symptom distress and impact scores were clinically and statistically significantly higher in the catastrophizing group. Higher PACU pain scores were associated with pain catastrophizing, but not first postoperative VT failure. A significant association between pain catastrophizing and symptom distress remained following multivariable analysis, as well as a relationship between high PCS scores and symptom impact. All quality-of-life subscales maintained the significant associations. This study, although unique in describing pain catastrophizing in this setting, includes various limitations such as its single-institutional nature, which may limit external generalizability. Furthermore, generalizability may also be limited for those electing nonsurgical management, as the study selected for women choosing surgery. Study strengths include its large number of patients cared for by fellowship-trained providers in a similar manner with uniform surgical practice and timing of measures for assessing pelvic pain and pelvic floor symptoms. Also, a relatively standard VT method was utilized. Although further investigation is warranted for describing pain catastrophizing and its role with pelvic floor symptoms and pain postoperatively, the results of this study support other investigative findings, which indicate the importance of understanding pain catastrophizing and its potential effect on patients undergoing pelvic floor surgery. Future studies around this relationship can potentially enable health care providers to tailor perioperative care for individuals with pain catastrophizing.

Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity

To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia. Single tertiary care academic medical center retrospective matched cohort. We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest. Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR=0.80; 95% CI: 0.69, 0.94; P=.005), PACU length of stay was 9.56minutes longer (95% CI: 2.62, 16.49; P=.007), and time between arrival to PACU and first pain score was 2.30minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P=.001). There were no statistically significant differences in the other secondary outcomes. The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.

Low-pressure versus standard-pressure pneumoperitoneum in minimally invasive colorectal surgery: a systematic review, meta-analysis, and meta-regression analysis.

We aimed to assess the efficacy and safety of low-pressure pneumoperitoneum (LPP) in minimally invasive colorectal surgery. A PRISMA-compliant systematic review/meta-analysis was conducted, searching PubMed, Scopus, Google Scholar, and clinicaltrials.gov for randomized-controlled trials assessing outcomes of LPP vs standard-pressure pneumoperitoneum (SPP) in colorectal surgery. Efficacy outcomes [pain score in post-anesthesia care unit (PACU), pain score postoperative day 1 (POD1), operative time, and hospital stay] and safety outcomes (blood loss and postoperative complications) were analyzed. Risk of bias2 tool assessed bias risk. The certainty of evidence was graded using GRADE. Four studies included 537 patients (male 59.8%). LPP was undertaken in 280 (52.1%) patients and associated with lower pain scores in PACU [weighted mean difference: -1.06, 95% confidence interval (CI): -1.65 to -0.47, P = 0.004, I 2 = 0%] and POD1 (weighted mean difference: -0.49, 95% CI: -0.91 to -0.07, P = 0.024, I 2 = 0%). Meta-regression showed that age [standard error (SE): 0.036, P < 0.001], male sex (SE: 0.006, P < 0.001), and operative time (SE: 0.002, P = 0.027) were significantly associated with increased complications with LPP. In addition, 5.9%-14.5% of surgeons using LLP requested pressure increases to equal the SPP group. The grade of evidence was high for pain score in PACU and on POD1 postoperative complications and major complications, and blood loss, moderate for operative time, low for intraoperative complications, and very low for length of stay. LPP was associated with lower pain scores in PACU and on POD1 with similar operative times, length of stay, and safety profile compared with SPP in colorectal surgery. Although LPP was not associated with increased complications, older patients, males, patients undergoing laparoscopic surgery, and those with longer operative times may be at risk of increased complications.

Minimal differences in acute postoperative pain after anterior cruciate ligament reconstruction with quadriceps versus hamstring autograft.

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon ( n = 31) or hamstring ( n = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups ( P > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups ( P > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P = 0.89). Maximum pain scores on POD 1-3 were similar between groups ( P > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 ( P > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period.

Race, ethnicity and postoperative pain in pediatric cancer patients: a single-institution retrospective study

BackgroundStudies have suggested racial and ethnic-based disparities in the intensity of postoperative pain experienced by patients. The objective of this study was to compare the peak and average post-anesthesia care unit (PACU) pain intensity scores of children of non-Hispanic (NH) White race to those of children of other racial/ethnic groups.MethodsSingle-institution retrospective study of children (≤18 years) who had undergone cancer-related surgical procedures from June 2016 through April 2022. Multivariable logistic regression was used to assess the association between race/ethnicity and the peak and average PACU pain intensity scores.ResultsOf the 1,009 unique patients, 74 (7.3%) were Asian, 93 (9.2%) were NH-Black, 310 (30.7%) were Hispanic/Latino, 51 (5.1%) identified as “Other” race (NH-Other), and 481 (47.7%) were NH-White. The median age [interquartile range (IQR)] was 13.7 years (IQR, 8.2–16.6), and 517 (51.2%) were female.In the multivariable analysis, the association between race/ethnicity and a peak PACU pain score greater than 3 was not significant (p = 0.062 for overall effect of race). However, upon comparing the peak PACU pain scores of children of other racial/ethnic groups to NH-White children, NH-Black children were 50.1% less likely than NH-White children to have a peak PACU pain score greater than 3 (odds ratio [OR], 0.499, 95% confidence interval [CI], 0.304–0.818; p = 0.006). Patient race/ethnicity was not associated with an average PACU pain score greater than 3 (p = 0.778).In the sub-group analysis of children who had undergone orthopedic or open abdominal surgeries, the proportions of children with peak and average PACU pain scores which were greater than 3 were not significantly different across racial/ethnic groups (p = 0.250 and p = 0.661, respectively).ConclusionsIn this retrospective study of children who had undergone cancer-related surgery, NH-Black children had significantly lesser odds than NH-White children of having a peak PACU pain score of moderate or severe intensity. However, in the sub-group analysis of children who had undergone orthopedic or open abdominal procedures, peak and average PACU pain scores were not significantly different across racial/ethnic groups.

A Novel Approach to Improving Post-Operative Pain and Minimizing Opioid Consumption After a Hip Arthroscopy.

There have been many different approaches to controlling pain in patients undergoing hip arthroscopy. These include medications, nerve blocks, and intra-articular injections among many others. We introduced a combination of a pre-operative pericapsular nerve group (PENG) block, and intra-operative pericapsular injection of BKK (bupivacaine, ketamine, and ketorolac). Patients undergoing primary hip arthroscopy were identified. There were three patient cohorts based on type of anesthesia: general anesthesia only (GA), general anesthesia and a pericapsular Marcaine injection (GA/Marcaine), or GA with pre-operative PENG block and an intraoperative BKK pericapsular injection (GA+PENG/BKK). Data collected included post-operative pain scores in the PACU (Post-Anesthesia Care Unit), time spent in the PACU, inpatient opioid consumption (both PACU and inpatient), and outpatient opioid prescriptions filled. 20 patients received GA, 11 patients received GA/Marcaine, and 20 patients received GA+PENG/BKK. The GA+PENG/BKK group had average PACU pain score of 3.9 out of 10 compared to 7.7 in the GA group (p<.001) and 6.6 in the GA/Marcaine injection group (p=.048). The GA+PENG/BKK group had shorter mean PACU times than either other group (p<.001). The GA+PENG/BKK also consumed less opioids than the GA or GA/Marcaine groups in the PACU (p<.001), and in the total inpatient stay (p=.002, p=.003), as well as outpatient (p=.019, p=.040). In patients undergoing a hip arthroscopy, performing a pre-operative PENG block and intra-operative BKK pericapsular injection will result in decreased postoperative pain, PACU time, and inpatient and outpatient opioids compared to general anesthesia only and general anesthesia with intracapsular Marcaine.

Efficacy of ultrasound-guided bilateral costal margin block in laparoscopy-assisted gastrectomy: A double-blind randomized trial

BackgroundUltrasound-guided costal margin block (CMB) is a superficial and easily applicable technique. The current study aims to investigate its analgesic efficacy in patients undergoing laparoscopy-assisted gastrectomy and describe its feasibility. MethodsForty-two patients undergoing laparoscopy-assisted gastrectomy were enrolled in this prospective, double-blind, randomized clinical trial. Patients were randomized to receive standard general anesthesia with (block group, n = 21) or without (control group, n = 21) ultrasound-guided bilateral CMB. The primary outcome was 24-h intravenous morphine equivalents after surgery. Secondary outcomes included consumption of titrated morphine, 24–48 h morphine equivalents, consumption of intraoperative remifentanil, numerical pain rating scale scores, time to first opioid dose, patient satisfaction, adverse effects, and recovery events. ResultsThe postoperative 24-h morphine equivalents in the block group were significantly reduced compared to the control group (14.4 ± 7.4 mg vs. 29.9 ± 9.8 mg, p < 0.001). Both the titrated morphine consumption in the post-anesthesia care unit (PACU) and intraoperative remifentanil consumption were lower in the block group than in the control group. Patients in the block group had relatively lower average pain scores in PACU and reported more satisfaction with pain relief. Adverse effects and hospital length of stay after surgery were comparable between the two groups (p > 0.05). ConclusionAs a novel and easily-performed technique, ultrasound-guided bilateral CMB can reduce opioid consumption in patients undergoing laparoscopy-assisted gastrectomy.

Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder: A Retrospective Cohort Study.

Autism spectrum disorder (ASD) is a neurocognitive disorder characterized by impairments in communication and socialization. There are little data comparing the differences in perioperative outcomes in children with and without ASD. We hypothesized that children with ASD would have higher postoperative pain scores than those without ASD. Pediatric patients undergoing ambulatory tonsillectomy/adenoidectomy, ophthalmological surgery, general surgery, and urologic procedures between 2016 and 2021 were included in this retrospective cohort study. ASD patients, defined by International Classification of Diseases-9/10 codes, were compared to controls utilizing inverse probability of treatment weighting based on surgical category/duration, age, sex, race and ethnicity, anesthetizing location, American Society of Anesthesiology physical status, intraoperative opioid dose, and intraoperative dexmedetomidine dose. The primary outcome was the maximum postanesthesia care unit (PACU) pain score, and secondary outcomes included premedication administration, behavior at induction, PACU opioid administration, postoperative vomiting, emergence delirium, and PACU length of stay. Three hundred thirty-five children with ASD and 11,551 non-ASD controls were included. Maximum PACU pain scores in the ASD group were not significantly higher than controls (median, 5; interquartile range [IQR], 0-8; ASD versus median, 5; IQR, 0-8 controls; median difference [95% confidence interval {CI}] of 0 [-1.1 to 1.1]; P = .66). There was no significant difference in the use of premedication (96% ASD versus 95% controls; odds ratio [OR], 1.5; [95% CI, 0.9-2.7]; P = .12), but the ASD cohort had significantly higher odds of receiving an intranasal premedication (4.2% ASD versus 1.2% controls; OR, 3.5 [95% CI, 1.8-6.8]; P < .001) and received ketamine significantly more frequently (0.3% ASD versus <0.1% controls; P < .001). Children with ASD were more likely to have parental (4.9% ASD versus 1.0% controls; OR, 5 [95% CI, 2.1-12]; P < .001) and child life specialist (1.3% ASD versus 0.1% controls; OR, 9.9 [95% CI, 2.3-43]; P < .001) presence at induction, but were more likely to have a difficult induction (11% ASD versus 3.4% controls; OR, 3.42 [95% CI, 1.7-6.7]; P < .001). There were no significant differences in postoperative opioid administration, emergence delirium, vomiting, or PACU length of stay between cohorts. We found no difference in maximum PACU pain scores in children with ASD compared to a similarly weighted cohort without ASD. Children with ASD had higher odds of a difficult induction despite similar rates of premedication administration, and significantly higher parental and child life specialist presence at induction. These findings highlight the need for future research to develop evidence-based interventions to optimize the perioperative care of this population.

Effects of Preexisting Anxiety and Depression on Postoperative Outcomes in Patients Aged 30 Years and Younger Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Background: Mental health influences postoperative outcomes in orthopedic procedures. Increasing attention is being paid to this effect. Purpose: We sought to evaluate the effect of diagnosed depression, anxiety, or both on postoperative outcomes in patients who have undergone hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Methods: We conducted a retrospective cohort study of 289 patients aged 30 years or younger who underwent hip arthroscopy for FAIS at a single institution from January 2014 to June 2021. Univariate statistics were used to assess differences between patients diagnosed with depression, anxiety, or both, and those without these diagnoses. Differences included demographics, operative characteristics, and postoperative outcomes: duration of postanesthesia care unit (PACU) stay, PACU pain scores, complications, reoperations, postoperative injections, 90-day emergency department (ED) visits, and patient-reported outcome measures (PROMs). Multivariate analysis was used to evaluate risk factors for postoperative complications, including wound infection, documented reinjury, postoperative intra-articular hip injection, and any reoperation. Results: Patients diagnosed with depression, anxiety, or both were more likely to be older, female, and have a higher comorbidity burden. At the time of surgery, they were more likely to undergo concomitant procedures, including bursectomy and iliotibial band release. Postoperatively, they had longer PACU stays (90.5 vs 75.1 minutes) and higher first PACU pain scores (5.9 vs 4.6), as well as higher rates of postoperative injection (18.1 vs 9.2%), any reoperation (13.9% vs 4.6%), and revision hip arthroscopy (11.1% vs. 3.7%). Diagnoses of depression, anxiety, or both were independently predictive of any reoperation (odds ratio [OR] = 2.841) and revision hip arthroscopy (OR = 3.401). Conclusion: This retrospective cohort study found that, in patients undergoing hip arthroscopy for FAIS, there was an association between a diagnosis of depression, anxiety, or both, and increased comorbidities, higher first PACU pain scores, longer PACU stays, and increased rates of postoperative injection, any reoperation, or revision hip arthroscopy. Targeted interventions may improve outcomes, but further study is warranted.

Intraoperative use of the machine learning-derived nociception level monitor results in less pain in the first 90 min after surgery.

In this pooled analysis of two randomized clinical trials, intraoperative opioid dosing based on the nociception level-index produced less pain compared to standard care with a difference in pain scores in the post-anesthesia care unit of 1.5 (95% CI 0.8-2.2) points on an 11-point scale. The proportion of patients with severe pain was lower by 70%. Severe postoperative pain remains a significant problem and associates with several adverse outcomes. Here, we determined whether the application of a monitor that detects intraoperative nociceptive events, based on machine learning technology, and treatment of such events reduces pain scores in the post-anesthesia care unit (PACU). To that end, we performed a pooled analysis of two trials in adult patients, undergoing elective major abdominal surgery, on the effect of intraoperative nociception level monitor (NOL)-guided fentanyl dosing on PACU pain was performed. Patients received NOL-guided fentanyl dosing or standard care (fentanyl dosing based on hemodynamic parameters). Goal of the intervention was to keep NOL at values that indicated absence of nociception. The primary endpoint of the study was the median pain score obtained in the first 90 min in the PACU. Pain scores were collected at 15 min intervals on an 11-point Likert scale. Data from 125 patients (55 men, 70 women, age range 21-86 years) were analyzed. Sixty-one patients received NOL-guided fentanyl dosing and 64 standard care. Median PACU pain score was 1.5 points (0.8-2.2) lower in the NOL group compared to the standard care; the proportion of patients with severe pain was 70% lower in the NOL group (p = 0.045). The only significant factor associated with increased odds for severe pain was the standard of care compared to NOL treatment (OR 6.0, 95% CI 1.4 -25.9, p = 0.017). The use of a machine learning-based technology to guide opioid dosing during major abdominal surgery resulted in reduced PACU pain scores with less patients in severe pain.

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

Improved Pain and Perioperative Outcomes After Hip Arthroscopy With the Pericapsular Nerve Group Block

To compare early postoperative pain in patients undergoing hip arthroscopy with versus without the pericapsular nerve group (PENG) block. A retrospective chart review of prospectively collected data was performed to identify patients who underwent hip arthroscopy at a single institution between May 2019 and October 2021. Patients were included if they received general anesthesia and were opioid naive. Patients who received the PENG block were compared with patients who did not. Opioid, benzodiazepine, and antiemetic medication administration was recorded both intraoperatively and for the duration of the patient's stay in the postanesthesia care unit (PACU). Opioids administered were converted to morphine milligram equivalents (MMEs). Pain was assessed with a visual analog scale. Time to discharge (in minutes) and complications were recorded. A total of 53 patients were identified for inclusion, of whom 28 received the PENG block and 25 did not. Opioid consumption was significantly lower in the PENG block group both intraoperatively (16.9 ± 14.1 MMEs vs 40.6 ± 18.3 MMEs, P < .001) and in the PACU (14.4 ± 11.4 MMEs vs 31.2 ± 20.1 MMEs, P < .001). The highest recorded PACU pain score was significantly greater in the no-PENG block group (7.0 ± 1.9 vs 5.3 ± 2.1, P= .004). Within the PENG block group, fewer patients required antiemetics (0 vs 4, P= .043). There was a greater time to discharge in the no-PENG block group (161 ± 50 minutes vs 129 ± 34 minutes, P= .008). No complications, including postoperative falls, were noted in either group. The PENG block improves perioperative outcomes by decreasing pain, opioid consumption, time to discharge, antiemetic requirements, and benzodiazepine requirements after hip arthroscopy. Level III, retrospective comparative therapeutic trial.