Postanesthesia Care Unit Time Research Articles

Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study.

IntroductionAn opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing.MethodsA prospective, pilot study was performed in 10 patients (3–8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain.ResultsThe study cohort included 10 patients, 3–8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients’ guardians were satisfied or highly satisfied with their child’s pain control.ConclusionThis opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.

Active Versus Passive Discharge Voiding Protocols and Urinary Retention Rates after Same-Day Minimally Invasive Hysterectomy

Study Objective The primary objective was to determine proportion of patients discharged with a urinary catheter after undergoing a same-day minimally invasive hysterectomy (MIH) for a benign gynecological condition according to active versus passive discharge voiding protocol. Secondary objectives included assessing post anesthesia care unit (PACU) duration and postoperative urinary retention (PUR) rate ≤2 weeks of discharge. Design Retrospective observational data-only cohort study. Setting A large integrated healthcare system serving over one-million reproductive-aged women annually. Patients or Participants Patients ≥18 years old, undergoing a same-day MIH for benign gynecological conditions without urogynecology procedures 2015-2018, were categorized into active or passive voiding trial groups. An active voiding trial was defined as a patient arriving in PACU with a catheter, retrograde filling the bladder with 300ml, then allowing for voiding ≥50% within 30 minutes. If unable to void this volume, then discharged with a catheter to be removed within 24 hours. A passive voiding trial involved filling or not filling the bladder prior to arriving in PACU without a catheter, then allowing for voiding or performing a straight catheterization in PACU if unable to void. Interventions N/A. Measurements and Main Results We found 1644 (83.2%) patients underwent passive voiding trials and 333 (16.8%) active voiding trials. Proportion of patients discharged with a catheter was lower in the passive voiding group than the active voiding group (5.4% versus 10.5%, P=0.001). Passive group had shorter mean PACU time than active group (218±86 versus 240±93 minutes, P Conclusion Within a large integrated healthcare system, passive voiding trials were associated with a smaller proportion of patients discharged with a catheter, shorter PACU duration, and lower PUR rate. This suggests that passive voiding trials can be safely utilized after a benign MIH to reduce hospital duration, optimize healthcare resources, and ultimately improve patient experience.

The effects of neostigmine on postoperative cognitive function and inflammatory factors in elderly patients \u2013 a randomized trial

BackgroundPostoperative cognitive dysfunction is a common postoperative complication in elderly patients. In elderly patients, the decline of organ function and neuromuscular junction function make them more sensitive to muscle relaxants. They are more likely to experience residual muscle relaxation after surgery, which may cause various adverse events. Neostigmine, a commonly used muscle relaxant antagonist, can reduce the expression of inflammatory factors, thereby reducing the pro-inflammatory response and neurodegeneration of the cerebral cortex and hippocampus after surgery. The study aimed at observing the effect of different doses of neostigmine on postoperative cognitive function and peripheral inflammatory factors in elderly patients.MethodsOne hundred thirty-two elderly patients who underwent a radical section of gastrointestinal cancer at First Affiliated Hospital of Dalian Medical University were divided into neostigmine and saline groups at a 2:1 ratio. Neostigmine was intravenously injected in the post-anesthesia care unit (PACU) according to the train-of-four ratio (TOFR) T4/T1. When TOFR was ≤0.5, 0.04 mg/kg neostigmine was administered, whereas when TOFR was > 0.5, 0.02 mg/kg neostigmine was injected. The main observation indexes were cognitive function, interleukin 1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α), and interleukin 6 (IL-6) in peripheral blood at the different times before and after the surgery. Secondary observation indicators include the number of atropine injection, extubating time, PACU residence time, incidence of hypoxemia, hypercapnia, and postoperative nausea and vomiting in PACU, time of exhaustion, and length of hospitalization.ResultsThe extubating and PACU times in 0.04 mg/kg and 0.02 mg/kg groups were significantly shorter than those in the control group (P < 0.001). The incidence of early postoperative cognitive decline in 0.04 mg/kg and 0.02 mg/kg groups was 10 and 15.7%, respectively, which were significantly lower than those in the control group (P = 0.013).ConclusionIn elderly patients, 0.02–0.04 mg/kg neostigmine could significantly reduce the incidence of early postoperative cognitive decline without affecting peripheral inflammatory factors.Trial registrationTrial registration: Chinese Clinical Trial Registry, ChiCTR2000031739. Registered 8 April 2020 - Retrospectively registered, http://www.medresman.org.cn.

Comparison of Dexamethasone 4mg vs 8mg Doses in Total Joint Arthroplasty Patients: A Retrospective Analysis.

IntroductionDexamethasone is commonly administered intraoperatively to control postoperative nausea and vomiting (PONV) and pain. There is limited evidence of the ideal dosage of dexamethasone during surgery. Dexamethasone administration may increase blood glucose levels, posing unique challenges in maintaining acceptable blood glucose levels in patients with diabetes.ObjectiveCompare two doses of dexamethasone (4mg and 8mg) for outcomes in patients undergoing hip and knee arthroplasty.MethodsMedical records of 3,194 patients having undergone total hip arthroplasty (THA) and total knee arthroplasty (TKA) between January 1, 2016 and December 31, 2017 who were administered dexamethasone were reviewed. The eligible population included male and female patients aged 18-89, who underwent elective hip and knee replacement surgery and were administered dexamethasone intraoperatively. Demographics, clinical variables, and preoperative diabetic status were recorded. Primary outcomes included: blood glucose levels, incidence of PONV, post-anesthesia care unit (PACU) time, and length of stay (LOS). Postoperative complications such as periprosthetic joint injection and urinary tract infections (UTI) were also examined within 90 days of surgery. The 30-day readmissions rate was also collected for analysis.ResultsThere was no PONV in the entire patient population. There were no significant differences between 4mg and 8mg dexamethasone in patients with or without diabetes, for preop to postop blood glucose difference, surgical timing, and post-operative complications.ConclusionDexamethasone in both 4mg and 8mg dose was effective in PONV prophylaxis. The effects of 4mg and 8mg dexamethasone were the same in individuals with and without diabetes and the increases in blood glucose were not significantly different. Dexamethasone should not be withheld, as its benefits seem to outweigh the risks even in patients with diabetes.

Application of Intravenous Lidocaine in Obese Patients Undergoing Painless Colonoscopy: A Prospective, Randomized, Double-Blind, Controlled Study.

ObjectivePropofol for procedural sedation and analgesia (PSA) for colonoscopy can result in a high prevalence of severe respiratory depression. Studies have shown that intravenous (IV) infusion of lidocaine can reduce propofol requirements significantly and increase the ventilatory response to carbon dioxide in humans. We tested the hypothesis that IV lidocaine could improve propofol-induced respiratory depression in obese patients during colonoscopy.MethodsNinety obese patients scheduled for painless colonoscopy were randomized to receive lidocaine (1.5 mg/kg, then 2 mg/kg/h, IV) or the same volume of 0.9% saline. Intraoperative sedation was provided by propofol. The primary outcome was the number of oxygen-desaturation episodes. Secondary outcomes were: the number of apnea episodes; total propofol consumption; time to the first hypoxia episode; time to consciousness loss; intraoperative hemodynamic parameters; awakening time; adverse events; duration of post-anesthesia care unit (PACU) stay; satisfaction of endoscopists and patients.ResultsDemographic characteristics between the two groups were comparable. The number of oxygen-desaturation episodes in group L (1.49±1.12) decreased by 0.622 (P=0.018) compared with that in group N (2.11±1.32), and the number of apnea episodes in group L decreased by 0.533 (P<0.001). Kaplan–Meier curves showed that the median time to the first hypoxia episode was longer in group L (86.78 s) than that in group N (63.83 s) (Log rank P=0.0008). The total propofol consumption, awakening time, and duration of PACU stay were reduced in group L. There was no significant difference in the prevalence of adverse events (P>0.05 for all). Satisfaction scores for endoscopists and patients in group L were higher than that in group N (P<0.001).ConclusionIntravenous infusion of lidocaine could significantly reduce the number of oxygen-desaturation and apnea episodes in obese patients during painless colonoscopy. This method is worthy of clinical promotion.Clinical Trials RegistrationChiCTR2000028937.

Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery.

Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk. A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time. Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes. The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.

The Financial and Humanistic Costs Associated with Residual Neuromuscular Blockade

To review the financial and humanistic costs associated with residual neuromuscular blockade (rNMB). A recent systematic review and meta-analysis of randomized controlled trials suggested that sugammadex was superior to neostigmine in producing faster and more reliable reversal of neuromuscular blockade (NMB). The literature on clinical effectiveness of reversal agents, including time to recovery from NMB, time to tracheal extubation, incidence of postoperative residual NMB, and adverse events, indicate that sugammadex is superior to neostigmine. Cost-effectiveness including costs related to postoperative complications, hospital length of stay, operating room and postanesthesia care unit time, drug acquisition, and objective neuromuscular monitoring remain unclear. Objective neuromuscular monitoring was shown to be clinically effective and is universally recommended. Some recent data suggest that objective monitoring can be cost-effective, regardless of the selected antagonist, in confirming complete recovery of neuromuscular function and avoiding additional costs related to residual NMB and associated postoperative pulmonary complications.

Time-Driven activity-based costing identifies opportunities for process efficiency and cost optimization for robot-assisted laparoscopic pyeloplasty

Robot-assisted laparoscopic pyeloplasty (RALP) is a commonly performed procedure in children, but its actual cost implications on the healthcare ecosystem have not been adequately defined. Time-driven activity-based costing (TDABC) is a novel cost accounting method derived from value based healthcare systems that may offer one pathway to assess institutional costs. To determine the true cost of a robot-assisted laparoscopic pyeloplasty (RALP) in the pediatric population using TDABC, and compare it to traditional cost accounting. And to utilize TDABC to minimize cost and improve time-flow efficiency. The RALP care pathway was defined from patient arrival to the pre-operative suite to discharge from the post-anesthesia care unit (PACU). Process maps were created with an interdisciplinary team to survey RALP activities. Retrospective time stamps were obtained from the electronic medical record for fiscal year 2016 (FY16) RALP cases, and were validated by prospectively stopwatch timing additional RALP cases. Male and female pediatric patients undergoing a unilateral RALP during FY16 and during the prospective study period (June 2017-October 2017) were included. Procedure costs were calculated using TDABC after determining the capacity cost rate for all personnel and assets, and multiplying them with the time stamps. 25 RALP cases were analyzed for FY16. TDABC determined a total cost of $15 319/case, when direct, indirect and capital robot cost are included. Traditional cost accounting amounted to a total of $16 158/case. The current robot utilization rate is 22% of total capacity, effectively increasing the total RALP cost by 16%. Time stamps with the most variance were pre-operative services (115±27.5min), robotic console (142min±30.7min) and PACU times (145±101.1min) (Figure) DISCUSSION: This study represents the first TDABC implementation in robot-assisted pediatric procedures. Previous TDABC in other areas of urology similarly revealed discrepancies between traditional cost accounting and TDABC. The present study demonstrates a higher total cost than previous cost accounting studies for the RALP, however, this is the first effort to include indirect costs in the final calculations. This study does convey the limitations of a retrospective analysis and those inherent to a single institution study. TDABC defined the magnitude of cost variation based on robot utilization of a RALP. Traditional cost accounting overestimates the actual costs of a RALP. TDABC also identified high-cost and high variability loci in the RALP process map that will be targeted for process and quality improvement while further reducing assessed costs.

Integrating the STOP-Bang Questionnaire Into the Preanesthetic Assessment at a Military Hospital

PurposeThis quality improvement project integrated the STOP-Bang (Snoring, Tiredness, Observed apnea, Blood Pressure, Body Mass Index, Age, Neck circumference, male Gender) questionnaire into the preanesthetic assessment to identify patients at risk for obstructive sleep apnea (OSA), decrease postanesthesia care unit (PACU) length of stay (LOS), and decrease unanticipated admissions. DesignThis is an observational pre/post design and retrospective chart review. MethodsRegistered nurses assessed STOP-Bang scores among patients seen in the preanesthesia clinic and documented scores in the electronic health record. After PACU discharge, the electronic health record was reviewed for OSA risk stratification, PACU LOS, and unanticipated admissions. FindingsForty-eight percent of patients screened were identified as intermediate or high risk. No difference existed between preimplementation and postimplementation PACU times (P = .767). No unanticipated admissions were identified during either period. ConclusionsThe STOP-Bang questionnaire increased identification of surgical patients at risk for OSA but did not affect PACU LOS or unanticipated admissions.

Perioperative Dexmedetomidine for outpatient cataract surgery: a systematic review

BackgroundCataract surgery is one of the most common procedures performed worldwide in the elderly. Various medications can provide effective anesthesia and analgesia for cataract surgery, but undesirable side effects limit the utility of each medication or combination of medications. Dexmedetomidine may serve as an anesthesia adjunct for outpatient cataract surgery in the elderly.MethodsSearches were conducted in Cochrane, Embase, and PubMed for randomized clinical trials investigating the use of dexmedetomidine in adult patients undergoing outpatient, or ambulatory, cataract surgery with sedation and topical or peribulbar block. Ninety-nine publications were identified, of which 15 trials satisfied the inclusion criteria. A total of 914 patients were included in this review. The following data were collected: American Society of Anesthesiologists’ (ASA) physical status and age of study patients; method of blinding and randomization; medication doses and routes of administration; and intraoperative levels of sedation. We also recorded statistically significant differences between dexmedetomidine and other study medications or placebo with respect to the following outcomes: hemodynamic and respiratory parameters; pain; sedation; post-operative nausea and vomiting (PONV); discharge from post-anesthesia care unit (PACU) or recovery times; patient satisfaction; surgeon satisfaction; and effects on intraocular pressure (IOP).ResultsHypotension with or without bradycardia was reported following bolus doses of dexmedetomidine ranging from 0.5–1.0 mcg/kg with or without a continuous dexmedetomidine infusion. Delayed PACU discharge times were associated with the use of dexmedetomidine, but no clear association was identified between delayed recovery and higher levels of intraoperative sedation. Better analgesia and higher patient satisfaction were commonly reported with dexmedetomidine as well as reductions in IOP.ConclusionsOverall, this review demonstrates better analgesia, higher patient satisfaction, and reduced IOP with dexmedetomidine for outpatient cataract surgery when compared to traditional sedatives, hypnotics, and opioids. These benefits of dexmedetomidine, however, must be weighed against relative cardiovascular depression and delayed PACU discharge or recovery times. Therefore, the utility of dexmedetomidine for outpatient cataract surgery should be considered on a patient-by-patient basis.

MP63-15 DOES SIZE MATTER? PAIN SCORES AND NARCOTIC USAGE AMONGST SHEATH SIZES IN AMBULATORY PERCUTANEOUS NEPHROLITHOTOMY (PCNL) PROCEDURES

INTRODUCTION AND OBJECTIVE: Smaller PCNL tracts are becoming popular due to an increasing ability to clear even large stones as well as decreasing tissue trauma. We postulate that smaller tracts may decrease post-operative pain and narcotic usage in the post-anesthesia care unit (PACU). METHODS: All mini-PCNL (mPCNL, n=32) and standard tract PCNLs (sPCNL, n=67) performed by a single surgeon at an ambulatory surgery center within the last 6 months were analyzed. mPCNL procedures were performed with a 16.5/17.5 French dilator/sheath metal set. sPCNL procedures were performed with a 24/28-30/34 French sheath with balloon dilation. Patient demographics, stone characteristics, and operative room (OR) times were recorded. Pain scores (Numerical Rating Scale, 0-10) on arrival, 15, 60 minutes, and at discharge were recorded. Aldrete scores (Oxygenation, Respiration, Circulation, Consciousness, Activity scores ranked 0-2 for a total score from 0-10) after surgery were recorded. Post-operative PACU morphine equivalents were tracked. RESULTS: mPCNL patients tended to be younger (51 vs 57, p=0.04), had lower stone burdens (17.5 vs 36.4 mm, p=0.0001), and shorter procedures (OR time 84 vs 93, p=0.03 and intracorporeal time 36 vs 44 min, p=0.04). Despite this, mPCNL patients tended to have higher pain scores at 15 (1.78 vs 0.7, p=0.04) and 60 minutes (2.56 vs 1.33, p=0.03). This was not correlated with changes in Aldrete scores or PACU time. Finally, PACU morphine equivalent usage was almost triple in the mPCNL cohort (2.94 vs 1.03, p=0.02). CONCLUSIONS: mPCNL patients tended to have higher pain scores and require higher doses of narcotics in the PACU. Plans for a prospective matched study with single step metal dilation vs balloon dilation are underway. Increased intra-renal pressures are known to occur in mPCNL procedures; however, it is not clear if these increased pressures account for the increased need for pain control or if the dilation technique (metal dilation for mPCNL versus radial dilation for sPCNL) contribute to the increased pain noted post-procedure.Source of Funding: NA

Effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures: a randomized clinical trial

BackgroundLaparoscopic surgery has become a standard of care for many gynecological surgeries due to its lower morbidity, pain and cost compared to open techniques. Unfortunately, the use of carbon dioxide (CO2) to insufflate the abdomen is the main contributor to post-operative shoulder pain.MethodsWe aim to assess the effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures. We hypothesize that maintaining the patient in Trendelenburg for 24 h postoperatively will significantly decrease postoperative shoulder pain and analgesic consumption. After obtaining written informed consent, 108 patients were prospectively randomized into two groups. In the control group, patients underwent standard gynecologic laparoscopic procedures; then after passive deflation of the pneumoperitoneum at the end of the surgery, the patients were placed in supine head up position in the post anesthesia care unit (PACU) and received our institution’s common postoperative care. Patients in the intervention group were subjected to the same maneuver but were positioned in a Trendelenburg position (20 °) once fully awake and cooperative in the PACU and retained this position for the first 24 h. Numerical rating scale (NRS) was used to assess shoulder pain and nausea upon patient arrival to the PACU, at 4, 6, 12 (primary outcome) and 24 h postoperatively. Time to first rescue pain medication, total rescue pain medications and overall satisfaction with pain control were recorded. 101 patients were included in the final data analysis.ResultsBoth groups were comparable in terms of baseline characteristics. NRS pain scores were significantly lower in the intervention group at 12 h compared to the control group (0 [0–1] versus 5 [1–4], p < 0.001), furthermore improvement in postoperative shoulder pain between time of arrival to PACU (time zero) and 12 h postoperatively was significantly higher in patients allocated to the experimental group compared to the control group. Pain scores were significantly lower in patients allocated to the experimental group versus the control group (0 [0–1] versus 5 [1–4], p < 0.001).ConclusionIn conclusion, Trendelenburg position is an easy non-pharmacologic intervention that is beneficial in reducing postoperative shoulder pain following gynecologic laparoscopic surgery.Trial registrationRetrospectively registered at Clinicaltrials.gov, registration number NCT04129385, date of registration: June 28, 2019

Comparison of clinical outcomes of acetaminophen IV vs PO in the peri-operative setting for laparoscopic inguinal hernia repair surgeries: A triple-blinded, randomized controlled trial.

Acetaminophen is available in a variety of modalities but there is conflicting evidence as to whether intravenous provides superior analgesia than oral formulations METHODS: A prospective, randomized, triple-blinded clinical trial was conducted in which 100 participants, scheduled for any laparoscopic unilateral hernia repair surgery in the ambulatory setting, were computer randomized to receive either 975 mg oral acetaminophen or 1000 mg of intravenous acetaminophen. The primary outcomes evaluated were post-anesthesia care unit (PACU) pain scores at arrival, 1 hour discharge, 6 hour post-op as well as total opioid use intraoperatively and in PACU. Secondary outcomes were PACU length of stay, patient reported total opioid use in the first 24 h, pain scores 24 hour post-op and patient satisfaction. We found that no significant difference was appreciated between the oral and intravenous acetaminophen groups in any of the primary or secondary outcomes with the p-value of the pain score on arrival of 0.173, pain score at 1 h 0.544, pain score on discharge from PACU 0.586, pain score at 6 h 0.234, pain score at 24 h 0.133, total morphine milligram equivalents (MME) intraoperatively 0.096, total MME in PACU 0.960, time in PACU 0.15, home opioid MME 0.336, and overall patient satisfaction 0.067. We concluded that in the ambulatory surgery population the efficacy of oral and intravenous acetaminophen is equivalent.

P141. Awake spinal fusion: comparative outcome analysis of spinal anesthesia in lumbar fusion

BACKGROUND CONTEXT Spinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies and discectomies. However, very few spine surgeons have extended the use of SA to lumbar fusion surgery, and few studies have documented its use in the literature. The authors posit that SA may lead to lower postoperative pain than GA, and thus have implemented use of a novel thoracolumbar interfascial plane (TLIP) block for additional long-lasting analgesia. PURPOSE The purpose of this study was to evaluate the effectiveness of SA and SA+TLIP block in patient outcomes following spinal fusion surgery. STUDY DESIGN/SETTING Patients undergoing lumbar spine fusion surgery were included in this study. Patients were categorized based on anesthetic modality. The setting of the study was a suburban, tertiary-care level university-affiliated hospital. PATIENT SAMPLE A total of 111 patients, 53 males and 58 females, were included in the study, with an age range of 20 to 87 years old. Leading diagnoses were: spondylolisthesis (68 patients), stenosis (62 patients) and degenerative disc disease (5 patients). OUTCOME MEASURES The authors recorded patient demographic information, BMI, diagnosis, comorbidities, levels operated on, post-anesthesia care unit (PACU) time, pain scores, adverse events, opioid doses administered and length of stay. METHODS The authors retrospectively reviewed the charts of all 111 patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015-2018. 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 groups based on anesthetic modality: GA; SA; or SA+TLIP block. RESULTS A total of 29 patients received SA, 46 received GA and 36 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 out of 10 and 1.69±0.95/10, respectively) than the GA group (5.96±0.84/10, p CONCLUSIONS To our knowledge, the use of the preoperative TLIP block is a novel concept in spine surgery. In this study, we demonstrate that use of SA+TLIP in TLIF surgery can lead to less time spent in the PACU, lower pain scores, fewer opioid doses and can reduce average length of stay compared to GA. 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. Thus, SA and SA+TLIP block appear to be viable and beneficial alternatives to GA for TLIF surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P140. Cost effectiveness analysis of spinal anesthesia versus 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 objective of this study was to compare the cost and outcomes of SA and GA in minimally invasive transforaminal lumbar interbody fusion (TLIF) to demonstrate their relative cost-effectiveness. STUDY DESIGN/SETTING Patients undergoing minimally invasive TLIF were included in the study. Patients were stratified into two groups based on anesthetic modality: general anesthesia or spinal anesthesia. The setting of the study was a suburban, tertiary-care level university-affiliated hospital. PATIENT SAMPLE A total of 75 patients underwent minimally invasive TLIF surgery, 36 males and 39 females with an age range of 20 to 87 years old. The main diagnoses for these patients were spondylolisthesis (58 patients) and spinal stenosis (57 patients), while degenerative disc disease (5) and herniated discs (3) were less commonly seen, with many patients having multiple diagnoses. OUTCOME MEASURES The authors recorded patient demographic information, BMI, diagnosis, comorbidities, levels operated on, total OR time, total surgery time (incision to closure), time under anesthesia, post-anesthesia care unit (PACU) time, pain scores, adverse events, nausea/vomiting rates, opioid doses administered, length of stay and total net cost. METHODS The authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level TLIF surgery by a single surgeon at a single institution from 2015-2017. Costs were included in analysis if they were: 1) non-fixed; 2) incurred in the OR; and 3) directly related to patient care. All cost data represents net costs, and was obtained from the hospital revenue cycle team. 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±9.02 vs 195.63±11.27 min, 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 and opioid usage, and slight cost savings over GA. Thus, 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.

Operating room scheduling problem under uncertainty: Application of continuous phase-type distributions

This article studies the stochastic Operating Room (OR) scheduling problem integrated with a Post-Anesthesia Care Unit (PACU), the overall problem is called the Operating Theater Room (OTR) problem. Due to the inherent uncertainty in surgery duration and its consecutive PACU time, the completion time of a patient should be modeled as the sum of a number of random variables. Some researchers have proposed the use of the normal distribution for its well-known additive property, but there are questions regarding its fitting adequacy to real OTR data, which tends to be asymmetric with a long tail. We propose to estimate the surgery and PACU times with the family of Continuous PHase-type (CPH) distributions, which provides both fitting adequacy and additive property. We first compute the completion time of each patient analytically and compare the results with normal and lognormal distributions on a series of real OTR datasets. Then, we develop a search algorithm embedding a constructive heuristic and a meta-heuristic algorithm as a sequence generator engine for the patients, and apply the CPH distribution as a chance constraint to eventually find the schedule of each sequence in the OTR problem. The best algorithm among several tested constructive heuristic algorithms is used as the neighborhood structure of meta-heuristic algorithms. We finally construct a numerical example of OTR problem to illustrate the application of the proposed algorithm.

Sugammadex compared with Neostigmine/Glycopyrrolate: An Analysis of Total PACU Time, Responsiveness, and Potential for Economic Impact

Studies have previously shown sugammadex works faster and more effectively than neostigmine/glycopyrrolate at reversal of neuromuscular blockade by rocuronium and vecuronium. The purpose of this quality improvement study was to evaluate for differences in patient time spent in the operating room (OR), post-anesthesia care unit (PACU), and patient responsiveness between the sugammadex and neostigmine/glycopyrrolate groups at a small surgical center. Additionally, a cost analysis was conducted to assess potential savings associated with sugammadex use, taking into account the differences in OR time, PACU time, and medication acquisition cost. We conducted a prospective analysis of OR time, PACU time, and responsiveness for a total of 152 patients, 76 patients receiving neostigmine/glycopyrrolate and 76 patients receiving sugammadex, undergoing planned surgery over an 8-week period. We identified an average decrease in total OR time of 6 minutes in the sugammadex group (neostigmine/glycopyrrolate [Mean: 86 min, Median: 77 min, Range 32-211 min] vs sugammadex [Mean: 80 min, Median: 77 min, Range 40-150 min]). Furthermore, there was an average decrease in total PACU time of 6 minutes in the sugammadex group (neostigmine/glycopyrrolate [Mean: 60 min, Median: 56 min, Range 32-154 min] vs sugammadex [Mean: 54 min, Median: 51 min, Range: 28-94 min]). Additionally, the percent of patients fully awake at the end of PACU stay was higher in the sugammadex group than the neostigmine/glycopyrrolate group (86% vs 79% respectively). Cost was evaluated for generating hypotheses. The additional cost of using sugammadex was estimated at $77 per person when compared to neostigmine/glycopyrrolate. However, if the use of sugammadex decreased the time in OR and PACU by an average of 12 minutes per patient, it is possible that it could provide a potential savings of $579 per patient after estimating a soft savings of reduced OR, PACU, and staff time. Overall cost saving per patient with sugammadex, which was calculated after subtracting additional medication acquisition cost, is $502. It is possible that if this value is extrapolated to 988 patients, this might suggest a potential cost savings of $495,976 per year. We hope this study provokes future research to determine if Sugammadex is a potentially viable economical option for the routine reversal of neuromuscular blockade.

An unconditional logistic regression analysis of factors of prolonged post-anesthesia care unit duration for lower limbs trauma surgery patients

Objective To study the relative factors which influence the post-anesthesia care unit (PACU) stay of the patients underwent the lower limb orthopedic surgery. Methods A total of 442 patients who underwent orthopedic surgery from 2014 to 2017 were investigated. According to the patients′ anesthesia and recovery records, the age, sex, hemoglobin(Hb), surgical procedures, bleeding volume and anesthetic methods, etc. were collected. The possible variables that lead to the discharge delay from PACU were assigned for the regression analysis. The Logistic regression analysis was used in the analysis of the related factors of the delay in PACU. Results The age, anemia, pulmonary function, kidney function, American Society of Anesthesiologists(ASA) level, use of dexmedetomidine (Dex), the consumption of fentanyl, inhalation anesthetics, lumbar-sciatic nerve block, urine volume, hypothermia, bleeding volume, infusion volume and transfusion volume had effects on the delay in PACU. Multivariate analysis showed that the age>65 years, Hb<100 g/L, forced expiratory volume in one second (FEV1)<60%, high ASA grade and hypothermia can prolong the duration of PACU stay after operation. The use of Dex, lumbar-sciatic plexus block, urine volume can shorten the time in PACU. Conclusions Age, Hb level, lung function, ASA level, the use of Dex, lumbar-sciatic plexus block, urine volume, body temperature and transfusion volume were related to the duration in PACU in patients with orthopedic trauma surgery. Key words: Orthopedic surgery; Post-anesthesia care unit; Delay

Comparison of surgical field visibility during propofol or desflurane anesthesia for middle ear microsurgery

BackgroundTo compare surgical field visibility between patients given propofol/remifentanil (PR) or desflurane/remifentanil (DR) anesthesia.MethodsA total of 80 adult patients undergoing middle ear microsurgery due to cholesteatoma otitis media with American Society of Anesthesiologists physical status I and II were randomly assigned to the PR or DR groups. The depth of anesthesia was titrated to maintain a Bispectral index (BIS) between 40 and 50. Remifentanil was titrated to maintain the mean blood pressure within ±30% change of the pre-induction value. Surgical field visibility was rated at several timepoints by the surgeons using the Boezaart scores.ResultsAverage Boezaart scores for surgical field visibility at different time points were < 2 in both PR and DR groups. Surgical field visibility score was lower in the PR group than in the DR group. Requirement for remifentanil was higher in the PR group (850 (488/1330) μg) than in the DR group (258 (143/399) μg, P < 0.0001). The site effect concentration of remifentanil was higher in the PR group (3.6(2.8/5.0)ng/ml) than in the DR group (1.7 (1.0/1.6) ng/ml, P < 0.0001). Hemodynamic profile (i.e., heart rate and mean blood pressure) was similar between groups (P > 0.05). Extubation time (PR group, 21 min vs. DR group, 19 min; P = 0.199) and post-anesthesia care unit time (PR group, 37 min vs. DR group, 34 min; P = 0.324) were comparable between groups.ConclusionAlthough PR anesthesia resulted in lower surgical field visibility scores than DR anesthesia, both groups had scores < 2, meaning no clinical differences between the two groups. DR provided acceptable operative conditions as well, albeit more remifentanil consumption was noted in the DR group.Trial registrationChina Clinical Research Information Service, ChiCTR-1,800,015,537. Registered 5 April 2018. Date of enrolment of the first participant to the trial: 2 May 2018.

Comparison between the effect of epidural anesthesia combined with epidural analgesia and general anesthesia combined with intravenous analgesia on prognosis of ovarian cancer patients

Application value of epidural anesthesia combined with epidural analgesia and general anesthesia combined with intravenous analgesia in ovarian cancer surgery was explored. In total 298 ASA I–III grade patients with ovarian cancer, undergoing extensive total hysterectomy and pelvic lymphotomy, were retrospectively analyzed. Patients were divided into two groups: the epidural anesthesia combined with epidural analgesia group (group A, 158 cases), and the general anesthesia combined with intravenous analgesia group (group B, 140 cases). The first exhaust time, incidence of adverse reactions, Aldrete score, and recovery were observed, and the visual analogue scale (VAS) scores during resting, exercise and cough at 24 h after surgery were recorded. Fasting venous blood (2 ml) was drawn at the same time before anesthesia and at 24 h after anesthesia in both groups to determinate cortisol (COR) and C-reactive protein (CRP) levels. The first exhaust time and incidence of adverse reactions in group A were significantly lower than those in group B (P<0.05). The Aldrete score and extubation time (ET) in group A were significantly higher than that in group B. Eye opening time (EOT), recovery orientation time (ROT) and post-anesthesia care unit (PACU) time in group A were significantly lower than those in group B (P<0.05). The VAS scores in group A during resting, exercise and cough were lower than those in group B (P<0.05). Compared with before anesthesia, the levels of COR and CRP increased significantly in both groups at 24 h after anesthesia (P<0.05), while the level of COR and CRP in group A was significantly lower than that in group B, at 24 h after surgery (P<0.05). Epidural anesthesia combined with epidural analgesia has better analgesic effect, higher safety, lower incidence of adverse reactions, and is beneficial to the recovery of patients with ovarian cancer after radical operation when compared with general anesthesia combined with intravenous analgesia.