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High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery

July 24, 2024 by Dr. Clemens Leave a Comment

AUTHORS: Aakre, Elin Kismul MD et al

Anesthesia & Analgesia 139(2):p 313-322, August 2024.

BACKGROUND:

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery.

METHODS:

We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality.

RESULTS:

Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13–9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07–6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01–2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02–1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68–0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55–0.83) or frailty (AUC 0.69, 95% CI, 0.57–0.82) alone.

CONCLUSIONS:

After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

The Accuracy of the Learning-Curve Cumulative Sum Method in Assessing Brachial Plexus Block Competency

July 24, 2024 by Dr. Clemens Leave a Comment

AUTHORS: de Oliveira Filho et al

Anesthesia & Analgesia 139(2):p 281-290, August 2024.

BACKGROUND:

The learning-curve cumulative sum method (LC-CUSUM) and its risk-adjusted form (RA-LC-CUSUM) have been proposed as performance-monitoring methods to assess competency during the learning phase of procedural skills. However, scarce data exist about the method’s accuracy. This study aimed to compare the accuracy of LC-CUSUM forms using historical data consisting of sequences of successes and failures in brachial plexus blocks (BPBs) performed by anesthesia residents.

METHODS:

Using historical data from 1713 BPB performed by 32 anesthesia residents, individual learning curves were constructed using the LC-CUSUM and RA-LC-CUSUM methods. A multilevel logistic regression model predicted the procedure-specific risk of failure incorporated in the RA-LC-CUSUM calculations. Competency was defined as a maximum 15% cumulative failure rate and was used as the reference for determining the accuracy of both methods.

RESULTS:

According to the LC-CUSUM method, 22 residents (84.61%) attained competency after a median of 18.5 blocks (interquartile range [IQR], 14–23), while the RA-LC-CUSUM assigned competency to 20 residents (76.92%) after a median of 17.5 blocks (IQR, 14–25, P = .001). The median failure rate at reaching competency was 6.5% (4%–9.75%) under the LC-CUSUM and 6.5% (4%–9%) for the RA-LC-CUSUM method (P = .37). The sensitivity of the LC-CUSUM (85%; 95% confidence interval [CI], 71%–98%) was similar to the RA-LC-CUSUM method (77%; 95% CI, 61%–93%; P = .15). Identical specificity values were found for both methods (67%; 95% CI, 29%–100%, P = 1).

CONCLUSIONS:

The LC-CUSUM and RA-LC-CUSUM methods were associated with substantial false-positive and false-negative rates. Also, small lower limits for the 95% CIs around the accuracy measures were observed, indicating that the methods may be inaccurate for high-stakes decisions about resident competency at BPBs.

KEY POINTS

Question: How accurate are the learning-curve cumulative sum (LC-CUSUM) method and its risk-adjusted form (RA-LC-CUSUM) in detecting competency at brachial plexus blocks?

Findings: Both tests showed substantial false-positive and false-negative rates and small lower confidence limits for the accuracy measures.

Meaning: The LC-CUSUM and RA-LC-CUSUM may be inaccurate for high-stakes decisions about resident competency at brachial plexus blocks.

The Effects of Intraoperative Methadone on Postoperative Pain Control in Pediatric Patients

July 24, 2024 by Dr. Clemens Leave a Comment

Authors: Azamfirei, Razvan MS et al

Anesthesia & Analgesia 139(2):p 263-271, August 2024.

Inadequate perioperative pain control has deleterious effects on children’s development and can lead to heightened pain experiences and the avoidance of future medical procedures. Reports of perioperative use of methadone in children are increasing, as it has a favorable pharmacodynamic profile; however, the effectiveness of methadone in reducing postoperative pain has not been established. We, therefore, aimed to provide a scoping review of the literature comparing the effect of intraoperative methadone versus other opioids on postoperative opioid consumption, pain scores, and adverse events in pediatric patients. We identified studies in PubMed, Scopus, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception to January 2023. Postoperative opioid consumption, pain scores, and adverse events were extracted for analysis. We screened 1864 studies, of which 83 studies were selected for full-text review. Five studies were included in the final analysis. Postoperative opioid consumption was decreased overall in children who received methadone compared to those who did not. The majority of studies indicated that methadone was superior to other opioids in reported pain scores, while the frequency of adverse events was similar between the groups. Although the data reviewed highlight a potential benefit of intraoperative methadone in pediatric patients, 4 of the 5 studies had serious methodological concerns. Thus, we cannot make strong recommendations for the regular use of methadone in the perioperative setting at this time. Our results highlight the need for large, well-designed randomized trials to fully evaluate the safety and efficacy of intraoperative methadone in diverse pediatric surgical populations.

Adequate management of postoperative pain is a fundamental component of perioperative care. Yet, postoperative pain is inadequately managed in up to 80% of patients. The effects of undertreated postoperative pain extend beyond temporary patient discomfort and dissatisfaction and include a wide range of negative outcomes, including increased morbidity, functional and quality-of-life impairments, delayed recovery, and chronic postsurgical pain. Children are at particular risk of inadequate analgesia, due to heterogeneity in ages and development and challenges in pain assessment. As such, behavioral studies demonstrate the long-term effects of insufficient pain control, including heightened pain experiences and avoidance of future medical procedures.

Short- and intermediate-acting opioids, such as fentanyl, sufentanil, morphine, and hydromorphone, are the primary opioids utilized for perioperative analgesia in children and adults. However, administration of short-acting opioids as intravenous (IV) boluses leads to rapid fluctuations in serum levels and may lead to periods of inadequate analgesia alternating with periods of oversedation. Continuous infusions can lead to increased tolerance and central sensitization, higher-than-required doses of opioids, and inability to respond quickly to changes in pain level. The introduction of patient-controlled analgesia (PCA) has improved perioperative pain control, but this strategy has limitations. PCA is ideally used for the maintenance of analgesia, rather than establishing analgesia de novo, and is challenging in younger populations where a proxy is required.

Methadone is a synthetic opioid that induces analgesic effects primarily through agonism of μ-opioid receptors and secondarily through antagonism of N-methyl-d-aspartate (NMDA) receptors and serotonin transporters. When administered intravenously, methadone has a rapid onset of action of 8 minutes and an elimination half-life of 24 to 36 hours in adult patients. In children and adolescents, methadone has been shown to have similar pharmacokinetics with a rapid onset of action (2 minutes) and a long elimination half-life (19.2–35.5 hours). The extended duration of effect has solidified methadone as a cornerstone therapy in the management of opiate dependence and neuropathic and cancer pain; however, combined with the rapid onset of action, it may be a viable option for postoperative, acute pain as well reflected by successful use in spinal fusions and cardiac anesthesia. Despite these advantages, reports of perioperative use remain limited with no attempts to systematically synthesize the effects of intraoperative methadone on postoperative analgesia in pediatric populations. The objective of this study is to review postoperative analgesia outcomes in pediatric patients receiving intraoperative methadone compared to patients receiving other intraoperative opioids or placebo.

METHODS

Literature Search and Study Selection

A comprehensive search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase was conducted. With the expertise of a medical librarian (K.L.), the databases were searched from the date of database inception to January 2023. An additional search was performed on ClinicalTrials.gov in January 2023; principal investigators of completed, but unpublished trials were contacted to obtain study and protocol data. As part of a series of literature reviews, the search strategy for each database included the following terms and their synonyms: methadone, pediatric, surgical, operative, anesthesia, ventilation, critical care (Supplemental Content 1, Appendix 1, https://links.lww.com/AA/E391). References from included articles and review articles were manually searched to identify additional studies for inclusion. The review was not registered, and a protocol was prepared. The study does not qualify as human subject research. Thus, institutional review board approval was not required for the analysis of published data.

Inclusion and Exclusion Criteria

English-language prospective, peer-reviewed studies (randomized or nonrandomized) involving pediatric patients (≤18 years) were included in this study. We included all studies with a prospective component that compared the usage of intraoperative methadone in pediatric patients undergoing surgery to placebo groups, groups receiving other intraoperative opioids, or groups receiving “standard of care.” We also included studies where intraoperative methadone was part of a bundle of interventions that were compared to usual care. Duplicated studies, studies for which an English-language full text was not available, and studies in adult populations were excluded from the review. Given this review’s focus on mapping existing prospective evidence, retrospective studies were excluded.

Data Extraction and Quality Assessment

Search results were imported into the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) and deduplicated. Study titles and abstracts were screened by 2 independent investigators (R.A. and D.P.). For studies that passed title and abstract review, the full text was independently analyzed by both reviewers to ensure inclusion criteria were met. The data for predetermined outcomes in the review protocol, postoperative pain scores, postoperative opioid consumption, and adverse events were extracted from studies that met inclusion criteria after a full-text review. Any disagreements were resolved by consensus. For each outcome, studies reporting the outcome were summarized. A summary of the studies reporting each outcome was created. Adverse event data identified by the original authors were extracted.

Table. – Studies Included in the Scoping Review

Study	Design	Overall risk of bias (tool)	N	Patient sample	Intervention	Intervention timing	Outcome measures and timing	Main findings
Berde et al 1991²²	Randomized, double-blind, controlled trial	High (RoB 2)	35	Pediatric patients (3‐7 y) undergoing surgery	Methadone IV 0.2 mg/kg versus morphine IV 0.2 mg/kg	Single, preincisional dose	Total opioid consumption on the operative day and first postoperative day	Decreased supplemental opioid dosages on the first perioperative day
							Mean pain scores (Oucher, ACCS, and CHEOPS) for the first postoperative 36 h	Lower pain scores in the methadone group
							Adverse events	No major adverse events
Berde et al 1988²³	Randomized, double-blind, controlled trial	High (RoB 2)	41	Pediatric patients (≤18 y) undergoing	Protocol A: methadone IV 0.2 mg/kg versus morphine IV 0.2 mg/kg	Protocol A: single dose immediately after induction	Total opioid consumption in the first postoperative 12 h and 24 h	No significant difference in total opioid consumption for protocol A
				Protocol A: orthopedic, urologic, and general surgery	Protocol B: methadone IV 0.1 mg/kg versus morphine IV 0.1 mg/kg	Protocol B: single dose after intraoperative wake-up test		Decreased 12-h total opioid consumption in the methadone group in protocol B
				Protocol B: posterior spinal fusion surgery
Martin et al 2018²⁴	Randomized, controlled trial	Some concerns (RoB 2)	60	Pediatric patients (≤18 y) undergoing posterior spinal fusion surgery	Methadone IV 0.1 mg/kg + remifentanil IV versus magnesium IVB 50 mg/kg + IV 10 mg/kg/h + remifentanil versus remifentanil	Single dose immediately after induction	Total opioid consumption in the OR, PACU, and first postoperative 24 h	Decreased total opioid consumption in the methadone group
Martin et al 2018²⁴	Randomized, controlled trial	Some concerns (RoB 2)	60			Single dose immediately after induction	Mean pain scores (VAS) in PACU, inpatient ward and overall	No difference between remifentanil and magnesium groups
Tams et al 2020²⁵	Nonrandomized interventional study with historical controls	Critical (ROBINS-I)	40	Pediatric patients (≤18 y) undergoing posterior spinal fusion	Multicomponent clinical pathway containing intraoperative methadone IVB (0.25‐0.4 mg/kg)	Single intraoperative dose, no specified timing	Total opioid consumption during the first postoperative 24 h	No difference in pain scores
							Mean pain scores (NRS) for 24 h postoperatively	No difference in the number of adverse effects
								Decreased 24 h postoperative opioid requirement
								Decreased postoperative pain scores
								Decreased LOS
Ye et al 2020²⁶	Nonrandomized interventional study with historical controls	Critical (ROBINS-I)	122	Pediatric patients (≤18 y) undergoing posterior spinal fusion	Multicomponent clinical pathway containing intraoperative methadone IVB (0.1 mg/kg) with postoperative Q12H IV methadone boluses (0.1 mg/kg) versus previous practice	Single intraoperative dose, no specified timing	Total opioid consumption on each postoperative day	Increased POD 0 opioid usage
							Mean pain scores (NRS) for each postoperative day	Higher POD 0 pain scores
							Length of stay	Decreased POD 2 and POD 3 pain scores
								Decreased overall opioid usage
								Decreased LOS

Abbreviations: ACCS, Analogue Chromatic Continuous Scale; CHEOPS, Children’s Hospital of Eastern Ontario Pain Scale; IV, intravenous; IVB, intravenous bolus; LOS, length of stay; NRS, numeric rating scale; OR, odds ratio; PACU, postanesthesia care unit; POD, postoperative day; RoB, Risk of Bias; VAS, visual analogue scale.

Figure 1.:

PRISMA flow diagram of included studies. PRISMA indicates Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Critical appraisal of the evidence was performed with the ROBINS-I tool for nonrandomized studies and RoB 2 tool for randomized studies. Plots were generated using the robvis tool. This article adheres to the applicable PRISMA guidelines.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of included studies is depicted in Figure 1. Of the 7548 studies identified by electronic searches for title and abstract review, 5684 duplicates were removed leaving 1864 studies for title and abstract screening. Of those, 83 studies were assessed for eligibility by full-text review. We identified 5 studies for inclusion in the scoping review, comprising a total of 298 patients (Table). Additionally, we identified 3 registered but unpublished randomized, controlled trials. As the quality of the unpublished trials cannot be evaluated, the results are not included in the synthesis. Given the heterogeneity in interventions, outcome measures, patient populations, and surgery types, a meta-analysis of the published findings was not possible.

Quality Assessment

We assessed the evidence quality of the included studies using the ROBINS-I tool for the nonrandomized studies and the RoB 2 tool for the randomized studies (Figure 2). Despite the magnitude of the effect, Tams et al was assessed as having a critical risk of bias due to confounding and heterogeneity of the intervention. Ye et al was assessed as having a critical risk of bias, due to the heterogeneity of the intervention. No nonrandomized study reported information regarding missing data.

Figure 2.:

Summary of the risk of bias assessments using ROBINS-I for nonrandomized studies (A, B) and RoB 2 for randomized studies (C, D) for the included studies. RoB indicates Risk of Bias; ROBINS-I, Risk Of Bias In Non-randomised Studies of Interventions.

Berde et al and Berde et al demonstrated a high risk of bias as the study dosages were not equipotent between the arms of the study. Additionally, the authors measured pain using multiple scales, which raises some concerns regarding the selective reporting of the result domain. The study by Martin et al raises some concerns regarding the risk of bias as there was not sufficient information to assess whether any deviations from the trial protocol occurred.

Postoperative Pain Scores

Postoperative pain scores were reported by 4 studies. Berde et al performed a randomized, double-blind trial comparing intraoperative methadone (0.2 mg/kg) to intraoperative morphine (0.2 mg/kg) in 35 children undergoing major surgery. Mean Oucher and Analogue Chromatic Continuous Scale (ACCS) scores were lower in the methadone group for each period with complete data (P < .05). When ACCS scores were categorized as mild-moderate versus severe, patients in the methadone group had significantly fewer severe pain scores compared to the morphine group (P < .001).

Martin et al compared methadone IV 0.1 mg/kg + remifentanil IV to magnesium IV bolus 50 mg/kg + IV 10 mg/kg/h + remifentanil IV, as well as to remifentanil in a randomized controlled trial in 60 patients undergoing posterior spinal fusion surgery. Visual analogue scale (VAS) scores were not significantly different in either the postanesthesia care unit (PACU) (methadone and remifentanil versus remifentanil: 6.0 vs 5.2, Δ = 0.8, 95% CI [−1.1 to 2.5]) or in the first 24 hours on the inpatient ward (4.8 vs 4.8, Δ = 0, 95% CI [−1.6 to 1.7]).

Tams et al compared the effects of a multicomponent clinical pathway containing gabapentin, acetaminophen, intraoperative methadone (0.25–0.4 mg/kg), hydromorphone PCA as well as additional nutrition, bowel care, and mobilization interventions to previous clinical practice in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. They observed decreased postoperative numeric rating scale (NRS) pain scores in the methadone group compared to the control group (3.4 vs 4.8, Δ = −1.4, 95% CI [−2.6, −0.2]). In particular, NRS scores were significantly lower on the operative day. However, no difference in postoperative pain scores was observed when high and low-dose methadone groups were compared separately to the control group.

Finally, Ye et al compared a methadone-based multimodal analgesia protocol containing intraoperative methadone (0.1 mg/kg), as well as postoperative scheduled methadone, oxycodone, methocarbamol, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and pro re nata (PRN) IV opioids, to a previous protocol containing intraoperative intrathecal morphine and postoperative gabapentin, morphine PCA (postoperative day 0 [POD 0]), scheduled oxycodone/hydrocodone (POD 1), and PRN IV morphine, ketorolac, and acetaminophen in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Postoperative NRS pain scores were significantly increased on the operative day, but significantly decreased on POD 2 and POD 3 for the methadone group compared to the control group.

Postoperative Opioid Consumption

Postoperative opioid consumption was reported in 4 studies. Berde et al report the results of a randomized double-blind trial comparing intraoperative methadone to intraoperative morphine in 41 pediatric patients, using 2 different protocols. In the first protocol, used for orthopedic, urologic, and general surgeries, patients received either methadone (0.2 mg/kg) or morphine (0.2 mg/kg) following standard induction. For patients treated with the first protocol, there were no observable differences between the groups in both 12- and 24-hour opioid consumption. In the second protocol, used for posterior spinal fusion cases, patients were initially maintained on fentanyl and isoflurane anesthesia; following the intraoperative wake-up test, patients received either methadone (0.1 mg/kg) or morphine (0.1 mg/kg). Patients receiving methadone had significantly decreased opioid requirements at both 12 and 24 hours postoperatively. Berde et al (1991) found decreased opioid consumption on the operative day (P = .049), but no significant difference on the first postoperative day.

Tams et al observed significantly decreased opioid requirements in the first 24 postoperative hours in the methadone group compared to the control group (10 vs 41 IV morphine milligram equivalents [MMEs]; Δ = −29 IV MME; 95% CI [−45 to −15]). This finding was observed in both the high- and low-dose methadone groups. Ye et al found significantly increased opioid usage during the operative day (29.3 vs 9.9 IV MME; P < .001) in the methadone group compared to the control group. POD 2 and POD 3 opioid usage was significantly decreased in the methadone group, as was total opioid usage during the hospital stay (98.1 vs 127.5 IV MME). Martin et al did not report cumulative postoperative opioid consumption. However, total opioid consumption, including intraoperative opioids, was decreased in patients receiving methadone and remifentanil compared to patients receiving remifentanil alone (0.26 vs 0.34 hydromorphone mg/kg; Δ = −0.08; 95% CI [−0.14 to −0.01]). Opioid consumption in the PACU (0.01 vs 0.01 hydromorphone mg/kg; Δ = 0; 95% CI [−0.01 to 0.00]) or the inpatient ward (0.24 vs 0.29 hydromorphone mg/kg; Δ = −0.05; 95% CI [−0.11 to 0.01]) did not show a statistically significant difference between the groups.

Adverse Events

All 5 studies reported on the presence of adverse events. Berde et al (1991) was not able to identify differences in postoperative recovery measures between the methadone and morphine groups. There were no reported adverse events, including naloxone usage, delayed emergence from anesthesia, or need for postoperative ventilatory assistance. Berde et al (1988) found no clinically significant hypoventilation in either the methadone or morphine group. Martin et al showed no significant differences in times to eye opening, following commands, tracheal extubation, or length of stay between the methadone and remifentanil groups. The authors reported 1 episode of excessive bleeding in the methadone group and no other intraoperative events in the remaining groups. Tams et al did not explicitly discuss perioperative adverse events. They reported decreased emergence time in the low-dose methadone group compared to the control group; they additionally observed increased emergence time in the high-dose methadone group, which led to a protocol change; however, this was not statistically significant. Ye et al did not observe any opioid-related adverse effects in their study.

DISCUSSION

In our scoping review of intraoperative methadone use in pediatric surgical patients, methadone appears to be associated with decreased consumption of opioids in the first 24 hours postoperatively compared to patients receiving other shorter-acting opioids or pain management strategies. This is the first review formally examining the quality of the evidence surrounding methadone usage in pediatric patients. Our formal assessment of existing evidence expands on recent works discussing the heterogeneity in pediatric methadone usage. The low quality of evidence identified by our paper cautions against an overly broad interpretation of the results. However, our results are consistent with several meta-analyses completed in adult populations, showing similarly decreased opioid consumption in the methadone group. Our review identified 3 studies suggesting that compared to patients receiving shorter-acting opioids, pain scores in patients receiving methadone were reduced. One study did not demonstrate a difference in pain scores. The potential benefit of methadone is likely the result of its quick onset, long duration of action, and more consistent plasma concentrations. The multimodal pharmacodynamic effects provide enhanced analgesia with a concomitant lower requirement for overall opioid utilization to achieve an equivalent or enhanced degree of analgesia compared to standard opioids. Additionally, methadone decreases the reuptake of norepinephrine and serotonin potentially modulating the subjective perception of pain. The observed decreased opioid requirements could be the result of the improved pain control resulting from the combined effect of those pathways.

Our review suggests that methadone may be noninferior to other short-acting opioids in subjective measures of pain compared. The heterogeneity in the instruments used to report pain scores prevented a meta-analysis. In individual studies, regardless of the instrument used, methadone was superior to other opioids in the subjective report of pain or did not demonstrate significant differences in pain scores. In one study, subjective measures of pain were increased on POD 0 in patients receiving methadone-based pain control; however, these patients engaged in physical therapy earlier, had shorter lengths of stay, lower pain scores on POD 2 and POD 3, and fewer reports of significant postoperative pain after discharge; additionally, their total opioid consumption was decreased. Several studies in adult populations also highlight the superiority or noninferiority of methadone in managing subjective measures of pain.

The studies identified by this review did not report differences in the frequency of adverse events between the groups. However, due to the small sample size, it is possible that adverse events may not be adequately detected. Several studies examined extubation rates and the need for naloxone, but the results were too heterogeneous for a quantitative analysis. Still, the results suggest that the usage of methadone is likely as safe as the current standard of care.

The existing data suggest potential benefits of methadone in reducing postoperative opioid requirements without affecting pain scores or causing increases in adverse events. However, due to the limited number of high-quality studies, and only 1 recent randomized controlled trial among them, we cannot recommend routine usage of methadone. Large, randomized controlled trials are needed to further evaluate its effectiveness. The role of methadone in enhanced recovery after surgery (ERAS) protocols should also be evaluated but not replace evaluation of individual components of the protocols.

It is important to note that our study focuses exclusively on intraoperative methadone in pediatric populations. The use of preoperative methadone has been reported in some pediatric studies as part of a multimodal analgesia, but the limited data available and the nature of the studies precluded a detailed examination of this topic. The adult literature suggests that preoperative methadone may have the potential to decrease postoperative opioid consumption. However, the benefit of preoperative methadone in pediatric populations remains uncertain due to the limited data available.

The reported doses varied between 0.1 and 0.4 mg/kg, but the variations in protocols and methods make it difficult to draw conclusions regarding the optimal dosage. Tams et al reduced the methadone dose from 0.4 to 0.25 mg/kg due to oversedation concerns; in contrast, Barnett et al utilized a total dose of up to 0.4 mg/kg but administered in multiple doses based on clinical response. Komen et al suggest that a minimum of 0.15 mg/kg methadone is needed to improve postoperative pain variables compared to other opioids. However, the appropriate dosage will likely depend on the surgical procedure as well as the timing of administration. Of note, methadone exhibits significant difference in metabolism depending on the carriage of CYP450 isoforms. To this date, while there are studies examining in vitro and in vivo measures of pediatric methadone metabolism based on CYP2B6 and CYP2C19 status, none of the studies examine outcome measures related to pain control; additionally, existing studies do not examine CYP3A4 or CYP2D6 status, which are additional contributors to methadone metabolism. The influence of genetic mediators of methadone clearance can affect the adequacy of pain control and should be considered when determining adequate methadone dosing strategy for future studies.

Our study has several limitations. First, the sample sizes of the included studies were small, totaling only 298 patients. Second, all the randomized controlled trials exhibited some form of bias, either due to lack of blinding or due to lack of equipotency between the study arms. Nonrandomized studies exhibited significant heterogeneity in interventions and dosing strategies, with all included studies implementing several interventions in addition to the introduction of intraoperative methadone and exhibiting a critical risk of bias in at least one domain. Third, some variability in the opioid used in the control group, as well as the opioids used for postoperative analgesia, exists. Fourth, outcome measures for both opioid usage and pain scores were heterogeneously reported and not standardized; additionally, studies reported adverse reports inconsistently. Fifth, the overall quality of evidence was low, with all studies exhibiting some form of potential bias or methodological flaw. Sixth, given our inability to obtain complete data for the unpublished trials, our synthesis may exclude relevant results. Finally, due to the nature of the study and the available evidence, we are unable to make any recommendations regarding pediatric methadone usage.

CONCLUSIONS

In our scoping review, pediatric patients who received intraoperative methadone had decreased opioid consumption compared to patients who received shorter-acting opioids; pain scores and the rate of adverse events were similar between the groups. However, we cannot make strong recommendations for the regular usage of methadone based on these studies, as only a small number of interventional studies were available for analysis. The results underscore the need for large, well-designed randomized trials to fully evaluate the safety and efficacy of intraoperative methadone in diverse surgical populations.

The Global Anesthesia Workforce Survey: Updates and Trends in the Anesthesia Workforce

July 24, 2024 by Dr. Clemens Leave a Comment

AUTHORS: Law, Tyler J. MD, MSc, FRCPC et al

Anesthesia & Analgesia 139(1):p 15-24, July 2024.

BACKGROUND:

There is a large global deficit of anesthesia providers. In 2016, the World Federation of Societies of Anaesthesiologists (WFSA) conducted a survey to count the number of anesthesia providers worldwide. Much work has taken place since then to strengthen the anesthesia health workforce. This study updates the global count of anesthesia providers.

METHODS:

Between 2021 and 2023, an electronic survey was sent to national professional societies of physician anesthesia providers (PAPs), nurse anesthetists, and other nonphysician anesthesia providers (NPAPs). Data included number of providers and trainees, proportion of females, and limited intensive care unit (ICU) capacity data. Descriptive statistics were calculated by country, World Bank income group, and World Health Organization (WHO) region. Provider density is reported as the number of providers per 100,000 population.

RESULTS:

Responses were obtained for 172 of 193 United Nations (UN) member countries. The global provider density was 8.8 (PAP 6.6 NPAP 2.3). Seventy-six countries had a PAP density <5, whereas 66 countries had a total provider density <5. PAP density increased everywhere except for high- and low-income countries and the African region.

CONCLUSIONS:

The overall size of the global anesthesia workforce has increased over time, although some countries have experienced a decrease. Population growth and differences in which provider types that are counted can have an important impact on provider density. More work is needed to define appropriate metrics for measuring changes in density, to describe anesthesia cadres, and to improve workforce data collection processes. Effort to scale up anesthesia provider training must urgently continue.

KEY POINTS

Question: How many anesthesia providers are there worldwide, and how has this number changed since 2016?
Findings: The number of anesthesia providers worldwide has increased over time, but not everywhere, and many countries still lack sufficient providers.
Meaning: Though global efforts have increased anesthesia provider numbers, significant work is still required, along with routine data reporting methods.

Science, Medicine, and the Anesthesiologist

July 24, 2024 by Dr. Clemens Leave a Comment

Author: Steven Cohen, M.D.

Anesthesiology July 2024, Vol. 141, A13–A15

A multi-ancestry genetic study of pain intensity in 598,339 veterans. Nat Med 2024; 30:1075–84. PMID: 38429522.

Genetics has been shown to account for between 25% and up to 60% of pain, which can span the spectrum between pain sensitivity and tolerance, response to analgesics, and a host of psychological predisposing factors. In this cross-sectional study, 598,339 individuals enrolled in the U.S. Department of Veterans Affairs’ Million Veteran Program aiming to identify genetic loci associated with chronic pain, which was estimated by using the median of median numerical rating scale pain scores. A subgroup analysis was performed in 291,759 veterans of African, Hispanic, and European ancestry who did not have a lifetime diagnosis of opioid use disorder. They identified 126 independent genetic loci, 69 of which were previously unidentified. Pain was described as severe, moderate, and mild in 24.4%, 19.2% and 4.5%, respectively, of the full cohort, with comparable rates in the sample without opioid use disorder. Pain intensity genetically correlated with different pain phenotypes (particularly multisite pain), substance use disorders and other psychiatric characteristics, education level and cognitive traits, as well as social variables such as obesity and smoking. Drugs identified as having possible analgesic effects included anticonvulsants, psychoanaleptics, and methoxyflurane, an anesthetic agent used as an analgesic drug outside of the United States.

Take home message: This large genetic study provides clues to important molecular contributors to the experience of pain and highlights potential drug targets. Generalization to a broader population (including Asian, Native American, and nonveteran populations) and clinical studies to confirm these findings are needed.

Perioperative Plasma in Addition to Red Blood Cell Transfusions Is Associated With Increased Venous Thromboembolism Risk Postoperatively

July 23, 2024 by Dr. Clemens Leave a Comment

AUTHORS: Choi, Una E. BA et al

Anesthesia & Analgesia 139(2):p 254-261, August 2024. |

CKGROUND:

Perioperative red blood cell (RBC) transfusions increase venous thromboembolic (VTE) events. Although a previous study found that plasma resuscitation after trauma was associated with increased VTE, the risk associated with additional perioperative plasma is unknown.

METHODS:

A US claims and EHR database (TriNetX Diamond Network) was queried. We compared surgical patients who received perioperative plasma and RBC to patients who received perioperative RBC but not plasma. Subanalyses included (1) all surgeries (n = 48,580) and (2) cardiovascular surgeries (n = 38,918). Propensity score matching was performed for age at surgery, ethnicity, race, sex, overweight and obesity, type 2 diabetes, disorders of lipoprotein metabolism, essential hypertension, neoplasms, nicotine dependence, coagulopathies, sepsis, chronic kidney disease, liver disease, nonsteroidal anti-inflammatory analgesics, platelet aggregation inhibitors, anticoagulants, hemoglobin level, outpatient service utilization, and inpatient services; surgery type was included for “all surgeries” analyses. Outcomes included 30-day mortality, postoperative VTE, pulmonary embolism (PE), and disseminated intravascular coagulation (DIC).

RESULTS:

After matching the surgical cohorts, compared to only RBC, plasma + RBC was associated with higher risk of postoperative mortality (4.52% vs 3.32%, risk ratio [RR]: 1.36 [95% confidence interval, 1.24–1.49]), VTE (3.92% vs 2.70%, RR: 1.36 [1.24–1.49]), PE (1.94% vs 1.33%, RR: 1.46 [1.26–1.68]), and DIC (0.96% vs 0.35%, RR: 2.75 [2.15–3.53]). Among perioperative cardiovascular patients, adding plasma to RBC transfusion was associated with similar increased risk.

CONCLUSIONS:

When compared with perioperative RBC transfusion, adding plasma was associated with increased 30-day postoperative mortality, VTE, PE, and DIC risk among surgical and cardiovascular surgical patients. Reducing unnecessary plasma transfusion should be a focus of patient blood management to improve overall value in health care.

10 things to know about ASCs right now

July 23, 2024 by Dr. Clemens Leave a Comment

Author: Francesca Mathewes

Becker’s ASC Review

Advances in technology and the cost effectiveness of ASCs have made them a fast-growing market.

Here are 10 key takeaways:

1. Fast growth. The ASC market is projected to reach $60 billion by 2030, reflecting a compound annual growth rate of 6% from 2023 to 2030. Advancements in technology and devices are a big growth driver.

2. ASCs are gaining a greater share of high-acuity procedures. ASCs continue to perform a greater number of high-acuity procedures, particularly in orthopedics and cardiology. In 2023, CMS added 11 procedures to the ASC-covered list that were not included in the proposed rule, including total-shoulder arthroplasty.

3. The industry is still highly fragmented. According to a report from VMG Health, 68% of ASCs are independently owned. The remaining 32% are owned by ASC chains, the largest being Tenet’s United Surgical Partners International and Optum’s SCA Health, and other healthcare operators.

4. Private equity continues to eye ASCs, though activity has slowed. While many ASCs are independently owned, PE groups are playing an increasingly larger role in mergers and acquisitions. Two of the largest ASC chains — Surgery Partners and AmSurg — have PE ownership, and smaller groups are PE-backed as well.

5. Mega-mergers are shaping the industry. The three biggest include Tenet Healthcare’s $425 million majority purchase of Dallas-based United Surgical Partners in 2015, Nashville, Tenn.-based AmSurg and Envision Healthcare’s $10 billion 2016 merger and Optum’s 2017 acquisition of Deerfield, Ill.-based SCA Health.

6. ASCs struggle with staffing shortages. ASCs continue to face staffing shortages as they compete with hospitals and health systems who are able to offer higher salaries. This is consistent with staffing issues throughout the healthcare sector. The workforce lost 145,213 providers from 2021 to 2022.

7. Reimbursements are decreasing. CMS’ finalized payment rate for ASCs in 2024 is 3.1%, down from 3.8% 2023. Many leaders are concerned about how low reimbursements will affect their ability to meet margins.

8. Costs are increasing. Costs for supplies and staffing are high along with inflation. ASCs spend on average $2.2 million on employee salaries and wages, about 21.3% of net revenue, according to the VMG Health’s “Multi-Specialty ASC Benchmarking Study.”

9. Cardiology is the fastest growing specialty. ASCs are increasingly looking to cardiology for growth. In 2021, cardiology received the highest estimated Medicare payment increases, according to Avanza’s “2022 Key ASC Benchmarks and Industry Figures” report.

10. Independent ASCs have an edge when it comes to physician recruitment. While physicians nationwide are migrating toward employed models, many are drawn to ASCs potential for more autonomy and control over the quality of care.

Patient in Mayfield Head Pins Requiring Prone Bronchoscopy for Mucus Plug Obstruction

July 23, 2024 by Dr. Clemens Leave a Comment

Authors: Veligandla S, Pasca I F, Radhakrishnan T, et al.

Cureus 16(7): e64270. doi:10.7759/cureus.64270

Abstract

Mucus plug obstruction is a common complication in prone patients associated with loss of ventilation and hemodynamic instability. This case presents a 62-year-old female with chronic bronchitis who underwent posterior cervical fusion for a type III dens fracture with extension into the pars articularis and pedicles. Glycopyrrolate was administered to assist with fiberoptic intubation. After successful intubation, bronchoscopy revealed copious endotracheal secretions requiring preoperative therapeutic removal. Despite extensive removal of thick endotracheal secretions preoperatively, obstructive mucus plugging developed intraoperatively with complete loss of end-tidal carbon dioxide (ETCO₂) while the patient was in Mayfield head pins. With limited airway access, suctioning and prone flexible bronchoscopy were performed, successfully restoring ETCO₂. This experience underscores the need for heightened awareness and preparedness for mucus plug obstruction in chronic bronchitis patients undergoing prone cervical spine surgeries.

Introduction

The prone position poses challenges for the anesthesiologist in regard to addressing intraoperative airway complications. Prone positioning is required in posterior spine procedures, requiring the anesthesiologist to maneuver around a bulky cranial and spine stabilization apparatus which can be a significant obstacle in emergent situations. One possible complication in a prone patient is an obstruction of the endotracheal tube (ETT) by secretions or kinking [1]. Early diagnosis followed by rapid treatment of the potential loss of end-tidal carbon dioxide (ETCO₂) and ventilation is essential to preventing an impending hypoxic cardiac arrest [1]. Methods of addressing mucus plugs include preoperative suctioning of the airway to remove any sputum and mucus buildup as well as the administration of glycopyrrolate to reduce salivary secretions and albuterol to dilate the airways, respectively [2,3]. The ideal anesthetic management of mucus plugs is anticipating the complication and taking preemptive steps to reduce its incidence [1].

Here, we describe a challenging case of mucus obstruction in a prone patient placed in Mayfield head pins. This manuscript adheres to the applicable EQUATOR guideline. A written Health Insurance Portability and Accountability Act (HIPAA) authorization was obtained from the patient for the publication of this case report.

Case Presentation

A 62-year-old female with pertinent medical history consisting of hypertension and chronic bronchitis presented to the emergency department (ED) after a trip and fall at home while intoxicated. Radiographic imaging in the ED revealed numerous facial and cervical spine fractures including fractures to the right maxillary sinus, right orbital floor, possible left condylar neck, as well as a type III dens fracture with extension into the pars articularis and pedicles and a rotatory subluxation of C1 and C2 on the left (Figure 1). Magnetic resonance imaging (MRI) demonstrated disruption of the transverse atlantal ligament and atlanto-occipital membrane as well as severe cervical canal stenosis down to her C6-C7 region (Figure 2). The patient was scheduled for a C1-C4 posterior cervical fusion for her unstable C2 fracture.

$CT-images-demonstrating-the-type-III-dens-fracture-indicated-by-the-black-arrow-on-(a)-axial-view,-(b)-sagittal-view,-and-(c)-coronal-view$

Figure 1: CT images demonstrating the type III dens fracture indicated by the black arrow on (a) axial view, (b) sagittal view, and (c) coronal view

CT: Computed tomography

$T2-sagittal-MRI-of-the-cervical-spine-demonstrating-the-type-III-dens-fracture-indicated-by-the-white-arrow$

Figure 2: T2 sagittal MRI of the cervical spine demonstrating the type III dens fracture indicated by the white arrow

MRI: Magnetic resonance imaging

Given the patient’s history of chronic bronchitis and productive cough on preoperative evaluation, and the planned surgical approach in the prone position with Mayfield head pins, the decision was made for planned bronchoscopy after intubation. A standard size 7 mm internal diameter (ID) cuffed ETT was inserted aided by fiberoptic and video laryngoscopy without removal of the cervical stabilization collar to prevent movement of the unstable cervical spine. Following intubation, bronchoscopy through the newly inserted ETT revealed thick mucus plugs, concentrated in the right mainstem bronchus. Copious suctioning was performed and all mucus collections in the right and left bronchi were bronchoscopically removed. The patient was then positioned in Mayfield head pins and subsequently into a prone position by the anesthesia and neurosurgery teams.

Approximately four hours after surgical incision, the patient experienced a sudden and complete loss of ETCO₂ without any discernible movement of the well-taped ETT, and she experienced a decrease in oxygen saturation to the 70s despite attempts at manual breathing bag ventilation. Suctioning was performed on the trachea using a 14 French suction catheter removing a large volume of mucus with no change in the patient’s respiratory status. The surgical team was alerted of the patient’s desaturation, the incision was temporarily closed, and an intraoperative chest X-ray was obtained to rule out ETT migration. As the gurney was brought into the room to turn the patient to the supine position, bronchoscopy was performed expeditiously. Extensive mucus plugs were removed from the trachea and bilateral mainstem bronchi, and the patient’s ETCO₂ and oxygen saturation returned to baseline. The surgical team was then able to complete the operation successfully, without the need to reposition the patient from the prone position.

Discussion

In this case report, we describe the challenges of addressing mucus plugging in a prone patient while having to maneuver around Mayfield pins. Given the patient’s productive cough during the interview with a history of chronic bronchitis, a condition often associated with airway mucus plugs, we anticipated the possibility of mucus plugging and took preemptive steps to minimize the risk of plugging by using albuterol, glycopyrrolate, and bronchoscopy for removal of secretions [2,3].

The present case underscores the challenges in averting mucus plug formation, even when employing standard preventive practices. Despite these efforts, mucus obstructions persisted, necessitating intraoperative albuterol administration and additional suctioning for effective removal. In 2022, a case report described two patients with loss of ETCO₂ due to bronchospasm and extensive mucus plugging by the condition “silent lung” in which there is a sudden loss of ventilation and any respiratory sounds via auscultation that ultimately required epinephrine to regain hemodynamic stability [4]. It’s worth noting that the use of Mayfield head pins, while a common practice in neurosurgery, poses a challenge when a swift transition to a supine position is required during emergency airway management [5]. In cases where rapid repositioning is not feasible, or where the airway is not easily accessible, applying a flexible bronchoscope is a viable option to visualize and suction the airway. Few case reports and studies exist describing flexible bronchoscopy in the prone position in acute respiratory distress syndrome (ARDS) patients in the intensive care unit (ICU); however, we could find no case reports describing prone bronchoscopy for mucus plug clearance during anesthesia [6]. Two case reports describe prone bronchoscopy during anesthesia: one finding extrinsic tracheal compression during prone spine surgery and another describing two cases of prone bronchoscopy for tracheal narrowing in two patients with Duchenne muscular dystrophy [7,8].

Additional methods of improving mucus clearance and preventing mucus obstruction preoperatively include the use of a noninvasive mechanical insufflation-exsufflation (MI-E) device, often referred to as a “cough assist” device, to induce forceful coughing and to clear mucus as well as a preoperative regimen of inhaling nebulized hypertonic saline twice daily [9-11].

Alternative methods of addressing mucus obstruction during surgery includes replacement of the ETT or the removal of the ETT and the use of bag-mask ventilation [1]. This approach requires the patient to be in the supine position, which was not an immediate option in our case due to cervical spine instability. Grimmett et al. discuss the use of an arterial embolectomy catheter to physically remove the obstruction by inflating the balloon distal to the obstruction prior to extracting the catheter [12]. Yet another option is the use of Magill forceps to remove mucus plugs; however, associated limitations include the potential for cuff perforation, risk for mucous membrane damage, and the size of the Magill forceps precluding insertion into the ETT; all of which are difficult in the prone position [13,14]. Mucus plugging in the prone position can occur even after preemptive bronchoscopy in patients with chronic bronchitis and can lead to loss of ETCO₂, inability to ventilate, and even cardiac arrest. While arrangements are being made to move the patient supine and rescue the airway, prone flexible bronchoscopy with therapeutic removal of secretions may be a life-saving intervention.

Conclusions

Sudden loss of ETCO₂, especially in the prone position with Mayfield head pins in place, requires immediate action with potentially catastrophic outcomes if a delay in diagnosis and treatment occurs. Immediate action requires first assessing all monitors and a thorough knowledge of the patient’s perioperative comorbidities. Patients with chronic bronchitis and chronic productive secretions need special attention to decrease the secretion burden and to treat a potential mucus plug should it occur in the prone position. Planning should include having a bronchoscope in the room, carefully taping the ETT to prevent displacement, and discussing with the surgical team in case the patient needs to be turned to supine emergently. Our bronchoscopy in the prone position is one of the first case reports that shows successful removal of the mucus plug without turning the patient supine with immediate return of ETCO₂ and successful completion of the spine surgery with excellent patient outcome.

References

Raphael D, Lin S, Canales C, Beaulieu K, Ricks C: Obstructive mucus plug in the prone position. MedEdPORTAL. 2015, 11:10016. 10.15766/mep_2374-8265.10016
Edgcombe H, Carter K, Yarrow S: Anaesthesia in the prone position. Br J Anaesth. 2008, 100:165-83. 10.1093/bja/aem380
Golden LR, DeSimone HA, Yeroshalmi F, Pranevicius M, Saraghi M: Severe intraoperative bronchospasm treated with a vibrating-mesh nebulizer. Anesth Prog. 2012, 59:123-6. 10.2344/12-00003.1
Liu T, Hong Y, Peng Y, Lu Y, Cao L: Successful adrenaline treatment of perioperative severe bronchospasm combined with a silent lung: two case reports. Transl Cancer Res. 2022, 11:1445-50. 10.21037/tcr-22-617
DiPaola MJ, DiPaola CP, Conrad BP, et al.: Cervical spine motion in manual versus Jackson table turning methods in a cadaveric global instability model. J Spinal Disord Tech. 2008, 21:273-80. 10.1097/BSD.0b013e31811513a4
Kalchiem-Dekel O, Shanholtz CB, Jeudy J, Sachdeva A, Pickering EM: Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position. Crit Care. 2018, 22:54. 10.1186/s13054-018-1983-3
Choi RM, Yoon JS, Noh JH, Kang KO, Ryu SW, Jun HJ, Cho SS: Airway obstruction by extrinsic tracheal compression during spinal surgery under prone position-a case report-. Korean J Anesthesiol. 2010, 59:S45-8. 10.4097/kjae.2010.59.S.S45
Lee DK, Lim BG, Lee IO, Oh HR, Lim SH, Lee MK: Unexpected tracheal narrowing during general anesthesia in the prone position of Duchenne muscular dystrophy patient-a report of two cases-. Korean J Anesthesiol. 2013, 64:S456-9. 10.4097/kjae.2013.64.5.456
Diaz AA, Orejas JL, Grumley S, et al.: Airway-occluding mucus plugs and mortality in patients with chronic obstructive pulmonary disease. JAMA. 2023, 329:1832-9. 10.1001/jama.2023.2065
Apps C, Morris K, Allum L, et al.: Use of mechanical insufflation exsufflation and manual techniques in an intubated adult with COVID-19 positioned in prone-a case study. Physiother Res Int. 2022, 27:e1961. 10.1002/pri.1961
Máiz Carro L, Martínez-García MA: Nebulized hypertonic saline in noncystic fibrosis bronchiectasis: a comprehensive review. Ther Adv Respir Dis. 2019, 13:10.1177/1753466619866102
Grimmett WG, Poh J: Clearance of an obstructed endotracheal tube with an arterial embolectomy catheter with the patient in the prone position. Anaesth Intensive Care. 1998, 26:579-81. 10.1177/0310057X9802600517
Arshad Z, Abbas H, Gupta L, Bogra J: Magill forceps-an aid for difficult intubation. Internet J Anesthesiol. 2013, 31:
Ehrensperger C, Gross J, Hempel V, Henn-Beilharz A, Rau A: The modified Magill forceps (Article in German). Anaesthesist. 1992, 41:218-20.

Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia

July 23, 2024 by Dr. Clemens Leave a Comment

AUTHORS: Sprung, Juraj MD, PhD^*

Anesthesia & Analgesia 139(1):p 26-34, July 2024.

BACKGROUND:

Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU).

METHODS:

We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics.

RESULTS:

Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49–0.61; P<.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0–1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51–4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P<.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 μg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28–1.33; P<.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98–1.01; P=.56).

CONCLUSIONS:

The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.

KEY POINTS

Questions: Does adding a propofol infusion to a volatile-based anesthetic decrease the need for rescue antiemetics in the postanesthesia care unit (PACU), and does the use of propofol shorten PACU stay?
Findings: Increased propofol infusion rate is associated with dose-dependent reduction in the use of rescue antiemetics in PACU but does not accelerate PACU recovery.
Meaning: Use of propofol infusion as an adjunct to volatile anesthesia is a valuable strategy to decrease the need for rescue antiemetics in PACU.

Global IT outage takes down health system EHRs, forces hospitals to cancel or delay services

July 23, 2024 by Dr. Clemens Leave a Comment

Author: Heather Landi

Fierce Healthcare

A widespread global IT outage impacted health systems, hospitals and clinics as electronic health record software has been knocked offline, forcing providers to cancel or delay non-emergency procedures and services.

Several states across the U.S. also reported that their emergency 911 call centers have been hit. The outage also impacted banks, media companies and airlines, with thousands of flights canceled.

CrowdStrike CEO George Kurtz said Friday morning the company is actively working with customers impacted by a defect found in a single content update for Windows hosts.

“This is not a security incident or cyberattack,” CrowdStrike said in a statement posted to its website and Kurtz also said in a post on X, formerly Twitter. “The issue has been identified, isolated and a fix has been deployed.”

“The system was sent an update, and that update had a software bug in it and caused an issue with the Microsoft operating system,” Kurtz said, as NBC reported. “Our systems are always looking for the latest attacks from these adversaries that are out there.”

For the healthcare industry, the massive IT outage comes five months after a massive ransomware attack at UnitedHealth Group’s Change Healthcare cause widespread disruption and a significant financial fallout for hospitals, pharmacies and medical groups. Although the Microsoft/CrowdStrike outage is not a security incident or a cyberattack, the disruption highlights how a glitch a third-party vendor can have a ripple effect on the industry.

Epic staff are working with customer IT teams to restore access as fixes or mitigation approaches are available from CrowdStrike.” — Epic spokesperson

Analysts at Fitch Ratings report that the widespread fallout will likely be muted for non-profit hospitals despite short-term impacts and scaling back normal operations.

Hospital computer systems impacted

Some healthcare centers report that they are not affected by the outage while others had to suspend medical visits, surgeries and procedures.

Mass General Brigham said the worldwide software outage affected many of its systems impacting providers’ access to clinical systems, including patient health records and scheduling.

The health system canceled all non-urgent medical visits at all of its hospitals and clinics Friday, according to a statement posted to its website.

The health system said hospitals are open for urgent appointments and procedures, and emergency rooms remain open.

The outage prompted Kaiser Permanente to activate its national command center at 4:30 a.m. PT to address the incident, evaluate the impacts to care operations, computer systems and servers, and coordinate recovery as needed, according to Steve Shivinsky, director of national media relations at the health system.

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About Dr. Clemens

BACKGROUND:

METHODS:

RESULTS:

CONCLUSIONS:

BACKGROUND:

METHODS:

RESULTS:

CONCLUSIONS:

METHODS

Literature Search and Study Selection

Inclusion and Exclusion Criteria

Data Extraction and Quality Assessment

RESULTS

Quality Assessment

Postoperative Pain Scores

Postoperative Opioid Consumption

Adverse Events

DISCUSSION

CONCLUSIONS

BACKGROUND:

METHODS:

RESULTS:

CONCLUSIONS:

A multi-ancestry genetic study of pain intensity in 598,339 veterans. Nat Med 2024; 30:1075–84. PMID: 38429522.

CKGROUND:

METHODS:

RESULTS:

CONCLUSIONS:

Abstract

Introduction

Case Presentation

Figure 1: CT images demonstrating the type III dens fracture indicated by the black arrow on (a) axial view, (b) sagittal view, and (c) coronal view

Figure 2: T2 sagittal MRI of the cervical spine demonstrating the type III dens fracture indicated by the white arrow

Discussion

Conclusions

References

BACKGROUND:

METHODS:

RESULTS:

CONCLUSIONS:

Hospital computer systems impacted

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