Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64-101. [PMID: 20052816 DOI: 10.1097/aap.0b013e3181c15c70]

Bibliometric analysis of advances in polysaccharide pharmacology research: A review

Polysaccharide pharmacology has attracted considerable scholarly interest due to its wide range of pharmacological activities, with notable examples such as heparin's anticoagulant mechanisms via antithrombin III interactions and its emerging role in tumor microenvironment modulation. This study presents a bibliometric analysis of the literature pertinent to polysaccharide pharmacology, aiming to elucidate key insights within this research field. Utilizing the Web of Science database, we applied bibliometric analysis methods and utilized tools such as CiteSpace and VOSviewer to systematically investigate the current research landscape, hotspots, and developmental trends in polysaccharide pharmacology. This bibliometric study analyzed 2418 Web of Science publications (2006-2024) using CiteSpace and VOSviewer, revealing China, the US, Germany, and India as leading contributors. The identified keywords are categorized into four clusters: (1) "Anti-inflammatory and anticoagulant properties of polysaccharides," (2) "Multi-omics analysis of polysaccharides," (3) "Pharmacology and bioactivity of natural plants," and (4) "Applications of polysaccharide derivatives." Current research priorities focus on immunomodulation, including dual roles of lipopolysaccharides (LPS) as both endotoxins and immunomodulators in vaccine development, anti-tumor activities leveraging heparin's tumor microenvironment regulation, and drug delivery. This study offers a comprehensive analysis of polysaccharide pharmacology, with the objective of advancing mechanistic understanding in foundational research and facilitating clinical translation within this field.

Analysis on the causes of unsatisfactory prevention effect of postpartum VTE in Chinese women

Preventing venous thromboembolism (VTE) in obstetrics remains challenging, with cases still occurring despite preventive measures. The aim of this study is to investigate the underlying causes by analyzing potential issues in current postpartum VTE prevention strategies in China. This retrospective study was conducted in our hospital from May 2021 to August 2024. VTE risk was assessed using the Chinese Expert Consensus on VTE Prevention and Treatment during Pregnancy and Puerperium (Chinese Consensus), and preventive measures were implemented accordingly. Clinical variables, timing of prophylaxis, and the predictive accuracy of the Chinese Consensus were analyzed. The VTE group had higher D-dimer levels and longer hospital stays and shorter gestational ages (P < 0.05). Significant differences were observed in postpartum hemorrhage (PPH), premature birth, autoimmune diseases, and cesarean delivery (P < 0.05). Despite 65.4% receiving thromboprophylaxis, 25.2% developed VTE, with higher incidences in those without prophylaxis. Pneumatic therapy and LMWH were effective in high-risk patients (P < 0.05). Early VTE occurred 6 h postpartum, with 41.8% within 48 h. Most preventive measures were initiated at 24-48 h postpartum, potentially delaying optimal protection. The ROC analysis showed an AUC of 0.497 (P = 0.937), indicating limited predictive efficacy of the Chinese Consensus. Current postpartum VTE prevention is inadequate, as some at-risk patients still miss the opportunity for pneumatic therapy and LMWH anticoagulation after delivery. Initiating LMWH prophylaxis 24 h postpartum appears to be delayed. The predictive ability of the Chinese Consensus for assessing VTE risk is limited. Future research is essential to optimize prevention strategies and reduce the incidence of postpartum VTE.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition)

Hemorrhagic complications associated with regional anesthesia are extremely rare. The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy reviews the published evidence since 2018 and provides guidance to help avoid this potentially catastrophic complication.The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy uses similar methodology as previous editions but is reorganized and significantly condensed. Therefore, the clinicians are encouraged to review the earlier texts for more detailed descriptions of methods, clinical trials, case series and pharmacology. It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade. In previous versions, the anticoagulant doses were described as prophylactic and therapeutic. In this version, we will be using 'low dose' and 'high dose,' which will allow us to be consistent with other published guidelines and more accurately describe the dose in the setting of specific patient characteristics and indications. For example, the same 'high' dose may be used in one patient as a treatment for deep venous thrombosis (DVT) and in another patient as prophylaxis for recurrent DVT. Due to the increasing ability to obtain drug-specific assays, we have included suggestions for when ordering these tests may be helpful and guide practice. Like previous editions, at the end of each recommendation the authors have clearly noted how the recommendation has changed from previous editions.

Safety Analysis of Visual Percutaneous Tracheostomy in Neurocritical Care Patients with Anticoagulation and Antithrombosis

BACKGROUND

This study aims to evaluate the safety of visual percutaneous tracheostomy (vPDT) in neurologic intensive care unit (NICU) patients who are under anticoagulant and antithrombotic therapy.

METHODS

A retrospective cohort study was conducted on 54 NICU patients who underwent vPDT at Tai'an Central Hospital from September 2022 to September 2023. The cohort included 36 men and 18 women aged 36-90 years (mean age 62.24 ± 12.24 years). Patients were divided into two groups based on their treatment: an anticoagulant and antithrombotic group (22 patients) and a non-anticoagulant and non-antithrombotic group (32 patients). Clinical data, including demographic information, comorbidities, Glasgow Coma Scale (GCS) score before vPDT, time from NICU admission to vPDT, laboratory indicators, and vPDT complications, were analyzed.

RESULTS

The incidence of vPDT complications in the anticoagulant and antithrombotic group was 18.2%, involving three cases of minor intraoperative bleeding and one case of posterior airway wall injury. The non-anticoagulant and non-antithrombotic group had an 18.8% complication rate, including four cases of minor intraoperative bleeding, one case of subcutaneous emphysema with local infection, and one unrelated death. No significant difference in vPDT complications was observed between the two groups (P > 0.05). However, the anticoagulant and antithrombotic group had a higher average age, higher GCS scores, and longer time intervals from NICU admission to vPDT and from intubation to vPDT (all P < 0.05).

CONCLUSION

vPDT appears to be a safe and feasible procedure for NICU patients receiving anticoagulant and antithrombotic therapy, with no significant increase in complications compared to those not on such therapies.

Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.

Cervical Spinal Epidural Hematoma After Spinal Anesthesia for Cesarean Section in the Parturient Using Long-Term Low Dose Aspirin

Spinal epidural hematoma (SEDH) is a rare but serious complication associated with spinal anesthesia (SA). We present an unusual case of cervical SEDH occurring 24 h after a lumbar puncture for a cesarean section. The patient, who was on low-dose aspirin due to preeclampsia, initially exhibited neurological symptoms resembling a stroke. Despite a normal magnetic resonance imaging (MRI) of the brain, further investigations revealed a SEDH located between the C3 and T1 segments, well beyond the L3-L4 puncture site. Although coagulation tests were normal, this case underscores the potential risk of low-dose aspirin in affecting platelet function, which may contribute to SEDH development. It also emphasizes the importance of considering spinal MRI when neurological symptoms arise after SA, even if initial cranial MRI results are normal. She underwent emergency C3-T1 laminectomy through a dorsal midline approach. Her motor, sensory, and sphincter functions fully recovered at follow-up.

Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review

Importance

Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.

Observations

For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.

Conclusions and Relevance

When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

Pilot epinephrine dose-finding study to counter epidural-related blood pressure reduction

OBJECTIVE

An unwanted side effect associated with epidural analgesia is the reduction in blood pressure (BP) due to the sympathetic blockade. This study evaluated the hemodynamic effects of adding different epinephrine concentrations to epidurally injected local anesthetic solution to counteract sympathectomy. We hypothesized that epinephrine could mitigate the decrease in BP possibly caused by the local anesthetic, specifically decreasing the incidence of hypotension.

METHODS

Sixty-six patients were enrolled in a randomized, controlled, quadruple-blinded prospective study into three groups: epidural ropivacaine 0.2% without epinephrine (control) or with 2 µg/mL or 5 µg/mL epinephrine. Our primary outcome was the assessment of differences in hypotension between groups, defined as a >20% decrease in hypotension from baseline to the end of the intraoperative period.

RESULTS

Forty-seven patients completed the study, and 19 were withdrawn. Fifteen patients were in the control group, while 16 patients received 0.2% ropivacaine +2 µg/mL epinephrine, and 16 received 0.2% ropivacaine +5 µg/mL epinephrine. The overall rate of hypotension was 21.3% (10/47). There were no statistically significant differences in hypotension rates between the control group (33%) and groups receiving either +2 µg/mL (13%, p=0.165) or +5 µg/mL (19%, p=0.353) of epinephrine. In secondary analyses, respiratory rate showed greater decreases in control groups across the perioperative period compared with treatment groups (p=0.016) CONCLUSION: Adding epinephrine to the epidural local anesthetic did not significantly decrease the rate of hypotension. However, epinephrine mitigated decreases in respiratory rate across the perioperative period. Future studies will focus on increasing group size and higher epinephrine concentrations (10 µg/mL).

TRIAL REGISTRATION NUMBER

NCT02722746.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Electrical storm treatment by percutaneous stellate ganglion block: the STAR study

BACKGROUND AND AIMS

An electrical storm (ES) is a clinical emergency with a paucity of established treatment options. Despite initial encouraging reports about the safety and effectiveness of percutaneous stellate ganglion block (PSGB), many questions remained unsettled and evidence from a prospective multicentre study was still lacking. For these purposes, the STAR study was designed.

METHODS

This is a multicentre observational study enrolling patients suffering from an ES refractory to standard treatment from 1 July 2017 to 30 June 2023. The primary outcome was the reduction of treated arrhythmic events by at least 50% comparing the 12 h following PSGB with the 12 h before the procedure. STAR operators were specifically trained to both the anterior anatomical and the lateral ultrasound-guided approach.

RESULTS

A total of 131 patients from 19 centres were enrolled and underwent 184 PSGBs. Patients were mainly male (83.2%) with a median age of 68 (63.8-69.2) years and a depressed left ventricular ejection fraction (25.0 ± 12.3%). The primary outcome was reached in 92% of patients, and the median reduction of arrhythmic episodes between 12 h before and after PSGB was 100% (interquartile range -100% to -92.3%). Arrhythmic episodes requiring treatment were significantly reduced comparing 12 h before the first PSGB with 12 h after the last procedure [six (3-15.8) vs. 0 (0-1), P < .0001] and comparing 1 h before with 1 h after each procedure [2 (0-6) vs. 0 (0-0), P < .001]. One major complication occurred (0.5%).

CONCLUSIONS

The findings of this large, prospective, multicentre study provide evidence in favour of the effectiveness and safety of PSGB for the treatment of refractory ES.

Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial

BACKGROUND

The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia.

METHODS

A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized.

RESULTS

A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm.

CONCLUSIONS

Long-term outcomes were similar with spinal versus general anesthesia.

EDITOR’S PERSPECTIVE

Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial

INTRODUCTION

Prior studies have demonstrated that patients presenting for elective surgery may have higher-than-expected residual anti-Xa level activity at or beyond 24 hours following their last treatment dose of enoxaparin. Given that 24 hours of abstinence is currently recommended by both European and American societies before the performance of neuraxial or deep anesthetic/analgesic procedures, determining the actual timeframe at which residual anti-Xa level activity reliably falls below 0.2 IU/mL, the lower limit of the target range for thromboprophylaxis, is critical.

METHODS

This was a prospective observational trial. Consenting patients on treatment-dose enoxaparin were randomized to either a 24-hour group (last dose at 07:00 the day prior to surgery) or a 36-hour group (last dose at 19:00 2 days prior to surgery). On arrival for surgery, blood samples were obtained to assess residual anti-Xa level activity and renal function. The primary outcome was residual anti-Xa level activity following the last treatment dose of enoxaparin. Incorporating all patients, linear regression modeling was performed to predict the timepoint at which the level of anti-Xa activity reliably fell below 0.2 IU/mL.

RESULTS

103 patients were analyzed. Time from the last dose at which residual anti-Xa activity fell below 0.2 IU/mL, based on the upper bound of the 95% CI, was 31.5 hours. No correlation overall between age, renal function, or sex was found.

CONCLUSION

Residual levels of anti-Xa activity do not reliably fall below 0.2 IU/mL 24 hours following discontinuation of treatment-dose enoxaparin. Therefore, current time-based guidelines are not conservative enough. Routine anti-Xa testing should be strongly considered, or current time-based guidelines should be reassessed.

TRIAL REGISTRATION NUMBER

NCT03296033.

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) Investigators. Preoperative psychological resilience and recovery after hip fracture: Secondary analysis of the REGAIN randomized trial

BACKGROUND

How psychological resilience influences postoperative outcomes remains poorly characterized. We tested the hypothesis that psychological resilience is associated with lower odds of death or new inability to walk independently and other outcomes at 60 days after hip fracture surgery.

METHODS

This was a pre-planned secondary analysis of a multicenter randomized trial comparing spinal versus general anesthesia for hip fracture surgery. We analyzed data on 1360 adults aged 50 years or older who were hospitalized for hip fracture surgery at one of 46 US or Canadian hospitals and provided psychological resilience data preoperatively as measured via the Brief Resilience Scale. Major exclusions were the inability to walk without human assistance before fracture and contraindications to spinal anesthesia. Death or new inability to walk independently at 60 days after surgery was the primary outcome; death or new nursing home residence at 60 days and 60-day mortality were secondary outcomes.

RESULTS

Greater psychological resilience was associated with lower odds of death or new inability to walk at day 60 (adjusted odds ratio [aOR] 0.77; 95% Confidence Interval [CI], 0.61 to 0.98; p = 0.03). We observed a similar association between psychological resilience and outcomes among patients who did not experience complications after surgery (aOR 0.72; CI 0.55 to 0.94, p = 0.02), but not those who had complications (aOR 1.00; CI 0.59 to 1.69, p = 0.99). Psychological resilience was associated with lower odds of 60-day death or new nursing home residence (aOR 0.73; 95% CI 0.58 to 0.93; p < 0.001) but not with 60-day mortality (aOR 0.92; 95% CI 0.56 to 1.49; p = 0.73).

CONCLUSIONS

Psychological resilience is associated with better outcomes for older adults after hip fracture surgery, but largely among those who do not have postoperative complications. Future interventions may focus on improving psychological resilience preoperatively or providing support to patients with lower psychological resilience.

Evaluation of perioperative routine coagulation testing versus thromboelastography for major liver resection - A single-arm, prospective, interventional trial (PORTAL trial)

BACKGROUND AND AIMS

The International Normalised Ratio (INR), which assesses the loss of procoagulant factors in the extrinsic pathway, fails to evaluate the coagulation abnormalities comprehensively after a major liver resection, which often leads to reduced synthesis of procoagulant and anticoagulant-factors. This study was conducted with an aim to study the trend and compare the results of routine coagulation tests and thromboelastography (TEG) during the perioperative period in patients undergoing major liver resections (≥3 segments).

METHODS

Twenty-five patients who underwent a major liver resection were enrolled. This prospective, single-arm, interventional study was performed with the primary objective of determining the serial changes in conventional coagulation tests and TEG during the perioperative period in patients undergoing major liver resections, at the preincision period, intraoperative period, postoperatively, at 48 h and on the fifth postoperative day. Transfusion requirements of blood components were also assessed with a TEG-guided replacement strategy. Spearman rank-order correlation was used to study the relationships of coagulation tests (both TEG and conventional tests) at each time point.

RESULTS

The prothrombin time (PT)-INR was elevated in 14 patients (56%) at the intraoperative, immediate postoperative and 48-h time points in contrast to the TEG parameters, which remained normal in all patients. Blood component transfusion was avoided in 4, 11 and 10 patients at the intraoperative, immediate postoperative and 48-h time points, respectively.

CONCLUSION

International Normalised Ratio overestimates the coagulopathy in patients undergoing major liver resection, and a thromboelastography-guided transfusion strategy reduces overall transfusion requirements.

Epidural hematoma risks associated with ceasing vs maintaining anticoagulant and/or antiplatelet medications for cervical and thoracic interlaminar epidural steroid injections

Background

There is a lack of substantiated evidence to support or refute the risks of ceasing vs maintaining anticoagulant and/or antiplatelet medications (ACAP) prior to cervical and thoracic interlaminar epidural steroid injections. The ACAP medication is frequently stopped pre-procedure due to concerns for potential bleeding complications, particularly epidural hematomas (EH). This article provides evidence regarding EH incidence in this population.

Methods

Data for this study was collected retrospectively on all patients from September 19, 2009-Jun 16, 2017 who were scheduled for an Interlaminar Cervical and/or Thoracic Epidural Steroid Injections (IL-CTESI) and were on an ACAP medication at the time a procedure was scheduled. All possible adverse outcomes were then retrospectively analyzed via extensive data mining of the electronic medical record system with special emphasis on EHs.

Results

591 IL-CTESI were performed on patients taking ACAP medications. In total, 351 patients ceased their ACAP medication prior to the procedure and 240 maintained ACAP medication. Our findings demonstrate that there were no clinically relevant incidents of EHs in either cohort.

Conclusions

This data gives critical insight into the post-procedural EH risk for patients who had continued or stopped taking their ACAP medications prior to their IL-CTESI. The results from this study suggest re-evaluating the potential post-procedural EH risks associated with continuing vs ceasing these medications.

Multidisciplinary care of the pregnant patient with or at risk for venous thromboembolism: a recommended toolkit from the Foundation for Women and Girls with Blood Disorders Thrombosis Subcommittee

The care of pregnant persons with/at risk of venous thromboembolism is complex and often challenging. Although guidelines have been published regarding the use of specific therapies, such as anticoagulants; in this population, none have provided guidance on how to coordinate multidisciplinary care of these patients. Here we provide an expert consensus on the role of various providers in the care of this patient population, as well as necessary resources and suggestions for best practices.

Neurological pain relief interventional radiology procedures

Neurological interventions have taken on a significant role in interventional radiology (IR) practice. Indications fall under three main categories: (1) intraprocedural pain management, (2) cancer pain palliation, and (3) chronic non-cancer pain control. Short-term regional anaesthesia can be achieved with local anaesthetics, while longer-term pain control can be attained with radiofrequency neuromodulation (pulsed or otherwise) or thermal/chemical neurolysis. This review article summarises the therapeutic options, applications, and techniques of commonly used peripheral nerve and plexus interventions in IR.

Anticoagulation Regimens in Pregnancy

This article explores current recommendations for anticoagulation therapy in pregnancy, including antepartum, intrapartum, and postpartum guidelines. The authors review various screening strategies used to assess whether a patient is an appropriate candidate for anticoagulation during pregnancy and the postpartum period. The article includes dosing regimens, optimal surveillance, and medication reversal. The authors also address the challenges of transitioning between low-molecular-weight heparin and unfractionated heparin. Finally, there is a discussion of intrapartum anticoagulation management, especially as it relates to the administration of regional anesthesia, and the indications for and timing of thromboprophylaxis following delivery.

What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials.

QUESTIONS/PURPOSES

In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery?

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate).

RESULTS

At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved.

CONCLUSION

When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods.

LEVEL OF EVIDENCE

Level I, therapeutic study.

How to start an awake spine program: Protocol and illustrative cases

Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia. However, awake spinal surgery has recently gained traction due to evidence of decreased perioperative risks, postoperative opioid consumption, and costs, specifically in lumbar spine procedures. Despite the potential for improving outcomes, awake spine surgery has received resistance and has yet to become adopted at many healthcare systems. We aim to provide the fundamental steps in facilitating the initiation of awake spine surgery programs. We also present case reports of two patients who underwent awake spine surgery and reported improved clinical outcomes.

•

Starting an Awake Spine program is feasible and may improve clinical outcomes.

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Awake Spine Surgery is associated with reduced cardiopulmonary complications and opioid consumption.

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Awake Spine Surgery is effective at reducing LOS, HAC, and cost of surgery.

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Awake Spine Surgery increases the pool of patients eligible for spinal procedures.

Sex differences in neurovascular disorders

Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Preoperative and postoperative complications of cerebrospinal fluid drainage in descending thoracic and thoraco-abdominal aortic aneurysm surgery: a single-center retrospective study

PURPOSE

Cerebrospinal-fluid drainage (CSFD) has been performed to prevent paraplegia in descending thoracic or thoraco-abdominal aortic aneurysm (DTA/TAAA) surgery; however, CSFD itself has a risk of severe complications. We retrospectively investigated the incidence rates of CSFD-related preoperative and postoperative complications.

METHODS

Patients who underwent DTA/TAAA surgery with a CSFD catheter that was inserted on the day before surgery were enrolled. The incidence rates of complications from spinal puncture until DTA/TAAA surgery were investigated as preoperative CSFD complications, and the incidence rates from DTA/TAAA surgery to postoperative day 7 were investigated as CSFD-related postoperative complications.

RESULTS

Preoperative CSFD complications were analyzed in 123 cases. DTA/TAAA surgery was postponed due to bloody cerebrospinal fluid (2.5%) and due to meningitis (1.7%). The incidence rate of mild preoperative complications was 32.4%. Postoperative CSFD complications were analyzed in 108 cases. Intracranial hemorrhage occurred in 3.9% of cases in open surgery and other postoperative severe CSFD complications did not occur. The incidence rates of moderate/mild complications in open surgery were 2.6%/14.3% and those in TEVAR were 3.2%/19.4%.

CONCLUSION

Bloody cerebrospinal fluid and meningitis, which are severe complications associated with spinal puncture, occurred within 1 day after spinal puncture. The incidence rates of moderate/mild complications were high in both the preoperative and postoperative periods. These results showed that CSFD catheter insertion and management should be performed carefully with consideration given to the risks and benefits of CSFD.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Postoperative changes in cognition and cerebrospinal fluid neurodegenerative disease biomarkers

OBJECTIVE

Numerous investigators have theorized that postoperative changes in Alzheimer's disease neuropathology may underlie postoperative neurocognitive disorders. Thus, we determined the relationship between postoperative changes in cognition and cerebrospinal (CSF) tau, p-tau-181p, or Aβ levels after non-cardiac, non-neurologic surgery in older adults.

METHODS

Participants underwent cognitive testing before and 6 weeks after surgery, and lumbar punctures before, 24 h after, and 6 weeks after surgery. Cognitive scores were combined via factor analysis into an overall cognitive index. In total, 110 patients returned for 6-week postoperative testing and were included in the analysis.

RESULTS

There was no significant change from before to 24 h or 6 weeks following surgery in CSF tau (median [median absolute deviation] change before to 24 h: 0.00 [4.36] pg/mL, p = 0.853; change before to 6 weeks: -1.21 [3.98] pg/mL, p = 0.827). There were also no significant changes in CSF p-tau-181p or Aβ over this period. There was no change in cognitive index (mean [95% CI] 0.040 [-0.018, 0.098], p = 0.175) from before to 6 weeks after surgery, although there were postoperative declines in verbal memory (-0.346 [-0.523, -0.170], p = 0.003) and improvements in executive function (0.394, [0.310, 0.479], p < 0.001). There were no significant correlations between preoperative to 6-week postoperative changes in cognition and CSF tau, p-tau-181p, or Aβ42 changes over this interval (p > 0.05 for each).

INTERPRETATION

Neurocognitive changes after non-cardiac, non-neurologic surgery in the majority of cognitively healthy, community-dwelling older adults are unlikely to be related to postoperative changes in AD neuropathology (as assessed by CSF Aβ, tau or p-tau-181p levels or the p-tau-181p/Aβ or tau/Aβ ratios).

TRIAL REGISTRATION

clinicaltrials.gov (NCT01993836).

OUP accepted manuscript

Background

The relationship between anaesthetic technique and graft patency after open lower limb revascularization is unclear. The aim of this study was to evaluate the association between 30-day graft patency after elective infrainguinal bypass and anaesthetic technique (regional anaesthesia (RA, i.e. neuraxial and/or peripheral nerve blockade) compared with general anaesthesia (GA)).

Methods

Patients who underwent elective infrainguinal bypass in the 2014–2019 National Surgical Quality Improvement Program Vascular Procedure Targeted Lower Extremity Open data set were included. Excluded patients were those under 18 years old, those who did not receive RA or GA, and/or had an international normalized ratio of 1.5 of greater, a partial thromboplastin time more than 35 s, or a platelet count less than 80 × 10⁹/L. The primary outcome was primary graft patency without reintervention. The relationship between anaesthetic technique and patency was analysed with multivariable logistic regression.

Results

Included were 8893 patients with a mean(s.d.) age of 68(11) years and 31.5 per cent female. Within the cohort, 7.7 per cent (n = 688) patients received RA only, 90.4 per cent (n = 8039) GA only, and 1.9 per cent (n = 166) both GA and RA. In the RA-only group, 91.7 per cent (631 of 688) received neuraxial anaesthesia. The primary patency rate was 93.2 per cent (573 of 615) for RA only, and 91.5 per cent (6390 of 6983) for GA only (standardized mean difference, 0.063). RA was not associated with a higher rate of patency compared with GA (adjusted OR, 1.16; 95 per cent c.i., 0.83 to 1.63; P = 0.378).

Conclusion

There was no association between anaesthetic technique and 30-day graft patency after elective infrainguinal bypass surgery. Further prospective studies would be useful to study the impact of anaesthesia technique on important patient-centred outcomes such as long-term patency and non-home discharge.

Relationship Between Depression/Anxiety and Cognitive Function Before and 6 Weeks After Major Non-Cardiac Surgery in Older Adults

OBJECTIVE

To determine the relationship between affective measures and cognition before and after non-cardiac surgery in older adults.

METHODS

Observational prospective cohort study in 103 surgical patients age ≥ 60 years old. All participants underwent cognitive testing, Center for Epidemiologic Studies-Depression, and State Anxiety Inventory screening before and 6 weeks after surgery. Cognitive test scores were combined by factor analysis into 4 cognitive domains, whose mean was defined as the continuous cognitive index (CCI). Postoperative global cognitive change was defined by CCI change from before to after surgery, with negative CCI change indicating worsened postoperative global cognition and vice versa.

RESULTS

Lower global cognition before surgery was associated with greater baseline depression severity (Spearman's r = -0.30, p = 0.002) and baseline anxiety severity (Spearman's r = -0.25, p = 0.010), and these associations were similar following surgery (r = -0.36, p < 0.001; r = -0.26, p = 0.008, respectively). Neither baseline depression or anxiety severity, nor postoperative changes in depression or anxiety severity, were associated with pre- to postoperative global cognitive change.

CONCLUSIONS

Greater depression and anxiety severity were each associated with poorer cognitive performance both before and after surgery in older adults. Yet, neither baseline depression or anxiety symptoms, nor postoperative change in these symptoms, were associated with postoperative cognitive change.

Intercostal Cryo Nerve Block in Minimally Invasive Cardiac Surgery: The Prospective Randomized FROST Trial

INTRODUCTION

Intercostal cryo nerve block has been shown to enhance pulmonary function recovery and pain management in post-thoracotomy procedures. However, its benefit have never been demonstrated in minimal invasive thoracotomy heart valve surgery (Mini-HVS). The purpose of the study was to determine whether intraoperative intercostal cryo nerve block in conjunction with standard of care (collectively referred to hereafter as CryoNB) provided superior analgesic efficacy in patients undergoing Mini-HVS compared to standard-of-care (SOC).

METHODS

FROST was a prospective, 3:1 randomized (CryoNB vs. SOC), multicenter trial in patients undergoing Mini-HVS. The primary endpoint was the 48-h postoperative forced expiratory volume in 1 s (FEV1) result. Secondary endpoints were visual analog scale (VAS) scores for pain at the surgical site and general pain, intensive care unit and hospital length-of-stay, total opioid consumption, and allodynia at 6 months postoperatively.

RESULTS

A total of 84 patients were randomized to the two arms of the trial CryoNB (n = 65) and SOC (n = 19). Baseline Society of Thoracic Surgeons Predictive Risk of Mortality (STS PROM) score, ejection fraction, and FEV1 were similar between cohorts. A higher 48-h postoperative FEV1 result was demonstrated in the CryoNB cohort versus the SOC cohort (1.20 ± 0.46 vs. 0.93 ± 0.43 L; P = 0.02, one-sided two-sample t test). Surgical site VAS scores were similar between the CryoNB and SOC cohorts at all postoperative timepoints evaluated, but VAS scores not related to the surgical site were lower in the SOC group at 72, 94, and 120 h postoperatively. The SOC cohort had a 13% higher opioid consumption than the CryoNB cohort. One of 64 CryoNB patients reported allodynia that did not require pain medication at 10 months.

CONCLUSIONS

The results of FROST demonstrated that intercostal CryoNB provided enhanced FEV1 score at 48 h postoperatively with optimized analgesic effectiveness versus SOC. Future larger prospective randomized trials are warranted to determine whether intercostal CryoNB has an opioid-sparing effect in patients undergoing Mini-HVS.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02922153.

Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults

BACKGROUND

The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

METHODS

We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days.

RESULTS

A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30).

CONCLUSIONS

Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Comparison of epidural, spinal, and saddle block for holmium laser enucleation of prostate (HoLEP): A prospective randomized, comparative study

BACKGROUND

Holmium laser enucleation of the prostate (HoLEP) has become an important treatment modality for benign prostate hypertrophy. The aim of the present study was to compare regional anesthesia methods for HoLEP operation and to determine the optimal technique.

METHODS

Sixty patients with American Society of Anesthesiologists scores of I-III were randomly allocated into 3 groups. Patients in group E received an epidural block with 75 mg of bupivacaine plus 50 μg of fentanyl. In group S, 15 mg of bupivacaine and 50 μg fentanyl were used for spinal anesthesia. In group SA, patients received saddle block with 15 mg of bupivacaine and 50 μg of fentanyl.

RESULTS

Time to T10 dermatome block and to maximal level block were longest in group E (P < .05), and maximal sensorial block level was higher in group E than group SA (P < .05). There was a significant difference in postoperative motor block, but no difference in systolic blood pressure and heart rate.

CONCLUSION

Among 3 techniques, saddle block might be preferable in HoLEP because an adequate sensorial level was achieved with lower motor block and stable hemodynamics.

Analgesic considerations for induction of labor

Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.

Obstetric venous thromboembolism prophylaxis, risk factors and outcomes

PURPOSE OF REVIEW

Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities.

RECENT FINDINGS

Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant.

SUMMARY

Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.

Expert review: prevention of obstetrical venous thromboembolism

Venous thromboembolism represents a persistent proportionate cause of maternal mortality in the United States accounting for 9% to 10% of maternal deaths. Given that overall maternal mortality rose >40% since the late 1990s, it is likely that absolute venous thromboembolism mortality risk increased as well. This persistent risk may be secondary to increases in broad population-based risk factors for venous thromboembolism such as obesity and cesarean delivery. Widespread adoption of perioperative cesarean mechanical thromboprophylaxis is associated with reduced risk for venous thromboembolism events but has not been sufficient to reduce mortality. Experts agree that improved clinical care is required to reduce risk as it is unlikely that trends in venous thromboembolism risk factors will reverse course anytime soon. Experts further agree that improving prophylaxis and prevention may provide the largest benefit. However, how to best improve prophylaxis is highly controversial with both experts and guidelines in disagreement. In the United Kingdom, mortality risk decreased substantially following the 2004 recommendations for broader heparin prophylaxis without evidence of increased mortality risk from hemorrhage. A key clinical question in the United States is whether heparin prophylaxis should be expanded to patients hospitalized for cesarean delivery or an antepartum indication. Some experts, including us, support expanded heparin prophylaxis. Evidence supporting heparin prophylaxis includes (1) demonstration of safety and efficacy in the United Kingdom, (2) that mechanical prophylaxis-the primary alternative to heparin-has major limitations outside the immediate perioperative setting, and (3) that hospitalized cesarean and antepartum patients are at high relative risk of events. Experts against broader heparin prophylaxis cite concerns related to safety, efficacy, and cost. This expert review focused on whether heparin prophylaxis should be routinely used during antepartum hospitalizations and after cesarean delivery. First, we review the differences in major society guidelines. Second, we review arguments for and against broader heparin prophylaxis. Third, we discuss what future research may be most likely to further inform best practices. Fourth, we review practical clinical considerations with heparin prophylaxis, including access to neuraxial anesthesia. Given the best available data, we concluded that expanding heparin prophylaxis represents a modest intervention with the potential to meaningfully reduce venous thromboembolism mortality.

Analysis of the ESC/EACTS 2020 Atrial Fibrillation Guidelines With Perioperative Implications

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, with an individual lifetime risk of approximately 37% in the United States. Broadly defined as a supraventricular tachyarrhythmia with disorganized atrial activation, AF results in an increased risk of stroke, heart failure, valvular heart disease, and impaired quality of life, and confers a significant burden on the health of individuals and society. AF in the perioperative setting is common and a significant source of perioperative morbidity and mortality worldwide. The latest iteration of the European Society of Cardiology AF guidelines published in 2020 provide the clinician a valuable road map for the management of this arrythmia. This expert review will comprehensively analyze the 2020 European Society of Cardiology guidelines and provide perioperative management tools for the clinician.

Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study

OBJECTIVES

To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery.

DESIGN

A propensity score-matched retrospective study.

SETTING

A single tertiary medical center between January 2018 and December 2020.

PARTICIPANTS

Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy.

INTERVENTIONS

A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group).

MEASUREMENTS AND MAIN RESULTS

The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012).

CONCLUSIONS

This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.

The Financial Burden of Delayed Hip Fracture Surgery: A Single-Center Experience

Fragility hip fractures have become a worldwide epidemic with serious socioeconomic implications. The projected number of hip fractures by 2050 is estimated to reach 4.5 million cases. The aim of this study was to calculate the in-hospital financial burden on public health insurance funds related to the delayed treatment of hip fractures. This research took place in a tertiary university hospital that is a major trauma center in Thessaloniki, which is second largest city in Greece . A retrospective search was conducted in the electronic hospital database for patients older than 65 years, with low energy hip fractures that were surgically treated between November 18, 2018, and October 20, 2019. Age, length of stay (LOS), days to surgery, postoperative LOS, anticoagulation medication, major and minor complications, and the reimbursement that the hospital received from public health insurance funds were recorded. Cost deviation from the standard tariff for the treatment of these fractures was also calculated. Of a total of 145 patients, 32.4% had early surgery as opposed to 67.6% who were operated after 48 hours from admission. The excess financial burden from the baseline reimbursement for those operated within 48 hours from admission was 4,074.64€, while for the group that received delayed surgery it was 45,654.14€. Patients under any form of anticoagulation therapy were seven times more probable to have delayed surgery [OR=6.8; 95% confidence interval (CI): 2.97-18.18; p<0.01] and were 3.5 times more probable to have minor complications (OR: 3.6; 95% CI: 1.19-11.23; p<0.017). Early surgery is beneficial to the patient and reduces the economic burden on healthcare public funds. Every effort should be made to manage these patients in a timely manner.

Does thoracic epidural anaesthesia constitute over-instrumentation in video- and robotic-assisted thoracoscopic lung parenchyma resections?

PURPOSE OF REVIEW

Effective and sustained perioperative analgesia in thoracic surgery and pulmonary resection is beneficial to patients by reducing both postoperative pulmonary complications and the incidence of chronic pain. In this review, the indication of thoracic epidural anaesthesia in video- (VATS) and robotic-assisted (RATS) thoracoscopy shall be critically objectified and presented in a differentiated way.

RECENT FINDINGS

Pain following VATS and RATS has a negative influence on lung function by inhibiting deep respiration, suppressing coughing and secretion and favours the development of atelectasis, pneumonia and other postoperative pulmonary complications.In addition, inadequate pain therapy after these procedures may lead to chronic pain.

SUMMARY

Since clear evidence-based recommendations for optimal postoperative analgesia are still lacking in VATS and RATS, there can be no universal recommendation that fits all centres and patients. In this context, thoracic epidural analgesia is the most effective analgesia procedure for perioperative pain control in VATS and RATS-assisted surgery for patients with pulmonary risk factors.

Neurological complications of cardiovascular drugs

Cardiovascular drugs are used to treat arterial hypertension, hyperlipidemia, arrhythmias, heart failure, and coronary artery disease. They also include antiplatelet and anticoagulant drugs that are essential for prevention of cardiogenic embolism. Most neurologic complications of the cardiovascular drugs are minor or transient and are far outweighed by the anticipated benefits of treatment. Other neurologic complications are more serious and require early recognition and management. Overtreatment of arterial hypertension may cause lightheadedness or fatigue but often responds readily to dose adjustment or an alternative drug. Other drug complications may be more troublesome as in myalgia associated with statins or headache associated with vasodilators. The recognized bleeding risk of the antithrombotics requires careful calculation of risk/benefit ratios for individual patients. Many neurologic complications of cardiovascular drugs are well documented in clinical trials with known frequency and severity, but others are rare and recognized only in isolated case reports or small case series. This chapter draws on both sources to report the adverse effects on muscle, nerve, and brain associated with commonly used cardiovascular drugs.

A career in cardiac anaesthesia in India: The heart of the matter

Cardiac anaesthesia is a demanding, but fulfilling speciality which challenges the skills, knowledge, professional and personal competence of cardiac anaesthesiologists on a daily basis. This article outlines the brief history of the subspecialty of cardiac anaesthesia in India, its growth and progress over the decades, reasons for choosing it as a career option, variations in practice standards and how the speciality has been affected by the coronavirus 2019 pan?demic.

Anaesthetic implications of free-flap microvascular surgery for head and neck malignancies – A relook

Head and neck free-flap microvascular surgery is a type of surgery where multiple anaesthetic factors play a very important role in the outcome of the surgery while the conduct of anaesthesia itself may be quite challenging for the anaesthesiologist. In microvascular reconstruction of head and neck malignancies, flaps are used to reconstruct a primary defect formed by wide local excision. A free flap is raised after removing the neurovascular pedicle from the donor site and transplanting it by microvascular anastomosis to the new location. This gives rise to a secondary defect which is then repaired by direct suture or skin graft. The anaesthesiologist’s role includes optimizing the physiological conditions for the survival of the flap while decreasing morbidity at the same time. Failure of the free flap is attributed to numerous causes. This is an attempt to highlight them along with discussion of the anaesthesia-related issues that are faced during this type of surgery. The various pre-, intra- and postoperative factors affecting flap survival and overall postoperative outcome in the patient are discussed here.

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

Peripheral Cardiopulmonary Bypass in Two Patients With Symptomatic Tracheal Masses: Perioperative Challenges

Tracheal tumors or masses causing critical airway obstruction require resection for symptom relief. However, the location and extent of these tumors or masses often preclude conventional general anesthesia and tracheal intubation. Peripheral cardiopulmonary bypass often is required before anesthetizing these patients. Herein, two cases of patients with tracheal masses, in whom awake peripheral cardiopulmonary bypass was instituted, are reported. The first case was that of an obese male child weighing 102 kg, with tracheal rhinoscleroma, who developed Harlequin, or north-south, syndrome after institution of femorofemoral venoarterial partial cardiopulmonary bypass. The second case was that of a female patient with adenoid cystic carcinoma of the trachea causing near-total central airway occlusion. She had severe pulmonary artery hypertension, which prevented the use of venovenous bypass. Instead, femoral vein-axillary artery venoarterial bypass was established to avoid Harlequin syndrome. Some of the challenges encountered were the development of Harlequin syndrome with risk of myocardial and cerebral ischemia, type and conduct of extracorporeal bypass, choice of monitoring sites, and provision of regional anesthesia for peripheral extracorporeal cannulations. Management of such patients needs frequent troubleshooting and multidisciplinary coordination for a successful surgical outcome.

Management of Anticoagulation in Pregnant Women With Mechanical Heart Valves

Importance

Mechanical heart valves (MHVs) pose significant thrombogenic risks to pregnant women and their fetuses, yet the choice of anticoagulation in this clinical setting remains unclear. Various therapeutic strategies carry distinct risk profiles that must be considered when making the decision about optimal anticoagulation.

Objective

We sought to review existing data and offer recommendations for the anticoagulation of pregnant women with MHVs, as well as management of anticoagulation in the peripartum period.

Evidence Acquisition

We performed a literature review of studies examining outcomes in pregnant women receiving systemic anticoagulation for mechanical valves, and also reviewed data on the safety profiles of various anticoagulant strategies in the setting of pregnancy.

Results

Warfarin has been shown to increase rates of embryopathy and fetal demise, although it has traditionally been the favored anticoagulant in this setting. Low-molecular-weight heparin, when dosed appropriately with close therapeutic monitoring, has been shown to be safe for both mother and fetus.

Conclusions

We favor the use of low-molecular-weight heparin with appropriate dosing and monitoring for the anticoagulation of pregnant women with MHVs. Data suggest that this approach minimizes the thrombotic risk associated with the valve while also providing safe and effective anticoagulation that can be easily managed in the peripartum period.

Complications of Postoperative Epidural Analgesia For Oncologic Surgery: A Review of 18,895 Cases

OBJECTIVE

The risks of epidural analgesia (EA) differ depending on the population studied. We describe our experience with postoperative EA for oncologic surgery.

MATERIALS AND METHODS

We searched our Acute Pain Medicine database for cases in which postoperative EA was used between 2003 and 2012. We used word search to identify and catalog cases of neurological changes, magnetic resonance imaging or computed tomography of the spine, electromyography studies, and neurologist or neurosurgeon consultations. Medical records of patients with documented persistent neurological deficits and patients who had spine imaging or neurology consultations were reviewed further. In addition, we cross-checked medical records with billing diagnosis codes for spinal epidural abscess or hematoma.

RESULTS

We reviewed 18,895 cases in which postoperative EA was used. Complications included neurological symptoms in 2436 cases (12.9%), epidural insertion site abnormalities in 1062 cases (5.6%), complete epidural catheter migration in 829 cases (4.4%), epidural replacement in 619 cases (3.3%), and inadvertent dura puncture in 322 cases (1.7%). There were 6 cases of persistent deficits of uncertain etiology, 4 deep spinal infections (1:4724), and 2 cases of catheter tip shearing. No spinal epidural hematomas were identified (95% confidence interval, 0-0.0002).

DISCUSSION

Our findings provide a contemporary review of some risks associated with the use of postoperative EA for patients undergoing oncologic surgery. Despite a not-uncommon incidence of neurological changes, serious complications resulting in prolonged sequelae were rare.