Association between anesthesia technique and death after hip fracture repair for patients with COVID-19

PURPOSE

Patients with COVID-19 undergoing hip fracture surgeries have a 30-day mortality of up to 34%. We aimed to evaluate the association between anesthesia technique and 30-day mortality after hip fracture surgery in patients with COVID-19.

METHODS

After ethics approval, we performed a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program data set from January to December 2021. Inclusion criteria were age ≥ 19 yr, laboratory-confirmed SARS-CoV-2 infection within 14 days preoperatively, and hip fracture surgery under general anesthesia (GA) or spinal anesthesia (SA). Exclusion criteria were American Society of Anesthesiologists Physical Status V, ventilator dependence, international normalized ratio ≥ 1.5, partial thromboplastin time > 35 sec, and platelet count < 80 × 109 L-1. The primary outcome was all-cause 30-day mortality. The adjusted association between anesthetic technique and 30-day mortality was analyzed using multivariable logistic regression.

RESULTS

Of 23,045 patients undergoing hip fracture surgery, 331 patients met the study criteria. The median [interquartile range] age was 82 [74-88] yr, and 32.3% were male. The 30-day mortality rate was 10.0% (33/331) for the cohort (10.7%, 29/272 for GA vs 6.8%, 4/59 for SA; P = 0.51; standardized mean difference, 0.138). The use of SA, compared with GA, was not associated with decreased mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.21 to 1.8; E-value, 2.49).

CONCLUSION

Anesthesia technique was not associated with mortality in patients with COVID-19 undergoing hip fracture surgery. The findings were limited by a small sample size.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT05133648); registered 24 November 2021.

Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block

BACKGROUND

Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.

METHODS

After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R², scaled Brier score, and calibration slope.

RESULTS

The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R² 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041).

CONCLUSIONS

We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed.

CLINICAL TRIAL REGISTRATION

NCT05018104.

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.

COVID-19 and breast cancer at a Regional Breast Centre: our flexible approach during the pandemic

Purpose

In British Columbia (BC), there have been 2790 confirmed COVID-19 cases as of June 20, 2020. The aim of this project is to capture the effect of COVID-19 on the volume of surgery and adaptations to the surgical care of patients at a breast centre in BC.

Methods

All proven or suspected breast cancer cases treated with surgery between March 16, 2019 and April 30, 2019 and March 16, 2020 and April 30, 2020 through the Providence Breast Centre were included in this review. The date ranges in 2020 mark the early COVID-19 pandemic period in BC and the large shift in operating room access during this time.

Results

In 2019, 99 patients underwent surgery for proven breast cancer and 30 patients for suspected breast cancer. In 2020, 162 patients underwent surgery for breast cancer and 34 for suspected breast cancer. Wait times from core biopsy to surgery and surgery to oncology consultation were improved in 2020 with a reduction of core biopsy to surgery time from 58 to 28 days for patients seen during the pandemic. There was an increased use of regional anesthesia and same day discharge compared to 2019 with increases in regional anesthesia (41%–89%) and same day discharge (64%–86%) after adaptations to the pandemic were implemented.

Conclusions

Changes such as improved access to telemedicine, timing for cancer surgeries, and safer anesthetic techniques in response to the pandemic will change breast cancer surgical care beyond the pandemic era. Centralization and team-based care is the way forward.

Effect of Beam Steering on Echogenic and Nonechogenic Needle Visibility at 40°, 50°, and 60° Needle Insertion Angles

Currently, there is little understanding of the role of echogenic needles and beam steering at moderate angles of needle insertion. The ultrasound images of the echogenic and nonechogenic needles inserted into pork at 40°, 50°, and 60° were scored by anesthesiologists on a scale of 0-10. The effect of different levels of beam steer was also explored. At 40°, steep beam steering improves visualization of both nonechogenic and echogenic needles to an equal, satisfactory level. At 50° and 60°, visualization of nonechogenic needles is poor, whereas visibility of an echogenic needle was adequate and may be improved with steep beam steering.

Intrathecal hyperbaric versus isobaric bupivacaine for adult non-caesarean-section surgery: systematic review protocol

INTRODUCTION

Bupivacaine is the most commonly used local anaesthetic for spinal anaesthesia (SA). There are two forms of commercially available bupivacaine; isobaric bupivacaine (IB): a formulation with a specific gravity or density equal to cerebrospinal fluid, and hyperbaric bupivacaine (HB): a formulation with density heavier than cerebrospinal fluid. The difference in densities of the two available preparations is believed to affect the diffusion pattern that determines the effectiveness, spread and side-effect profile of bupivacaine. This systematic review will summarise the best available evidence regarding the effectiveness and safety on the use of HB compared with IB, when used to provide SA for surgery. Primarily, we will analyse the need for conversion to general anaesthesia. As secondary outcomes, we will compare the incidence of hypotension, incidence of nausea/vomiting, the onset time and duration of anaesthesia.

METHODS AND ANALYSIS

We will search key electronic databases using search strategy (1) injections, spinal OR intrathecal OR subarachnoid; (2) bupivacaine OR levobupivacaine; (3) hypobaric OR isobaric OR plain; (4) baricity. We will search MEDLINE, EMBASE and Cochrane databases, from their inception for randomised controlled trials, with no restrictions on language. Caesarean section surgery will be excluded. 2 reviewers will independently extract the data using a standardised form. Extracted items will include study characteristics, risk of bias domains, as per modified Cochrane risk of bias, participant disposition and study outcomes. We will conduct a meta-analysis for variables that can be compared across the studies. We will evaluate clinical heterogeneity by qualitatively appraising differences in study characteristics in participants, interventions and the outcomes assessed. We will report our findings as relative risks (dichotomous), and weighted mean differences (continuous) for individual outcomes, along with their 95% CIs.

ETHICS AND DISSEMINATION

We plan to submit, and will publish, our findings in a peer-reviewed scientific journal, and present our results at national and international meetings.

TRIAL REGISTRATION NUMBER

CRD42015017672.

Structural studies on the impurities of troglitazone

The impurity profile study of troglitazone has been carried out primarily by (liquid chromatography-mass spectrometry) LC-MS. Four process-related impurities have been detected by LC-MS and were confirmed by co-injection with authentic samples. Apart from the process-related impurities, two polar by-products were characterized by mass spectral data and comparison with reference samples, while one non-polar by-product and one degradation product have been isolated by means of preparative HPLC and characterized by 2D NMR and mass spectral study. Single-crystal X-ray diffraction studies have been carried out on the degradation product. The formation and characterization of these by-products and degradation product are discussed.

Troglitazone, an euglycemic antidiabetic drug

Troglitazone (or 5-{4-[(6-hydroxy-2,5,7,8-tetramethyl-chroman-2-yl) methoxy]benzyl}thiazolidine-2,4-dione, C24H27NO5S) is the first euglycemic drug. The molecules are held together in the lattice by intermolecular hydrogen bonds between the hydroxy O atom of the chroman moiety, and the ketone O and ring N atom of the thiazolidine-2,4-dione moiety.

Synthesis and biological activity of novel thiazolidinediones

Novel compounds having a dual pharmacophore were synthesised and evaluated for their insulin sensitiser and anti-inflammatory properties in different animal models.