Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose was to compare perioperative outcomes of patients who underwent general or regional anesthesia for intramedullary (IM) nailing of tibial shaft fractures (TSFs). METHODS:Retrospective chart review was performed on a consecutive series of low-energy TSF patients who presented to a single academic medical center and a level 1 trauma center who underwent operative repair with a reamed IM nail. Collected information included demographics, injury information, anesthesia type (general or regional i.e. peripheral nerve block), intra-operative opiate consumption (converted to morphine milliequivalents [MME], and post-operative pain visual-analog scale [VAS] pain scores. Patients were divided into 3 groups based on the type of anesthesia received and univariate analysis was performed to compare the 3 groups. RESULTS:Seventy-six patients were included, with an average age of 44.47±16.0 years. There were 38 (50 %) who were administered general anesthesia and 38 (50 %) who were administered regional anesthesia in the form of a peripheral nerve block. There were no differences between the groups with respect to demographics, medical co-morbidities, rate of open fractures or AO/OTA fracture classification. Regional anesthesia patients received less intra-operative MME than general anesthesia patients (17.57±10.6, 28.96±13.8, p < 0.001). Patients who received regional anesthesia also spent less time in the operating room, received less MME on post-operative day 1, and ambulated further on post-operative day 1, however none of these differences were statistically significant. There were no cases of missed post-operative compartment syndrome or complications related to the administration of the peripheral nerve block. CONCLUSIONS:Regional anesthesia in TSF surgery received less intra-operative opioid requirements, without any untoward effects. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III.

PURPOSE OF REVIEW/OBJECTIVE:To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes. RECENT FINDINGS/RESULTS:This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.

INTRODUCTION/UNASSIGNED:Older adults undergoing surgery are at risk of postoperative neurocognitive disorders, prompting the need for preoperative cognitive screening in this population. Traditionally, cognitive screening has been conducted in-person using brief assessment tools such as the Montreal Cognitive Assessment (MoCA) or the Mini-Mental State Examination (MMSE). More comprehensive test batteries, such as the Uniform Data Set (UDS) Neuropsychological Battery, and its remote testing version, the Uniform Data Set version 3 tele-adapted test battery (UDS v3.0 T-cog), have been developed to assess cognitive decline in normal aging and disease conditions, but have not been applied in the perioperative setting. METHODS/UNASSIGNED:We assessed the feasibility of using this remote UDS v3.0 T-cog battery for preoperative cognitive assessment in 81 older adults 65+ scheduled for lower extremity joint replacement surgery. RESULTS/UNASSIGNED:Our results indicate that the UDS v3.0 T-cog achieves 99% completion rates and demonstrates high patient satisfaction. Further, we found 28% of subjects were cognitively impaired in this patient cohort. DISCUSSION/UNASSIGNED:These findings suggest that the UDS v3.0 T-cog is a feasible tool for assessing cognitive function in the older adult perioperative population. To our knowledge, this is the first study to apply this comprehensive remote test battery in the preoperative setting.

Reducing pain and opioid consumption after total knee arthroplasty (TKA) is an important perioperative consideration. Though commonly used, the combined influence of tourniquets and adductor canal blocks (ACBs) on pain and opioid consumption is unknown. This study evaluated inpatient opioid consumption and pain between patients with TKA based on tourniquet and/or ACB use. Pain and opioid consumption were highest when a tourniquet, but no ACB was used, and lowest when an ACB, but no tourniquet was used - though absolute differences in pain scores were not clinically significant. Tourniquet and ACB use should be considered as part of TKA opioid-sparing protocols.

BACKGROUND/UNASSIGNED:Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels. METHODS/UNASSIGNED:A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS/UNASSIGNED: = .012). CONCLUSIONS/UNASSIGNED:In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

BACKGROUND:The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI). METHODS:Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed. RESULTS:Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029). CONCLUSIONS:Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.

OBJECTIVES/OBJECTIVE:To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip Block (LOH Block). DESIGN/METHODS:Retrospective. SETTING/METHODS:Level-I Trauma CenterPatients/Participants: 40 patients who presented between 11/2021 and 02/2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION/METHODS:Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve (FN) and accessory obturator nerve (AON). MAIN OUTCOME MEASUREMENTS/METHODS:Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS:A total of 120 patients (40 each: general, spinal, LOH block) were compared. The cohorts were similar in age, race, BMI, gender, CCI, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block group (p<0.05). Total OR time and anesthesia time were shortest for the LOH block cohort (p<0.05). Patients in the LOH block cohort also had lower post-operative pain scores (p<0.05). Length of hospital stay was shortest for patients in the LOH block cohort (p<0.05), and at time of discharge, patients in the LOH block cohort ambulated the furthest (p<0.05). No differences were found in regards to anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS:The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly requiring surgery. In addition, this block may decrease post-operative pain and length of hospital stay, and also allow for greater ambulation in the early post-operative period for hip fracture patients. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:Spinal anesthesia (SA) is the preferred method of anesthesia at many centers for total joint arthro- plasty (TJA). However, a small subset of patients fails SA, necessitating a conversion to general anesthesia (GA). This report assesses the patient characteristics associated with failed SA. METHODS:A retrospective study was conducted on patients who underwent SA during their primary TJA between Janu- ary 2015 and December 2016 at our institution. A subset of this group required a conversion from SA to GA. Anesthesia reports were reviewed for the number of attempts at SA and the documented reason for failure. The SA failure cohort was then subdivided into failure categories based on the reasons that had been provided. RESULTS:A total of 5,706 patients were included in this study, 78 of which experienced SA failure. The number of attempts was most strongly associated with SA failure, with three attempts resulting in a five times increased failure rate (OR = 4.73, p = 0.010) and four attempts resulting in 12 times increased failure rate compared to the no failure cohort (OR = 12.3, p < 0.001). Greater than two attempts occurred in 87.5% of the "technical failure" sub-group of the SA failure cohort (p < 0.001). No difference was demon- strated among the other patient characteristics, such as age, sex, body mass index, race, American Society of Anesthesia (ASA) score, and surgical time. CONCLUSIONS:The results suggest that the major predic- tor influencing spinal to general anesthesia conversion was the number of attempts at SA, especially among technical failure cases. Based on the results, it may be appropriate for anesthesiologists to convert to GA after two failed spi- nal attempts. Further studies are warranted to assess this relationship for firm clinical recommendations.

CASE:This case describes a 45-year-old man with documented history of untreated bilateral lower extremity psoriasis of equal severity who sustained a closed left tibial-fibular shaft fracture. After operative fixation with an intramedullary nail under a regional nerve block, the left lower extremity circumferential psoriatic plaque resolved throughout 1 year of follow-up with persistence of the contralateral limb disease. CONCLUSION:This case describes a rare outcome for a patient with bilateral leg psoriasis who experienced resolution of psoriatic plaques on the operated leg only after surgery. It is unknown which process: injury, anesthetic, surgery, or fracture healing mediated this unique finding.