Optimizing Robotic Hysterectomy for the Morbidly Obese Patient with a Surgical Safety Pathway
STUDY OBJECTIVE/OBJECTIVE:Obesity is a growing worldwide epidemic, and obese patients undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI pathway (HBP) for patients with a body mass index (BMI) of 40 or greater undergoing planned robotic hysterectomy. Our primary outcome was rate of all-cause perioperative complications in patients undergoing surgery with the utilization of the HBP. DESIGN/METHODS:A retrospective cohort study. SETTING/METHODS:An academic teaching hospital. PATIENTS/METHODS:) undergoing robotic hysterectomy. INTERVENTIONS/METHODS:The HBP was developed by a multidisciplinary team and was instituted January 1, 2016 as a quality improvement project. Morbidly obese patients undergoing robotic hysterectomy after this date were compared to consecutive historic controls. MEASUREMENTS AND MAIN RESULTS/RESULTS:Seventy-two patients underwent robotic hysterectomies on the HBP and were compared to 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of HBP, there has been a decrease in anesthesia time (-57.0 min; p=.001), total operating room time (-47.0 min; p=.020), lower estimated blood loss (median 150 cc [IQR 100-200] vs 200 cc [IQR 100-300]; p=.002), and overnight hospital admissions (33.3% vs 63.6%; p < 0.001). There were fewer all-cause complications seen in HBP (19.4% vs 37.9%; p=.023) and infectious complications (8.3% vs 33.3%; p=.001) and no increase in readmission rates (p=.400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio [OR] 0.353; p=.010) after controlling for covariate (total time in OR). CONCLUSION/CONCLUSIONS:HBP is a feasible method of optimizing outcome for morbidly obese patients undergoing major gynecologic surgery. Initiation of HBP can lead to decreased all-cause complications and overnight hospital admissions without increasing readmission rates.
Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review
Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.
Improving Operating Room Turnover Time in A New York City Academic Hospital via Lean
BACKGROUND:Prolonged operating room turnover time erodes patient and employee satisfaction and value. METHODS:Lean and value stream mapping was applied to three operating room teams at an academic health center in New York City and a solution called Performance Improvement Team (PIT Crew) was piloted. RESULTS:Overall, 10% of operating room turnover steps were considered non-valued and were eliminated and 25% of previously sequential steps were performed synchronously. Seven institutional dogmas were eliminated, and three hospital policies were changed. After 35 pilot turnovers, median operating room turnover time improved from 37 minutes (range 26-167) in historical matched controls to 14 minutes (range 10-45, p<0.0001) for the PIT Crew. Cost of the PIT Crew was $1,298 daily and estimated return on investment was $19,500 per day. CONCLUSIONS:Lean and value stream mapping identifies non-valued steps in operating room turnover and affords opportunities for efficiency. Once institutional rules and dogma are changed, culture and workflow improve and turnover time significantly improves. This process adds cost but is profitable. Scalability and sustainability is under further study, as is the "halo effect" on the culture in other non-PIT Crew operating rooms.
Continuous Infraclavicular Brachial Block Versus Single-Shot Nerve Block for Distal Radius Surgery: A Prospective Randomized Control Trial
OBJECTIVES/OBJECTIVE:To compare the efficacy of an infraclavicular single-shot nerve block to a continuous infusion through an OnQ infusion pump for rebound pain (between 12 and 24 hours postoperatively) and postoperative narcotic analgesia requirements in distal radius fractures. DESIGN/METHODS:Prospective randomized control trial. SETTINGS/METHODS:Performed at 2 hospitals affiliated with a large urban academic medical center. PATIENTS/METHODS:Fifty patients undergoing operative fixation of distal radius fractures (OTA/AO type 23B/C). INTERVENTION/METHODS:Patients were randomized to receive either an infraclavicular block as a single shot (SSB group) or a continuous infusion through an OnQ pump (OnQ group). MAIN OUTCOME MEASURES/METHODS:Visual analog scale (0-10) pain levels and amount of pain medication taken. RESULTS:At all time points after discharge, mean postoperative pain scores were lower in the OnQ group versus the SSB group but did not reach statistical significance. At 12 hours postoperatively, the SSB group and OnQ group pain scores, respectively, were 5.2 and 4.1 (P = 0.1615). At 24 hours, the pain scores for the SSB and OnQ group, respectively, were 5.4 and 4.8 (P = 0.1918). At these same time points, the Percocet taken were the same at 1.3 and 2.3 (P = 0.8328 and 0.8617). Overall 5 of 24 patients in the OnQ group had pump malfunctions with 4 being removed before 48 hours. CONCLUSION/CONCLUSIONS:OnQ pump is not associated with statistically improved postoperative pain control compared with a single nerve block for distal radius fractures and did not address rebound pain. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Reducing Post-Operative Pain Scores in Patients at Risk for Poor Pain Control through Perioperative Workflow Redesign [Meeting Abstract]
Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality
BACKGROUND: As specialists in perioperative medicine, anesthesiologists are well equipped to design and oversee the preoperative patient preparation process; however, the impact of an anesthesiologist-led preoperative evaluation clinic (PEC) on clinical outcomes has yet to be fully elucidated. The authors compared the incidence of in-hospital postoperative mortality in patients who had been evaluated in their institution's PEC before elective surgery to the incidence in patients who had elective surgery without being seen in the PEC. METHODS: A retrospective review of an administrative database was performed. There were 46 deaths from 64,418 patients (0.07%): 22 from 35,535 patients (0.06%) seen in PEC and 24 from 28,883 patients (0.08%) not seen in PEC. After propensity score matching, there were 13,964 patients within each matched set; there were 34 deaths (0.1%). There were 11 deaths from 13,964 (0.08%) patients seen in PEC and 23 deaths from 13,964 (0.16%) patients not seen in PEC. A subanalysis to assess the effect of a PEC visit on deaths as a result of failure to rescue (FTR) was also performed. RESULTS: A visit to PEC was associated with a reduction in mortality (odds ratio, 0.48; 95% CI, 0.22 to 0.96, P = 0.04) by comparison of the matched cohorts. The FTR subanalysis suggested that the proportion of deaths attributable to an unanticipated surgical complication was not significantly different between the two groups (P = 0.141). CONCLUSIONS: An in-person assessment at the PEC was associated with a reduction in in-hospital mortality. It was difficult to draw conclusions about whether a difference exists in the proportion of FTR deaths between the two cohorts due to small sample size.
Does Brachial Plexus Blockade Result in Improved Pain Scores After Distal Radius Fracture Fixation? A Randomized Trial
BACKGROUND: Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients' postoperative course and experience. QUESTIONS/PURPOSES: We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery? METHODS: A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits. RESULTS: Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 +/- 2.3 vs brachial plexus blockade 1.4 +/- 2.3; mean difference, 5.381; 95% CI, 3.850-6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 +/- 1.9 vs brachial plexus blockade 6.3 +/- 2.4; mean difference, -2.535; 95% CI, -4.028 to -1.040; p = 0.002) and 24 hours (general anesthesia 3.8 +/- 2.2 vs brachial plexus blockade 5.3 +/- 2.5; mean difference, -1.492; 95% CI, -3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 +/- 16 minutes vs brachial plexus blockade 125 +/- 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 +/- 137 minutes vs 197 +/- 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 mug +/- 93 mug vs 6.9 mug +/- 14 mug; p < 0.001) and morphine (2.9 mug +/- 3.6 mug vs 0.0 mug; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value). CONCLUSIONS: Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging "rebound pain" after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management. LEVEL OF EVIDENCE: Level 1, therapeutic study.
Continuous Popliteal Sciatic Nerve Block versus Single Injection Nerve Block for Ankle Fracture Surgery: a Prospective Randomized Comparative Trial
OBJECTIVES: To compare rebound pain and the need for narcotic analgesia following ankle fracture surgery for patients receiving perioperative analgesia through either a continuous infusion or a single injection nerve block. DESIGN: Prospective randomized controlled trial. SETTINGS: Surgeries were performed at two hospitals affiliated with a large urban academic medical center. PATIENTS/PARTICIPANTS: 50 patients undergoing operative fixation of an ankle fracture (AO/OTA Type 44). INTERVENTION: Participants were randomized to receive either a popliteal sciatic nerve block as a single shot (SSB group) or a continuous infusion through an On Q continuous infusion pump (On Q group). MAIN OUTCOME MEASUREMENTS: Visual Analog Scale and Numeric Rating Scale (0-10) pain levels and amount of pain medication taken. RESULTS: For all time points after discharge, mean postoperative pain scores and number of pain pills taken were lower in the On Q group vs. the SSB group. Pain scores were significantly lower in the On Q group at the 12 hour postoperative time point (p = 0.002) and at 2 weeks postoperatively. The number of pain pills taken in the first 72 hours was lower in the On Q group (14.9 vs. 20.0; p = 0.036). Overall, 7/23 patients in the On Q group had their pump malfunction and one patient accidently removed their catheter. CONCLUSIONS: Use of continuously infused regional anesthetic for pain control in ankle fracture surgery significantly reduces "rebound pain" and the need for oral opioid analgesia compared to single-shot regional anesthetic. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
The Impact of Popliteal Block on Postoperative Medication Administration and Time to Discharge from the Post-Anesthesia Care Unit
BACKGROUND: Previous studies have demonstrated the efficacy of popliteal block anesthesia in decreasing post - operative narcotic administration, nausea, and length of stay in patients undergoing foot and ankle surgeries. The purpose of this study was to compare the amount of narcotic medication administered, the need for anti-emetic medica - tion, PACU length of stay, and discharge status in patients treated surgically for ankle fractures who received popliteal blocks with those who received general anesthesia alone. METHODS: All patients being treated with open reduction and internal fixation for ankle fractures were randomized to receive either general anesthesia (GETA) or popliteal block. Postoperatively, data was collected on the duration of time in the PACU before discharge to home or to a hospital floor. Additional information was collection on the amount of anti-emetic and pain medication in the PACU. RESULTS: Fifty-one patients agreed to participate in the study. There was no significant difference between the two groups with regards to the need for anti-emetic medication, the amount of pain medication received in the PACU, or amount of time spent in the PACU. Patients who received a popliteal block were no more likely to be discharged to home from the PACU than those who received general anesthesia. DISCUSSION: While previous studies have demonstrated the efficacy of popliteal block in decreasing anti-emetic and pain medication administration in the PACU, we found no difference in the amount of medication administered. We found that popliteal block patients were no more likely to be discharged to home than those who received general anesthesia.