Author Reply to "Regarding 'Tranexamic Acid Has No Effect on Postoperative Hemarthrosis or Pain Control After Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft: A Double-Blind, Randomized, Controlled Trial'" [Letter]
Tranexamic Acid Has No Effect on Post-operative Hemarthrosis or Pain Control Following ACL Reconstruction Using Bone Patella Tendon Bone Autograft: A Double-Blinded Randomized Control Trial
PURPOSE/OBJECTIVE:The purpose of this double-blinded randomized controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone-patella tendon-bone (BTB) ACLR with regard to post-operative hemarthrosis, pain, opioid consumption, quadriceps atrophy and activation. METHODS:A controlled, randomized, double-blinded trial was conducted in 110 patients who underwent ACLR with BTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-gram boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated, and the volume of blood (ml) was recorded. Additionally, perioperative blood loss (ml); Visual Analog Scale (VAS) on postoperative days (POD) 1-7 and post-operative weeks (POW) 1, 6 and 12; postoperative opioid consumption POD 1-7; range of motion (ROM) and ability to straight leg raise (SLR) at POW 1, 6, 12; and pre and postoperative thigh circumference ratio (TCR). RESULTS:There was no significant difference in perioperative blood loss between the TXA and control groups (32.5ml v. 35.6ml, p=0.47). The TXA group had 23 knees aspirated; control group had 26 knees aspirated (p=0.56). No significant difference seen in postoperative hemarthrosis volume with IV TXA compared to those without (26.7ml v. 37.3ml, p=0.12). There was no significant difference in VAS score between the two groups (p=0.15), additionally, there was no difference in postoperative opioid consumption (p=0.33). There was no significant difference in ROM or ability to SLR, or post-operative TCR (p > 0.05 for all). CONCLUSION/CONCLUSIONS:IV TXA in patients who undergo ACLR with BTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early post-operative recovery regarding ROM or quadriceps reactivation.
Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur
BACKGROUND: The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS: We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS: Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION: A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.
An Evaluation of Patient Risk Factors to Determine Eligibility to Undergo Orthopaedic Surgery in a Freestanding Ambulatory Center A Survey of 4,242 Consecutive Patients
INTRODUCTION: The value proposition of surgery at freestanding ambulatory surgery centers (FSASCs) in terms of efficiency, safety, and patient satisfaction is well established and has led to increased FSASC utilization. However, there are comorbid conditions that disqualify certain patients from surgery at FSASCs. Understanding the percentage of patients whose comorbid conditions exclude them from FSASCs is important for the proper planning and utilization of operating room assets. We aim to understand the percentage of excluded patients, and we predict that certain procedures have higher rates of disqualification due to the types of patients who undergo them. METHODS: We reviewed the records of 4,242 consecutive patients undergoing outpatient orthopaedic surgeries in our hospital system from July 2015 to February 2016. Patient characteristics, comorbidities, and procedures performed were included in our database. We analyzed each case and determined eligibility for surgery at our FSASC based on established comorbidity exclusionary guidelines. Chi-square and t-tests were used to establish statistical significance. RESULTS: Of 4,242 patients, 878 (20.7%) were ineligible for surgery at our FSASC based on accepted exclusionary guidelines. The average body mass index (BMI) of FSASC-eligible patients was 27.37, compared to 31.68 for FSASC-ineligible patients (p < 0.001). The majority, 85.6% (543/634), of American Society of Anesthesiologists (ASA) class 3 patients were FSASC-ineligible. The most common reasons for excluding patients from surgery at our FSASC were morbid obesity (25.4% of ineligible cases), untreated obstructive sleep apnea (22.1%), age less than 13 (19.6%), and coronary artery disease with prior intervention (13.3%). When stratifying by procedure, the operations most likely to be FSASC-ineligible were contracture releases (39.13% ineligible, p = 0.03), trigger finger releases (36.14%, p < 0.001), carpal tunnel releases (30.63%, p = 0.009), tumor resections (38.89%, p = 0.056), rotator cuff repairs (25.47%, p = 0.078), and subacromial decompressions (30.23%, p = 0.12), primarily because these patients have more comorbidity (ASA 2.20 vs. 1.88, p < 0.001). CONCLUSIONS: Roughly 1 in 5 patients is ineligible for surgery at a freestanding ASC due to disqualifying comorbidities. Although FSASCs offer cost effective care that satisfies patients, we must understand that certain patients cannot have their surgeries at these venues. In addition, we must use additional caution when scheduling certain procedures at a FSASC. Therefore, as the number and complexity of the surgeries performed at FSASCs increase, we must better understand the factors that make patients better candidates for surgery in a hospital setting, thus minimizing transfers and readmissions and maximizing the value proposition of FSASCs.
Auricular Acupressure in the Prevention of Postoperative Nausea and Emesis A Randomized Controlled Trial
INTRODUCTION: Successful antiemesis contributes significantly to quality, safety, and patient satisfaction. Patients undergoing general anesthesia often experience postoperative nausea and vomiting (PONV). Acupressure offers a side effect-free alternative to common first-line antiemetics. Because the patient may perceive needle acupuncture as uncomfortable, acupressure is a desirable alternative for the prevention of PONV. METHODS: This study was a randomized, prospective, double-blinded clinical trial investigating the effect of acupressure in patients with a history of PONV and motion sickness. The three auricular acupressure points chosen were shen men, point zero, and the subcortex point. Rescue treatment for PONV with 4 mg intravenous ondansetron was used if the patient reported persistent nausea. A blinded observer recorded antiemetic rescue data, and postoperative analgesic use was recorded over 24 hours. Nausea, vomiting, and retching were assessed in the post-anesthesia care unit (PACU). RESULTS: Using univariate analysis, we ruled out the null hypothesis of equal means as a function of intervention group (p = 0.001). Pair-wise comparisons revealed a difference between placebo and test groups (p = 0.000) and also sham and test groups (p = 0.033) where age (p = 0.048) and gender (p = 0.003) were significant covariates. DISCUSSION: Our data reveal that auricular acupressure significantly decreases nausea during the PACU stay and within the 24 hours postoperatively. It is not clear whether the intervention decreases nausea as a primary effect or as a secondary result by decreasing narcotic requirements. Also, perception of nausea may be in part subjective. This is evidenced by our results in which subjects who received sham points fared better than the placebo subjects.
AURICULAR ACUPRESSURE IN PREVENTION OF POSTOPERATIVE NAUSEA AND EMESIS [Meeting Abstract]
Three partial-task simulators for teaching ultrasound-guided regional anesthesia
ABSTRACT: Simulation-based training is becoming an accepted tool for educating physicians before direct patient care. As ultrasound-guided regional anesthesia (UGRA) becomes a popular method for performing regional blocks, there is a need for learning the technical skills associated with the technique. Although simulator models do exist for learning UGRA, they either contain food and are therefore perishable or are not anatomically based. We developed 3 sonoanatomically based partial-task simulators for learning UGRA: an upper body torso for learning UGRA interscalene and infraclavicular nerve blocks, a femoral manikin for learning UGRA femoral nerve blocks, and a leg model for learning UGRA sciatic nerve blocks in the subgluteal and popliteal areas
Endpoint for successful, ultrasound-guided infraclavicular brachial plexus block - Reply [Letter]
"Atlas of Ultrasound and Nerve Stimulation-Guided Regional Anesthesia" [Book Review]
Case series: Septa can influence local anesthetic spread during infraclavicular brachial plexus blocks
PURPOSE: To ultrasonically identify the presence of septae within the neurovascular sheath and to assess their effect on local anesthetic spread when performing infraclavicular brachial plexus blocks. CLINICAL FEATURES: Thirty ASA status I and II patients scheduled for minor hand surgeries were enrolled in the study. Ultrasound guided infraclavicular brachial plexus blocks were performed on 28 patients. The images of the local anesthetic spread and the effect of the septum within the neurovascular sheath were analyzed. Septae were present in four of six patients where unilateral local anesthetic spread was seen. Septae were not visualized in the 22 patients with unrestricted local anesthetic spread after the initial injection. All 28 patients underwent their planned operations successfully with adequate anesthesia. CONCLUSIONS: Our study shows that the presence of septae within the neurovascular sheath may influence the pattern of local anesthetic spread associated with the infraclavicular approach to brachial plexus blocks