Journal of Clinical Anesthesia最新文献

Study objective

Describe dosing of local anesthetic when both a periarticular injection (PAI) and peripheral nerve block (PNB) are utilized for knee arthroplasty analgesia, and compare the dosing of local to suggested maximum dosing, and look for evidence of local anesthetic systemic toxicity (LAST).

Design

A single center retrospective cohort study between May 2018 and November 2022.

Setting

A major academic hospital.

Patients

Patients who had both a PAI and PNB while undergoing primary, revision, total, partial, unilateral, or bilateral knee arthroplasty.

Interventions

None.

Measurements

Calculate the dose of local anesthetic given via PAI, PNB, and both routes combined as based on lean body weight and compare that to the suggested maximum dosing. Look for medications, clinical interventions, and critical event notes suggestive of a LAST event.

Main results

There were 4527 knee arthroplasties where both a PAI and PNB were performed during the study period. When combining PAI and PNB doses, >75% of patients received more than the suggested maximum dose of 3 mg/kg lean body weight. The median local anesthetic dosing over the study period, 4.4 mg/kg (IQR 3.5,5.9), was 147% of the suggested maximum dose (IQR 117,197). There was no conclusive evidence of LAST among any of the patients in the study.

Conclusions

Over the course of our study, we had 4527 knee arthroplasties with a median PAI and PNB local anesthetic dose that was 147% of the suggested maximum without any clear clinical evidence of a LAST event.

Study objective

HR18034, composed of the ropivacaine encapsulated in multi-lamellar, concentric circular structure liposomes as the major component and a small amount of free ropivacaine, has performed well in animal experiments and phase I clinical trials. This trial was to investigate the efficacy, safety, pharmacokinetic profile and the minimum effective dose of HR18034 for postoperative analgesia after hemorrhoidectomy compared with ropivacaine.

Design

A multicenter, randomized, double-blind trial.

Setting

19 medical centers in China.

Patients

85 patients undergoing hemorrhoidectomy between October 2022 to November 2022.

Interventions

Patients were randomly divided into HR 18034 190 mg group, 285 mg group, 380 mg group and ropivacaine 75 mg group, receiving single local anesthetic perianal injection for postoperative analgesia.

Measurements

The primary outcome was the area under the resting state NRS score -time curve within 72 h after injection. The second outcomes included the proportion of patients without pain, the proportion of patients not requiring rescue analgesia, cumulative morphine consumption for rescue analgesia, etc. Safety was evaluated by adverse events incidence and plasma ropivacaine concentrations were measured to explore the pharmacokinetic characteristics of HR18034.

Main results

The areas under the NRS score (at rest and moving states)-time curve were significantly lower in HR 18034 380 mg group than ropivacaine 75 mg at 24 h, 48 h, and 72 h after administration. However, this superiority was not observed in HR18034 190 mg group and 285 mg group. There was no difference in cumulative morphine consumption for rescue analgesia between HR 18034 groups and ropivacaine group.

Conclusions

HR 18034 380 mg showed superior analgesic efficacy and equivalent safety compared to ropivacaine 75 mg after hemorrhoidectomy, thus preliminarily determined as minimum effective dose.

Study objective

Depression is a common cause of long-lasting disability and preoperative mental health state that has important implications for optimizing recovery in the perioperative period. In older elective surgical patients, the prevalence of preoperative depression and associated adverse pre- and postoperative outcomes are unknown. This systematic review and meta-analysis aimed to determine the prevalence of preoperative depression and the associated adverse outcomes in the older surgical population.

Design

Systematic review and meta-analysis.

Setting

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) for relevant articles from 2000 to present.

Patients

Patients aged ≥65 years old undergoing non-cardiac elective surgery with preoperative depression assessed by tools validated in older adults. These validated tools include the Geriatric Depression Scale (GDS), Hospital Depression and Anxiety Scale (HADS), Beck Depression Inventory-II (BDI), Patient Health Questionnaire-9 (PHQ-9), and the Centre for Epidemiological Studies Depression Scale (CESD).

Interventions

Preoperative assessment.

Measurement

The primary outcome was the prevalence of preoperative depression.

Additional outcomes included preoperative cognitive impairment, and postoperative outcomes such as delirium, functional decline, discharge disposition, readmission, length of stay, and postoperative complications.

Main Results

Thirteen studies (n = 2824) were included. Preoperative depression was most assessed using the Geriatric Depression Scale-15 (GDS-15) (n = 12). The overall prevalence of preoperative depression was 23% (95% CI: 15%, 30%). Within non-cancer non-cardiac mixed surgery, the pooled prevalence was 19% (95% CI: 11%, 27%). The prevalence in orthopedic surgery was 17% (95% CI: 9%, 24%). In spine surgery, the prevalence was higher at 46% (95% CI: 28%, 64%). Meta-analysis showed that preoperative depression was associated with a two-fold increased risk of postoperative delirium than those without depression (32% vs 23%, OR: 2.25; 95% CI: 1.67, 3.03; I²: 0%; P ≤0.00001).

Conclusions

The overall prevalence of older surgical patients who suffered from depression was 23%. Preoperative depression was associated with a two-fold higher risk of postoperative delirium. Further work is needed to determine the need for depression screening and treatment preoperatively.

Study objective

Identify changes and trends in the real value of Medicare payments for anesthesia services between 2000 and 2020 and how it may affect practices.

Design

Retrospective analysis.

Setting

We utilized the Physician/Supplier Procedure Summary (PSPS) datasets of Medicare Part B claims to identify high volume anesthesia services in 2020 with 20 years of data. The Consumer Price Index was used as a measure of inflation to adjust prices.

Patients

The PSPS datasets contain summaries of all annual Medicare Part B claims and payment amounts by carrier and locality.

Interventions

Patients receiving anesthesia services.

Measurements

For each service, identified by Current Procedural Terminology (CPT) codes, we trended the average Medicare payment per procedure from 2000 to 2020 and calculated year to year changes and compound annual growth rate (CAGR). We also evaluated base and time units for each CPT code and the national Medicare anesthesia conversion factor (CF) for the same years.

Main results

The average Medicare payment in the study sample increased 20.1% from 2000 to 2020. After adjusting for inflation, the average Medicare payment per anesthesia service decreased by 20.8% over that period. The Medicare anesthesia CF increased 24.9% in the same period, and after adjusting for inflation, the real value of the CF decreased 16.9%. Average CAGR across the 20 anesthesia services was 0.88%, compared to the average annual inflation at 2.06%.

Conclusions

Average Medicare payment for common anesthesia services after adjusting for inflation have decreased from 2000 to 2020, consistent with findings in other physician specialties. Understanding these trends is important for practice viability and suggests significant financial implications for anesthesia practices and hospitals if the trend were to continue.

Study objective

To compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy.

Design

A prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial.

Setting

A single tertiary academic medical center.

Patients

126 adults aged 18–65 years undergoing elective laparoscopic cholecystectomy.

Interventions

Patients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion.

Measurements

The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of −6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events.

Main results

124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117–127) for lidocaine, 124 (119–126) for ESPB, and 112 (108–117) for placebo. Lidocaine was non-inferior to ESPB (median difference  –1, 97.5% CI: −4 to ∞). Both lidocaine (median difference 9, 95% CI: 6–12, P < 0.001) and ESPB (median difference 10, 95% CI: 7–13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred.

Conclusions

For patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.