Bupivacaine-Induced Hepatotoxicity in a Healthy Patient Without Chronic Liver Disease After Shoulder Arthroscopy

Introduction: Bupivacaine is a local anesthetic which has been increasingly used in the post-operative state for pain control. Hepatotoxicity is a rare complication, and few cases are reported in patients with chronic liver disease. We present a case of acute liver injury from bupivacaine use in a healthy patient without prior history of liver disease. Case Description/Methods: A 68-year-old female with a past medical history of primary hypertension and recent nontraumatic complete tear of the right rotator cuff, presents to the hospital with fatigue, loss of appetite, and nausea. She recently underwent an arthroscopy of the right shoulder with repair of the rotator cuff two weeks prior. Her surgery was uncomplicated, and patient was started on bupivacaine ONQ pump infusion at 5 ml/hr for three days for post-operative pain. Further history reveals patient is non-alcoholic without prior liver disease, including cirrhosis. Review of systems is concerning for associated generalized abdominal discomfort. Physical exam demonstrated jaundice with scleral icterus with mild periumbilical tenderness to palpation without hepatosplenomegaly or ascites. Labs demonstrated elevated total bilirubin of 10.2 mg/dL with Alkaline phosphatase, ALT, and AST being 924 U/L, 429 U/L, and 279 U/L, respectively. Imaging studies including CT abdomen and pelvis with contrast, abdominal ultrasound, MRCP, and portal vein doppler were negative. Additional work up for underlying liver disease including acetaminophen and ethanol levels, SARS-CoV2, Hepatitis panel, EBV antigen, and urine toxicology were negative. It was determined patient had bupivacaine induced hepatotoxicity. Patient's health improved with conservative management and she was discharged with instructions for close monitoring of her LFTs. Discussion(s): Bupivacaine is an amino-amide anesthetic which binds to the intracellular portion of voltage-gated sodium channels and prevents depolarization of pain signals. It is metabolized by the liver and thus reports of hepatotoxicity, although rare, occur in patients with underlying liver pathology. Our patient became symptomatic with acute rise in LFTs. An extensive workup for other etiologies of acute liver toxicity was negative. Rapid vascular uptake of the drug is the most common reason for bupivacaine toxicity;and this remains a possibility for the mechanism of toxicity in our patient. A prior case report of bupivacaine hepatotoxicity demonstrated a cholestatic pattern, which is consistent with our findings.

Outcomes of coblation tonsillectomy versus bipolar electrocautery tonsillectomy in pediatric population

Background: Bipolar electrocautery tonsillectomy has been the preferred technique for many otolaryngologists, yet coblation tonsillectomy is gaining popularity in the current practice. This study aims at comparing both techniques in terms of pain, bleeding, and healing. Result(s): A total of 120 patients were randomly divided into two equal groups. Overall mean pain score associated with coblation tonsillectomy was statistically less than that caused by bipolar electrocautery throughout the follow-up period (p < 0.001). The difference in pain duration was statistically longer for the bipolar group. The incidence of postoperative hemorrhage-both reactionary and secondary-was statistically higher in the bipolar group. Coblation tonsillectomy showed statistically shorter duration of healing (p < 0.001). Conclusion(s): Coblation tonsillectomy is associated with less pain severity and shorter pain duration, fewer bleeding incidents, and more prompt healing.Copyright © 2022, The Author(s).

Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series

Background: Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neuro-surgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objective(s): To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Method(s): We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Result(s): Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 +/- 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients;63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusion(s): Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.Copyright © 2023, Author(s).

Silver nitrate-induced skin inflammation mimicking surgical infection

Silver has been in medicine for hundreds of years and has proven antimicrobial properties. It was widely used until the Second World War, when antibiotics emerged. Silver nitrate (SN) sticks (75% silver nitrate and 25% potassium nitrate) are currently employed as a topical haemostatic agent for various cutaneous surgical procedures. In the initial phase of the COVID-19 pandemic, faced with a limited supply of personal protective equipment, we used SN stick haemostasis for several skin surgical procedures (including excisions). COVID-19-related guidance from the Trust recommended the avoidance of electrocautery owing to the generation of surgical plume;hence, SN stick haemostasis seemed a pragmatic option. Four female patients with a mean age of 67 years (range 48-75) presented with swelling, erythema and pain at the surgical site within a week of the procedure. Three had ellipse excisions for suspected melanoma and squamous cell carcinomas, and one had a shave excision for possible seborrhoeic keratosis. Postsurgical wound infection was suspected, but repeated microbiological swabs did not grow any pathogens. All patients failed to respond to broad-spectrum oral antibiotics, even after two courses. The inflammatory changes took up to 4 weeks to settle, with topical corticosteroids used for wound healing. On contact with moisture, SN sticks deliver free silver ions that form an eschar as they bind to the tissue and occlude vessels. The longer the tip contacts the tissue, the greater the degree of the resultant caustic action. It is widely used in clinical practice, especially wound care (overgranulation, epibole and delayed healing). A 2020 review found an increased incidence of postoperative pain along with pigmentary changes in surgical wounds treated with SN sticks vs. aluminium chloride hexahydrate and ferric subsulfate. In skin surgery, SN is used to cauterize superficial wounds after curettage and shave excision. It does not generate aerosol and, in a pandemic setting, this particular feature can be valuable. However, the potential to cause aseptic skin inflammation that mimics postoperative infection is noteworthy. There are no evidence-based guidelines for its use in dermatology. We believe that the SN is an effective haemostatic agent but can induce significant tissue inflammation in some patients, particularly if it is used in excisions when the cauterized tissue is closed. If SN-induced haemostasis for excision was to be adopted in clinical practice, our experience suggests that larger studies and guidelines are recommended.

Day case thoracoscopy in a UK district general hospital

Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Korábban SARS-CoV-2-fertozésen átesett betegek mutéti érzéstelenítése és perioperatív ellátása.

Összefoglaló. A korábban SARS-CoV-2-vírusfertozésen átesett betegeknél különösen fontos az elektív mutét idopontjának megválasztása. Egy több, mint százezer beteget felölelo tanulmány szerint átlagosan 7 hét szükséges az elektív mutétre bocsátáshoz. Sürgos mutétek esetében a beteg általános állapota és a mutéttol várt javulás alapján mérlegelendo a mutét idopontja. A vitális indikációjú mutétek képezik a legnagyobb rizikót, hiszen ezen esetekben igen csekély ido és lehetoség van a preoperatív betegelokészítésre. A SARS-CoV-2-vírusfertozés nem minden esetben múlik el nyomtalanul. Szövodményeként felléphetnek cardiopulmonalis, véralvadási, központi idegrendszeri, mozgásszervi problémák, akut veseelégtelenség, ion- és vércukorháztartás felborulása, valamint gastrointestinalis eltérések is, melyek lehetnek rövid vagy hosszú távúak, illetve egyes esetekben maradandó károsodások is. A preoperatív kivizsgálási stratégiát, a mutéti érzéstelenítés módszerét (általános vagy regionális), valamint az intraoperatív monitorozást ezen szövodmények súlyosságának, valamint a mutét típusához megfeleloen kell megválasztani. A posztoperatív idoszakban a SARS-CoV-2-vírusfertozésen átesett betegek körében gyakrabban lehet szükség emelt szintu monitorozásra vagy intenzív osztályos megfigyelésre. Orv Hetil. 2022; 163(18): 695-701. Summary. The timing of elective surgery is very important in patients, who suffered SARS-CoV-2 virus infection. According to a study of more than 100,000 patients, it takes approximately seven weeks to be safely admitted to elective surgery. In the case of emergency surgeries, the date of the surgery should be considered based on the patient's general condition and the expected improvement from the surgery. Surgery with a vital indication takes the greatest risk, as there is very little time and opportunity for preoperative examination in these cases. SARS-CoV-2 virus infection does not go away without a trace. Complications may include cardiopulmonary, coagulation, central nervous system, locomotor problems, acute renal failure, ionic and diabetic disorders, and gastrointestinal abnormalities, which may be short-term or long-term, and in some cases permanent. The preoperative examination strategy, the method of anesthesia (general or regional) and the intraoperative monitoring should be chosen according to the severity of these complications and the type of surgery. In the postoperative period, patients suffered with SARS-CoV-2 virus infection may require more frequent monitoring or intensive ward monitoring. Orv Hetil. 2022; 163(18): 695-701.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19. Copyright © 2022 Elsevier Ltd

The Effect of Topical Dexamethasone on Postoperative Pain Intensity in Patients Undergoing Dacryocystorhinostomy Procedure

Background and Objective: It is very important and necessary to use certain methods in order to prevent or reduce the intensity of pain after surgery. Of all known methods, those that avoid the dangerous side effects of opioids or nonsteroidal anti-inflammatory drugs (NSAIDs) can be useful. The present study was conducted with the aim of investigating the effect of topical dexamethasone on postoperative pain intensity in patients undergoing dacryocystorhinostomy (DCR). Method(s): This double-blind randomized clinical trial was conducted on 80 patients aged 18-75 who were candidates for DCR and referred to Khatam Al-Anbia Hospital in Mashhad. Patients were randomly divided into control and intervention (dexamethasone) groups. In the intervention group, at the end of the procedure, a tampon impregnated with dexamethasone was placed in the upper part of the middle concha. In the control group, a tampon washed in distilled water was placed in the same place. Pain intensity was recorded on a verbal rating scale (VRS) 0, 3, 6, 12, 18 and 24 hours after the operation. Finding(s): There was no significant difference in pain intensity at different time points in the two groups of intervention and control;the frequency of severe pain during recovery was equal to 22.5% and 15.7%, within 3 hours after the operation was equal to 17.5% and 10.0%, within 6 hours after the operation was equal to 12.5% and 0.5%, within 12 hours after the operation was equal to 12.5% and 2.5%, within 18 hours after the operation was equal to 0% and 2.5% and within 24 hours after the operation was equal to 0% and 0%, respectively. There was no significant difference in the process of changes in pain intensity during the 24 hours of the study based on the follow-up test. Conclusion(s): The results of the study showed that topical use of a single dose of dexamethasone (8 mg) could not reduce postoperative pain as well as the need for opioids in DCR surgery. Copyright © 2023, Babol University of Medical Sciences. All rights reserved.

New Aspects of Lung Transplantation: A Narrative Overview Covering Important Aspects of Perioperative Management.

The management of lung transplant patients has continued to evolve in recent years. The year 2021 was marked by the publication of the International Consensus Recommendations for Anesthetic and Intensive Care Management of Lung Transplantation. There have been major changes in lung transplant programs over the last few years. This review will summarize the knowledge in anesthesia management of lung transplantation with the most recent data. It will highlight the following aspects which concern anesthesiologists more specifically: (1) impact of COVID-19, (2) future of transplantation for cystic fibrosis patients, (3) hemostasis management, (4) extracorporeal membrane oxygenation management, (5) early prediction of primary graft dysfunction, and (6) pain management.

Hybrid Pain Management Strategy Attenuated Acute Pain and Reduced Left-Over Opioid Doses

Problem: Clinicians treating postprocedure acute pain after third molar removal face a twofold challenge: attenuating pain levels while simultaneously limiting leftover opioid doses. Strategies for achieving the dual goals range from “letting patients decide,” which can lead to leftover doses and misuse, or “letting clinicians decide,” only prescribing opioids for those predicted to experience severe discomfort, which risks under-managing acute pain. A hybrid strategy relies on joint decision-making between the patient and clinician. The hypothesis for this IRB-approved prospective study was that a hybrid-strategy would be successful in moderating acute pain and reducing leftover opioid doses. Methods and Materials: This study included patients who met the American Society of Anesthesiologists, risk classification I or II, ages 18 to 35 years, with at least 2 mandibular third molars removed. Patients being treated for opioid addiction/abuse were excluded. All enrolled subject patients were consented and treated with a multimodal analgesic protocol consisting of intraoperative IV preventive antibiotics, dexamethasone, ketorolac, ondansetron, local anesthetics including liposomal bupivacaine and postoperative cold therapy, and scheduled ibuprofen. Patients were given 2 prescriptions (Rx), each for 4 doses of Hydrocodone/APAP 5/325, to be taken as needed for pain;1 Rx could be filled on the day of surgery, the second on any subsequent day. Opioid Rx data were retrieved from patient records and North Carolina Controlled Substances Reporting System. Pain scores and opioid-use data for each postsurgery day (PSD) were derived from a 14-day diary recorded by subjects. For the patients in this series, the goal was median pain levels ranked 1 or 2 on a 7-point scale, meaning no pain and minimal pain by postoperative day (POD) 3. Descriptive statistics were used for analyses. Results: Data were analyzed from 96 eligible patients treated consecutively from 2018 to 22, with a 15-month hiatus from COVID-19. Fifty-two patients (54%) did not fill an opioid prescription. Twenty-seven patients (28%) filled 1 opioid prescription and 17 patients (18%) filled 2 of the prescriptions. The patients who filled 1 prescription had 72 leftover doses (67% of possible doses), and the patients who filled 2 prescriptions had 50 leftover doses (74% of possible doses). Median worst pain levels reached 1 to 2 out of 7 on POD 4;median average pain on POD 3. Conclusions: The hybrid strategy reduced the number of opioid doses in circulation without compromising the patient's postoperative pain level. Decreasing the number of leftover opioid doses is an important step toward addressing opioid addiction and overdose. References: 1 Magraw CBL, Pham M, Neal T, Kendell B, Reside G, Phillips C, White RP Jr: A multimodal analgesic protocol may reduce opioid use after third molar surgery: A pilot study. Oral Surg Oral Med Oral Path Oral Radiol 126:214, 2018. 2 Pham M, Magraw C, Neal T, Kendell B, Reside G, Phillips C, White R: A Multi-modal Analgesic Protocol reduced opioid use/misuse after 3rd Molar Surgery: An Exploratory Study. Submitted Oral Surg Oral Med Oral Path Oral Radiol March 2019 3 Pham M, Magraw C, Neal T, Kendell B, Reside G, Phillips C, White R: A Multimodal Analgesic Protocol reduced acute pain levels after 3rd molar surgery. In preparation JOMS 4 White RP Jr, Shugars DA, Shafer DM, Laskin DM, Buckley MJ, Phillips C: Recovery after third molar surgery: clinical and health-related quality of life outcomes. J Oral and Maxillofacial Surgery 61:535, 2003. 5 American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 116:248, 2012 6-Savarese JJ, Tabler NG Jr: Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management. J Health Care Risk Manag 37:24, 2017

Avoidable admissions in gynecology oncology patients undergoing minimally invasive hysterectomy (520)

Objectives: To determine the rate and identify factors associated with potentially avoidable admissions following a minimally invasive hysterectomy. Methods: Patients who underwent a minimally invasive hysterectomy for a suspected or known gynecologic malignancy between January 2019 to July 2021 were identified in our institution's prospectively curated quality improvement surgical database. Preoperatively, patients were assessed for planned same-day discharge versus a planned admission. Reasons for those who were admitted despite a planned same-day discharge were characterized as the following: anesthesia-related, comorbid conditions, intraoperative factors, social factors, system issues, and uncontrolled pain. For planned admissions, reasons for admission were categorized as necessary and potentially unavoidable. Descriptive statistics were used to summarize the cohort. Results: A total of 380 patients were identified, of which 267 (70%) patients had a planned same-day discharge, and 113 (30%) had an anticipated admission. Same-day surgery discharge rates increased over time (Figure 1). Two hundred and thirty-five patients (88%) were successfully discharged the same day. Of these patients, 17 (7%) presented to the emergency department (ED) within 30 days, and the re-admission rate in this group was 12% (n=2). Thirty-two patients did not successfully discharge on the same day, and five patients (15%) presented to the ED for evaluation within 30 days. Most unplanned admissions were anesthesia-related (n=15, 47%), followed by system issues (n=7, 22%), such as failure to recognize comorbid conditions in the preoperative period, intraoperative factors (n=5, 16%), postoperative pain (n=3, 9%), and social factors (n=2, 6%). Among the 113 anticipated admissions, 78 (69%) patients were deemed necessary due to multi-factorial comorbid conditions or surgical complexity. However, 35 (31%) patients could have been optimized for same-day discharge;reasons for which included patients with comorbid conditions that could have been optimized preopera- tively, such as poorly controlled diabetes (n=13, 12%), system issues, (n= 8, 7%), social factors (n= 7, 6%), anesthesia-related (n= 4, 4%), and surgical complexity (n=3, 3%). [Formula presented] Conclusions: Most patients were successfully discharged the same day, and of those who were deemed unsuitable for same-day discharge, nearly half could have been optimized for same-day discharge. Unplanned admissions in the anticipated same-day discharge cohort were primarily due to anesthesia-related concerns in the immediate postoperative period and where patient comorbid conditions could have been better optimized in the preoperative period. Recognizing potential areas for improvement and further optimizing same-day discharge will allow hospital systems to continue providing care for gynecologic oncology patients during COVID-19 surges.

Jahrestagung der DGAI 2022

The proceedings contain 73 papers. The topics discussed include: immune phenotypes correlate with the outcome of severe covid-19 infection;erector spinae plane blocks in postoperative pain - a meta-analysis;42 % of women report a desire to receive more treatment - new QUIPS module shows need for improvement of pain therapy during natural delivery;and immunological characterization of COVID-19 endotypes of critically ill patients.

Arteriovenous Malformation of Upper Lip - a short cure for gross deformity

Aim: To evaluate the safety and success of facial artery ligation alone in arteriovenous malformation of upper lip in non-affording patients. Methodology: This prospective study was conducted at Department of Plastic surgery, on 11 consecutive patients with recurrent upper lip arteriovenous malformation who couldn’t afford angioembolization and frequent hospital visits for staged procedures. We did debulking of lesion after facial artery ligation and cosmetic lip correction. Results: Total 11 patients (9 males and 2 females) were included in this study. Majority of patients showed satisfactory results with facial artery ligation alone. One patient lost the follow up. No significant complication was noted in any patient. No recurrence was noted at 6 months and 1 year follow-up. Patient satisfaction rate remained 8.6±0.96 as per VAC. Conclusion: facial artery ligation alone provides an easy and approachable option for arteriovenous malformation where cost affordability for angioemboization and repeated hospital visits are main limitations.

Effectiveness of ketofol versus propofol induction on hemodynamic profiles in adult elective surgical patients: A Randomized Controlled Trial

Background: Most of the time propofol and ketamine have been used as an induction agent in adult surgical patients but propofol may cause cardiorespiratory depression while ketamine increases heart rate and arterial blood pressure. On the other hand, the clinical effects of propofol and ketamine seem to be complementary. Ketofol is most commonly used for procedural sedation hence exploring its effectiveness for induction will be paramount for the clinical care of surgical patients. Objective: This study aims to compare the hemodynamic changes between ketofol and propofol within 30 min after induction of general anesthesia for elective surgical patients. Methodology: A Double-blind Randomized Controlled Trial was done on 62 patients aged between 18 and 65 years and the American Society of Anesthesiologist class I & II those have been allocated randomly into ketofol and propofol groups. A change in systolic blood pressure, mean arterial pressure, and heart rate within 30mins was followed for both groups. After the normal distribution of data was tested analytic statistics were calculated for variables in the study using Mixed ANOVA, Independent samples T-test, and Mann Whitney U test as appropriate, and for categorical data Chi-square test or fisher's exact test was used for analysis. P-value < 0.05 is considered statistically significant with a power of 90%. Results: Both the mean systolic blood pressure and mean arterial pressure were significantly decreased in the propofol group immediately after induction, at 5th minute, 10th minute, and 15th minute compared to the baseline value with a statistically significant value of (p < 0.05). There was a significant increase in mean heart rate in the ketofol group immediately after induction and on the 5th minute after induction compared to the baseline value (p = 0.001 and p = 0.022 respectively). Conclusion and recommendations: We conclude the administration of ketofol (0.75 mg/kg of ketamine and 1.5 mg/kg of propofol) for induction of general anesthesia has better hemodynamic stability than propofol during the first 30 min after induction. We recommend to researchers to do further randomize controlled trials, with invasive blood pressure measurement and multicenter study.

Considerations for Better Management of Postoperative Pain in Light of Chronic Postoperative Pain: A Narrative Review.

Chronic postoperative pain (CPOP) is prevalent, with particularly high rates in breast surgery, thoracotomy, and amputation. As the world emerges from the coronavirus disease 2019 (COVID-19) lockdowns, it is expected that there will be an increase in surgical procedures, elevating the importance of preventing CPOP in the coming years. Risk factors are emerging to better stratify patients at high risk for CPOP. Perioperative analgesia plays an important role in managing acute postoperative pain and in some cases may limit its transition to CPOP. Acute postoperative pain is adaptive, normal, expected, and has a well-defined trajectory, while CPOP is maladaptive and, as a form of chronic pain, is challenging to treat. Good analgesia, early ambulation, and rehabilitation efforts may be helpful in preventing CPOP following certain surgeries. Enhanced Recovery After Surgery (ERAS) protocols present guidance to help promote recovery and prevent CPOP.

Penile Prosthesis Now An In office Procedure: A Single Center Experience In The US

Introduction: Inflatable penile prosthesis (IPP), an implantable device for treatment of ED, historically have always been done in a hospital setting or outpatient setting. These surgeries are now done more frequently around the world as an in-office procedures. With the increase risk of COVID infections and the improvement of IPP technique we began performing this procedure in the office under local and total intravenous anesthesia. Objective: To present the nuances of office based 3 piece penile prosthesis and the outcome data for the feasibility of in-office implants while minimizing complications. Methods: A retrospective chart review was performed on the 10 IPP patients who had surgery in the office based setting in our clinic. The age ranges varied from 34-58 years of age. All pateints who opted for IPP in the office were screened for any and history of pelvic surgery, renal failure, cardiac stents or heart failure. Preoperatively, Antibiotics used were Vancomycin, Amikacin and oral Fluconazole and oral Neurontin for analgesia. All patients had a preoperative COVID nasal swab or had the vaccine prior to surgery. Intraoperatively Vancomycin, Amikacin and Fluconazole were used for irrigation and implant prep. Smaller table sets with stacking sterile field was used with headlights and loupes. IV sedation was used with the assistance of an anesthesiologist who used Propofol for sedation. A propofol bolus was given prior to entering the space of retzius. The patients also received a penile and pudendal block with a mixture of 1% Lidocaine, 0.5% Marcaine and 1mg Solumedrol for post-op pain management. Postoperatively, Neurontin and Tylenol were given PO and Toradol was given IV. Results: Of the 10 patients selected, 0 patients had infections we had even with a drain being in place 2 patients suffered a hematoma. 1 patient suffered urinary retention, resolving after 24 hours. Patients were cleared for device use between 5 to 8 weeks. 1 patient's implant was recalled;however, the patient did not have a desire for re-operation and has the device and works around the valve. The average procedure time was 53.5 minutes. Incision size range was 1.7 cm to 2.5 cm in length.Drains were placed in all patients for 24 to 48 hours with out puts of 90-160cc. Patients were discharged after 90 minutes in recovery phase. Conclusions: Office based penile prosthesis is safe and feasible in the post COVID world. Nuances such was headlights, loupes and adequate block-aid and sterile field efficiency with preloading and stacking are a necessity. With careful patient selection, in-office implantable penile prosthesis implant can be a safe feasible alternative for patients that have severe ED, have gone through alternative therapies, but either cannot afford and or insurance does not cover this procedure. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

The patient perspective on day case arthroplasty

Introduction: Day Case Arthroplasty has been validated as a safe strategy for reducing length of stay for patients undergoing elective arthroplasty. With the ongoing recovery of elective activities following the COVID pandemic and long waiting lists;day case arthroplasty offers a solution for both hospitals and patients. Reducing length of stay will reduce the cost of day case arthroplasty which benefits hospitals, whilst the faster discharge reduces unnecessary exposure to an increased risk of COVID for patients. This study aims to establish the patient perspective on day case arthroplasty to inform the set-up of a patient cantered day case arthroplasty service. Method: Data was collected at routine preoperative assessment clinics via a structured questionnaire which combined both quantitative and qualitative methods. The questionnaire covered patient demographics, issues pertaining to same-day discharge, level of concern related to common problems faced by patients after joint replacement surgery and patient preference for same day discharge versus more traditional rehabilitation methods. Results: The study included 79 patients with 43% preferring same day discharge. Postoperative pain, surgical complications and wound healing were the most significant concerns elicited. Patients who preferred same day discharge were statistically younger. The majority of patients felt that their rehabilitation could be completed at home. Conclusions: The results of this study highlight the demand for day case arthroplasty in this cohort of patients with younger patients preferring same day discharge. Identifying significant concerns will be important to formulate effective perioperative protocols to ensure successful implementation of a patient cantered day case arthroplasty service.

Improving management of women presenting with groin hernias at royal devon and exeter hospital (RD&E)

Aim: Determine the percentage of women with groin hernia undergoing laparoscopic repair at RD&E hospital and if it was offered during clinic visit. Background: The lifetime risk of groin hernia in women is 3-5.8%. The incidence of missed femoral hernia at re-operation after open repair in women is 41%. The HerniaSurge group has recommended laparoscopic repair of all groin hernias in women as it offers opportunity to identify all types of groin hernias and reduces post-operative pain and recurrence. Method: All female patients undergoing groin hernia surgery at RD&E hospital from 1 Feb 2018-31 Jan 2020 were identified. Patients undergoing surgery after this period were not included as the surgical practice was changing due to COVID-19 pandemic. Electronic patient records including clinic letters, operative notes, radiology reports and follow up letters were reviewed. Results: 117 female patients undergoing groin hernia repair were identified. During clinic visit, rationale for laparoscopic surgery was documented only in 29/117 while discussion regarding material risks of surgery was documented in 51/117. Only 41/117 (35%) patients underwent laparoscopic hernia repair. Conclusion and second cycle: The current practice at RD&E requires improvements in terms of documentation of material risks associated with groin hernia repair and offering laparoscopic repair for women with groin hernias. For the next cycle, we aim to present at the local audit meeting and then collect further data to evaluate improvements in practice. We also aim to create a standardised electronic clinic letter and operative note format to bring uniformity of care.

The effect of the disruption caused by the COVID-19 pandemic on the rates of post-tonsillectomy complications after the recovery of services

Aim: In June 2020, and after the first wave of the COVID outbreak has settled, we resumed operating in our trust for elective surgery in three different hospitals. However, it was thought that the number of posttonsillectomy complications had increased. We performed an audit to evaluate the rate of post-tonsillectomy complications in our trust and investigate possible causes. Method: We measured the rates of patients who developed complications post-operatively during the period from June to November 2020 and compared it to the rates in the pre-COVID year and the national rate. Moreover, we scrutinized retrospectively the operative notes of each patient presenting with a post-tonsillectomy complication and identified risk factors. Results: In the study period, we performed 129 tonsillectomies. Of these patients, 14 presented with complications;11of which had bleeding, while 3 had post-operative pain. Two patients needed to return to the theatre to control the bleeding. During the same period in 2019, 28 patients had complications out of a total of 199 patients. The rate of complications in 2020 was 10% which compared favourably with the previous year (14%). The highest number of patients (9/14) was in a hospital which posed a new environment to our surgeons. Dissection by Bipolar diathermy was the most contribute factor for bleeding in most patients (11/14). Conclusions: The disruption caused by the pandemic situation did not influence overall rates of complications. However, the hospital which presented a new operating environment had the highest rate.