Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic.

PURPOSE: Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage. METHODS: A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions. RESULTS: Thirty-seven patients met the highly selective eligibility criteria for "healthy patient, healthy anastomosis." SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores. CONCLUSIONS: In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.

Effect of Stellate Ganglion Block Combined with Lidocaine at Different Concentrations for Preemptive Analgesia on Postoperative Pain Relief and Adverse Reactions of Patients Undergoing Laparoscopic Cholecystectomy.

Objective: To explore the effect of stellate ganglion block (SGB) combined with lidocaine at different concentrations for preemptive analgesia on postoperative pain relief and adverse reactions of patients undergoing laparoscopic cholecystectomy (LC). Methods: Ninety patients undergoing LC in our hospital from June 2019 to June 2020 were selected as the subjects and were randomly divided into group A (30 cases), group B (30 cases), and group C (30 cases), all patients received SGB, and 10 mL of lidocaine at concentrations of 0.25%, 0.5%, and 0.75% was, respectively, administered to patients in groups A, B, and C, so as to compare the analgesic effect, adverse reactions, and clinical indicators among the three groups. Results: At T 1 and T 2, group C obtained obviously lower NRS scores than groups A and B (P < 0.001); compared with groups A and B, group A had obviously higher onset time (P < 0.001) and significantly lower duration (P < 0.001); no obvious differences in the hemodynamic indexes among the groups were observed (P > 0.05); group C obtained obviously higher BCS score than groups A and B; and the total incidence rate of adverse reactions was obviously higher in group C than in groups A and B (P < 0.05). Conclusion: Performing SGB combined with 0.5% lidocaine to patients undergoing LC achieves the optimal analgesic effect; such anesthesia plan can effectively stabilize patients' hemodynamics, present higher safety, and promote the regulation of the body internal environment. Further research will be conducive to establishing a better anesthesia plan for such patients.

Association of Use of Tourniquets During Total Knee Arthroplasty in the Elderly Patients With Post-operative Pain and Return to Function.

Objective: During total knee arthroplasty (TKA), tourniquet may negatively impact post-operative functional recovery. This study aimed at investigating the effects of tourniquet on pain and return to function. Methods: Pubmed, Embase, and Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15th, 2020. Search terms included; total knee arthroplasty, tourniquet, and randomized controlled trial. RCTs evaluating the efficacies of tourniquet during and after operation were selected. Two reviewers independently extracted the data. Effect estimates with 95% CIs were pooled using the random-effects model. Dichotomous data were calculated as relative risks (RR) with 95% confidence intervals (CI). Mean differences (MD) with 95% CI were used to measure the impact of consecutive results. Primary outcomes were the range of motion (ROM) and visual analog scale (VAS) pain scores. Results: Thirty-three RCTs involving a total of 2,393 patients were included in this study. The mean age is 65.58 years old. Compared to no tourniquet group, the use of a tourniquet resulted in suppressed ROM on the 3rd post-operative day [MD, -4.67; (95% CI, -8.00 to -1.35)] and the 1st post-operative month [MD, -3.18; (95% CI, -5.92 to -0.44)]. Pain increased significantly when using tourniquets on the third day after surgery [MD, 0.39; (95% CI, -0.19 to 0.59)]. Moreover, tourniquets can reduce intra-operative blood loss [MD, -127.67; (95% CI, -186.83 to -68.50)], shorter operation time [MD, -3.73; (95% CI, -5.98 to -1.48)], lower transfusion rate [RR, 0.85; (95% CI, 0.73-1.00)], higher superficial wound infection rates RR, 2.43; [(5% CI, 1.04-5.67)] and higher all complication rates [RR, 1.98; (95% CI, 1.22-3.22)]. Conclusion: Moderate certainty evidence shows that the use of a tourniquet was associated with an increased risk of higher superficial wound infection rates and all complication rates. Therefore, the findings did not support the routine use of a tourniquet during TKA.

UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): what does analysis of linked, routinely collected national data sets tell us about mid-late term revision risk after hip replacement? Retrospective cohort study.

OBJECTIVE: To identify patients at risk of mid-late term revision of hip replacement to inform targeted follow-up. DESIGN: Analysis of linked national data sets from primary and secondary care (Clinical Practice Research Datalink (CPRD-GOLD); National Joint Registry (NJR); English Hospital Episode Statistics (HES); Patient-Reported Outcome Measures (PROMs)). PARTICIPANTS: Primary elective total hip replacement (THR) aged≥18. EVENT OF INTEREST: Revision surgery≥5 years (mid-late term) after primary THR. STATISTICAL METHODS: Cox regression modelling to ascertain risk factors of mid-late term revision. HR and 95% CI assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision. RESULTS: NJR-HES-PROMs data were available from 2008 to 2011 on 142 275 THR; mean age 70.0 years and 61.9% female. CPRD GOLD-HES data covered 1995-2011 on 17 047 THR; mean age 68.4 years, 61.8% female. Patients had minimum 5 years postprimary surgery to end 2016. In NJR-HES-PROMS data, there were 3582 (2.5%) revisions, median time-to-revision after primary surgery 1.9 years (range 0.01-8.7), with 598 (0.4%) mid-late term revisions; in CPRD GOLD, 982 (5.8%) revisions, median time-to-revision 5.3 years (range 0-20), with 520 (3.1%) mid-late term revisions.Reduced risk of mid-late term revision was associated with older age at primary surgery (HR: 0.96; 95% CI: 0.95 to 0.96); better 6-month postoperative pain/function scores (HR: 0.35; 95% CI: 0.27 to 0.46); use of ceramic-on-ceramic (HR: 0.73; 95% CI: 0.56 to 0.95) or ceramic-on-polyethylene (HR: 0.76; 95% CI: 0.58 to 1.00) bearing surfaces.Increased risk of mid-late term revision was associated with the use of antidepressants (HR: 1.32; 95% CI: 1.09 to 1.59), glucocorticoid injections (HR: 1.33; 95% CI: 1.06 to 1.67) and femoral head size≥44 mm (HR: 2.56; 95% CI: 1.09 to 6.02)No association of gender, obesity or Index of Multiple Deprivation was observed. CONCLUSION: The risk of mid-late term THR is associated with age at primary surgery, 6-month postoperative pain and function and implant factors. Further work is needed to explore the associations with prescription medications observed in our data.

Clinical outcomes of low-pressure pneumoperitoneum in minimally invasive urological surgery.

The adoption of minimally invasive laparoscopic techniques has revolutionised urological practice. This necessitates a pneumoperitoneum (PNP) and the impact the PNP pressure has on post-operative outcomes is uncertain. During the current COVID-19 era guidance has suggested the utilisation of lower PNP pressures to mitigate the risk of intra-operative viral transmission. Review the current literature regarding the impact of pneumoperitoneum pressure, within the field of urology, on post-operative outcomes. A search of the PubMed, Medline and EMBASE databases was undertaken to identify studies that met the inclusion criteria. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were adhered to. Ten studies, that included both randomised controlled trials and retrospective case series reviews, were identified that met the inclusion criteria. The effect of PNP pressure on outcomes following prostatectomy, live donor nephrectomy, partial nephrectomy and a variety of benign upper tract procedures were discussed. Low pressure PNP appears safe when compared to high pressure PNP, potentially reducing post-operative pain and rates of ileus. When compared to general surgery, there is a lack of quality evidence investigating the impact of PNP pressures on outcomes within urology. Low pressure PNP appears non-inferior to high pressure PNP. More research is required to validate this finding, particularly post-cystectomy and nephrectomy.

Pericapsular nerve group (PENG) block provides improved short-term analgesia compared with the femoral nerve block in hip fracture surgery: a single-center double-blinded randomized comparative trial.

BACKGROUND: The femoral nerve block (FNB) may be used for analgesia in hip fracture surgery. The pericapsular nerve group (PENG) block is a novel regional technique and may provide better pain reduction while preserving motor function, but these blocks have not been directly compared. METHODS: In a single-center double-blinded randomized comparative trial, patients presenting for hip fracture surgery received analgesia with either FNB or PENG block. The primary outcome measure was pain scores (Numeric Rating Scale (NRS) 0 to 10). Secondary outcomes were postoperative quadriceps strength, opiate use, complications, length of hospital stay, and patient-reported outcomes. RESULTS: Sixty patients were randomized and equally allocated between groups. Baseline demographics were similar. Postoperatively in recovery (day 0), the PENG group experienced less pain compared with the FNB group. (In the PENG group, 63% experienced no pain, 27% mild pain, and 10% moderate to severe pain. In comparison, 30% of the FNB group reported no pain, 27% mild pain, and 36% moderate to severe pain; p=0.04). This was assessed using an 11-point Likert NRS. Quadriceps strength was better preserved in the PENG group in the recovery unit (assessed using Oxford muscle strength grading, 60% intact in the PENG group vs none intact in the FNB group; p<0.001) and on day 1 (90% intact vs 50%, respectively; p=0.004). There was no difference in other outcomes. CONCLUSIONS: Patients receiving a PENG block for intraoperative and postoperative analgesia during hip fracture surgery experience less postoperative pain in the recovery room with no difference detected by postoperative day 1. Quadriceps strength was better preserved with the PENG block. Despite the short-term analgesic benefit and improved quadriceps strength, there were no differences detected in the quality of recovery.

Comparison of the short-term outcomes of using DST and PPH staplers in the treatment of grade III and IV hemorrhoids.

Stapled hemorrhoidopexy has a few advantages such as less postoperative pain and faster recovery compared with conventional hemorrhoidectomy. There are two major devices used for stapled hemorrhoidopexy, PPH stapler (Ethicon EndoSurgery) and DST stapler (Covidien). This study was conducted to investigate the postoperative outcomes among patients with grade III and IV hemorrhoids who underwent hemorrhoidopexy with either of these two devices. A total of 242 consecutive patients underwent stapled hemorrhoidopexy with either PPH stapler (110 patients) or DST stapler (132 patients) at a single center in 2017. We performed a retrospective case-control study to compare the short-term postoperative outcomes and the complications between these two groups. After matching the cases in terms of age, gender, and the grade of hemorrhoids, there were 100 patients in each group (PPH versus DST). There were no significant differences in the postoperative visual analog scale (VAS) score and analgesic usage. Among complications, the incidence of anorectal stricture was significantly higher in the DST group (p = 0.02). Evaluation of the mucosal specimen showed that the total surface area, the muscle/mucosa ratio and the surface area of the muscle were also significantly higher in the DST group (p = 0.03). Further analysis of the DST group demonstrated that patients with anorectal stricture after surgery are younger than patients without anorectal stricture, and higher muscle/mucosa ratio (p = 0.03) and a higher surface area of the muscle (p = 0.03) also measured in the surgical specimen. The two devices provide similar outcomes of postoperative recovery. Patients who underwent DST stapled hemorrhoidopexy had a higher incidence rate of stricture, larger area of muscle excision, and higher muscle/mucosa ratio in the surgical specimen. Further investigation is warranted for a better understanding of the correlation between muscle excision and anorectal stricture.

Efficacy of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain, Pulmonary Function, and Opioid Consumption Following Cardiothoracic Procedures: A Systematic Review.

OBJECTIVE: Transcutaneous electrical nerve stimulation (TENS) is a minimally invasive method for treating pain. In the most recent review published in 2012, TENS was associated with increased pain relief following cardiothoracic surgery when compared to standard multimodal analgesia. The purpose of this systematic review and meta-analysis is to determine if adding TENS to current pain management practices decreases pain and analgesic use and improves pulmonary function for postcardiothoracic surgery patients. MATERIALS AND METHODS: CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, PubMed, and ClinicalTrials.gov were searched using specific keywords. Covidence was used to screen, select studies, and extract data by two independent reviewers. The Cochrane Risk of Bias tool assessed risk of bias. Visual analog scale (VAS) and pulmonary function data were exported for meta-analysis using a random effects model. RESULTS: The search yielded 38 articles. Eight randomized controlled trials met inclusion criteria for the literature review. Five studies were included in the meta-analysis of pain at 24, 48, and 72 hours postoperatively. Data were analyzed using the standard mean difference (SMD). TENS had a significant impact on VAS at rest (-0.76 SMD [95% confidence interval, CI = -1.06 to -0.49], p < 0.00001) and with coughing (-1.11 SMD [95% CI = -1.64 to -0.56], p < 0.0001). FEV1 improved after 72 hours (1.00 SMD [95% CI = 0.66-1.35], p < 0.00001), as did forced vital capacity (1.16 SMD [95% CI = 0.23-2.10], p = 0.01). CONCLUSION: The addition of TENS therapy to multimodal analgesia significantly decreases pain following cardiothoracic surgery, increases the recovery of pulmonary function, and decreases the use of analgesics.

Regional anesthesia educational material utilization varies by World Bank income category: A mobile health application data study.

INTRODUCTION: Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level. METHODS: We retrospectively analyzed data collected from the free Android app "Anesthesiologist" from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block). RESULTS: Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic. CONCLUSION: The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.

Laparoscopic Gastrointestinal Surgery During COVID-19 Pandemic: Single-Center Experience.

Background: COVID-19 era has put laparoscopic surgery a risk procedure because of theoretical risk of viral transmission of COVID-19. However, safe evacuation of stagnant air during laparoscopic surgery is also necessary to safeguard health care warriors. Methods: We are reporting experience of 24 laparoscopic surgeries using a closed smoke evacuation/filtration system using a ultra low-particulate air (ULPA) filtration capability (ConMed AirSeal® System) at a single center between March 22, 2020, and May 30, 2020. All surgeries were either urgent or emergency in nature. Results: Totally, 17 males and 7 females who required urgent surgery. Most common indication for laparoscopic intervention was acute cholecystitis and complications related to acute cholecystitis. Owing to the closed smoke evacuation system, low intra-abdominal pressure was maintained during all surgeries. Of all procedures, only 0.8 time per procedure, the laparoscope taken out for cleaning. Mean time for completion of surgery was 58 minutes. Compliance of surgical staff was high due to the deemed safe smoke evacuation system. Mean of postoperative pain score was low. Mean hospital stay was 4.9 days. Conclusions: We propose to use a closed smoke evacuation/filtration system with ULPA filtration capability or similar devices in each minimally invasive surgery to reduce risks of transmission as minute as possible until we have enough knowledge about the pattern of disease transmission.