The impact of health literacy on shared decision making before elective surgery: a propensity matched case control analysis.

BACKGROUND: Poor health literacy affects over 90 million Americans. The primary aim of the study was to evaluate a possible association between health literacy and decision conflict in surgical patients. METHODS: Patients undergoing a diverse number of elective surgeries were enrolled in the study. Health literacy was measured using the Newest Vital Sign instrument and decision conflict using the low literacy version of the Decision Conflict Scale. RESULTS: 200 patients undergoing elective surgeries were included in the study. Patients who had greater health literacy scores had lower decision conflict scores, Spearman's rho = - 0.43, P < 0.001. Following propensity-score matching to account for potential covariates, the median (IQR) decision conflict score was 20 (0 to 40) for patients with poor health literacy compared to 0 (0 to 5) for patients with adequate literacy, P < 0.001. CONCLUSIONS: Poor health literacy is associated with greater decision conflict in patients undergoing elective surgical procedures. Strategies should be implemented to minimize decision conflict in poor health literacy patients undergoing elective surgical procedures.

The Effect of Intraoperative Systemic Lidocaine on Postoperative Persistent Pain Using Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials Criteria Assessment Following Breast Cancer Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: To compare the incidence in postsurgical persistent pain following breast cancer surgery in women receiving intravenous lidocaine compared to saline using validated pain instruments in accordance with the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. METHODS: The study was a randomized, double-blinded, placebo-controlled, clinical trial. Subjects were randomized into Group 1 (1.5 mg/kg bolus of intravenous lidocaine followed by a 2 mg/kg/hour infusion) or Group 2 (normal saline at the same bolus and infusion rate). Patients were evaluated at 3 and 6 months for the presence of chronic persistent postsurgical pain. RESULTS: One hundred forty-eight patients were included in the study analysis. There were no differences in quality of recovery, pain burden, or opioid consumption between groups at 24 hours. Pain (yes/no) at 6 months attributed to surgery was reported in 29% of Group 2 vs. 13% of Group 1 patients (P = 0.04); however, only 3 subjects (5%) in Group 1 and 2 subjects (3%) in Group 2 met IMMPACT criteria for persistent postoperative pain (P = 0.99). DISCUSSION: Perioperative infusion of lidocaine has been reported to decrease the incidence of postsurgical pain at 3 and 6 months following mastectomy using dichotomous (yes/no) scoring. Although intravenous lidocaine reduced the reported incidence of pain at rest at 6 months, pain with activity, pain qualities, and the physical or emotional impact of the pain were unaffected. Future studies evaluating postsurgical persistent pain should adhere to the IMMPACT recommendations in order to more accurately describe the effect of an intervention on persistent pain.

Single dose systemic acetaminophen to improve patient reported quality of recovery after ambulatory segmental mastectomy: A prospective, randomized, double-blinded, placebo controlled, clinical trial.

Few systemic drug interventions are efficacious to improve patient reported quality of recovery after ambulatory surgery. We aimed to evaluate whether a single dose systemic acetaminophen improve quality of recovery in female patients undergoing ambulatory breast surgery. We hypothesized that patients receiving a single dose systemic acetaminophen at the end of the surgical procedure would have a better global quality of postsurgical recovery compared to the ones receiving saline. The study was a prospective randomized double blinded, placebo controlled, clinical trial. Healthy female subjects were randomized to receive 1 g single dose systemic acetaminophen at the end of the surgery or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test. The association between opioid consumption and quality of recovery was evaluated using Spearman rho. P < .05 was used to reject the null hypothesis for the primary outcome. Seventy subjects were randomized and sixty-five completed the study. Patients' baseline characteristics and surgical factors were similar between the study groups. There was a clinically significant difference in the global QoR-40 scores between the acetaminophen and the saline groups, median (IQR) of 189 (183 to 194) and 183 (175 to 190), respectively, P = .01. In addition, there was an inverse relationship (Spearman's rho= -0.33) between oral opioid consumption at home (oral morphine equivalents) and 24 hour postoperative quality of recovery, P = .007. A single dose of systemic acetaminophen improves patient reported quality of recovery after ambulatory breast surgery. The use of systemic acetaminophen is an efficacious strategy to improve patient perceived quality of postsurgical recovery and analgesic outcomes after hospital discharge for ambulatory breast surgery.

The effect of sevoflurane compared to propofol maintenance on post-surgical quality of recovery in patients undergoing an ambulatory gynecological surgery: A prospective, randomized, double-blinded, controlled, clinical trial.

OBJECTIVE: The main objective of the current investigation was to evaluate the effect of propofol used as anesthetic maintenance compared to sevoflurane on global post-surgical quality of recovery in female patients undergoing ambulatory gynecological surgery. DESIGN: The study was a prospective randomized double blinded, controlled, clinical trial. INTERVENTIONS: Healthy female subjects were randomized to receive propofol or sevoflurane as anesthetic maintenance. MEASUREMENTS: The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24h after surgery. Other data collected included opioid consumption, pain scores and time to hospital discharge. P<0.05 was used to reject the null hypothesis for the primary outcome. MAIN RESULTS: Ninety subjects were randomized and sixty seven completed the study. Patient's baseline characteristics and surgical factors were not different between study groups. There was not a clinically significant difference in the global QoR-40 scores between the sevoflurane and the propofol groups, median (IQR) of 175 (163 to 181) and 176 (163 to 184), respectively, P=0.97. There was an inverse relationship (ρ=-0.42) between the opioid consumption in PACU (IV morphine equivalents) and 24h postoperative quality of recovery (P<0.001) and an inverse relationship (ρ=-0.48) between the oral opioid consumption at home (oral morphine equivalents) and 24h postoperative quality of recovery, P<0.001. CONCLUSIONS: Our current results do not support the use of total intravenous anesthesia as an efficacious strategy to improve global quality of recovery after ambulatory surgery. Opioid consumption in the PACU is an earlier surrogate that can be utilized to identify ambulatory patients with a high likelihood to develop poor global quality of recovery and who may benefit from more efficacious strategies to improve global quality of recovery. TRIAL REGISTRATION: ClinicalTrial.gov; url: http://www.clinicaltrials.gov; registration identified: NCT 01755234.

Dose-ranging effect of systemic diphenhydramine on postoperative quality of recovery after ambulatory laparoscopic surgery: a randomized, placebo-controlled, double-blinded, clinical trial.

STUDY OBJECTIVE: Diphenhydramine is an antihistamine with previously demonstrated analgesic and antiemetic properties. However, it is unknown if the beneficial perioperative properties of diphenhydramine can translate to a better quality of postsurgical recovery. The main objective of the current investigation was to investigate dose-ranging effects of diphenhydramine on quality of recovery after surgery. SETTING: Tertiary hospital in the United States. DESIGN: A prospective, randomized, double-blind trial. INTERVENTION: Saline, diphenhydramine 25 >mg, or diphenhydramine 50 mg given intravenously before induction. MEASUREMENTS: The primary outcome was global Quality of Recovery-40 at 24hours. Postoperative pain, nausea, opioid consumption, and discharge time were also evaluated. MAIN RESULTS: Ninety subjects were randomized, and 75 completed the study. The median (interquartile range) Quality of Recovery-40 scores were not different among study groups: 164 (151-189), 169 (159-181), and 172 (157-185) for the saline, 25-mg diphenhydramine, and 50-mg diphenhydramine groups, respectively (P=.74). Postoperative nausea was decreased in the 50-mg group, 3 of 24 (12.5%), compared with the saline group, 12 of 27 (44%), P=.01. There was an inverse linear association between postoperative opioid consumption and quality of recovery (R(2)=0.37, P<.001). CONCLUSIONS: Diphenhydramine does not provide dose-ranging improvements on postoperative quality of recovery after ambulatory laparoscopic gynecologic surgery. Our results support a recent concept that not all postoperative nausea and vomiting symptoms are clinically important. Future studies evaluating postoperative nausea and vomiting should include patient-centered outcomes to validate the clinical importance of the examined interventions.

Perioperative Dexamethasone and the Development of Chronic Postmastectomy Pain: A Single-Center Observational Cohort Study.

BACKGROUND AND OBJECTIVES: Perioperative modulation of the surgical inflammatory response has been hypothesized as a viable pharmacological preventive target for the development of chronic pain after surgery. The objective of the current investigation was to evaluate an association between intravenous dexamethasone 4 to 20 mg on the day of surgery with self-reported pain in the breast or axilla 3 months or more after mastectomy. METHODS: The study was a secondary data analysis of a prospective cohort investigation. Subjects who have undergone mastectomy surgery were evaluated at least 3 months after the surgical procedure for the presence of chronic postsurgical pain using validated pain questionnaires. Binary logistic regression analysis was used to determine the odds of development of chronic postsurgical pain in subjects who did and did not receive perioperative dexamethasone. RESULTS: Three hundred ten patients were included in the study. Fifty-two patients (17%) met the IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) criteria for chronic pain in the breast and/or axillary region. Two hundred eleven (68%) of 310 subjects received perioperative dexamethasone on doses varying from 4 to 20 mg. The incidence of chronic pain in the mastectomy group who received perioperative dexamethasone was not different, 15 (15.2%) of 84 compared with 37 (17.5%) of 211 in the group who did not receive perioperative dexamethasone, difference -2% (95% confidence interval, -10 to 7; P = 0.75). CONCLUSIONS: Perioperative dexamethasone is not associated with a reduction in the incidence and/or severity of chronic postmastectomy pain. In addition, we did not detect a dose-response effect of dexamethasone on the incidence of chronic postsurgical pain.

Reliability and validity of assessing subspecialty level of faculty anesthesiologists' supervision of anesthesiology residents.

BACKGROUND: Supervision of anesthesiology residents is a major responsibility of faculty (academic) anesthesiologists. Supervision can be evaluated daily for individual anesthesiologists using a 9-question instrument. Faculty anesthesiologists with lesser individual scores contribute to lesser departmental (global) scores. Low (<3, "frequent") department-wide evaluations of supervision are associated with more mistakes with negative consequences to patients. With the long-term aim for residency programs to be evaluated partly based on the quality of their resident supervision, we assessed the 9-item instrument's reliability and validity when used to compare anesthesia programs' rotations nationwide. METHODS: One thousand five hundred residents in the American Society of Anesthesiologists' directory of anesthesia trainees were randomly selected to be participants. Residents were contacted via e-mail and requested to complete a Web-based survey. Nonrespondents were mailed a paper version of the survey. RESULTS: Internal consistency of the supervision scale was excellent, with Cronbach's α = 0.909 (95% CI, 0.896-0.922, n = 641 respondents). Discriminant validity was found based on absence of rank correlation of supervision score with characteristics of the respondents and programs (all P > 0.10): age, hours worked per week, female, year of anesthesia training, weeks in the current rotation, sequence of survey response, size of residency class, and number of survey respondents from the current rotation and program. Convergent validity was found based on significant positive correlation between supervision score and variables related to safety culture (all P < 0.0001): "Overall perceptions of patient safety," "Teamwork within units," "Nonpunitive response to errors," "Handoffs and transitions," "Feedback and communication about error," "Communication openness," and rotation's "overall grade on patient safety." Convergent validity was found also based on significant negative correlation with variables related to the individual resident's burnout (all P < 0.0001): "I feel burnout from my work," "I have become more callous toward people since I took this job," and numbers of "errors with potential negative consequences to patients [that you have] made and/or witnessed." Usefulness was shown by supervision being predicted by the same 1 variable for each of 3 regression tree criteria: "Teamwork within [the rotation]" (e.g., "When one area in this rotation gets busy, others help out"). CONCLUSIONS: Evaluation of the overall quality of supervision of residents by faculty anesthesiologists depends on the reliability and validity of the instrument. Our results show that the 9-item de Oliveira Filho et al. supervision scale can be applied for overall (department, rotation) assessment of anesthesia training programs.

Thermal quantitative sensory testing to predict postoperative pain outcomes following gynecologic surgery.

OBJECTIVE: To evaluate the relationship of preoperative thermal quantitative sensory testing (QST) values with postoperative pain and opiate consumption in opiate-naïve patients following gynecologic surgery. DESIGN: Single blind observational study. SETTINGS: Surgical center of an academic medical center. METHODS: QST was performed preoperatively on 124 opioid-naïve patients. Pain outcomes were assessed on arrival to the post-anesthesia care unit and at 6 hourly intervals for 24 hours. Subjects were reclassified to three groups: Group 1 had a heat pain threshold above and a cold pain threshold below the median; Group 2 had either a heat pain threshold below or a cold pain threshold above the median; Group 3 had a heat pain threshold below and a cold pain threshold above the median. The primary outcome measure was the 24-hour morphine consumption. RESULTS: One hundred twenty subjects were evaluated. Median (interquartile range) warm and cold pain thresholds were 44.8 (42.4-46.9) °C and 10.5 (3.2-19.0) °C, respectively. Heat pain thresholds demonstrated a negative (rho = -0.23, P = 0.01) and cold thresholds a positive correlation (rho = 0.21, P = 0.02) with 24-hour morphine consumption. Median morphine consumption was 19 (2-33) mg (P = 0.004) equivalents greater in subjects (N = 46) with heat pain thresholds <45 °C and cold pain thresholds >10 °C than subjects with heat pain thresholds >45 °C and cold pain thresholds <10 °C. DISCUSSION: Reduced tolerance to both heat and cold thermal pain stimulus was associated with increased postoperative analgesic requirements. Combined responses to multiple pain modalities may be more useful than a single stimulus paradigm.

Lack of association between breast reconstructive surgery and the development of chronic pain after mastectomy: a propensity matched retrospective cohort analysis.

OBJECTIVES: To compare if mastectomy with reconstructive surgery had greater incidence of chronic pain compared to mastectomy surgery alone. MATERIALS AND METHODS: The study was a retrospective cohort. Patients who underwent mastectomies with and without reconstruction responded to the modified short form Brief Pain Inventory and the short form McGill pain questionnaire to identify and characterize pain at least 6 months after the surgical procedure. Propensity matching analysis was used to control for covariates differences in the study groups. RESULTS: 310 subjects were included and 132 patients (43%) reported the presence of chronic pain. After propensity score matching to adjust for covariate imbalances, the incidence of chronic pain in the mastectomy group who had additional surgery for breast reconstruction was not different compared to the group who had mastectomy surgery alone, 26 out of 68 (38%) and 27 out of 68 (39%), respectively P = 1.0. Among patients who had chronic pain, breast reconstruction did not increase the intensity of worst pain in the last 24 h, median (IQR) of 2 (1-5) compared to 4 (1-5) in the no reconstruction group, P = 0.41. Type of reconstruction (breast implants vs. flap tissue) did not result in greater incidence and/or intensity of chronic pain. CONCLUSIONS: Breast reconstruction after mastectomy does not result in a greater incidence of chronic pain compared to mastectomy alone. Female patients undergoing breast cancer surgery should not incorporate chronic pain in their decision to undergo reconstructive surgery after mastectomy.

Systemic magnesium to improve quality of post-surgical recovery in outpatient segmental mastectomy: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: It remains to be determined if perioperative systemic magnesium can improve postoperative quality of recovery of patients undergoing ambulatory procedures. The main objective of the current investigation was to evaluate the effect of systemic magnesium on postoperative quality of recovery in patients undergoing outpatient segmental mastectomies. METHODS: The study was a prospective randomized, double-blind, placebo-controlled, clinical trial. Female subjects were randomized to receive intravenous magnesium (MgSO4 50mg/kg in 100 mL of normal saline over 15 min before anesthesia induction, followed by an infusion of 15 mg/kg/hour) or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. RESULTS: 50 subjects were recruited and 46 completed the study. Patients in the magnesium group had better global Quality of Recovery scores compared with the saline group, with a median difference of 24 (99% CI, 3 to 33), P<0.001. After discharge from hospital, subjects in the magnesium group required less oral opioids, median (IQR) of 10 (0 to 20) (oral milligrams of morphine equivalents) than the saline group, 30 (20 to 40) (P<0.001). The postoperative systemic magnesium concentrations were substantially higher in the magnesium group, 1.25 ± 0.28 mmol/L compared to control, 0.71 ± 0.11 mmol/L, P<0.0001. Simple linear regression demonstrated a direct linear relationship between the postoperative systemic magnesium concentrations and 24 hour postoperative quality of recovery scores (P = 0.004), and also an inverse relationship with pain burden in the postoperative care unit (P = 0.01). CONCLUSIONS: Systemic magnesium improves postoperative quality of recovery in patients undergoing outpatient segmental mastectomy. Systemic magnesium is a safe, inexpensive, efficacious strategy to improve quality of recovery after ambulatory surgery.