The Impact of Missing Postoperative Longitudinal Pain Data on Study Results Investigating Analgesia from Transversus Abdominis Plane Block on Postoperative Day One Following Abdominal Surgery: A Single-Center Retrospective Chart Review.

Background: The aims of this study are to analyze the association between the number of recorded pain scores and baseline pain following surgery, analgesia technique, and patient demographics, as well as the substitution of missing data with the results from mean substitution, last observation carried forward, regression imputation, multiple imputation, and mixed models. Methods: This retrospective chart review was approved by the Institutional Review Board (IRB). The following data were collected: patient demographics (age, gender, body mass index (BMI), race, and ethnicity); surgery type and date; analgesia with or without transversus abdominis plane (TAP) block; as well as the time, date, and value for all postoperative pain scores on the first postoperative day (POD). The following null hypotheses were tested: (1) the number of pain recordings will be independent of TAP block analgesia, baseline pain on POD 1, and patient demographics; and (2) there will be no significant differences in pain scores with and without TAP block analgesia following complete case analysis, mean substitution, last observation carried forward, regression imputation, multiple imputation, and mixed models. Results: This study analyzed 486 patients including 2562 recorded pain scores. An increase in age by one year is, on average, associated with a 0.04 (95% confidence interval (CI) -0.060 to -0.025) decrease in the number of pain scores recorded (p < 0.001). Black race is associated with 0.763 less pain scores, on average (95% CI -1.49 to -0.039) and this value is statistically significant (p = 0.039). All datasets with substituted values for missing data yield lower pain scores for patients who did not receive TAP block. Significant differences in recorded pain scores are only noted for scores recorded between 0400 and 0759 and 1600-1959 in mixed models. Conclusion: Discrepancies in pain score recordings among patients are associated with age and black race. When these discrepancies are addressed with statistical methods, clinically significant differences are appreciated.

The problem with dichotomizing quality improvement measures.

The Anesthesia Quality Institute (AQI) promotes improvements in clinical care outcomes by managing data entered in the National Anesthesia Clinical Outcomes Registry (NACOR). Each case included in NACOR is classified as "performance met" or "performance not met" and expressed as a percentage for a length of time. The clarity associated with this binary classification is associated with limitations on data analysis and presentations that may not be optimal guides to evaluate the quality of care. High compliance benchmarks present another obstacle for evaluating quality. Traditional approaches for interpreting statistical process control (SPC) charts depend on data points above and below a center line, which may not provide adequate characterizations of a QI process with a low failure rate, or few possible data points below the center line. This article demonstrates the limitations associated with the use of binary datasets to evaluate the quality of care at an individual organization with QI measures, describes a method for characterizing binary data with continuous variables and presents a solution to analyze rare QI events using g charts.

Simultaneous comparison of depth of sedation performance between SedLine and BIS during general anesthesia using custom passive interface hardware: study protocol for a prospective, non-blinded, non-randomized trial.

BACKGROUND: Intraoperative brain function monitoring with processed electroencephalogram (EEG) indices, such as the bispectral index (BIS) and patient state index (PSI), may improve characterization of the depth of sedation or anesthesia when compared to conventional physiologic monitors, such as heart rate and blood pressure. However, the clinical assessment of anesthetic depth may not always agree with available processed EEG indices. To concurrently compare the performance of BIS and SedLine monitors, we present a data collection system using shared individual generic sensors connected to a custom-built passive interface box. METHODS: This prospective, non-blinded, non-randomized study will enroll 100 adult American Society of Anesthesiologists (ASA) class I-III patients presenting for elective procedures requiring general anesthesia. BIS and SedLine electrodes will be placed preoperatively according to manufacturer recommendations and their respective indices tracked throughout anesthesia induction, maintenance and emergence. The concordance between processed EEG indices and clinical assessments of anesthesia depth will be analyzed with chi-square and kappa statistic. DISCUSSION: Prior studies comparing brain function monitoring devices have applied both sensors on the forehead of study subjects simultaneously. With limited space and common sensor locations between devices, it is not possible to place both commercial sensor arrays according to the manufacturer's recommendations, thus compromising the validity of these comparisons. This trial utilizes a custom interface allowing signals from sensors to be shared between BIS and SedLine monitors to provide an accurate comparison. Our results will also characterize the degree of agreement between processed EEG indices and clinical assessments of anesthetic depth as determined by the anesthesiologists' interpretations of acute changes in blood pressure and heart rate as well as the administration, or change to the continuous delivery, of medications at these timepoints. Patient factors (such as burst suppression state or low power EEG conditions from aging brain), surgical conditions (such as use of electrocautery), artifacts (such as electromyography), and anesthesia medications and doses (such as end-tidal concentration of volatile anesthetic or hypnotic infusion dose) that lead to lack of agreement will be explored as well. TRIAL REGISTRATION: Clinical Trials ( ClinicalTrials.gov ), NCT03865316 . Registered on 4 February 2019 - retrospectively registered. SPONSOR: Masimo Corporation.

Interfascial Plane Blocks and Laparoscopic Abdominal Surgery: A Narrative Review.

Laparoscopic abdominal surgery has become a mainstay of modern surgical practice. Postoperative analgesia is an integral component of recovery following laparoscopic abdominal surgery and may be improved by regional anesthesia or intravenous lidocaine infusion. There is inconsistent evidence supporting the use of interfascial plane blocks, such as transversus abdominis plane (TAP) blocks, for patients undergoing laparoscopic abdominal surgery as evidenced by variable patterns of local anesthetic spread and conflicting results from studies comparing TAP blocks to local anesthetic infiltration of laparoscopic port sites and multimodal analgesia. Quadratus lumborum (QL) and erector spinae plane (ESP) blocks may provide greater areas of somatic analgesia as well as visceral analgesia, which may translate to more significant clinical benefits. Aside from the locations of the surgical incisions, it is unclear what other factors should be considered when choosing one regional technique over another or deciding to infuse lidocaine intravenously. We reviewed the current literature in attempt to clarify the roles of various regional anesthesia techniques for patients undergoing laparoscopic abdominal surgery and present one possible approach to evaluating postoperative pain.

Perioperative Dexmedetomidine for outpatient cataract surgery: a systematic review.

BACKGROUND: Cataract surgery is one of the most common procedures performed worldwide in the elderly. Various medications can provide effective anesthesia and analgesia for cataract surgery, but undesirable side effects limit the utility of each medication or combination of medications. Dexmedetomidine may serve as an anesthesia adjunct for outpatient cataract surgery in the elderly. METHODS: Searches were conducted in Cochrane, Embase, and PubMed for randomized clinical trials investigating the use of dexmedetomidine in adult patients undergoing outpatient, or ambulatory, cataract surgery with sedation and topical or peribulbar block. Ninety-nine publications were identified, of which 15 trials satisfied the inclusion criteria. A total of 914 patients were included in this review. The following data were collected: American Society of Anesthesiologists' (ASA) physical status and age of study patients; method of blinding and randomization; medication doses and routes of administration; and intraoperative levels of sedation. We also recorded statistically significant differences between dexmedetomidine and other study medications or placebo with respect to the following outcomes: hemodynamic and respiratory parameters; pain; sedation; post-operative nausea and vomiting (PONV); discharge from post-anesthesia care unit (PACU) or recovery times; patient satisfaction; surgeon satisfaction; and effects on intraocular pressure (IOP). RESULTS: Hypotension with or without bradycardia was reported following bolus doses of dexmedetomidine ranging from 0.5-1.0 mcg/kg with or without a continuous dexmedetomidine infusion. Delayed PACU discharge times were associated with the use of dexmedetomidine, but no clear association was identified between delayed recovery and higher levels of intraoperative sedation. Better analgesia and higher patient satisfaction were commonly reported with dexmedetomidine as well as reductions in IOP. CONCLUSIONS: Overall, this review demonstrates better analgesia, higher patient satisfaction, and reduced IOP with dexmedetomidine for outpatient cataract surgery when compared to traditional sedatives, hypnotics, and opioids. These benefits of dexmedetomidine, however, must be weighed against relative cardiovascular depression and delayed PACU discharge or recovery times. Therefore, the utility of dexmedetomidine for outpatient cataract surgery should be considered on a patient-by-patient basis.

Conservative Management of Neuropathic Pain in a Patient With Pancoast-Tobias Syndrome: A Case Report.

Pancoast-Tobias syndrome characterizes the signs and symptoms of a superior pulmonary sulcus tumor, and includes arm and shoulder pain, atrophy of intrinsic hand muscles, and ipsilateral Horner syndrome. The rarity and overall poor prognosis of patients with superior pulmonary sulcus tumors associated with Pancoast-Tobias syndrome has led to few reports detailing pain management strategies with adjunctive therapies, such as continuous infusions of ketamine and lidocaine, chemotherapy, radiation, and multimodal oral medication regimens. This case highlights the diagnosis and treatment of pain in a patient with Pancoast-Tobias syndrome.

Assessing the Agreement Between Radiologic and Clinical Measurements of Lumbar and Cervical Epidural Depths in Patients Undergoing Prone Interlaminar Epidural Steroid Injection.

BACKGROUND: Fluoroscopy-guided epidural steroid injection (ESI) commonly is performed to treat radicular pain yet can lead to adverse events if the needle is not advanced with precision. Accurate preoperative assessment of the distance from the skin to the epidural space holds the potential for reducing the risks of adverse effects from ESI. It was hypothesized that the distance from the skin to the epidural space as measured on preoperative magnetic resonance imaging (MRI) would agree with the distance traveled by a Tuohy needle to reach the epidural space during midline, interlaminar ESI. This study compared the final needle depth measurement at the point of loss of resistance (LOR) from cervical or lumbar ESI to the distance from the skin to the anterior and posterior borders of the epidural space on the associated cervical and lumbar preoperative MRI. METHODS: This retrospective chart review analyzed the procedure notes, MRI, and demographic data of patients who received a prone, interlaminar ESI at an outpatient chronic pain clinic between June 1, 2013, and June 1, 2015. The following data were collected: body mass index (BMI), age, sex, intervertebral level of the ESI, and LOR depth. We then measured the distance from the skin surface to the anterior border of the ligamentum flavum (ligamentum flavum depth [LFD]) and dura (dura depth [DD]) on MRI. A total of 335 patients were categorized into the following patient subgroups: age ≥65 years, age <65 years, BMI ≥30 kg/m (obese), BMI <30 kg/m (nonobese), male, and female. Secondary analyses were then performed to compare the agreement between LOR depth and DD with that between LOR depth and LFD within each patient subgroup. Intraclass correlation coefficient (ICC) and Bland-Altman plot were used to assess the agreement between DD or LFD and LOR depth. RESULTS: Data from 335 ESIs were analyzed, including 147 cervical ESIs and 188 lumbar ESIs. Estimated ICC values for the agreement between LOR depth and LFD for all lumbar and cervical measurements were 0.88 (95% confidence interval [CI], 0.85-0.91) and 0.72 (95% CI, 0.64-0.79), respectively. Estimated ICC values for the agreement between LOR depth and DD for all lumbar and cervical measurements were 0.86 (95% CI, 0.82-0.89) and 0.69 (95% CI, 0.60-0.77), respectively. CONCLUSIONS: This study assessed the agreement between MRI-derived measurements of epidural depth and those determined clinically. MRI-derived measurements from the skin to the anterior border of the ligamentum flavum, which represents the most posterior aspect of the epidural space, revealed stronger agreement with LOR depths than did measurements to the dura or the most anterior aspect of the epidural space. These results require further analysis and refinement before supporting clinical application.