Oral versus intravenous acetaminophen for perioperative pain management in adult patients undergoing non-cardiac surgery: A quantile segmented regression analysis.

STUDY OBJECTIVE: Determine whether preferential use of perioperative enteral acetaminophen is associated with changes in perioperative pain, narcotic administration, or time to meeting criteria for post anesthesia care unit (PACU) discharge, compared to preferential parenteral administration. DESIGN: Retrospective Cohort with quantile segmented regression analysis. Groups determined by date of surgery, one year pre-initiative and one year post-initiative. SETTING: Operating room and PACU of a tertiary academic medical center. PATIENTS: Adult (age > 18 years), ASA status 1-5, non-pregnant patients undergoing non-cardiac surgery of less than six hours duration admitted to the PACU postoperatively. INTERVENTIONS: A multidisciplinary initiative to preferentially utilize enteral over parenteral acetaminophen. MEASUREMENTS: The primary outcome was narcotic consumption in the PACU. Secondary outcomes were intraoperative narcotic administration, pain score on PACU admission and discharge, and time to meeting criteria for PACU discharge. RESULTS: 24,701 patients were included in the analysis; 12,379 had surgery prior to the initiative and 12,322 after. Enteral acetaminophen administration increased preoperatively from 13.49% to 26.84%, and postoperatively from 43.16% to 51.45%, while intraoperative parenteral APAP use dropped from 43.23% to 6.81%. Quantile Segmented regression analysis after adjusting for period (pre versus postintervention), day, age, gender, inpatient status, and ASA class demonstrated a decrease in adjusted median perioperative acetaminophen dose (-175 mg P < 0.001), with no significant difference in level change of intraoperative or PACU narcotic administration. There was no significant difference in median time to meet criteria for PACU discharge, though there was a significant change in the slope, (-0.36, p = 0.007.) Median pain scores measured on a standard 0-10 numeric rating scale at PACU admission did not change, while median pain scores at PACU discharge decreased slightly (-0.24 p < 0.001). There was no change in the probability of PONV. CONCLUSION: In adult patients undergoing non-cardiac surgery of <6 h duration, preferential use of enteral rather than parenteral acetaminophen is associated with non-inferior outcomes in narcotic requirements, pain scores, time to PACU discharge, and probability of PONV when compared with routine parenteral administration. Further studies are needed to validate these findings.

Diagnosis and Treatment of New-Onset Perioperative Atrial Fibrillation.

This article reviews medical and surgical risk factors for developing atrial fibrillation (AF), the most common sustained dysrhythmia in the United States. Evidence for assessment and management of patients with AF, including AF newly identified in the preoperative clinic, immediately preoperatively, intraoperatively, and unstable AF, is presented. A stepwise approach to guide anesthetic decision-making in the assessment of newly identified preoperative AF is proposed. Anesthetic considerations, including the potential impacts of anesthetic and vasopressor selection, and current evidence related to rate control and rhythm control via pharmacologic or electrical cardioversion as well as anticoagulation strategies are discussed.

ECMO for Metabolic Crisis in a Patient with Mitochondrial Disease.

Patients with mitochondrial disease exhibit disrupted pyruvate oxidation, resulting in intraoperative and perioperative physiologic derangements. Increased enzymatic conversion of pyruvate via lactate dehydrogenase during periods of fasting or stress can lead to metabolic decompensation, with rapid development of fatal lactic acidosis. We describe the intraoperative management and postoperative critical care of a patient with mitochondrial disease who presented for repair of esophageal perforation following repair of a paraesophageal hernia. His surgery was complicated by the development of metabolic crisis and severe lactic acidosis which became resistant to conventional therapy before ultimately resolving with the initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Management of Neuraxial Analgesia in a Parturient with Factor XIII Deficiency: A Case Report and Proposed Management Algorithm.

Factor XIII (FXIII) deficiency is a rare coagulation defect that can be associated with significant bleeding. A 28-year-old pregnant woman, with a history of hemorrhagic stroke secondary to severe congenital FXIII deficiency, presented in active labor requesting an epidural. Factor XIII levels had been monitored throughout her pregnancy and treated with intermittent factor XIII infusions to maintain factor levels above 30% of normal. After careful multidisciplinary peripartum evaluation and FXIII replacement, neuraxial analgesia was performed without complication. Neuraxial analgesia can be performed without complication in patients with FXIII deficiency if FXIII levels are carefully managed and no other coagulopathy exists.

Anesthetic Management for Ehlers-Danlos Syndrome, Hypermobility Type Complicated by Local Anesthetic Allergy: A Case Report.

BACKGROUND Ehlers-Danlos syndrome, hypermobility type is characterized by increased extensibility, permeability, and fragility of the affected cartilaginous tissues, including the trachea, larynx, and skin. Anesthetic considerations for patients with this syndrome include intubation difficulties secondary to the collapse of fibro-elastic tissues in the trachea and a reported resistance to local anesthetics. CASE REPORT Our patient was a 22-year-old G4P0030 woman with a history of morbid obesity, seizures, Barrett's esophagus, hypermobility being evaluated for Ehlers-Danlos syndrome, and anaphylaxis to an unknown local anesthetic who was scheduled for cesarean delivery. She refused allergy testing. After rapid-sequence induction of general anesthesia, video laryngoscopy facilitated endotracheal intubation. Delivery and recovery were uneventful for the mother and child. CONCLUSIONS No guidelines for neuraxial or general anesthesia exist for patients with Ehlers-Danlos syndrome, hypermobility type. Increased rates of cervical spine instability and local anesthetic resistance have been reported in this population and should be considered when developing the anesthetic plan.

Standard Setting for Clinical Performance of Basic Perioperative Transesophageal Echocardiography: Moving beyond the Written Test.

BACKGROUND: Credible methods for assessing competency in basic perioperative transesophageal echocardiography examinations have not been reported. The authors' objective was to demonstrate the collection of real-world basic perioperative transesophageal examination performance data and establish passing scores for each component of the basic perioperative transesophageal examination, as well as a global passing score for clinical performance of the basic perioperative transesophageal examination using the Angoff method. METHODS: National Board of Echocardiography (Raleigh, North Carolina) advanced perioperative transesophageal echocardiography-certified anesthesiologists (n = 7) served as subject matter experts for two Angoff standard-setting sessions. The first session was held before data analysis, and the second session for calibration of passing scores was held 9 months later. The performance of 12 anesthesiology residents was assessed via the new passing score grading system. RESULTS: The first standard-setting procedure resulted in a global passing score of 63 ± 13% on a basic perioperative transesophageal examination. The global passing score from the second standard-setting session was 73 ± 9%. Three hundred seventy-one basic perioperative transesophageal examinations from 12 anesthesiology residents were included in the analysis and used to guide the second standard-setting session. All residents scored higher than the global passing score from both standard-setting sessions. CONCLUSIONS: To the authors' knowledge, this is the first demonstration that the collection of real-world anesthesia resident basic perioperative transesophageal examination clinical performance data is possible and that automated grading for competency assessment is feasible. The authors' findings demonstrate at least minimal basic perioperative transesophageal examination clinical competency of the 12 residents.

Spinal Anesthesia in a Patient With a History of Systemic Capillary Leak Syndrome (Clarkson Disease).

OBJECTIVE: The aim of this study was to review the relative risks, benefits, and anesthetic considerations of neuraxial, regional, and general anesthesia in a patient with known systemic capillary leak syndrome (SCLS) who presents for elective total knee replacement. CASE REPORT: Systemic capillary leak syndrome (or Clarkson disease) is a rare disorder involving endothelial dysfunction of uncertain pathogenesis characterized by the development of hypotension, hemoconcentration, and hypoalbuminemia in the absence of secondary causes of shock. Literature regarding the anesthetic management of such patients is extremely sparse. To date, all published cases involved those who experienced exacerbations preoperatively, intraoperatively, or postoperatively. There are no reports pertaining to the anesthetic management of patients with a history of the disease who are under remission. We present a case report of a patient with a history of SCLS who underwent elective unilateral total knee arthroplasty under spinal anesthesia. The patient tolerated the procedure well without any evidence of perioperative capillary leak exacerbation. CONCLUSIONS: Spinal anesthesia constitutes a viable option for a patient with a history of SCLS in sustained remission. It remains unclear whether general or neuraxial anesthesia confers the best risk-to-benefit ratio for such patients.