Opioid versus non-opioid postoperative pain management in otolaryngology.

BACKGROUND: The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC). METHODS: A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups. RESULTS: The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel. CONCLUSIONS: HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Airway Management During the Last 100 Years.

A large variety of airway devices, techniques, and cognitive tools have been developed during the last 100 years to improve airway management safety and became a topic of major research interest. This article reviews the main developments in this period, starting with modern day laryngoscopy in the 1940s, fiberoptic laryngoscopy in the 1960s, supraglottic airway devices in the 1980s, algorithms for difficult airway in the 1990s, and finally modern video-laryngoscopy in the 2000s.

Risk factors for labor epidural conversion failure requiring general anesthesia for cesarean delivery.

Background and Aims: To evaluate the rate and risk factors of labor epidural conversion failure requiring general anesthesia for Caesarean delivery (CD). Material and Methods: Pregnant patients requiring conversion from labor to CD with a pre-existing labor epidural at our institution from 2009 to 2014 were identified. Through a retrospective review, we compared successful epidural conversion with those who required general anesthesia for CD. Patient characteristics were analyzed to identify risk factors for failed epidural conversion for CD. Results: A total of 673 patients were included in the study. The rate of epidural conversion failure was 21%. Main risk factors for epidural conversion failure requiring general anesthesia included: younger maternal age (95% CI 0.94, P = 0.0002) and supplementation of intravenous fentanyl (95% CI 0.19, P < 0.0001) or midazolam (95% CI 0.26, P = 0.0008) during CD. A higher risk of conversion failure was also associated with a more urgent CD (CD category 1, 2, and 3 vs category 4). Conclusion: Consistent with previous reports, young age and the urgency of CD increases the likelihood of epidural conversion failure. While conversion failure is likely multifactorial and complex, many of these factors are suggestive of inadequate and poorly functioning labor epidurals prior to CD. Prospective studies to further evaluate these factors are necessary, and the best prevention of epidural conversion failure is diligent diagnosis and evaluation of ineffective labor epidural analgesia prior to impending CD.

Successful Implementation of a Robust Medical Student Curriculum in Anesthesiology.

Increasing medical student enrollment creates challenges for clinical course directors to accommodate students and to provide consistency in clinical experiences. We discuss curricular modifications addressing these challenges specific to anesthesiology electives through the creation of 2-week anesthesiology electives to provide scheduling flexibility in the clinical years. We also incorporated curricular enhancements as a consistent didactic framework congruent with the clinical experience. Since initiating these electives in 2017, annual student enrollment increased >33%. More fourth-year students have enrolled in these courses. The annual number of students matching anesthesiology has maintained ≥8% graduating class. Our highest has been 15% in 2020.

An Objective Pain Score for Chronic Pain Clinic Patients.

Objectives: Although numerous studies have looked at the numeric rating scale (NRS) in chronic pain patients and several studies have evaluated objective pain scales, no known studies have assessed an objective pain scale for use in the evaluation of adult chronic pain patients in the outpatient setting. Subjective scales require patients to convert a subjective feeling into a quantitative number. Meanwhile, objective pain scales utilize, for the most part, the patient's behavioral component as observed by the provider in addition to the patient's subjective perception of pain. This study aims to examine the reliability and validity of an objective Chronic Pain Behavioral Pain Scale for Adults (CBPS) as compared to the traditional NRS. Methods: In this cross-sectional study, patients were assessed before and after an interventional pain procedure by a researcher and a nurse using the CBPS and the NRS. Interrater reliability, concurrent validity, and construct validity were analyzed. Results: Interrater reliability revealed a fair-good agreement between the nurse's and researcher's CBPS scores, weighted kappa values of 0.59 and 0.65, preprocedure and postprocedure, respectively. Concurrent validity showed low positive correlation for the preprocedure measurements, 0.34 (95% CI 0.16-0.50) and 0.47 (95% CI 0.31-0.61), and moderate positive correlation for the postprocedure measurements, 0.68 (95% CI 0.56-0.77) and 0.67 (95% CI 0.55-0.77), for the nurses and researchers, respectively. Construct validity demonstrated an equally average significant reduction in pain from preprocedure to postprocedure, CBPS and NRS median (IQR) scores preprocedure (4 (2-6) and 6 (4-8)) and postprocedure (1 (0-2) and 3 (0-5)), p < 0.001. Discussion. The CBPS has been shown to have interrater reliability, concurrent validity, and construct validity. However, further testing is needed to show its potential benefits over other pain scales and its effectiveness in treating patients with chronic pain over a long-term. This study was registered with ClinicalTrial.gov with National Clinical Trial Number NCT02882971.

Combined epidural-general anaesthesia vs general anaesthesia in neonatal gastrointestinal surgery: A randomized controlled trial.

BACKGROUND: Post-operative ileus is a frequent complication of gastrointestinal surgery under general anaesthesia. The aim of this study was to investigate whether combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery in neonates undergoing elective gastrointestinal surgery. METHODS: A randomized controlled trial including 60 neonates who underwent gastrointestinal surgery at a university hospital was performed. Thirty neonates received combined epidural-general anaesthesia (CEGA), and 30 neonates received general anaesthesia (GA) alone. The primary outcome was the post-operative time to tolerance of full enteral nutrition. The secondary outcomes were the post-operative time defaecation, the duration of nasogastric drainage, and infections. RESULTS: After excluding two neonates from the CEGA group, where repeated attempts at epidural catheterization were unsuccessful, a total of 58 patients completed the study (CEGA: 28; GA: 30). Full enteral nutrition was tolerated earlier in CEGA vs the GA group (4.0 vs 8.0 days; P = .0001). Time to defaecation was shorter in the CEGA group (3.5 vs 5.0 days; P = .0001). Duration of nasogastric drainage was similar between groups (7.0 vs 7.0 days; P = .9502). Fewer patients in the CEGA group experienced post-operative infection (35.7% vs 60.0%; P = .038). CONCLUSION: Combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery and a lower infection risk after gastrointestinal surgery in neonates.

Ambu AuraGain versus intubating laryngeal tube suction as a conduit for endotracheal intubation.

BACKGROUND AND AIMS: Newly developed supraglottic airway devices (SGAs) are designed to be used both for ventilation and as conduits for endotracheal intubation with standard endotracheal tubes (ETTs). We compared the efficacy of the Ambu AuraGain (AAG) and the newly developed intubating laryngeal tube suction disposable (ILTS-D) as conduits for blind and fiber-optically guided endotracheal intubation in an airway mannequin. MATERIAL AND METHODS: This is a prospective, randomized, crossover study in an airway mannequin, with two arms: blind ETT insertion by medical students and fiber-optically guided ETT insertion by anesthesiologists. The primary outcome variable was the time to achieve an effective airway through an ETT using AAG and ILTS-D as conduits. Secondary outcome variables were the time to achieve effective supraglottic ventilation and successful exchange with an ETT, and the success rates for blind endotracheal intubation and fiber-optically guided intubation techniques for both SGAs. RESULTS: Forty participants were recruited to each group. All participants were able to insert both devices successfully on the first attempt. For blind intubation, the success rate for establishing a definitive airway with an ETT using the SGA as a conduit was significantly higher with ILTS-D (82.5%) compared with AAG (20.0%) (P < 0.001). None of the participants were able to successfully complete the exchange of the SGA for the ETT with the AAG. In the fiber optic guided intubation group, the rate of successful exchange was significantly higher with ILTS-D (84.6%) compared with AAG (61.5%) (P = 0.041). CONCLUSION: The ILTS-D successfully performs in an airway mannequin with higher success rate and shorter time for blindly establishing an airway with an ETT using the SGA as a conduit, compared with AAG. Further clinical trials are warranted.

A double blind randomized placebo controlled pilot study of single-dose preoperative modafinil for functional recovery after general anesthesia in patients with obstructive sleep apnea.

BACKGROUND: We theorized that modafinil, an atypical psychomotor stimulant, utilized to improve daytime somnolence in patients with obstructive sleep apnea, would improve functional recovery after general anesthesia by improving time to extubation, post-anesthesia care unit (PACU) length of stay and subjective recovery after general anesthesia. METHODS: A double blind, randomized, placebo-controlled pilot study was performed. 102 patients with the diagnosis of obstructive sleep apnea (OSA) were randomized to receive either 200 mg of modafinil or placebo before general anesthesia. The trial was terminated for futility. The primary outcome was PACU length of stay between groups. Secondary functional metrics of improved post-anesthesia recovery were compared between groups. RESULTS: No difference between groups was found on the primary outcome of PACU length of stay (PACULOS). Emergence from general anesthesia was not significantly different when assessed by the time period between termination of volatile anesthetic and extubation. Similarly, no difference between groups was found in intraoperative bispectral index (BIS) values, postoperative pain scores or narcotic consumption (morphine equivalent units). In the post-anesthesia care unit, respiratory rate was increased and mean arterial pressure was lower in the modafinil group. CONCLUSIONS: Our results suggest that the use of single-dose preoperative modafinil may not improve functional recovery after general anesthesia in patients with the diagnosis of OSA. Further research is needed before use of atypical psychomotor stimulants in this surgical population.

A comparison between the Supreme laryngeal mask airway and the laryngeal tube suction during spontaneous ventilation: A randomized prospective study.

BACKGROUND AND AIMS: The Supreme laryngeal mask airway (SLMA) and the laryngeal tube suction-disposable (LTS-D), both second-generation supraglottic airway devices, have a record of efficiency when used for airway management in mechanically ventilated patients, during general anesthesia. There is no published data comparing these two devices in patients breathing spontaneously during general anesthesia. MATERIAL AND METHODS: Eighty patients with normal airways undergoing elective general anesthesia with spontaneous ventilation were randomized to airway management with a SLMA or LTS-D. Efficacy and adequacy of oxygenation and ventilation were compared. RESULTS: No cases of desaturation of oxygen saturation (SpO2) values of less than 95% occurred with either device. The mean difference for SpO2 between the two devices (0.7%) has no clinical significance. Slight hypercapnia was noted with both devices to acceptable values during spontaneous ventilation. CONCLUSIONS: Both SLMA and LTS-D are suitable and effective for airway management in patients breathing spontaneously during general anesthesia for minor surgery of short duration.

Development and Assessment of Pictorial Guide for Improved Accuracy of Visual Blood Loss Estimation in Cesarean Delivery.

INTRODUCTION: Estimated blood loss for surgical procedures performed via visual estimation is known to be an inaccurate method. Blood loss estimation is further complicated during cesarean delivery (CD) by a large volume loss for a short period as well as the presence of amniotic fluid. We hypothesized that a pictorial guide depicting premeasured blood volumes and materials commonly used in a CD would improve clinician accuracy in estimated blood loss. METHODS: A simulated CD scene was used to assess the ability of clinicians to estimate the amount of blood lost by a CD patient. Accuracy of the estimates was assessed before and after they had access to the pictorial guide created for the study. RESULTS: Before the intervention, 52% of participants estimated more than 25% above or below actual blood loss volume. With use of the guide, clinicians became more accurate at blood loss estimation. After the intervention, the number of participants estimating within 5% of the actual volume increased from 7% before to 24% (P = 0.033). CONCLUSIONS: An institution-specific pictorial guide is effective at improving the accuracy of visual blood loss estimation in a simulation and may help improve clinical care in CD.

The EasyTube during general anesthesia for minor surgery: A randomized, controlled trial.

BACKGROUND: The EasyTube (EzT) is a supraglottic airway device that is used for emergency airway situations. Ventilation during general anesthesia should also be feasible, but literature on the EzT is scarce. We evaluated the EzT in comparison with the endotracheal tube (ETT) in its use during general anesthesia in a comparative study. METHODS: A total of 400 patients with American Society of Anesthesiologists (ASA) physical status I to II scheduled for minor surgery in 4 centers were randomized for ventilation via the ETT or EzT. RESULTS: In all patients, the EzT and the ETT could be inserted within 3 attempts. In all EzT patients, the inspiratory and expiratory minute volumes (6.64 ±â€Š0.71 and 6.34 ±â€Š0.69 L/min) were sufficient to reach target oxygenation values, similar to ETT patients (P  =  .59). Mean peak pressure, mean plateau pressure, and mean dynamic compliance did not differ between the groups. Sore throat and blood on the cuff after removal were the most frequent complications in both groups. CONCLUSION: Ventilation for up to 1 hour during general anesthesia in patients with ASA physical status I to II with the EzT is feasible and safe.

Inter-center comparison of EasyTube and endotracheal tube during general anesthesia in minor elective surgery.

BACKGROUND: The EasyTube® (EzT) is a supraglottic airway device (SAD) enabling ventilation irrespective of its placement into the esophagus or trachea. Data obtained on SADs from multicenter studies, performed in highly specialized centers cannot always be transferred to other sites. However, data on comparability of different sites are scarce. This study focused on inter-site variability of ventilatory and safety parameters during general anesthesia with the EzT. METHODS: 400 patients with ASA physical status I-II undergoing general anesthesia for elective surgery in four medical centers (EzT group (n = 200), ETT group (n = 200)). Mallampati classification, success of insertion, insertion time, duration of ventilation, number of insertion attempts, ease of insertion, tidal volumes, leakage, hemodynamic parameters, oxygenation, and complications rates with the EasyTube (EzT) or endotracheal tube (ETT) in comparison within the sites and in between the sites were recorded. RESULTS: Intra-site and inter-site comparison of insertion success as primary outcome did not differ significantly. The inter-site comparison of expiratory minute volumes showed that the volumes achieved over the course of anesthesia did not differ significantly, however, mean leakage at one site was significantly higher with the EzT (0.63 l/min, p = 0.02). No significant inter-site differences in heart rate, blood pressure, or oxygenation were observed. Sore throat and blood on the cuff after removal of the device were the most frequent complications with significantly more complications at one site with the EzT (p = 0.01) where insertion was also reported significantly more difficult (p = 0.02). CONCLUSION: Performance of the EzT but not the ETT varied between sites with regard to insertion difficulty, leakage, and complications but not insertion success, ventilation, hemodynamics, and oxygenation parameters in patients with ASA physical status 1-2 during general anesthesia undergoing minor elective surgery.

"Are We hurting ourselves?" What is the prevalence of back pain in anesthesia providers?

STUDY OBJECTIVE: Back injuries are a highly reported category of occupational injury in the health care setting. The daily clinical activities of an anesthesia provider, including lifting, pushing stretchers, transferring patients, and bending for procedures, are risk factors for developing low back pain. The purpose of this study is to investigate the prevalence of work related low back pain in anesthesia providers. DESIGN/SETTING: We conducted a cross-sectional survey study of anesthesia providers at an academic institution. PATIENTS: The target population included all 141 clinical anesthesia providers employed by the Penn State Milton S. Hershey Medical Center Department of Anesthesia. INTERVENTIONS: A survey study was conducted using the Oswestry Disability Index (ODI), a validated scoring system for low back pain. Additional questions related to the daily activities of clinical anesthesia practice were also asked. The survey instrument underwent pretesting and clinical sensibility testing to ensure validity and consistent interpretation. MEASUREMENTS: The primary self-reported measures were the prevalence of low back pain in anesthesia providers and an assessment of disability based on the ODI. Secondary functional measures included the impact of low back pain on work flow. MAIN RESULTS: Nearly half (46.6%) of respondents suffer from low back pain attributed to clinical practice. In this subset of respondents, 70.1% reported not having back pain prior to their anesthesia training. Of those with low back pain, 44% alter their work flow, and 9.8% reported missing at least one day of work. Six providers (5.3%) required surgical intervention. Using the ODI score interpretation guidelines, 46% of respondents had a "mild disability" and 2% had a "moderate disability." Respondents reporting feeling "burned out" from their job had a significantly higher average ODI score compared to those who did not (6.8 vs 3.3, respectively; P=.01). CONCLUSIONS: Nearly half of all anesthesia providers sampled suffer from low back pain subjectively attributed to their clinical practice. This leads to changes in work flow and missed days of work. The results of this study suggest a deficiency in the effectiveness of anesthesia training programs in teaching proper techniques to prevent musculoskeletal injuries.

A randomized prospective controlled trial comparing the laryngeal tube suction disposable and the supreme laryngeal mask airway: the influence of head and neck position on oropharyngeal seal pressure.

BACKGROUND: The Laryngeal Tube Suction Disposable (LTS-D) and the Supreme Laryngeal Mask Airway (SLMA) are second generation supraglottic airway devices (SADs) with an added channel to allow gastric drainage. We studied the efficacy of these devices when using pressure controlled mechanical ventilation during general anesthesia for short and medium duration surgical procedures and compared the oropharyngeal seal pressure in different head and-neck positions. METHODS: Eighty patients in each group had either LTS-D or SLMA for airway management. The patients were recruited in two different institutions. Primary outcome variables were the oropharyngeal seal pressures in neutral, flexion, extension, right and left head-neck position. Secondary outcome variables were time to achieve an effective airway, ease of insertion, number of attempts, maneuvers necessary during insertion, ventilatory parameters, success of gastric tube insertion and incidence of complications. RESULTS: The oropharyngeal seal pressure achieved with the LTS-D was higher than the SLMA in, (extension (p=0.0150) and right position (p=0.0268 at 60 cm H2O intracuff pressures and nearly significant in neutral position (p = 0.0571). The oropharyngeal seal pressure was significantly higher with the LTS-D during neck extension as compared to SLMA (p= 0.015). Similar oropharyngeal seal pressures were detected in all other positions with each device. The secondary outcomes were comparable between both groups. Patients ventilated with LTS-D had higher incidence of sore throat (p = 0.527). No major complications occurred. CONCLUSIONS: Better oropharyngeal seal pressure was achieved with the LTS-D in head-neck right and extension positions , although it did not appear to have significance in alteration of management using pressure control mechanical ventilation in neutral position. The fiberoptic view was better with the SLMA. The post-operative sore throat incidence was higher in the LTS-D. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02856672 , Unique Protocol ID:BnaiZionMC-16-LG-001, Registered: August 2016.

Phenylephrine infusion for spinal-induced hypotension in elective cesarean delivery: Does preload make a difference?

BACKGROUND AND AIMS: Patients undergoing elective cesarean delivery (CD) have a high-risk of spinal-induced hypotension (SIH). We hypothesized that a colloid preload would further reduce SIH when compared with a crystalloid preload. MATERIAL AND METHODS: Eighty-two healthy parturients undergoing elective CD were included in the study. Patients were randomly assigned to two groups (41 patients in each group) to receive either Lactated Ringer's solution (1500 ml) or hydroxyethyl starch (6% in normal saline, 500 ml) 30 min prior to placement of spinal anesthesia. All patients were treated with a phenylephrine infusion (100 mcg/min), titrated during the study. RESULTS: There was no statistical difference between groups with regards to the incidence of hypotension (10.8% in the colloid group vs. 27.0% in the crystalloid group, P = 0.12). There was also no difference between groups with respect to bradycardia, APGAR scores, and nausea and vomiting. Significantly less phenylephrine (1077.5 ± 514 mcg) was used in the colloid group than the crystalloid group (1477 ± 591 mcg, P = 0.003). CONCLUSION: The preload with 6% of hydroxyethyl starch before CD might be beneficial for the prevention of SIH.