Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis.

BACKGROUND: Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation. METHODS: Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness. RESULTS: We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias. CONCLUSIONS: The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023413984).

Effect of Prior Formal Education on Successful Thoracic Epidural Placement By Anesthesia Residents.

OBJECTIVE: Catheter placement for thoracic epidural analgesia (TEA) is technically challenging; however, methods for teaching this technique to anesthesia residents have not been well-studied. The present study aimed to determine optimal teaching methods for proficient TEA catheter placement by comparing video-based formal resident education with traditional bedside training by attending physicians. DESIGN: Prospective, randomized study. SETTING: Large academic hospital, single institution. PARTICIPANTS: The study comprised 76 postgraduate year 3 and 4 anesthesiology residents (38 intervention, 38 control). INTERVENTIONS: Formal education included an instructional video on proper TEA technique. MEASUREMENTS AND MAIN RESULTS: Measures of proficiency in TEA catheter placement included the time needed to complete the procedure successfully and the success of placement as indicated by patient confirmation. Residents who received formal video instruction had similar success in catheter placement and similar procedure times compared with the traditionally trained residents. The overall success rate was 99.2%, with faculty intervention required in only 17% of cases. More experienced residents (ie, having placed more epidural catheters) were faster at TEA catheter placement. CONCLUSIONS: Formal video education for TEA catheter placement provided no additional improvement of resident proficiency compared with traditional training at a high-volume academic center. The success rate was very high in this group of residents; however, experiences at other institutions may vary. Future studies are needed to determine optimum teaching strategies for TEA.

Randomized Prospective Study Evaluating Single-Injection Paravertebral Block, Paravertebral Catheter, and Thoracic Epidural Catheter for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) has improved patient outcomes; however, postoperative pain remains potentially severe. The objective of this study was to compare adjunct analgesic modalities for VATS, including paravertebral nerve blockade (PVB) and thoracic epidural anesthesia (TEA). DESIGN: Prospective, randomized trial. SETTING: Large academic hospital, single institution. PARTICIPANTS: Adult patients undergoing VATS. INTERVENTIONS: Ultrasound-guided PVB catheter, ultrasound-guided single-injection PVB, or TEA. MEASUREMENTS AND MAIN RESULTS: Postoperative visual analog scale pain scores (at rest and with knee flexion) and opioid usage were recorded. Pain scores (with movement) for the TEA group were lower than those for either PVB group at 24 hours (p ≤ 0.008) and for the PVB catheter group at 48 hours (p = 0.002). Opioid use in TEA group was lower than that for either PVB group at 24 and 48 hours (p < 0.001) and 72 hours (p < 0.05). Single-injection PVB was faster compared with PVB catheter placement (6 min v 12 min; p < 0.001) but similar to TEA (5 min). Patient satisfaction, nausea, sedation, and 6-month postsurgical pain did not differ between groups. CONCLUSIONS: TEA led to lower pain scores and opioid requirement for VATS procedures compared with PVB techniques. Single-injection PVB was faster and equally as effective as PVB catheter, and it led to similar patient satisfaction as TEA; therefore, it should be considered in patients who are not ideal candidates for TEA.

Transversus abdominis plane (TAP) block for laparoscopic live donor nephrectomy: Continuous catheter infusion provides no additional analgesic benefit over single-injection ropivacaine.

BACKGROUND: Transversus abdominis plane (TAP) blocks are useful for adjunctive pain control following laparoscopic live donor nephrectomy (LLDN). The objective was to determine if TAP catheter provides additional analgesia compared with single-injection TAP block alone for kidney donors. METHODS: In this prospective, double-blinded, randomized controlled trial, LLDN patients received a single TAP injection of 30 mL 0.2% ropivacaine and had a catheter inserted into the TAP space. Postoperatively, either 0.2% ropivacaine (TAP catheter group; TAP-C) or saline (TAP saline group; TAP-S) was infused at 10 mL/h. Pain scores, narcotic usage, nausea, and sedation were evaluated at 1, 12, 24, 36, 48, and 60 hours. RESULTS: The study population included 70 patients (35 randomly assigned to each group). No differences in pain scores, narcotic usage, nausea, or sedation were observed at any time point (with the exception of lower median pain score for TAP-S at 60 hours; 3.2 vs 3.9 for TAP-C; P = .03). CONCLUSIONS: The lower pain score for placebo group at 60-hour postoperative is likely clinically insignificant. The TAP catheter infusion provided no benefit over a single-injection TAP block; thus, the added risk and cost are not supported. Liposomal bupivacaine should be evaluated in future studies.

Prospective Comparison of Ultrasound-Guided Versus Palpation Techniques for Arterial Line Placement by Residents in a Teaching Institution.

BACKGROUND: Arterial line insertion is traditionally done by blind palpation. Residents may need multiple attempts for successful insertion, leading to longer procedure times and many failed attempts. OBJECTIVE: We hypothesized that ultrasound guidance (USG) would be faster and more successful than traditional blind palpation (TBP) for radial artery line placement by residents. METHODS: Patients undergoing elective surgery requiring a radial arterial line were randomized to either the USG or TBP groups. Exclusion criteria included a need for arterial line placement in an awake patient, emergent surgery, or American Society of Anesthesiologists (ASA) physical status class VI. After the induction of anesthesia, a postgraduate year 3 (PGY-3) or PGY-4 anesthesia resident placed an arterial line by either USG or TBP. RESULTS: A total of 412 patients and 85 of 106 residents (80%) in the training program were included. The 2 groups were similar with respect to sex, weight, height, ASA class, baseline systolic blood pressure, and baseline heart rate. USG was faster than TBP (mean times 171.1 ± 16.7 seconds versus 243.6 ± 23.5 seconds, P = .012), required fewer attempts (mean 1.78 ± 0.11 versus 2.48 ± 0.15, P = .035), and had an improved success rate (96% versus 90%, P = .012). CONCLUSIONS: We found that residents using USG in an academic institution resulted in significantly faster placement of the arterial lines, fewer attempts, and fewer catheters used.

Local anesthetic systemic toxicity: update on mechanisms and treatment.

PURPOSE OF REVIEW: With increases in use of regional anesthesia, local anesthetic systemic toxicity (LAST) has been a topic of interest and debate. Despite many years of research, the exact cause and best treatment of LAST (particularly local anesthetic cardiotoxicity) remain unclear. This review will summarize what is known and what remains uncertain about LAST and its treatment, including information published in the past 12-18 months. RECENT FINDINGS: Several authorities, including the American Society of Regional Anesthesia and Pain Medicine, have published guidelines on prevention and treatment of LAST. Experimental data continue to add to better understanding of LAST and its treatment. The data are not entirely consistent, but themes include continued evidence to support the ideas that LAST cardiotoxicity occurs primarily at sodium channels, lipid emulsion is a reasonably well tolerated and effective treatment, and there may be qualitative differences in cardiotoxicity caused by low and high-potency local anesthetics. SUMMARY: Regarding mechanism(s) of LAST, the evidence remains mixed, but it is likely that local anesthetic cardiotoxicity primarily arises from a blockade of sodium channels. As for treatment, in addition to ventilation, oxygenation, and chest compressions, lipid emulsion therapy should be a primary element in the treatment of cardiovascular LAST. The use of epinephrine and vasopressin should be tailored to specifics of an episode of LAST, and doses should be kept as low as possible while still achieving the desired effects.