Current Trends and Future Directions for Outpatient Total Joint Arthroplasty: A Review of the Anesthesia Choices and Analgesic Options.

The aging population and the obesity epidemic have led to an increased rate of joint arthroplasty procedures, specifically total knee arthroplasty and total hip arthroplasty. These surgeries are associated with increased hospital length of stay and, consequently, higher costs. Despite the benefits of outpatient surgery, only a small percentage of total joint arthroplasties (TJAs) are done in this manner. We reviewed the most up-to-date trends for outpatient TJA and discussed essential factors for a successful outpatient program, including the proper patient selection process and best available anesthetic and analgesic options, along with their risks and benefits. Risk stratification tools, such as the Outpatient Arthroplasty Risk Assessment, are helpful for predicting outcomes regarding outpatient TJA, and neuraxial anesthesia should be considered to minimize complications and facilitate early discharge. A multimodal analgesia regimen could be effective for pain management in outpatient TJA, and the currently recommended peripheral nerve blocks for total hip arthroplasty and total knee arthroplasty are the fascia iliaca compartment block and adductor canal block, respectively. However, blocks should be carefully considered for outpatient procedures. Enhanced recovery after surgery (ERAS) protocols help to guide perioperative care teams and allow for improved patient recovery, decreased length of stay, and increased patient satisfaction.

A Meta-Analysis of Remote Ischemic Preconditioning in Lung Surgery and Its Potential Role in COVID-19.

Purpose: To determine the effects of remote ischemic preconditioning (RIPC) on pulmonary gas exchange in people undergoing pulmonary surgery and discuss a potential role of RIPC in COVID-19. Method: A search for studies examining the effects of RIPC after pulmonary surgery was performed. RevMan was used for statistical analyses examining measures of A-ado2, Pao2/Fio2, respiratory index (RI), a/A ratio and Paco2 obtained earlier after surgery (i.e., 6-8 hours) and later after surgery (i.e., 18-24 hours). Results: Four trials were included (N = 369 participants). Significant (p < 0.05) overall effects of RIPC were observed early after surgery on A-ado2 and RI (SMD -0.84 and SMD -1.23, respectively), and later after surgery on RI, Pao2/Fio2, and a/A ratio (SMD -0.39, 0.72, and 1.15, respectively) with the A-ado2 approaching significance (p = 0.05; SMD -0.45). Significant improvements in inflammatory markers and oxidative stress after RIPC were also observed. Conclusions: RIPC has the potential to improve pulmonary gas exchange, inflammatory markers, and oxidative stress in people with lung disease undergoing lung surgery and receiving mechanical ventilation. These potential improvements may be beneficial for people with COVID-19, but further investigation is warranted.

Objectif : déterminer les effets du préconditionnement ischémique à distance (PCID) sur les échanges gazeux pulmonaires chez les personnes qui subissent une opération pulmonaire et discuter du rôle potentiel du PCID sur la COVID-19. Méthodologie : les chercheurs ont procédé à une recherche sur les effets du PCID après une opération pulmonaire. Ils ont utilisé le logiciel RevMan pour effectuer les analyses statistiques des mesures du gradient artério-alvéolaire (A-ao2), du rapport entre la pression partielle d'oxygène et la fraction inspirée en oxygène (Pao2/Fio2), de l'indice respiratoire (IR), du gradient alvéolo-artériel (a-A) et de la pression partielle de dioxyde de carbone (Paco2) obtenus de six à huit heures après l'opération, puis de 18 à 24 heures après l'opération. Résultats : les chercheurs ont inclus quatre études (N = 369 participants). Ils ont observé des effets globaux importants (p < 0,05) du PCID peu après l'opération sur l'A-ao2 et l'IR (DMS = −0,84 et DMS = −1,23, respectivement), puis plus tard après l'opération sur l'IR, le Pao2/Fio2 et le gradient a-A (DMS = −0,39, 0,72 et 1,15, respectivement), et l'A-ao2 avoisine une valeur significative (p = 0,05; DMS = −0,45). Ils ont également observé des améliorations notables aux marqueurs inflammatoires et au stress oxydatif après le PCID. Conclusions : le PCID a le potentiel d'améliorer les échanges gazeux pulmonaires, les marqueurs inflammatoires et le stress oxydatif chez les personnes atteintes d'une maladie pulmonaire qui subissent une opération pulmonaire et reçoivent une ventilation mécanique. Ces améliorations potentielles peuvent être bénéfiques aux personnes atteintes de la COVID-19, mais d'autres recherches s'imposent.

The assessment of a growing mobile anesthesia practice from 2016 to 2019: A retrospective observational cohort study of 89,999 cases comparing ambulatory surgery (ASC) and office-based surgery (OBS) centers using a high-fidelity, anesthesia-specific electronic medical record (EMR).

Office-based surgery (OBS) has emerged as a significant subspecialty of ambulatory surgery. There are few clinical trials and limited published data on patient characteristics, anesthesia, or outcomes distinguishing OBS from ambulatory surgery centers (ASCs). We examined retrospective data from a large mobile anesthesia practice for 89,999 procedures from 2016 to 2019. Data was abstracted from billing and an anesthesia-specific electronic medical record, segregating procedures performed in ASCs versus OBS. The number and breadth of procedures increased substantially. Compared to ASCs, OBS patients were more likely male (52% vs. 48%), older (61 years vs. 55 years), and to have a higher American Society of Anesthesiologists (ASAs) status (33% vs. 20% ASA 3 or higher). The procedure mix varied substantially between the two settings. The major complication rate was 0.07% for the ASCs and 0.24% for OBS (p = 0.2, confidence interval [CI] -0.15 to 0.04). Minor complications were 11.2% in OBS versus 17.3% the ASCs (p < 0.0001, 95% CI 5.2-7). The practice demonstrates a low rate of complications, and despite the limitations of this study, the organization and structure of this large mobile anesthesia practice serves as a template for effective risk mitigation and patient safety.

Patients, procedures, and PPE: Safe office-based anesthesia recommendations in the COVID-19 era.

The growth of office-based surgery (OBS) has been due to ease of scheduling and convenience for patients; office-based anesthesia safety continues to be well supported in the literature. In 2020, the Coronavirus Disease 19 (COVID-19) has resulted in dramatic shifts in healthcare, especially in the office-based setting. The goal of closing the economy was to flatten the curve, impacting office-based and ambulatory practices. Reopening of the economy and the return to ambulatory surgery and OBS and procedures have created a challenge due to COVID-19 and the infectious disease precautions that must be taken. Patients may be more apt to return to the outpatient setting to avoid the hospital, especially with the resurgence of COVID-19 cases locally, nationally, and worldwide. This review provides algorithms for screening and testing patients, selecting patients for procedures, choosing appropriate procedures, and selecting suitable personal protective equipment in this unprecedented period.

Hypertensive crisis during spinal anesthesia due to undiagnosed pheochromocytoma.

Undiagnosed pheochromocytoma poses significant intraoperative challenges to the anesthesiologist. These tumors generally cause profound hypotension after spinal anesthesia. We present an unusual case of a hypertensive crisis occurring in a patient under spinal anesthesia. Due to intraoperative hemodynamic instability, the case was converted to general anesthesia with a volatile anesthetic. Postoperative workup was consistent with a pheochromocytoma. Pheochromocytomas are rare, but given their significant intraoperative morbidity and mortality, they should be considered in the differential diagnosis of unexpected intraoperative hemodynamic changes.

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019.

PURPOSE OF REVIEW: Office-based anesthesia (OBA) is rapidly growing across the world. Availability of less invasive interventions has facilitated the opportunity of offering new procedures in office-based settings to patient populations that would not have been considered in the past. This article provides a practical approach to discuss and analyze newest literature supporting different practices in the field of OBA. In addition, an update of the most recent guidelines and practice management directives is included. RECENT FINDINGS: Selected procedures may be performed in the office-based scenario with exceedingly low complication rates, when the right patient population is selected, and adequate safety protocols are followed. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards among other. SUMMARY: New evidence exists supporting procedures in the office-based scenario in areas such as plastic and cosmetic surgery, dental and oral surgery, ophthalmology, endovascular procedures and otolaryngology. Different systematic approaches have been developed (guidelines and position statements) to promote standardization of safe practices through emergency protocols, safety checklists, medication management and surgical risk reduction. New regulations and accreditation measures have been developed to homogenize practice and promote high safety standards.

Office-Based Anesthesia: A Comprehensive Review and 2019 Update.

Over the last 25 years, with an exponential growth in the complexity of patients and procedures in the office-based setting, the topic of patient safety is becoming more fundamental. Current research efforts focus on the implementation of customizable safety checklists for both the patient and provider, and an emergency manual specifically adapted to guide providers though challenging and unexpected emergencies in this unique setting. Additional efforts are focusing on legislative changes and accreditation to standardize and ensure increased accountability and patient safety.

Safe anesthesia for office-based plastic surgery: Proceedings from the PRS Korea 2018 meeting in Seoul, Korea.

There has been an exponential increase in plastic surgery cases over the last 20 years, surging from 2.8 million to 17.5 million cases per year. Seventy-two percent of these cases are being performed in the office-based or ambulatory setting. There are certain advantages to performing aesthetic procedures in the office, but several widely publicized fatalities and malpractice claims has put the spotlight on patient safety and the lack of uniform regulation of office-based practices. While 33 states currently have legislation for office-based surgery and anesthesia, 17 states have no mandate to report patient deaths or adverse outcomes. The literature on office-base surgery and anesthesia has demonstrated significant improvements in patient safety over the last 20 years. In the following review of the proceedings from the PRS Korea 2018 meeting, we discuss several key concepts regarding safe anesthesia for officebased cosmetic surgery. These include the safe delivery of oxygen, appropriate local anesthetic usage and the avoidance of local anesthetic toxicity, the implementation of Enhanced Recovery after Surgery protocols, multimodal analgesic techniques with less reliance on narcotic pain medications, the use of surgical safety checklists, and incorporating "the patient" into the surgical decision-making process through decision aids.

A Case Report of Suspected Malignant Hyperthermia: How Will the Diagnosis Affect a Patient's Insurability?

The purpose of this case report is to increase awareness that a diagnosis of malignant hyperthermia may have long-lasting or permanent effects on a patient's insurance eligibility or premiums despite legislation providing varying levels of protection from preexisting conditions or genetic discrimination. We present a case of severe rigors, unexplained severe metabolic acidosis, and severe hyperthermia in a patient after general anesthesia for extensive head and neck surgery. The patient was treated for malignant hyperthermia and demonstrated a significant clinical improvement with the administration of dantrolene. Even with an "almost certain" diagnosis of malignant hyperthermia by clinical presentation, genetic testing was negative and the gold-standard caffeine-halothane contracture test has yet to be performed. Laboratory results, clinical grading scales, and genetic testing support a diagnosis of malignant hyperthermia but the gold standard is a live muscle biopsy and caffeine-halothane contracture test. A clinical diagnosis of MH or a positive caffeine-halothane contracture test could result in exclusion from genetic discrimination legislature due to the fact that diagnosis can be confirmed without genetic testing. The fate of the Affordable Care Act may also affect how insurance companies scrutinize this disease. Improving accuracy of MH diagnosis in hospital discharge records will be crucial.

The Need for Accreditation of Office-Based Interventional Vascular Centers.

The rise in office-based interventional vascular laboratories in recent years was prompted in part by expedient ambulatory patient experience and favorable outpatient procedural reimbursement. While studies have shown that clinical safety and treatment efficacy can be achieved in office-based vascular facilities, critics have raised various concerns due to inconsistent patient care standards and lack of organizational oversight to ensure optimal patient outcome. Available literature showed widely varied clinical outcomes which were partly attributable to nonuniform standards in reporting clinical efficacy and adverse events. In this report, various concerns and pitfalls of office-based interventional vascular centers are discussed. Strategies to improve patient care delivery in office-based laboratories including accreditations which serve as external validation of processes to ensure patient care and safety are also mentioned. Finally, the requirements to obtain accreditation in an office-based practice and the differences between these nationally recognized accrediting organizations are discussed herein.

Case report: management of differential diagnosis and treatment of severe anaphylaxis in the setting of spinal anesthesia.

The purpose of this case report is to educate fellow anesthesiologists of a complicated differential diagnosis for sudden cardiovascular collapse after spinal anesthesia. We report a case where anaphylaxis occurred while under spinal anesthesia and resulted in difficult resuscitation. A 58-year-old woman undergoing bilateral knee replacements under spinal anesthesia experienced sudden seizure and cardiovascular collapse from acute anaphylactic shock while administering a cephalosporin. Local anesthetic toxicity, high spinal, and anaphylaxis were considered due to overlapping of symptoms. Successful resuscitation required prolonged advanced cardiac life support with substantially larger doses of epinephrine. Anaphylactic shock under spinal anesthesia is an acute and life-threatening complication, worsened by the spinal-induced sympathectomy, and aggressive resuscitation is warranted. Despite the presence of overlapping symptoms of differential diagnoses, rapid identification of the cause of cardiovascular collapse is crucial given that resuscitation treatment modalities may conflict. Timing of antibiotic administration should be adjusted for spinal anesthesia cases to allow time to detect possible anaphylaxis.