Effect of an opioid-free anesthetic on postoperative opioid consumption after laparoscopic bariatric surgery: a prospective, single-blinded, randomized controlled trial.

INTRODUCTION: Opioid administration has the benefit of providing perioperative analgesia but is also associated with adverse effects. Opioid-free anesthesia (OFA) may reduce postoperative opioid consumption and adverse effects after laparoscopic bariatric surgery. In this randomized controlled study, we hypothesized that an opioid-free anesthetic using lidocaine, ketamine, and dexmedetomidine would result in a clinically significant reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique. METHODS: Subjects presenting for laparoscopic or robotic bariatric surgery were randomized in a 1:1 ratio to receive either standard opioid-inclusive anesthesia (group A: control) or OFA (group B: OFA). The primary outcome was opioid consumption in the first 24 hours postoperatively in oral morphine equivalents (OMEs). Secondary outcomes included postoperative pain scores, patient-reported incidence of opioid-related adverse effects, hospital length of stay, patient satisfaction, and ongoing opioid use at 1 and 3 months after hospital discharge. RESULTS: 181 subjects, 86 from the control group and 95 from the OFA group, completed the study per protocol. Analysis of the primary outcome showed no significant difference in total opioid consumption at 24 hours between the two treatment groups (control: 52 OMEs vs OFA: 55 OMEs, p=0.49). No secondary outcomes showed statistically significant differences between groups. CONCLUSIONS: This study demonstrates that an OFA protocol using dexmedetomidine, ketamine, and lidocaine for laparoscopic or robotic bariatric surgery was not associated with a reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique using fentanyl.

Monthly multidisciplinary complex spine conference: a cost-analysis utilizing time-driven activity-based costing.

PURPOSE: To understand costs and provide an initial framework associated with conference implementation as it pertains to complication prevention. METHODS: Team members' time spent on conference preparation, presentation, and follow-up tasks was recorded and averaged to determine the time required to prepare and present one patient. Using 2022 hourly wage rates based on our urban hospital setting, wage values were calculated for each personnel type and applied to their time spent. The total cost of the conference was annualized and calculated from the time spent in the three phases of the conference multiplied by the wage rate. Published data on complication rates and associated costs before and after conference implementation were used to calculate total cost reduction. RESULTS: With 3 active spine surgeons and 108 patients per year, the total time investment was 104.04 min per patient, costing $21,791 annually. Total RN equivalent value per patient was 5.25 for all three phases. Using a historical model, this multidisciplinary approach for adult spinal deformity reduced complications by 51% at 30 days, resulting in cost savings of $418,518 per year. Thus, the model demonstrates that implementation of this approach resulted in a potential total savings of $396,726/year. CONCLUSION: Implementing a cost-saving tool for managing complex spinal disorders is a responsibility of the spine team, who should lead a multidisciplinary conference. The combination of TDABC and lean methodology can effectively demonstrate the variable costs associated with this multidisciplinary effort and models provide evidence of potential cost-savings when applied to a multidisciplinary adult spinal deformity conference. These findings should encourage clinicians and administrators to allocate resources to improve patient care by reducing complications and costs.

Evaluation of machine learning models as decision aids for anesthesiologists.

Machine Learning (ML) models have been developed to predict perioperative clinical parameters. The objective of this study was to determine if ML models can serve as decision aids to improve anesthesiologists' prediction of peak intraoperative glucose values and postoperative opioid requirements. A web-based tool was used to present actual surgical case and patient information to 10 practicing anesthesiologists. They were asked to predict peak glucose levels and post-operative opioid requirements for 100 surgical patients with and without presenting ML model estimations of peak glucose and opioid requirements. The accuracies of the anesthesiologists' estimates with and without ML estimates as reference were compared. A questionnaire was also sent to the participating anesthesiologists to obtain their feedback on ML decision support. The accuracy of peak glucose level estimates by the anesthesiologists increased from 79.0 ± 13.7% without ML assistance to 84.7 ± 11.5% (< 0.001) when ML estimates were provided as reference. The accuracy of opioid requirement estimates increased from 18% without ML assistance to 42% (p < 0.001) when ML estimates were provided as reference. When ML estimates were provided, predictions of peak glucose improved for 8 out of the 10 anesthesiologists, while predictions of opioid requirements improved for 7 of the 10 anesthesiologists. Feedback questionnaire responses revealed that the anesthesiologist primarily used the ML estimates as reference to modify their clinical judgement. ML models can improve anesthesiologists' estimation of clinical parameters. ML predictions primarily served as reference information that modified an anesthesiologist's clinical estimate.

Comparison of continuous intravenous lidocaine versus transversus abdominis plane block for kidney transplant surgery: a randomized, non-inferiority trial.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane (TAP) blocks are associated with an improvement in postoperative analgesia following kidney transplant surgery. However, these blocks carry inherent risk and require a degree of expertise to perform successfully. Continuous intravenous lidocaine may be an effective alternative. In this randomized, non-inferiority study, we hypothesized that a continuous lidocaine infusion provides similar postoperative analgesia to a TAP block. METHODS: Subjects presenting for kidney transplant surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection TAP block (TAP group) or a continuous infusion of lidocaine (Lido group). The primary outcome of this non-inferiority study was opioid consumption within the first 24 hours following surgery. Secondary outcomes included pain scores, patient satisfaction, opioid-related adverse events, time to regular diet, and persistent opioid use. RESULTS: One hundred and twenty subjects, 59 from the TAP group and 61 from the Lido group, completed the study per protocol. Analysis of the primary outcome showed a cumulative geometric mean intravenous morphine equivalent difference between the TAP (14.6±3.2 mg) and Lido (15.9±2.4 mg) groups of 1.27 mg (95% CI -4.25 to 6.79; p<0.001), demonstrating non-inferiority of the continuous lidocaine infusion. No secondary outcomes showed clinically meaningful differences between groups. CONCLUSIONS: This study demonstrates that a continuous infusion of lidocaine offers non-inferior postoperative analgesia compared with an ultrasound-guided unilateral, single-injection TAP block in the first 24 hours following kidney transplant surgery. TRIAL REGISTRATION NUMBER: NCT03843879.

Three-times-daily subcutaneous unfractionated heparin and neuraxial anesthesia: a retrospective review of 928 cases.

BACKGROUND AND OBJECTIVES: Subcutaneous (SC) unfractionated heparin (UFH) administered 3 times daily (TID) is widely used for venous thromboembolism prophylaxis in the perioperative period. There are no data in the literature regarding the incidence of adverse outcomes with neuraxial analgesia in the setting of this regimen. In this retrospective review, we report the incidence of untoward events related to anticoagulation with SC UFH TID in patients with indwelling epidural catheters. METHODS: We queried the electronic hospital databases to identify patients receiving thoracic epidural analgesia in conjunction with 5000 U UFH SC TID from July 2008 to October 2010. In this group, we identified the diagnoses of neuraxial hematoma, deep vein thrombosis, or pulmonary embolism and examined measured blood coagulation parameters. In addition, we determined the percentage of patients receiving concomitant therapy with ketorolac. RESULTS: We identified 928 patients who received thoracic epidural analgesia in conjunction with 5000 U UFH SC TID during this period. There were no cases of neuraxial bleeding. Seven patients had a diagnosed deep vein thrombosis or pulmonary embolism. Thirty-four percent (315/928) of patients received ketorolac. The measured activated thromboplastin time was more than 40 seconds (35 seconds being the upper limit of normal) in 115 patients (12%). CONCLUSIONS: Given the rare incidence of neuraxial hematoma, statements regarding the appropriateness of epidural analgesia in the setting of TID SC UFH cannot be made from this limited sample size. At present, information regarding epidural hematoma in the setting of a TID SC UFH dosing regimen does not exist in the literature. Our study represents an initial step in the accumulation of data needed to prove or disprove the safety of this practice.