Johnson, Rebecca L.

Cannabis use is increasingly common, and with a growing number of jurisdictions implementing legalization frameworks, it is likely that providers will encounter more patients who use cannabis. Therefore, it is important for providers to understand the implications of cannabis use and practical considerations for the perioperative period. Cannabis affects multiple organ systems and may influence intraoperative anesthesia, as well as postoperative pain management. The effects of cannabis and key anesthetic considerations are reviewed here.

Background and objectives Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement. Results Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Background Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. Methods A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. Results Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). Conclusions Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Objective The objective of this study was to introduce musculoskeletal physical examination skills in the gross anatomy course as a teaching tool and to evaluate medical students’ perceptions of this experience. Methods A list of 27 clinical examinations of the upper and lower limbs was generated from published core recommendations for undergraduate medical education. During gross anatomy laboratory sessions, teaching assistants (third year medical students) presented one or two of the clinical skills related to that day’s dissection to groups of 3–4 students at a time. The anatomic relationships tested by the clinical examinations were highlighted. One question on the laboratory examination at the end of the unit was an Objective Structured Clinical Examination (OSCE) station where students were given a clinical scenario and asked to demonstrate a physical examination that they would use in evaluating the patient. Following the upper and lower limb units, the students were given a Likert‐scale survey to evaluate their perceptions of the experience. Results Survey responses indicated that most students felt the physical examination demonstrations improved their understanding of the clinical significance of the related anatomy, increased their interest in and motivation to learn the material, and made the laboratory experience more enjoyable. Conclusions Introducing musculoskeletal physical examination skills in the gross anatomy course can be an effective way to emphasize the clinical significance of the anatomy, thereby enhancing students’ motivation to learn the material.

Background There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques. Methods We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement. Results Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified. Conclusions Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Background Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications. Methods Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed. Results There were 343 falls among 200 186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10 000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 – 3.6) per 100 000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001). Conclusions The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.

BACKGROUND: Retrospective and prospective studies 2 decades ago from the authors’ institution reported the incidence of perioperative ulnar neuropathy persisting for at least several months in a noncardiac adult surgical population to be between 30 and 40 per 100,000 cases. The aim of this project was to assess the incidence and explore risk factors for perioperative ulnar neuropathy in a recent cohort of patients from the same institution using a similar definition for ulnar neuropathy. METHODS: We performed a retrospective incidence and case-control study of all adults (≥18 years) undergoing noncardiac procedures with anesthesia services between 2011 and 2015. Each incident case of persistent ulnar neuropathy within 6 months of surgery was matched by age, sex, procedure date, and procedure type to 5 surgical patient controls. For the case-control study, separate conditional logistic regression analyses were performed to assess specific risk factors including the patient’s body position and arm position, as well as body mass index (BMI), surgical duration, and selected patient comorbidities. RESULTS: Persistent ulnar neuropathy of at least 2 months duration was found in 22 of 324,124 anesthetics for patients who underwent these procedures during the study period for an incidence rate of 6.8 (95% confidence interval [CI], 4.3-10.3) per 100,000 anesthetics. The incidence of ulnar neuropathy was higher in men compared to women (10.7 vs 3.0 per 100,000; P = .016). From the matched case-control study, the odds of ulnar neuropathy increased with higher BMI (odds ratio [OR] = 1.67 [1.16-2.42] per 5 kg/m 2 increase in BMI; P = .006), history of cancer (OR = 6.46 [1.64-25.49]; P = .008), longer procedures (OR = 1.53 [1.18-1.99] per hour; P = .001), and when 1 or both arms were tucked during surgery (OR = 6.16 [1.85-20.59]; P = .003). CONCLUSIONS: The incidence of persistent perioperative ulnar neuropathy observed in this study was lower than the incidence reported 2 decades ago from the same institution and using a similar definition for ulnar neuropathy. Several of the previously reported risk factors continue to be associated with the development of persistent perioperative ulnar neuropathy, providing ongoing targets for practice changes that might further decrease the incidence of this problem.

Background Postoperative in-hospital pneumonia is a serious complication. This study aims to investigate the association between 3 preoperative stratification tools (American Society of Anesthesiologists Physical Status [ASA-PS] score, Charlson Comorbidity Index [CCI], and Rockwood Frailty Deficit Index [FI]) and risk for postoperative pneumonia. Methods We identified adult patients who developed postoperative pneumonia following noncardiothoracic surgery under general anesthesia, between January 1, 2016 and December 31, 2017. Patients with postoperative pneumonia were 1:1 matched to control subjects based on age, sex, and the exact type of operations. Medical records were reviewed to identify variables that may be associated with risk for developing postoperative pneumonia. Analyses adjusted for clinical characteristics were performed using the conditional logistic regression, taking into account 1:1 matched set case-control study design. Results We identified 211 cases of postoperative pneumonia, and all 3 tested stratification tools were associated with increased risk: ASA-PS (after all adjustments of American Society of Anesthesiologists (ASA) III, odds ratio 4.17 [95% confidence interval 1.74-10.01]; ASA > III 24.03 [6.54-88.32]), CCI (CCI values > 3, 1.29 [1.02-1.63] per unit CCI score), and frail FI score 3.25 (1.45-7.27). Because of incomplete intake documentation, the FI could not be calculated in 57 (13.5%) patients, but these “unknown frailty” patients were also at increased risk for postoperative pneumonia, 3.15 (1.29-7.72). Discussion Three commonly used stratification indices (ASA-PS score, CCI, and FI) were associated with increased risk for postoperative pneumonia. Patients unable to complete intake form to calculate the FI were also at increased risk.

Background and objectives Thoracic paravertebral blockade is often used as an anesthetic and/or analgesic technique for breast surgery. With ultrasound guidance, the rate of complications is speculated to be lower than when using landmark-based techniques. This investigation aimed to quantify the incidence of pleural puncture and pneumothorax following non-continuous ultrasound-guided thoracic paravertebral blockade for breast surgery. Methods Patients who received thoracic paravertebral blockade for breast surgery were identified by retrospective query of our institution’s electronic database over a 5-year period. Data collected included patient demographics, level of block, type and volume of local anesthetic, occurrence of pleural puncture, occurrence of pneumothorax, evidence of local anesthetic toxicity, and patient vital signs. The incidence of block complications, including pleural puncture, pneumothorax, and local anesthetic toxicity, were ascertained. Results 529 patients underwent 2163 thoracic paravertebral injections. Zero pleural punctures were identified during block performance; however, two patients were found to have a pneumothorax on postoperative chest X-ray (3.6 per 1000 surgeries, 95% CI 0.5 to 13.6; 0.9 per 1000 levels blocked, 95% CI 0.1 to 3.3). There were no cases of local anesthetic systemic toxicity or associated lipid emulsion therapy administration. Conclusions Pneumothorax following non-continuous ultrasound-guided thoracic paravertebral block using a parasagittal approach is an uncommon occurrence, with a similar rate to pneumothorax following breast surgery alone.