Publications by authors named "Girish P Joshi"

173 Publications

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

Anesth Analg 2021 05;132(5):1223-1230

From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine.

Methods: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data.

Results: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia.

Conclusions: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.
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http://dx.doi.org/10.1213/ANE.0000000000005446DOI Listing
May 2021

Outcomes of Sleep Apnea Surgery in Outpatient and Inpatient Settings.

Anesth Analg 2021 05;132(5):1215-1222

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

Background: Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility.

Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses.

Results: A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77).

Conclusions: This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study.
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http://dx.doi.org/10.1213/ANE.0000000000005394DOI Listing
May 2021

Anesthesia care for coronavirus disease (COVID-19) patients: Results from a survey evaluating opinions of American Society of Anesthesiologists (ASA) members.

Anaesth Crit Care Pain Med 2021 Mar 18;40(3):100840. Epub 2021 Mar 18.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, TX, USA.

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http://dx.doi.org/10.1016/j.accpm.2021.100840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970655PMC
March 2021

Meta-analyses of gabapentinoids for pain management after knee arthroplasty: A caveat emptor? A narrative review.

Acta Anaesthesiol Scand 2021 Mar 17. Epub 2021 Mar 17.

Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark.

The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta-analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta-analyses should critically assess the clinical aspects of the included studies.
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http://dx.doi.org/10.1111/aas.13820DOI Listing
March 2021

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations.

Reg Anesth Pain Med 2021 May 12;46(5):433-445. Epub 2021 Jan 12.

Department of Cardiovascular Sciences, KULeuven, Leuven, Belgium.

Background And Objectives: Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.

Strategy And Selection Criteria: Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.

Results: Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.

Conclusions: Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.
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http://dx.doi.org/10.1136/rapm-2020-101933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070600PMC
May 2021

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques.

Plast Reconstr Surg Glob Open 2020 Dec 17;8(12):e3224. Epub 2020 Dec 17.

Department of Plastic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.
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http://dx.doi.org/10.1097/GOX.0000000000003224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787285PMC
December 2020

Preoperative Carbohydrate Loading on Outcomes after Cardiac Surgery: A Flawed Meta-Analysis. Comment on: "The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials". 2020, , 3105.

Nutrients 2020 12 21;12(12). Epub 2020 Dec 21.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX 75390-9068, USA.

We read, with interest, the publication in on the effects of preoperative carbohydrate loading on outcomes after cardiac surgery [...].
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http://dx.doi.org/10.3390/nu12123904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766376PMC
December 2020

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review.

Anesth Analg 2021 04;132(4):1003-1011

Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas.

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.
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http://dx.doi.org/10.1213/ANE.0000000000005330DOI Listing
April 2021

Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations.

Eur Spine J 2020 Nov 27. Epub 2020 Nov 27.

Anesthesia and Intensive Care Department, Inserm, INRA, Univ Rennes, CHU Rennes, CIC 1414 NuMeCan, 35000, Rennes, France.

Purpose: With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy.

Methods: A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020-assessing post-operative pain using analgesic, anaesthetic and surgical interventions-were identified from MEDLINE, EMBASE and Cochrane Databases.

Results: Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended. Some interventions-gabapentinoids and intrathecal opioid administration-although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence.

Conclusion: Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations.
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http://dx.doi.org/10.1007/s00586-020-06661-8DOI Listing
November 2020

Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon.

Plast Reconstr Surg Glob Open 2020 May 26;8(5):e2833. Epub 2020 May 26.

Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.

Pain management is a central focus for the plastic surgeon's perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities-preoperative, intraoperative, and postoperative settings.
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http://dx.doi.org/10.1097/GOX.0000000000002833DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605865PMC
May 2020

Spinal anesthesia for ambulatory surgery: current controversies and concerns.

Curr Opin Anaesthesiol 2020 Dec;33(6):746-752

University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Purpose Of Review: General anesthesia is a popular choice for ambulatory surgery. Spinal anesthesia is often avoided because of perceived delays due to time required to administer it and prolonged onset, as well as concerns of delayed offset, which may delay recovery and discharge home. However, the reports of improved outcomes in hospitalized patients undergoing total joint arthroplasty have renewed the interest in spinal anesthesia. This review article critically assesses the role of spinal anesthesia in comparison with fast-track general anesthesia for the outpatient setting.

Recent Findings: The purported benefits of spinal anesthesia include avoidance of airway manipulation and the adverse effects of drugs used to provide general anesthesia, improved postoperative pain, and reduced postoperative opioid requirements. Improved postoperative outcomes after spinal anesthesia in hospitalized patients may not apply to the outpatient population that tends to be relatively healthier. Also, it is unclear if spinal anesthesia is superior to fast-track general anesthesia techniques, which includes avoidance of benzodiazepine premedication, avoidance of deep anesthesia, use of an opioid-sparing approach, and minimization of neuromuscular blocking agents with appropriate reversal of residual paralysis.

Summary: The benefits of spinal anesthesia in the outpatient setting remain questionable at best. Further studies should seek clarification of these goals and outcomes.
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http://dx.doi.org/10.1097/ACO.0000000000000924DOI Listing
December 2020

Enhanced recovery pathways for ambulatory surgery.

Authors:
Girish P Joshi

Curr Opin Anaesthesiol 2020 Dec;33(6):711-717

University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Purpose Of Review: Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes.

Recent Findings: Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis.

Summary: Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.
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http://dx.doi.org/10.1097/ACO.0000000000000923DOI Listing
December 2020

Perioperative Opioid Administration.

Anesthesiology 2021 04;134(4):645-659

Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
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http://dx.doi.org/10.1097/ALN.0000000000003572DOI Listing
April 2021

Think Before You Administer: Is Routine Benzodiazepine Premedication Before Endoscopy in Adults Necessary?

Anesth Analg 2020 09;131(3):738-740

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas.

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http://dx.doi.org/10.1213/ANE.0000000000004784DOI Listing
September 2020

Ambulatory Extended Recovery: Coming to an Operating Theater Near You.

Anesth Analg 2020 09;131(3):695-698

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1213/ANE.0000000000004984DOI Listing
September 2020

Surgical Support for Severe COVID-19 Patients: A Retrospective Cohort Study in a French High-Density COVID-19 Cluster.

Surg Innov 2020 Dec 2;27(6):564-569. Epub 2020 Sep 2.

Department of Orthopaedic and Plastic Surgery, University Hospital of Strasbourg, FMTS, University of Strasbourg, France.

The COVID-19 epidemic has resulted in a massive surge in the need for intensive care unit (ICU) care. To avoid being overwhelmed, hospitals had to adapt and support the ICU teams in structured ICU care including involving surgical teams. This work aims at describing the collaborative efforts between the ICU care team and the Surgical Task Force (STF) during a surge of ICU activity in a University Hospital in a French high-density COVID-19 cluster. This retrospective single center study analyzed the STF workflow and the ICU population. The study included 55 patients hospitalized in our ICU, ICU-converted step-down units, and post-anesthesia care units. The primary measure was the global daily STF activity. The secondary measure was the daily activity for each of the 5 tasks accomplished by the STF. The STF attempted 415 phone calls for 55 patients' families, 237 mobilizations of patients requiring prone positions, follow-up of 20 patients requiring medevac, and contribution to ethical discussion for 2 patients. The mean (SD) daily number of successful phones calls, ethical discussions, mobilizations of patients requiring prone positions and medevac follow-up were 18 (7), .1 (.4), 10 (7), and 2 (3), respectively. No actions for discharge summaries writing were required. The maximum number of daily mobilizations for patients requiring prone positions was 25. The maximum number of daily attempted phone calls and successful phone calls were 37 and 26, respectively. Surgeons' technical and nontechnical skills represented an effective support for ICU teams during the COVID-19 pandemic.
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http://dx.doi.org/10.1177/1553350620954571DOI Listing
December 2020

Unanticipated Hospital Admission After Ambulatory Surgery: The Devil Is in the Details.

Anesth Analg 2020 08;131(2):494-496

Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas.

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http://dx.doi.org/10.1213/ANE.0000000000004947DOI Listing
August 2020

Author's Reply: Evidence-Based Management of Postoperative Pain in Adults Undergoing Laparoscopic Sleeve Gastrectomy.

World J Surg 2020 11;44(11):3965-3966

Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1007/s00268-020-05673-1DOI Listing
November 2020

Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery.

Acta Anaesthesiol Scand 2020 10 16;64(9):1270-1277. Epub 2020 Jul 16.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.

Background: The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair.

Materials And Methods: The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions.

Results: A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used.

Conclusions: Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.
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http://dx.doi.org/10.1111/aas.13660DOI Listing
October 2020

Comparison of Regional Anesthesia Timing on Pain, Opioid Use, and Postanesthesia Care Unit Length of Stay in Patients Undergoing Open Reduction and Internal Fixation of Ankle Fractures.

J Foot Ankle Surg 2020 Jul - Aug;59(4):788-791. Epub 2020 May 10.

Professor, Department of Anesthesiology & Pain Management, University of Texas Southwestern, Dallas, TX.

Regional nerve blocks are an effective method of managing acute pain associated with surgery. The relative benefit of preoperative versus postoperative peripheral nerve blocks is not entirely clear. The primary aim of this study was to determine differences in pain scores in patients undergoing preoperative block versus postoperative block versus no block. We hypothesized that patients receiving preoperative blocks would have reduced pain scores and decreased opioid use in the immediate postoperative period. We conducted a retrospective cohort analysis of 302 consecutive patients undergoing unilateral open reduction and internal fixation of ankle fracture under general anesthesia. We identified 3 groups: preoperative block, postoperative block, or no block. Data obtained from our electronic medical records included demographic information, postanesthesia care unit length of stay, pain scores obtained preoperatively, upon arrival to the postanesthesia care unit, and upon discharge from the postanesthesia care unit as well as intraoperative and postanesthesia care unit opioid utilization. Patients receiving preoperative block had significantly lower pain scores, less intraoperative or postanesthesia care unit opioid use, and shorter postanesthesia care unit dwell time compared with patients receiving postoperative block or no block. Preoperative popliteal sciatic and adductor canal blocks in patients undergoing ankle fracture surgery appears to be more effective than either postoperative block or no block.
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http://dx.doi.org/10.1053/j.jfas.2019.05.012DOI Listing
May 2020

Readmission Rate After 2-level Lumbar Decompression: A Propensity-matched Cohort Study Comparing Inpatient and Outpatient Settings.

Clin Spine Surg 2021 Feb;34(1):E1-E6

Departments of Anesthesiology and Pain Management.

Study Design: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015.

Objective: Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings.

Summary Of Background Data: In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge.

Methods: The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients.

Results: A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P<0.001). In the matched sample, there was no statistically significant difference in the 30-day readmission rate (odds ratio, 0.82; 95% confidence interval, 0.64-1.04; P=0.097) between the two cohorts; however, the ambulatory cohort had a lower 30-day postoperative major complication rate (odds ratio, 0.55; 95% confidence interval, 0.38-0.79; P=0.002).

Conclusions: After 2-level lumbar decompression performed on inpatient versus outpatient basis, the 30-day readmission rate is similar. However, the 30-day postoperative complication rate is significantly lower in the ambulatory setting. The reasons for these differences need further exploration.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000000990DOI Listing
February 2021

COVID-19: Role of Ambulatory Surgery Facilities in This Global Pandemic.

Anesth Analg 2020 07;131(1):31-36

Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas.

Coronavirus disease 2019 (COVID-19) has now become a global pandemic. This has led the United States to declare a national emergency and resulted in a ban on all elective diagnostic and therapeutic procedures as well as elective surgery in inpatient and outpatient settings. Ambulatory surgery facilities (ASF) that perform only elective procedures are thus likely to be closed. However, these facilities may be able to assist acute care hospitals as essential (urgent and emergent) surgeries and diagnostic and therapeutic procedures will still need to be performed. The aim of this article is to explore the potential contribution of ASFs in the current health care crisis. It is important to understand that COVID-19-related information is continually evolving, and thus, the discussion provided here is subject to change.
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http://dx.doi.org/10.1213/ANE.0000000000004847DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173085PMC
July 2020

Failure to rescue after major abdominal surgery: The role of hospital safety net burden.

Am J Surg 2020 10 12;220(4):1023-1030. Epub 2020 Mar 12.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.

Background: We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume.

Methods: Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden.

Results: Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume.

Conclusion: Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.
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http://dx.doi.org/10.1016/j.amjsurg.2020.03.014DOI Listing
October 2020

Functional recovery after knee arthroplasty with regional analgesia.

Eur J Anaesthesiol 2020 03;37(3):253-254

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ) and Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark (HK).

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http://dx.doi.org/10.1097/EJA.0000000000001146DOI Listing
March 2020

Perioperative use of opioids: Current controversies and concerns.

Best Pract Res Clin Anaesthesiol 2019 Sep 17;33(3):341-351. Epub 2019 Jul 17.

University of Texas Southwestern Medical Center, Dallas, TX, USA.

In the midst of an epidemic of opioid abuse and overdose-related morbidity and mortality, the use of opioids remains the most common means of providing analgesia in the perioperative period. In this article, we review the risks and benefits of opioid use in preoperative, intraoperative and post-operative phases of care. Furthermore, we describe the role that surgeons and anaesthesiologists can play in reducing perioperative opioid use and mitigate their adverse effects, from both an individual and a population health perspective.
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http://dx.doi.org/10.1016/j.bpa.2019.07.009DOI Listing
September 2019

Surgical site infiltration: A neuroanatomical approach.

Best Pract Res Clin Anaesthesiol 2019 Sep 25;33(3):317-324. Epub 2019 Jul 25.

University of Texas Southwestern Medical Center, Dallas, TX, USA.

Local anaesthetic administration into a surgical wound blocks the noxious stimuli that result from surgical insult at the site of origin. Surgical site infiltration (also known as local infiltration analgesia) is easy to perform, safe and inexpensive. In addition, it avoids motor blockade, which is particularly relevant for lower limb surgery. The best approach to surgical site infiltration includes meticulous, systematic and extensive surgical site local anaesthetic infiltration in the various tissue planes under direct visualisation before closure of the surgical wound. Local anaesthetic solutions that could be used include bupivacaine HCl, ropivacaine or liposomal bupivacaine diluted with preservative-free normal (0.9%) saline to a total volume depending on the size of the incision. Bupivacaine and ropivacaine are sometimes combined with additives, which have controversial benefits. Continuous wound infusion with preperitoneal wound catheters is an effective pain modality in abdominal surgery and can be used as an alternative for neuraxial analgesia. It is essential that surgical site infiltration is combined with other non-opioid analgesics such as paracetamol and non-steroidal anti-inflammatory drugs to attain the maximum analgesic efficacy.
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http://dx.doi.org/10.1016/j.bpa.2019.07.017DOI Listing
September 2019

Interfascial plane blocks.

Best Pract Res Clin Anaesthesiol 2019 Sep 8;33(3):303-315. Epub 2019 Aug 8.

Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.
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http://dx.doi.org/10.1016/j.bpa.2019.08.001DOI Listing
September 2019

Postoperative pain management in the era of ERAS: An overview.

Best Pract Res Clin Anaesthesiol 2019 Sep 25;33(3):259-267. Epub 2019 Jul 25.

Section of Surgical Pathophysiology 7621, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. Electronic address:

Enhanced recovery after surgery (ERAS) programmes are increasingly becoming standard of care for several surgical procedures. However, compliance with ERAS protocols including pain management protocols remains poor. The PROSPECT (PROcedure-SPEcific Postoperative Pain ManagemenT) collaboration provides evidence-based, procedure-specific pain management recommendations presented as preoperative, intraoperative and postoperative interventions as well as surgical interventions that are easy to access, transparent and relevant to clinicians. This approach should facilitate incorporation of pain management recommendations in an ERAS protocol and improve compliance with the protocols. This article presents an improved approach to developing pain management guidelines as well as a pragmatic approach to procedure-specific perioperative pain management that could be incorporated in an ERAS pathway.
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http://dx.doi.org/10.1016/j.bpa.2019.07.016DOI Listing
September 2019

Preface.

Best Pract Res Clin Anaesthesiol 2019 Sep 21;33(3):257-258. Epub 2019 Oct 21.

Department of Anesthesiology, Assistance Publique Hopitaux de Paris, Sorbonne Université Paris VI, Tenon Hospital, Paris, France.

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http://dx.doi.org/10.1016/j.bpa.2019.10.001DOI Listing
September 2019

In Response.

Anesth Analg 2019 12;129(6):e202

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center/Penn State Health, Hershey, Pennsylvania Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Health System, Miami, Florida Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas,

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http://dx.doi.org/10.1213/ANE.0000000000004449DOI Listing
December 2019