Publications by authors named "Stavros G Memtsoudis"

287 Publications

Considerations when prescribing tramadol postoperatively, in response to Rocha-Romero.

Reg Anesth Pain Med 2022 Jul 29. Epub 2022 Jul 29.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA

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http://dx.doi.org/10.1136/rapm-2022-103938DOI Listing
July 2022

The Use of Critical Care Services After Orthopedic Surgery at a High-Volume Orthopedic Medical Center: A Retrospective Study.

HSS J 2022 Aug 28;18(3):344-350. Epub 2021 Oct 28.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA.

With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center. We retrospectively reviewed inpatient electronic medical record data (2016-2020) at a high-volume orthopedic hospital. Patients who required CCS and intermediate levels of care, including step-down unit (SDU) and telemetry services, were identified. We described characteristics related to patients, procedures, and outcomes, including type of advanced services required and surgery type. Of the 50,387 patients who underwent orthopedic inpatient surgery, 1.6% required CCS and 21.6% were admitted to an SDU. Additionally, 482 (1.0%) patients required postoperative mechanical ventilation and 3602 (7.1%) patients required continuous positive airway pressure therapy. Spine surgery patients were the most likely to require any form of advanced care (45.7%). This retrospective review found that approximately one-fourth of orthopedic surgery patients were admitted to units that provided critical and intermediate levels of care. These results may prove useful to hospitals in estimating needs and allocating resources for advanced and critical care services after orthopedic surgery.
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http://dx.doi.org/10.1177/15563316211055166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9247588PMC
August 2022

Patient care in rapid-expansion intensive care units during the COVID-19 pandemic crisis.

BMC Anesthesiol 2022 07 7;22(1):209. Epub 2022 Jul 7.

Department of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, Room A-1050, NY, 10065, New York, USA.

Background: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients.

Methods: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care.

Results: Sixty-six patients were admitted to Expansion ICUs from March 1 to April 30, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45-64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality.

Conclusions: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU.
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http://dx.doi.org/10.1186/s12871-022-01752-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9261025PMC
July 2022

Tramadol prescribed at discharge is associated with lower odds of chronic opioid use after elective total joint arthroplasty.

Reg Anesth Pain Med 2022 Jun 27. Epub 2022 Jun 27.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA

Introduction: We aimed to study the association between tramadol prescribed at discharge (after elective total hip and knee arthroplasty (THA/TKA) surgery) and chronic opioid use postoperatively.

Methods: This retrospective cohort study queried the Truven MarketScan database and identified patients who underwent an elective THA/TKA surgery between 2016 and 2018 and were prescribed opioids at discharge (n=81 049). Multivariable analysis was conducted to study the association between tramadol prescription at discharge and chronic opioid use, with additional analysis adjusting for the amount of opioids prescribed in oral morphine equivalents. Chronic opioid use was defined as filling ≥10 opioid prescriptions or prescriptions for ≥120 pills within the period from 90 days to 1 year after surgery.

Results: Overall, tramadol was prescribed at discharge in 11.0% of all THA/TKA cases. Of those, 26.9% and 73.1% received tramadol only or tramadol with another opioid, respectively. Chronic opioid use was observed in 5.4% of cases. After adjustment for relevant covariates, prescription of tramadol combined with another opioid at discharge was associated with lower odds of chronic opioid use comparing to prescription of other opioids (OR 0.69 CI 0.61 to 0.78).

Discussion: Among patients undergoing elective THA/TKA surgery and discharged with a prescription of opioids, we found that prescription of tramadol combined with another opioid was associated with lower odds of chronic opioid use. This finding must be considered in the context of the tramadol's pharmacology, as well-described genetic differences in metabolism that can make it ineffective in many patients, while for patients with ultrarapid metabolism can cause drug-drug interactions and adverse events, including feelings of high and seizures.
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http://dx.doi.org/10.1136/rapm-2022-103486DOI Listing
June 2022

Trends in the utilization of epidural steroid injections to treat back pain prior to spine surgery.

Pain Med 2022 Jun 16. Epub 2022 Jun 16.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, US.

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http://dx.doi.org/10.1093/pm/pnac095DOI Listing
June 2022

Improving Safety of Bilateral Knee Arthroplasty: Impact of Selection Criteria on Perioperative Outcome.

HSS J 2022 May 21;18(2):248-255. Epub 2021 May 21.

Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece; Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Orthopaedic Surgery, Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.

: Bilateral total knee arthroplasty (BTKA) procedures are associated with an increased risk of complications when compared with unilateral approaches. In 2006, in an attempt to reduce this risk, our institution implemented selection criteria that specified younger and healthier patients as candidates for BTKA. : We sought to investigate the effect of these selection criteria on perioperative outcomes. : In a retrospective cohort study, we used institutional data to identify patients who underwent BTKA between 1998 and 2014. Patients were divided into 2 groups: those who underwent surgery before the 2006 introduction of our selection criteria (1998-2006) and those who underwent surgery after (2007-2014). Groups were compared in terms of demographics, comorbidity burden, and incidence of perioperative complications. Regression analysis was performed, calculating incidence rate ratios to evaluate changes in complication rates. : Before the selection criteria were implemented in 2006, patients who underwent BTKA were older and had a higher comorbidity burden. The rate of major complications per 1000 hospital days decreased from 31.5 in 1998 to 7.9 in 2014. A reduction in cardiac complications was the most significant contributor to this decrease in major complications. : After stringent criteria for BTKA candidates were implemented at our institution, selection of younger patients with lower comorbidity burden was accompanied by a reduction in the incidence of operative complications. This suggests that introducing such criteria can be associated with a reduction in adverse perioperative outcomes.
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http://dx.doi.org/10.1177/15563316211014891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9096997PMC
May 2022

Anaesthesia practice in the first wave of the COVID-19 outbreak in the United States: a population-based cohort study.

Br J Anaesth 2022 07 15;129(1):e16-e18. Epub 2022 Apr 15.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2022.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9010244PMC
July 2022

Trends in discontinuation of buprenorphine following elective orthopedic surgery: a national database analysis.

Reg Anesth Pain Med 2022 May 10. Epub 2022 May 10.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA.

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http://dx.doi.org/10.1136/rapm-2022-103592DOI Listing
May 2022

Medicare/Medicaid Insurance Status Is Associated With Reduced Lower Bilateral Knee Arthroplasty Utilization and Higher Complication Rates.

J Am Acad Orthop Surg Glob Res Rev 2022 Apr 1;6(4). Epub 2022 Apr 1.

From the Department of Medicine, Hospital for Special Surgery, New York, NY (Dr. Mehta, Dr. Russell, and Dr. Goodman); the Department of Medicine (Dr. Mehta, Dr. Memtsoudis, Dr. Parks, Dr. Russell, and Dr. Goodman), and the Department of Population Health Sciences (Dr. Ho), Weill Cornell Medicine, New York, NY; the Department of Orthopedics (Dr. Bido and Dr. Parks), and the Department of Anesthesiology (Dr. Memtsoudis), Hospital for Special Surgery, New York, NY; and the Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY (Dr. Ibrahim).

Whether to undergo bilateral total knee arthroplasty (BTKA) depends on patient and surgeon preferences. We used the National Inpatient Sample to compare temporal trends in BTKA utilization and in-hospital complication rates among TKA patients ≥50 with Medicare/Medicaid versus private insurance from 2007 to 2016. We used multivariable logistic regression to assess the association between insurance type and trends in utilization and complication rates adjusting for individual-, hospital-, and community-level covariates, using unilateral TKA (UTKA) for reference. Discharge weights were used for nationwide estimates. About 132,400 (49.5%) Medicare/Medicaid patients and 135,046 (50.5%) privately insured patients underwent BTKA. Among UTKA patients, 62.7% had Medicare/Medicaid, and 37.3% had private insurance. Over the study period, BTKA utilization rate decreased from 7.18% to 5.63% among privately insured patients and from 4.59% to 3.13% among Medicaid/Medicare patients (P trend difference <0.0001). In multivariable analysis, Medicare/Medicaid patients were less likely to receive BTKA than privately insured patients. Although Medicare/Medicaid patients were more likely to develop in-hospital complications after UTKA (adjusted odds ratio, 1.06; 95% confidence interval, 1.002 to 1.12; P = 0.04), this relationship was not statistically significant for BTKAs. In this nationwide sample of TKA patients, BTKA utilization rate was higher in privately insured patients compared with Medicare/Medicaid patients. Furthermore, privately insured patients had lower in-hospital complication rates than Medicare/Medicaid patients.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00016DOI Listing
April 2022

Effect of portable negative pressure units on expelled aerosols in the operating room environment.

Reg Anesth Pain Med 2022 07 1;47(7):426-429. Epub 2022 Apr 1.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA

Introduction: Spontaneously breathing patients undergoing procedures under regional anesthesia can expose operating room personnel to infectious agents. The use of localized negative pressure within proximity of a patient's airway is expected to reduce the amount of bioaerosols dispersed particularly for anesthesia staff who are frequently near the patient's airway.

Methods: In the experiment, aerosols were produced using a polydisperse aerosol generator with nebulized saline. A portable negative pressure unit was set up at set distances of 10 cm and 30 cm with the aim of reducing aerosol particle counts detected by a laser-based particle counter.

Results: Without the portable negative pressure unit, the median concentration of 0.5 µm aerosols detected was 3128 (1533, 22832) particles/ft/min. With the portable negative pressure unit 10 cm and 30 cm from the site of aerosol emittance, the median concentration compared with background concentration was -0.5 (-8, 8) particles/ft/min and 398 (89, 1749) particles/ft/min, respectively.

Conclusions: For particle concentrations of 0.5 µm, 0.7 µm, and 1.0 µm a significant amount of aerosol reduction was observed (p<0.001). Further experiments are warranted to assess the safety of staff when encountering a potentially infectious patient in the operating room.
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http://dx.doi.org/10.1136/rapm-2022-103489DOI Listing
July 2022

Utilisation of prescription cannabinoids in different surgical cohorts in the United States: a population-based study.

Br J Anaesth 2022 06 29;128(6):e341-e342. Epub 2022 Mar 29.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2022.02.035DOI Listing
June 2022

An Overview of Commonly Used Data Sources in Observational Research in Anesthesia.

Anesth Analg 2022 03;134(3):548-558

Departments of Population Health Science and Policy.

Anesthesia research using existing databases has drastically expanded over the last decade. The most commonly used data sources in multi-institutional observational research are administrative databases and clinical registries. These databases are powerful tools to address research questions that are difficult to answer with smaller samples or single-institution information. Given that observational database research has established itself as valuable field in anesthesiology, we systematically reviewed publications in 3 high-impact North American anesthesia journals in the past 5 years with the goal to characterize its scope. We identified a wide range of data sources used for anesthesia-related research. Research topics ranged widely spanning questions regarding optimal anesthesia type and analgesic protocols to outcomes and cost of care both on a national and a local level. Researchers should choose their data sources based on various factors such as the population encompassed by the database, ability of the data to adequately address the research question, budget, acceptable limitations, available data analytics resources, and pipeline of follow-up studies.
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http://dx.doi.org/10.1213/ANE.0000000000005880DOI Listing
March 2022

Health Services Research in Anesthesia: A Brief Overview of Common Methodologies.

Anesth Analg 2022 03;134(3):540-547

Department of Population Health Science & Policy/Department of Orthopedics, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York.

The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning.
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http://dx.doi.org/10.1213/ANE.0000000000005884DOI Listing
March 2022

The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States.

Anesth Analg 2022 03;134(3):486-495

From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.

Background: Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population.

Methods: We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006-2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1).

Results: Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60-73]/64 [57-71] among short/long-acting compared to 69 [61-76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83-345] vs 256 [IQR, 153-431] with short-acting, and 329 [IQR, 195-540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years.

Conclusions: Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.
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http://dx.doi.org/10.1213/ANE.0000000000005854DOI Listing
March 2022

Factors associated with long-term opioid use in paediatric surgical patients.

Eur J Anaesthesiol 2022 03;39(3):277-278

From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery (KRD, HZ, LAW, JL, SGM), Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA (KRD, JL, SGM), Department of Pediatric and Adolescent Surgery, Paracelsus Medical University, Salzburg, Austria (HNL), Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai (JP) and Department of Health Policy and Research, Weill Cornell Medical College, New York, NY (SGM).

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http://dx.doi.org/10.1097/EJA.0000000000001533DOI Listing
March 2022

Interscalene Brachial Plexus Block with Liposomal Bupivacaine versus Standard Bupivacaine with Perineural Dexamethasone: A Noninferiority Trial.

Anesthesiology 2022 03;136(3):434-447

Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York.

Background: The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery.

Methods: A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events.

Results: A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], -1.1 [-1.8, -0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events.

Conclusions: Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000004111DOI Listing
March 2022

Association of perioperative midazolam use and complications: a population-based analysis.

Reg Anesth Pain Med 2022 04 12;47(4):228-233. Epub 2022 Jan 12.

Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria

Introduction: The benzodiazepine midazolam is the main sedative used in the perioperative setting, resulting in anxiolysis and a reduction in anesthetic dose requirements. However, benzodiazepine use is also associated with potentially serious side effects including respiratory complications, and postoperative delirium (POD). A paucity of population level data exists on current perioperative midazolam use in adult orthopedic surgery and its effects on complications. Using a large national dataset, we aimed to determine perioperative midazolam utilization patterns and to analyze its effect on postoperative outcomes.

Methods: Patients who underwent total knee and hip arthroplasty (TKA/THA) were identified from Premier database (2006-2019). Primary exposure of interest was midazolam use on the day of surgery. Multivariable logistic regression models were run to determine if midazolam was associated with postoperative cardiac and pulmonary complications, delirium, and in-hospital falls.

Results: Among 2,848,897 patients, more than 75% received midazolam perioperatively. This was associated with increased adjusted odds for in-hospital falls in TKA/THA (OR 1.1, 95% CI 1.07 to 1.14)/(OR 1.1, 95% CI 1.06 to 1.16), while a decrease in the adjusted odds for cardiac complications in TKA/THA (OR 0.94, 95% CI 0.91 to 0.97)/(OR 0.93, 95% CI 0.89 to 0.97), and pulmonary complications (OR 0.92, 95% CI 0.87 to 0.96) (all p<0.001) was seen. Most notably, the concurrent use of midazolam and gabapentinoids significantly increased the adjusted odds for postoperative complications, including pulmonary complications (OR 1.22, 95% CI 1.18 to 1.27)/(OR 1.29, 95% CI 1.22 to 1.37), naloxone utilization (OR 1.56, 95% CI 1.51 to 1.60)/(OR 1.49, 95% CI 1.42 to 1.56), and POD (OR 1.45, 95% CI 1.38 to 1.52)/(OR 1.32, 95% CI 1.23 to 1.34) in THA/TKA.

Conclusion: Perioperative midazolam use was associated with an increase in postoperative patient falls, and a decrease in cardiac complications. Notably, the combined use of midazolam and gabapentinoids was associated with a substantial increase in the odds for respiratory failure and delirium. Given the high prevalence of benzodiazepines perioperatively, the risk benefit profile should be more clearly established to inform perioperative decision making.
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http://dx.doi.org/10.1136/rapm-2021-102989DOI Listing
April 2022

Development and Internal Validation of Machine Learning Algorithms for Predicting Hyponatremia After TJA.

J Bone Joint Surg Am 2022 02;104(3):265-270

Department of Anesthesiology, Weill Cornell Medical College, New York, NY.

Background: The development of hyponatremia after total joint arthroplasty (TJA) may lead to several adverse events and is associated with prolonged inpatient length of stay as well as increased hospital costs. The purpose of this study was to develop and internally validate machine learning algorithms for predicting hyponatremia after TJA.

Methods: A consecutive cohort of 30,703 TJA patients from an institutional registry at a large, tertiary academic hospital were included. A total of 19 potential predictor variables were collected. Hyponatremia was defined as a serum sodium concentration of <135 mEq/L. Five machine learning algorithms were developed using a training set and internally validated using an independent testing set. Algorithm performance was evaluated through discrimination, calibration, decision-curve analysis, and Brier score.

Results: The charts of 30,703 patients undergoing TJA were reviewed. Of those patients, 5,480 (17.8%) developed hyponatremia postoperatively. A combination of 6 variables were demonstrated to optimize algorithm prediction: preoperative serum sodium concentration, age, intraoperative blood loss, procedure time, body mass index (BMI), and American Society of Anesthesiologists (ASA) score. Threshold values that were associated with greater hyponatremia risk were a preoperative serum sodium concentration of ≤138 mEq/L, an age of ≥73 years, an ASA score of >2, intraoperative blood loss of >407 mL, a BMI of ≤26 kg/m2, and a procedure time of >111 minutes. The stochastic gradient boosting (SGB) algorithm demonstrated the best performance (c-statistic: 0.75, calibration intercept: -0.02, calibration slope: 1.02, and Brier score: 0.12). This algorithm was turned into a tool that can provide real-time predictions (https://orthoapps.shinyapps.io/Hyponatremia_TJA/).

Conclusions: The SGB algorithm demonstrated the best performance for predicting hyponatremia after TJA. The most important factors for predicting hyponatremia were preoperative serum sodium concentration, age, intraoperative blood loss, procedure time, BMI, and ASA score. A real-time hyponatremia risk calculator was developed, but it is imperative to perform external validation of this model prior to using this calculator in clinical practice.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.00718DOI Listing
February 2022

Reply to 'Can we trust the black box?'

Reg Anesth Pain Med 2022 05 7;47(5):338-339. Epub 2021 Dec 7.

Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA

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http://dx.doi.org/10.1136/rapm-2021-103336DOI Listing
May 2022

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery: A Systematic Review and Meta-analysis.

JAMA Netw Open 2021 11 1;4(11):e2133394. Epub 2021 Nov 1.

Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, University of Texas, Houston.

Importance: The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown.

Objective: To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.

Data Sources: A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.

Study Selection: Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening.

Data Extraction And Synthesis: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model.

Main Outcomes And Measures: The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function.

Results: Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs).

Conclusions And Relevance: In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.33394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8593761PMC
November 2021

Pediatric Tibial Spine Fractures: Exploring Case Burden by Age and Sex.

Orthop J Sports Med 2021 Sep 16;9(9):23259671211027237. Epub 2021 Sep 16.

Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Background: Pediatric tibial spine fractures (TSFs) are a well-known clinical entity, but the epidemiology of these injuries is not fully understood. Further, there are limited data on outcomes after TSF treatment, specifically the proportion of patients requiring subsequent anterior cruciate ligament (ACL) reconstruction.

Purpose: To describe the distribution of TSF case burden by age and sex and to determine the proportion of patients undergoing subsequent ACL reconstruction or developing ACL insufficiency.

Study Design: Descriptive epidemiology study.

Methods: The Truven Health MarketScan database was queried to identify patients aged 7 to 18 years with TSFs between 2016 and 2018. Diagnosis and initial treatment (surgical vs nonoperative) were recorded based on database coding. Case burden by age and sex was calculated. The database, which includes longitudinal data, was then queried for subsequent diagnoses of ACL insufficiency as well as subsequent ACL reconstruction procedures performed among the patients.

Results: We found 876 cases of TSF, 71.3% of which were treated nonoperatively. The male to female ratio for case burden was 2.2:1. Cases peaked at age 13 to 14 years for boys and age 11 to 12 years for girls. Of all cases identified, 3.7% also had either a diagnosis code for ACL laxity entered in a delayed fashion into the database or a later procedure code for ACL reconstruction (considered together to represent "subsequent ACL insufficiency"). Only 15 subsequent ACL reconstructions (1.7% of cases) were found, all of which were among boys and 9 of which were among boys aged 13 to 14 years.

Conclusion: This longitudinal study is the largest epidemiological analysis of pediatric TSFs to date. We found low rates of subsequent ACL insufficiency and ACL reconstruction, with boys aged 13 to 14 years accounting for most of those cases. Rates of subsequent ACL reconstruction were lower than previously reported. Boys accounted for more than two times as many TSF cases as girls.
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http://dx.doi.org/10.1177/23259671211027237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8450686PMC
September 2021

Bariatric surgery and total knee/hip arthroplasty: an analysis of the impact of sequence and timing on outcomes.

Reg Anesth Pain Med 2021 11 30;46(11):941-945. Epub 2021 Aug 30.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.

Background: Patients with morbid obesity may require both bariatric surgery and total knee/hip arthroplasty (TKA/THA). How to sequence these two procedures with better outcomes remains largely unstudied.

Methods: This cohort study extracted claims data on patients with an obesity diagnosis that received both bariatric surgery and TKA/THA surgery within 5 years of each other (Premier Healthcare database 2006-2019). Overall, 1894 patients received bariatric surgery before TKA or THA, while 1000 patients underwent TKA or THA before bariatric surgery. Main outcomes and measures include major complications (acute renal failure, acute myocardial infarction, other cardiovascular complications, sepsis/septic shock, pulmonary complications, pulmonary embolism, pneumonia, and central nervous system-related adverse events), postoperative intensive care unit utilization, ventilator utilization, 30-day readmission, 90-day readmission, 180-day readmission and total hospital length of stay after the second surgery. Regression models measured the association between the complications and sequence of TKA/THA and bariatric surgery.

Results: Undergoing TKA/THA before bariatric surgery (compared with the reverse) was associated with higher odds of major complications (7.0% vs 1.9%; adjusted OR 4.8, 95% CI 3.1, 7.6, p<0.001). Similar patterns were also observed for intensive care unit admission, ventilator use postoperatively, 30-day, and 90-day readmissions. Patients who received a second surgery within 6 months of their first surgery exhibited worse outcomes, especially among the TKA/THA first patient cohort. Major complication incidences occurred at 20.5%, 12.5%, 5.1%, 5.0%, 5.8% and 8.5% with time between TKA/THA and bariatric surgery at <6 months, 6 months-1 year, 1-2, 2-3, 3-4 and 4-5 years, respectively.

Conclusions: Patients who require both bariatric surgery and TKA/THA should consider bariatric surgery before TKA/THA as it is associated with improved outcomes. Procedures should be staged beyond 6 months.
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http://dx.doi.org/10.1136/rapm-2021-102967DOI Listing
November 2021

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

Reg Anesth Pain Med 2021 11 25;46(11):971-985. Epub 2021 Aug 25.

Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.

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.
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http://dx.doi.org/10.1136/rapm-2021-102750DOI Listing
November 2021

Enhanced Recovery Components for Posterior Lumbar Spine Fusion: Harnessing National Data to Compare Protocols.

Clin Spine Surg 2022 02;35(1):E194-E201

Department of Orthopedics.

Study Design: This was a retrospective cohort study.

Objective: The aim of this study was to assess the most commonly used components of enhanced recovery after surgery (ERAS) combinations and their relative effectiveness.

Summary Of Background Data: Data is lacking on use and effectiveness of various ERAS combinations which are increasingly used in spine surgery.

Materials And Methods: Posterior lumbar fusion cases were extracted from the Premier Healthcare claims database (2006-2016). Seven commonly included components in spine ERAS protocols were identified: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics on the day of surgery, (4) early physical therapy, (5) no urinary catheter, (6) no patient-controlled analgesia, and (7) no wound drains. Outcomes were: length of stay, "any complication," blood transfusion, and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes, separately for 2006-2012 and 2013-2016. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

Results: Among 97,419 (74%; 2006-2012) and 34,932 (26%; 2013-2016) cases ERAS component variations decreased over time. The most commonly used combinations included multimodal analgesia, antiemetics, early physical therapy, avoidance of a urinary catheter, patient-controlled analgesia and drains (10% n=9401 and 19% n=6635 in 2006-2012 and 2013-2016, respectively), and did not include tranexamic acid. Multivariable models revealed minor differences between ERAS combinations in terms of length of stay and costs. The most pronounced beneficial effects in 2006-2012 were seen for the second most commonly (compared with less often) used ERAS combination(s) in terms of blood transfusion (OR: 0.65; CI: 0.59-0.71) and "any complication" (OR: 0.73; CI: 0.66-0.80), both P<0.05. In 2013-2016 the third most commonly used ERAS combination showed the strongest effect: blood transfusion OR: 0.63; CI: 0.50-0.78, P<0.05.

Conclusions: ERAS component variations decreased over time; maximum benefits were particularly seen in terms of transfusion and complication risk reduction. These findings may inform future ERAS utilization and clinical trials comparing various ERAS protocols.
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http://dx.doi.org/10.1097/BSD.0000000000001242DOI Listing
February 2022

Machine learning approaches in predicting ambulatory same day discharge patients after total hip arthroplasty.

Reg Anesth Pain Med 2021 09 15;46(9):779-783. Epub 2021 Jul 15.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA

Background: With continuing financial and regulatory pressures, practice of ambulatory total hip arthroplasty is increasing. However, studies focusing on selection of optimal candidates are burdened by limitations related to traditional statistical approaches. Hereby we aimed to apply machine learning algorithm to identify characteristics associated with optimal candidates.

Methods: This retrospective cohort study included elective total hip arthroplasty (n=63 859) recorded in National Surgical Quality Improvement Program dataset from 2017 to 2018. The main outcome was length of stay. A total of 40 candidate variables were considered. We applied machine learning algorithms (multivariable logistic regression, artificial neural networks, and random forest models) to predict length of stay=0 day. Models' accuracies and area under the curve were calculated.

Results: Applying machine learning models to compare length of stay=0 day to length of stay=1-3 days cases, we found area under the curve of 0.715, 0.762, and 0.804, accuracy of 0.65, 0.73, and 0.81 for logistic regression, artificial neural networks, and random forest model, respectively. Regarding the most important predictive features, anesthesia type, body mass index, age, ethnicity, white blood cell count, sodium level, and alkaline phosphatase were highlighted in machine learning models.

Conclusions: Machine learning algorithm exhibited acceptable model quality and accuracy. Machine learning algorithms highlighted the as yet unrecognized impact of laboratory testing on future patient ambulatory pathway assignment.
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http://dx.doi.org/10.1136/rapm-2021-102715DOI Listing
September 2021

Anterior Quadratus Lumborum Block Does Not Provide Superior Pain Control after Hip Arthroscopy: A Double-blinded Randomized Controlled Trial.

Anesthesiology 2021 09;135(3):433-441

Background: Hip arthroscopy is associated with moderate to severe postoperative pain. This prospective, randomized, double-blinded study investigates the clinically analgesic effect of anterior quadratus lumborum block with multimodal analgesia compared to multimodal analgesia alone. The authors hypothesized that an anterior quadratus lumborum block with multimodal analgesia would be superior for pain control.

Methods: Ninety-six adult patients undergoing ambulatory hip arthroscopy were enrolled. Patients were randomized to either a single-shot anterior quadratus lumborum block (30 ml bupivacaine 0.5% with 2 mg preservative-free dexamethasone) or no block. All patients received neuraxial anesthesia, IV sedation, and multimodal analgesia (IV acetaminophen and ketorolac). The primary outcome was numerical rating scale pain scores at rest and movement at 30 min and 1, 2, 3, and 24 h.

Results: Ninety-six patients were enrolled and included in the analysis. Anterior quadratus lumborum block with multimodal analgesia (overall treatment effect, marginal mean [standard error]: 4.4 [0.3]) was not superior to multimodal analgesia alone (overall treatment effect, marginal mean [standard error]: 3.7 [0.3]) in pain scores over the study period (treatment differences between no block and anterior quadratus lumborum block, 0.7 [95% CI, -0.1 to 1.5]; P = 0.059). Postanesthesia care unit antiemetic use, patient satisfaction, and opioid consumption for 0 to 24 h were not significantly different. There was no difference in quadriceps strength on the operative side between groups (differences in means, 1.9 [95% CI, -1.5 to 5.3]; P = 0.268).

Conclusions: Anterior quadratus lumborum block may not add to the benefits provided by multimodal analgesia alone after hip arthroscopy. Anterior quadratus lumborum block did not cause a motor deficit. The lack of treatment effect in this study demonstrates a surgical procedure without benefit from this novel block.

Editor’s Perspective:
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September 2021

Disparities in the provision of regional anesthesia and analgesia in total joint arthroplasty: The role of patient and hospital level factors.

J Clin Anesth 2021 12 2;75:110440. Epub 2021 Jul 2.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jclinane.2021.110440DOI Listing
December 2021

Differential Perioperative Outcomes in Patients With Obstructive Sleep Apnea, Obesity, or a Combination of Both Undergoing Open Colectomy: A Population-Based Observational Study.

Anesth Analg 2021 09;133(3):755-764

Departments of Orthopaedic Surgery, Population Health Science & Policy, and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.

Background: An increasing body of evidence demonstrates an association between obstructive sleep apnea (OSA) and adverse perioperative outcomes. However, large-scale data on open colectomies are lacking. Moreover, the interaction of obesity with OSA is unknown. This study examines the impact of OSA, obesity, or a combination of both, on perioperative complications in patients undergoing open colectomy. We hypothesized that while both obesity and OSA individually increase the likelihood for perioperative complications, the overlap of the 2 conditions is associated with the highest risk.

Methods: Patients undergoing open colectomies were identified using the national Premier Healthcare claims-based Database (2006-2016; n = 340,047). Multilevel multivariable models and relative excess risk due to interaction (RERI) analysis quantified the impact of OSA, obesity, or both on length and cost of hospitalization, respiratory and cardiac complications, intensive care unit (ICU) admission, mechanical ventilation, and inhospital mortality.

Results: Nine thousand twenty-eight (2.7%) patients had both OSA and obesity diagnoses; 10,137 (3.0%) had OSA without obesity; and 33,692 (9.9%) had obesity without OSA. Although there were overlapping confidence intervals in the binary outcomes, the risk increase was found highest for OSA with obesity, intermediate for obesity without OSA, and lowest for OSA without obesity. The strongest effects were seen for respiratory complications: odds ratio (OR), 2.41 (2.28-2.56), OR, 1.40 (1.31-1.49), and OR, 1.50 (1.45-1.56), for OSA with obesity, OSA without obesity, and obesity without OSA, respectively (all P < .0001). RERI analysis revealed a supraadditive effect of 0.51 (95% confidence interval [CI], 0.34-0.68) for respiratory complications, 0.11 (-0.04 to 0.26) for cardiac complications, 0.30 (0.14-0.45) for ICU utilization, 0.34 (0.21-0.47) for mechanical ventilation utilization, and 0.26 (0.15-0.37) for mortality in patients with both OSA and obesity, compared to the sum of the conditions' individual risks. Inhospital mortality was significantly higher in patients with both OSA and obesity (OR [CI], 1.21 [1.07-1.38]) but not in the other groups.

Conclusions: Both OSA and obesity are individually associated with adverse perioperative outcomes, with a supraadditive effect if both OSA and obesity are present. Interventions, screening, and perioperative precautionary measures should be tailored to the respective risk profile. Moreover, both conditions appear to be underreported compared to the general population, highlighting the need for stringent perioperative screening, documentation, and reporting.
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http://dx.doi.org/10.1213/ANE.0000000000005638DOI Listing
September 2021

Fascial plane blocks: a narrative review of the literature.

Reg Anesth Pain Med 2021 07;46(7):600-617

Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.
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http://dx.doi.org/10.1136/rapm-2020-101909DOI Listing
July 2021
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