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BackgroundEvaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).MethodsUsing previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.ResultsThe ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.ConclusionThis review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures. [ABSTRACT FROM AUTHOR]

Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for "block view" (which visualizes the block site and is maintained for needle insertion/injection). A "strong recommendation" was made if ≥75% of participants rated any structure as "definitely include" in any round. A "weak recommendation" was made if >50% of participants rated it as "definitely include" or "probably include" for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a "strong recommendation" was made for 60 structures on orientation scanning and 44 on the block view. A "weak recommendation" was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Although peripheral nerve blocks are associated with improved pain control and end outcomes among older adults with hip fracture, their current utilization among US hip fracture patients is not well understood. We characterized contemporary use of peripheral nerve blocks after hip fracture over time and identified predictors of nerve block receipt. DESIGN: Retrospective cohort study of claims data from one large national private US insurer. SETTING: US acute care hospitals. PARTICIPANTS: A total of 94 985 adults aged 50 years and older hospitalized for a femoral neck, intertrochanteric, or subtrochanteric fracture; 409 263 adults aged 50 years and older hospitalized for elective hip or knee arthroplasty between 2004 and 2016. MEASUREMENTS: Receipt of a peripheral nerve block for pain control, based on Current Procedural Terminology codes in physician service claims. RESULTS: Overall, 2874 hip fracture patients (3.0%; 95% confidence interval [CI] = 2.9‐3.1) received a nerve block for pain control, and the percentage receiving a block increased from.4% in 2004‐2006 (95% CI =.3%‐.6%) to 4.6% in 2013‐2016 (95% CI = 4.4%‐4.8%; P <.001). The adjusted odds of receiving a nerve block was lower for patients with vs without dementia (odds ratio [OR] =.88; 95% CI =.80‐.98; P =.02) and among patients aged 75 to 84 vs 64 years or younger (OR =.86; 95% CI =.74‐1.00; P =.02). The odds of nerve block receipt did not vary according to race, ethnicity, fracture location, or most other common comorbidities. Compared with patients with hip fracture, the adjusted odds of nerve block receipt were 2 times higher among patients undergoing elective hip replacement and more than 30 times higher among patients undergoing elective knee replacement. CONCLUSION: Although use of peripheral nerve blocks for pain control after hip fracture has increased over time, fewer than 5 of every 100 patients hospitalized with hip fracture currently receive a peripheral nerve block, suggesting possible underuse. J Am Geriatr Soc 68:835–840, 2020 See related Editorial by Ellen F. Binder [ABSTRACT FROM AUTHOR]

Objectives Pain control after shoulder arthroscopy can be challenging, often relying on opioids. The study aims to measure the quality of recovery (QoR) before and after implementation of a "Multimodal Perioperative Pain Protocol" (MP3) in patients undergoing ambulatory shoulder arthroscopy. Design Prospective cohort study. Setting Free-standing ambulatory surgery facility of a tertiary care academic center. Subjects Patients undergoing ambulatory shoulder arthroscopy. Methods The primary end point of the study was the QoR-9 score at 24 hours, 48 hours, and one week after surgery. Secondary end points included 1) measuring the quality of pain management using the Revised American Pain Society Patient Oriented Questionnaire (APS-POQ-R) and 2) postoperative opioid requirements. Results Data from132 patients in the control group (pre-intervention) and 120 patients in the MP3 group were analyzed. The QoR-9 scores were significantly higher for the MP3 group at all time points, but only met the minimal clinical important difference threshold at 24 hours (13.4 vs 14.9, P  < 0.05) and 48 hours (14.0 vs 15.0, P  < 0.05) postoperatively. Patients reported better quality of pain management after implementation of the MP3 in the domains of pain intensity, pain interference with activity, and sleep, and they reported the presence of negative emotions up to two days after ambulatory shoulder surgery. In addition, this protocol significantly reduced opioid consumption up to three days after surgery. Conclusions Implementation of the MP3 improved the overall QoR and many aspects of postoperative pain relief while reducing total opioid consumption in patients undergoing ambulatory shoulder surgery. [ABSTRACT FROM AUTHOR]

Introduction: Low serum albumin is associated with higher perioperative complications following total hip arthroplasty (THA). The distinct threshold for a significant rise in perioperative complications has not been defined for THA. The purpose of this study was to define the threshold at which perioperative complications rise after THA. Methods: We analysed the American College of Surgeons NSQIP database from 2006 to 2013. Our study cohort included unilateral primary THA with reported preoperative albumin levels. Patients were stratified by albumin level. We analysed mortality and 6 composite complication variables (any complication, any complication without transfusion, wound infection, systemic infection, cardiac/pulmonary complications, and any major complication). All data analysis was executed in STATA statistical software. Multivariable logistic regression analysis was used to adjust for odds ratios. Results: The final cohort included 24,586 patients who were stratified based upon serum albumin levels. Odds ratios after multivariable regression adjustment for age, gender, race, body mass index, ASA classification, and Charlson Comorbidity Index indicated a trend to elevated odds of complication for all composite complications (3 of which were statistically significant) when serum albumin level was <3.0 g/dL. Conclusion: Low serum albumin is associated with increased perioperative complications following THA. The threshold associated with an increase in major perioperative complications appears to be an albumin level of <3.0 g/dL. With attempts to correct modifiable risk factors prior to surgery, the threshold value at which perioperative complications increase is important to define. [ABSTRACT FROM AUTHOR]

Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion. [ABSTRACT FROM AUTHOR]

Objectives: Spinal anesthesia (SA) for Total Knee Arthroplasty (TKA) may be associated with better patients' outcomes. This study aims to assess the association between preoperative education about the advantage of SA over general anesthesia (GA) for TKA and the likelihood of patient choice of NA.Methods: Patients undergoing unilateral primary TKA were identified. Type of anesthesia (GA or SA), attendance of the (joints class), patient demographics, ASA status, anticoagulation status, and diagnosis of back problems were recoded. Regression analysis was used to assess the association between the type of anesthesia and attendance of the joints class.Results: 1010 patients were identified to have unilateral primary TKA. 31% of patients attended the joint class. Patients who attended the joints class were more likely to receive SA when compared to those who did not attend (OR=1.7, CI: 1.2-2.5, P=0.004) after adjusting for other variables.Conclusion: Preoperative education about advantages of SA may be associated with an increase in patients receiving SA for TKA.Practice Implications: Increase in patients receiving SA for TKA may improve outcomes. [ABSTRACT FROM AUTHOR]

Objective. This study aims to assess diaphragmatic excursion and measure pulmonary functions as measures of the degree to which the phrenic nerve is blocked after ISB with two different concentrations of ropivacaine: 0.2% and 0.1%. Design. Randomized, double-blinded study. Setting and Patients. Ambulatory surgical facility. Subjects. Fifty patients undergoing shoulder arthroscopy for rotator cuff repair. Methods. Patients were randomized to receive ultrasound-guided ISB with 20mL of either 0.2% or 0.1% ropivacaine. Diaphragmatic excursion was measured using M-mode ultrasound. Pulmonary functions were assessed by portable spirometer. Additional outcome data included oxygen saturation in post-anesthesia care unit (PACU), pain scores, quality of recovery scores (QOR), and opioid consumption over 72hour period after surgery. Results. Forced vital capacity (FVC) was significantly reduced 30minutes after block placement and in PACU in the 0.2% group when compared with the 0.1% group (P=0.04, P= 0.03, respectively). Forced expiratory volume (FEV1) was also significantly decreased in the 0.2% group in PACU when compared with the 0.1% group (P=0.04). There were no significant differences in pain scores, length of stay, and total opioid consumption in PACU. Patients who received 0.2% ropivacaine had a longer block duration (18 vs 11.9hours, P=0.04) and used less opioid in the 72hours after surgery (55mg vs 102mg codeine equivalents, P=0.02), when they were compared to their counterparts who received 0.1% for their block. Conclusion. 0.1% ropivacaine may impair pulmonary function less than 0.2% ropivacaine. The clinical significance of these differences needs to be further studied. [ABSTRACT FROM AUTHOR]

Objectives To determine hospital-level predictors of readmission after hip fracture or potentially related inpatient care processes. Design Retrospective cohort study. Setting U.S. acute care hospitals. Participants Fee-for-service Medicare beneficiaries who underwent hip fracture surgery between 2007 and 2009 (N = 458,526). Measurements Information was obtained on hospital case volumes, teaching status, bed count, nurse staffing, and technological capabilities from Medicare files, and multivariable logistic regression was used to measure the association between these factors and an endpoint of readmission or death at 30 days and between these factors and the timing of surgery. Results Participants treated in the highest-volume hospitals (>175 cases for the study period) had lower odds of readmission or death at 30 days than those treated in low-volume hospitals (≤12; adjusted odds ratio ( aOR) = 0.87, 95% confidence interval ( CI) = 0.83-0.92, P < .001). Higher nurse skill mix ( aOR = 0.88, 95% CI = 0.8-0.96; P = .007) and higher ratio of nurses to beds ( aOR = 0.98; 95% CI = 0.97-0.99; P < .001) were also associated with better 30-day outcomes. Greater hospital case volume was associated with lower odds of surgical delay beyond 48 hours. Conclusion Better nurse staffing and higher case volumes are associated with lower rates of readmission and mortality after hip fracture surgery; individuals treated at high-volume centers experienced fewer delays in treatment, potentially indicating better inpatient care processes. [ABSTRACT FROM AUTHOR]

Background: Dexamethasone has been studied as an effective adjuvant to prolong the analgesia duration of local anesthetics in peripheral nerve block. However, the route of action for dexamethasone and its potential neurotoxicity are still unclear. Methods: A mouse sciatic nerve block model was used. The sciatic nerve was injected with 60ul of combinations of various medications, including dexamethasone and/or bupivacaine. Neurobehavioral changes were observed for 2 days prior to injection, and then continuously for up to 7 days after injection. In addition, the sciatic nerves were harvested at either 2 days or 7 days after injection. Toluidine blue dyeing and immunohistochemistry test were performed to study the short-term and long-term histopathological changes of the sciatic nerves. There were six study groups: normal saline control, bupivacaine (10mg/kg) only, dexamethasone (0.5mg/kg) only, bupivacaine (10mg/kg) combined with low-dose (0.14mg/kg) dexamethasone, bupivacaine (10mg/kg) combined with high-dose (0.5mg/kg) dexamethasone, and bupivacaine (10mg/kg) combined with intramuscular dexamethasone (0.5mg/kg). Results: High-dose perineural dexamethasone, but not systemic dexamethasone, combined with bupivacaine prolonged the duration of both sensory and motor block of mouse sciatic nerve. There was no significant difference on the onset time of the sciatic nerve block. There was “rebound hyperalgesia” to thermal stimulus after the resolution of plain bupivacaine sciatic nerve block. Interestingly, both low and high dose perineural dexamethasone prevented bupivacaine-induced hyperalgesia. There was an early phase of axon degeneration and Schwann cell response as represented by S-100 expression as well as the percentage of demyelinated axon and nucleus in the plain bupivacaine group compared with the bupivacaine plus dexamethasone groups on post-injection day 2, which resolved on post-injection day 7. Furthermore, we demonstrated that perineural dexamethasone, but not systemic dexamethasone, could prevent axon degeneration and demyelination. There was no significant caspase-dependent apoptosis process in the mouse sciatic nerve among all study groups during our study period. Conclusions: Perineural, not systemic, dexamethasone added to a clinical concentration of bupivacaine may not only prolong the duration of sensory and motor blockade of sciatic nerve, but also prevent the bupivacaine-induced reversible neurotoxicity and short-term “rebound hyperalgesia” after the resolution of nerve block. [ABSTRACT FROM AUTHOR]

A poll of @ASRA Society Twitter followers yielded 92 responses, and over 60% agreed with the statement 'The #ASRASpring20 Livestream poster sessions were more engaging than prior moderated poster sessions in which I have participated'. Upgrading a social media strategy to increase Twitter engagement during the spring annual meeting of the American Society of regional anesthesia and pain medicine. [Extracted from the article]

The perioperative management of a patient receiving a bilateral hand transplant is presented. The anesthetic management required careful fluid administration, homeothermic temperature maintenance, and postoperative analgesia. The role of different anesthesia subspecialties is highlighted. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented discussing a study comparing spinal and general anesthesia for hip fracture surgery.