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BACKGROUND: Transversus abdominis plane (TAP) block is often used for post-operative analgesia in ventral hernia repair (VHR). Most studies evaluating TAP in VHR are single-center studies. Our objective was to evaluate the outcomes of TAP in VHR using a national database. MATERIALS AND METHODS: We conducted a retrospective cohort study using Vizient Clinical Database. We included outpatient VHR in adults between 2017 and 2019. Patient, hernia, operative, and hospital characteristics were collected. The patients were divided into two groups depending on whether or not they received TAP. One-to-one propensity score matching (PSM) was used to create balanced groups. Rate of overnight stay, in-hospital opioid prescribing, and costs were compared between both groups. RESULTS: A total of 108,765 patients met the inclusion criteria. After PSM, there were 1,459 patients in each group. There were no statistically significant differences in baseline characteristics between the matched groups. There was no difference in the rates of overnight stay between the two groups (no-TAP=6%, TAP=7%, odds ratio [OR]=1.3, 95% confidence interval [CI] [0.997,1.77]). There were no clinically significant differences in the percentage of patients prescribed opioids (no-TAP=96%, TAP=95%, OR=0.70, 95% CI [0.50, 0.99]) or mean number of opioid doses prescribed (no-TAP=2.7, TAP=2.7, mean pairwise difference [MPD]=0.02, 95% CI [–0.10, 0.13]). The TAP group was associated with higher median direct cost ($4,400 vs. $3,200; MPD=$1,200, 95% CI [$1,000, $1,400]) and total cost ($7,100 vs. $5,200; MPD=$1,900, 95% CI [$1,600, $2,100]) when compared with the no-TAP group. CONCLUSION: We found no evidence that TAP in outpatient VHR was associated with the reduction in the rate of overnight stay or in-hospital opioid prescribing. However, TAP was associated with higher procedural costs.

Introduction: Posterior spinal fusion (PSF) is a commonly performed orthopedic procedure to correct scoliosis in children. Continuous epidural analgesia (CEA) is a proposed means of providing analgesia following PSF. Whether a single epidural catheter with the tip in the upper thorax can provide adequate analgesia for PSF, which often spans the upper thoracic to lower lumbar regions, is unresolved in the literature., Method: In this single-center, retrospective study, we reviewed 69 consecutive patients undergoing PSF for adolescent idiopathic scoliosis (AIS) with CEA at our institution from October 1, 2020 to May 26, 2022. Data for the entire cohort was divided into two time intervals before and after epidural removal, group epidural (Epi) and group no epidural (No Epi). Daily intravenous and oral opioid morphine equivalents per kilogram (OME/kg) plus mean and maximal visual analogue pain scores (VAS 0-10) were recorded from post-anesthesia care unit (PACU) discharge to the end of postoperative day (POD) three.  Results: 57 patients were included in the study. Opioid usage was 4.5 times greater in the 19 hours following removal of the epidural catheter when compared to the entire period (mean 65 hours) the epidural was in place (Group Epi 0.154 OME/kg vs Group No Epi 0.690 OME/kg, p<0.001). 51% (29/57) of patients did not require opioids (intravenous or oral) while the epidural was in place, all patients required opioids after epidural removal. Mean opioid usage while the epidural was in place was 9.3 OME, equivalent to approximately 6 mg of oxycodone. Mean and maximum pain scores increased significantly after removal of the epidural on POD 3 (mean pain score: Epi 3.4 (1.8) vs No Epi 4.1 (1.7); p<0.001) (max pain score: Epi 4.9 (2.5) vs No Epi 6.3 (2.1); p<0.001).  Conclusions: This is the first study we are aware of to report pain scores and cumulative opioid requirements for PSF patients receiving CEA with a single epidural catheter before and after epidural removal. Opioid usage increased over four times in the 19 hours after epidural removal compared to the total opioid requirements while the epidural was infusing. Mean and maximum pain scores increased significantly after removal of the epidural on POD 3. This study firmly establishes that CEA with a single epidural catheter can provide profound analgesia for patients having PSF for AIS., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Halpern et al.)

Objective To evaluate the post-operative outcomes of patients with obstructive sleep apnea (OSA) given intraoperative ketamine. Design: case-control study A total of 574 patients (287 received ketamine and 287 were matched controls) diagnosed with OSA and body mass index (BMI) > 30 who received general anesthesia were included in this study. Patients given intraoperative ketamine were matched (1:1) with those who did not receive ketamine for age, gender, BMI, ethnicity, anesthesia time, intraoperative fentanyl dose, ketamine dose, and surgery type. A sub-analysis was performed based on the dose of ketamine administered and also on the surgery type. Measured outcomes include post-operative pain scores, post-operative opioid requirements, respiratory status, oxygen use, and duration post-operatively. Results Intraoperative ketamine use did not decrease pain scores or post-operative opioid use when compared with the control (no intraoperative ketamine) group. Patients who received high-dose ketamine had significantly higher post-operative pain scores (p=0.048) while in the post-anesthesia care unit (PACU) and required supplemental oxygen for a longer period of time (p = 0.030), pain scores were not significant for patients who underwent orthopedic/spine procedures (p = 0.074), and high-dose ketamine group patients who underwent orthopedic/spine surgery required significantly more opioids in the PACU (p = 0.031). Among patients who received low-dose ketamine, those who underwent head, ear, nose, and throat surgery required significantly more opioids in PACU (p = 0.022). Conclusions Low-dose intraoperative ketamine did not decrease pain scores or post-operative opioid use significantly and did not improve standard respiratory recovery parameters for OSA patients after surgery. Neither low- nor high-dose ketamine demonstrated the anticipated benefits of low pain scores and reduced post-operative opioid use. These outcomes will differ depending on the surgery type and dose of ketamine used., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Schreiner et al.)