A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4–22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0–3 [0–5]) in the control group vs. 1 (0–1 [0–4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.     

Perioperative Blood Transfusions Are Associated with a Higher Incidence of Thromboembolic Events After TKA: An Analysis of 333,463 TKAs

BackgroundGiven the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power.Questions/purposesTherefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as “non-elective” were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients’ transfusion status. Significance was determined at a p value < 0.05.ResultsAdjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching.ConclusionAfter controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team.Level of EvidenceLevel III, therapeutic study.     

Principles of preoperative assessment and enhanced recovery optimization for thoracic anaesthesia

A comprehensive preoperative assessment is imperative for patients undergoing lung surgery, ideally by way of a multidisciplinary team approach. This not only allows for clinicians to risk stratify patients and gain informed consent, but also to explore avenues in optimizing patients prior to surgery and plan for the delivery of the most appropriate postoperative care. A tripartite risk assessment combining risks of operative mortality, perioperative adverse cardiac events and postoperative dyspnoea should be assessed and discussed with patients. Those patients who continue towards surgical management may then be optimized with patient education addressing nutritional status, smoking cessation and alcohol dependency as well as the management of anaemia and physiological prehabilitation. This article aims to review existing guidelines for preoperative assessment in thoracic surgery as well as the latest preoperative guidance for enhanced recovery specific to thoracic surgery.     

Reporting and grading of complications after mid-urethral sling surgeries: Could the “Clavien-Dindo Classification” be adopted?

Background:To construct a modified model for reporting and grading of postoperative complications after the mid-urethral sling (MUS) procedure based on the Clavien-Dindo classification. In addition, complications of three different types of MUS were compared.Materials and methods:A PubMed search for postoperative complication after MUS was carried out for the period between January 1990 and July 2018. Reported complications were stratified in a plate form designed in accordance with grades of the Clavien-Dindo classification. Then, the proposed model was applied on reported complications in 160 females who underwent three different procedures of MUS (transvaginal tape [TVT], transobturator tape [TOT], and autologous fascial sling) with a minimum follow-up of 24 months.Results:The mean ± SD age at time of surgery was 46 ± 7 years. TVT was carried out in 75 (47%) patients, TOT in 40 (25%), and fascial sling in 45 (28%). The total number of complications was 62 in 43 (26.8%) patients. The vast majority of complications were Grade I and Grade II 19 (12%) and 21 (13%) out of 160 patients, respectively. Transient postoperative voiding difficulty (Grade II) and de novo urgency (Grade II) were the most prevalent complications in the fascial sling method (15.4% for each), whereas transient thigh pain (Grade II) was the most frequently reported complication after TOT (10%). Life-threatening vascular injury (Grade IV-a) was a serious complication in TVT cases.Conclusions:Postoperative complications of the MUS could be graded according to Clavien''s classification. The vast majority of complications were Graded I or II. TVT can cause serious life-threatening complications.