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Each year, more than 300 million surgical procedures are performed worldwide, with approximately 5% (15 million) conducted under spinal anesthesia (SA). This technique involves administering local anesthetics or opioids, or both, into the spinal space to induce numbness and weakness in the lower body, enabling pain-free surgery. One major application of spinal anesthesia is for cesarean delivery (C-section). In terms of medication selection, an area of ongoing research and discussion is whether hyperbaric spinal anesthesia is superior.

Bupivacaine, a long-acting local anesthetic, is the most common drug, often supplemented with opioids such as fentanyl, sufentanil, or morphine. It comes in two commercially available formulations: isobaric bupivacaine (IB) and hyperbaric bupivacaine (HB). IB has a density equal to that of cerebrospinal fluid (CSF), while HB has a density heavier than CSF. The denser (hyperbaric) bupivacaine is produced by adding glucose (80 mg/mL) to isobaric or plain bupivacaine. The difference in densities of the two preparations is believed to affect their diffusion patterns and thus determine their effectiveness, spread, and side-effect profile. In general, hyperbaric spinal anesthesia should spread more downwards, in the direction of gravity, because of its greater density. 

To be reliably hyperbaric in all patients, an anesthetic solution must have a baricity of at least 1.0015 at 37°C. The addition of dextrose to the anesthetic solution is the most common method used to achieve this. Because dextrose is neurologically benign, the concentrations used are usually far higher than those needed to increase baricity above 1.0015. The distribution of hyperbaric spinal anesthetic solutions in CSF is influenced by the patient’s position, with significant differences observed between horizontal or head-down positions and seated positions. 

The uptake of local anesthetics injected into the subarachnoid space determines which neuronal functions are affected during spinal anesthesia, while their elimination from the subarachnoid space determines the duration of these effects. The distribution of local anesthetics within CSF determines the extent of altered neuronal function. The physical characteristics of spinal anesthetic solutions, including weight/density of the solution, amount of anesthetic given, concentration of anesthetic in the injectate, and volume of anesthetic solution injected, are major determinants of their spread in CSF. 

Anesthesiologists performing spinal anesthesia must choose between the two most commonly available formulations, hyperbaric or isobaric bupivacaine. Despite more than 30 years of use, there is still disagreement regarding the preferred formulation. This decision is often based on personal experience, training, local institutional practices, and drug availability. 

Baricity is a significant factor in maternal hemodynamic changes during elective cesarean section, as demonstrated by a hospital-based prospective cohort study by Heloll et al. However, other studies have shown different findings, such as Uppal et al.’s meta-analysis. These authors show that isobaric bupivacaine produces greater changes in blood pressure, incidence of hypotension, and vasopressor requirement than hyperbaric bupivacaine after SA for elective cesarean section. Hyperbaric bupivacaine allows for a relatively rapid onset of motor block, with a shorter duration of motor and sensory block, while isobaric bupivacaine has a slower onset and provides a longer duration of both sensory and motor block. 

A recent Cochrane review found that intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the 4th thoracic vertebra (T4) level than isobaric bupivacaine. However, the overall quality of evidence for most outcomes is low or very low according to the GRADE method. Various advantages of isobaric and hyperbaric bupivacaine have been described, but no definitive evidence exists to recommend one form over the other.

References

1. Wildsmith JAW, McClure JH, Brown DT, Scott DB. Effects of posture on the spread of isobaric and hyperbaric amethocaine. Br J Anaesth. 1981 Mar;53(3):273-8.

2. Greene NM. Distribution of Local Anesthetic Solutions within the Subarachnoid Space. Anesthesia & Analgesia. 1985 July;64(7):715-730. 

3. Helill SE, Sahile WA, Abdo RA, Wolde GD, Halil HM. The effects of isobaric and hyperbaric bupivacaine on maternal hemodynamic changes post spinal anesthesia for elective cesarean delivery: A prospective cohort study. PLOS ONE 2019;14(12):e0226030. 

4. Uppal V, Retter S, Shanthanna H, Prabhakar C, McKeen DM. Hyperbaric Versus Isobaric Bupivacaine for Spinal Anesthesia: Systematic Review and Meta-analysis for Adult Patients Undergoing Noncesarean Delivery Surgery. Anesthesia & Analgesia 2017;125(5):1627-1637. 

5. Sng BL, Siddiqui FJ, Leong WL, Assam PN, Chan ES, Tan KH, Sia AT. Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section. Cochrane Database Syst Rev. 2016 Sep 15;9(9):CD005143.  

6. Solakovic N. Comparison of hemodynamic effects of hyperbaric and isobaric bupivacaine in spinal anesthesia. Med Arh. 2010;64:11–14. 

7. Muralidhar V, Kaul HL. Comparative evaluation of spinal anaesthesia with four different bupivacaine (0.5%) solutions with varying glucose concentrations. J Anaesthesiol Clin Pharmacol. 1999;15:165–168. 

Awake spine surgery, a ground-breaking approach in modern surgical practices, challenges traditional norms by allowing patients to remain conscious during certain spinal procedures ¹. In awake spine surgery, patients are consciously engaged throughout the procedure, providing real-time feedback to the surgical team and promoting a more personalized approach to care. This innovative technique is particularly advantageous for certain spinal surgeries, such as deformity corrections, where maintaining neurological function is critical. Spinal anesthesia is a key component of awake spine surgery.

Central to the success of awake spine surgery is the administration of spinal anesthesia. Unlike general anesthesia, which induces a state of unconsciousness, spinal anesthesia targets a specific region of the spine, numbing the part of the body served by nerves in that region of the spine while allowing the patient to remain awake and responsive. This technique not only minimizes the risks associated with general anesthesia but also offers distinct advantages in terms of patient collaboration and intraoperative monitoring.

A recent meta-analysis demonstrated the benefits of spinal anesthesia in awake spine surgery relative to general anesthesia in patients who had undergone various lumbar procedures ². Benefits may include reduced duration of anesthesia, cost, operative time, and postoperative complications. It is also associated with reduced cardiopulmonary complications and opioid consumption ³. Finally, spinal anesthesia for awake spine surgery avoids the negative systemic effects of general anesthesia. Relatedly, with the absence of general anesthesia-related grogginess, patients undergoing awake spine surgery often experience a quicker recovery. This rapid recovery facilitates early mobilization and may contribute to shorter hospital stays ⁴. Large prospective trials are necessary, however, to confirm these promising data.

Despite the potential for improving outcomes, awake spine surgery has been met with a certain degree of resistance and has yet to become widely adopted in many healthcare institutions. A recent manuscript sought to lay forth the fundamental steps critical to the initiation of an awake spine surgery program ³. The authors highlight that the development of an awake spine surgery program is a challenging one but one that has many advantages to patients and healthcare systems.

The success of awake spine surgery with spinal anesthesia hinges on appropriate patient selection and thorough preoperative education. Patients must be carefully screened to ensure they are suitable candidates for the procedure. Indeed, although no direct studies have identified the ideal candidate, there are certain contraindications. The contraindications for awake spine surgery include surgeries involving more than two vertebrae, surgeries with unpredictable durations, and patients with risks of respiratory compromise, among others ³.Additionally, educating patients about the awake spine surgery process, the role of spinal anesthesia, and the expected outcomes is crucial in fostering informed decision-making and allaying any anxieties.

In conclusion, awake spine surgery with spinal anesthesia allows patients to actively participate in their surgical experience, enhancing safety, reduces recovery time, and provides an alternative to traditional general anesthesia.

The evolving landscape of awake spine surgery will continue to stimulate ongoing research to refine techniques and expand indications, however. As technology advances, innovative approaches to intraoperative monitoring, pain management, and patient experience are likely to shape the future of awake spine surgery.

References

1. Awake spinal surgery: A paradigm shift in neurosurgery – Mayo Clinic. Available at: https://www.mayoclinic.org/medical-professionals/neurology-neurosurgery/news/awake-spinal-surgery-a-paradigm-shift-in-neurosurgery/mac-20531255. (Accessed: 30th January 2024)

2. Perez-Roman, R. J., Govindarajan, V., Bryant, J. P. & Wang, M. Y. Spinal anesthesia in awake surgical procedures of the lumbar spine: a systematic review and meta-analysis of 3709 patients. Neurosurg. Focus 51, (2021). doi: 10.3171/2021.9.FOCUS21464.

3. Waguia, R. et al. How to start an awake spine program: Protocol and illustrative cases. IBRO Neurosci. Reports 13, 69 (2022). doi: 10.1016/j.ibneur.2022.05.009

4. A Guide to Awake Spine Surgery – Desert Institute for Spine Care. Available at: https://www.sciatica.com/blog/what-is-awake-spine-surgery/. (Accessed: 30th January 2024)

As part of the Patient Protection and Affordable Care Act to improve transparency, accountability, and performance in healthcare services, the Quality Rating System (QRS) was developed to rate healthcare entities based on price and quality. This system plays a crucial role in guiding consumers, healthcare providers, and policymakers towards informed decision-making [1]. Centers for Medicare & Medicaid Services (CMS) calculates these quality ratings on a scale from 1 to 5 different measures [2]. Entities include qualified health insurance plans, healthcare facilities, and even individual providers.

CMS quality ratings extend to hospitals and various healthcare facilities, offering a standardized approach to evaluating their performance. These ratings consider factors such as mortality rates, readmission rates, patient safety, and the effectiveness of healthcare services. Patients can access these ratings to make informed decisions about where to seek medical treatment. Thus, hospitals are incentivized to achieve high ratings to attract patients and remain profitable [3]. Hospitals can also use these ratings to improve the quality of services they provide.

The scope of CMS quality ratings encompasses not only healthcare facilities but individual providers as well. Doctors, clinicians, groups, virtual groups, and Accountable Care Organizations are also subject to CMS ratings and performance review under the Doctors and Clinicians section of Medicare Care Compare and in the Provider Data Catalog [4]. Metrics such as patient satisfaction, adherence to clinical guidelines, and costs are assessed. These ratings help patients choose healthcare professionals who align with their preferences and healthcare needs. Further, providers and facilities are continuously incentivized to improve their performance and quality. This fosters a culture of accountability and encourages the adoption of best practices to achieve better patient outcomes and experiences [4].

Nursing homes, rehabilitation centers, and other long-term care facilities are also included in CMS quality ratings [5]. The Nursing Home Quality Initiative focuses on factors such as resident well-being, safety, and the quality of services provided for post- acute centers and for longer-term patients with chronic needs [5,6].

The scope of CMS quality ratings is vast and highlights a movement within healthcare towards standardization. The standardization of healthcare quality measurement allows patients not only to access information about health plans, but also incentivizes the healthcare industry to improve the quality of services and thus, overall patient outcomes. Further, by providing a comprehensive assessment of the performance of healthcare entities, these ratings promote transparency and accountability. As healthcare continues to evolve, quality ratings will remain a critical tool in the pursuit of delivering high-quality, patient-centered care.

References

1. Centers for Medicare and Medicaid Services Overall Hospital Quality Star Rating. 2019 Available online: https://www.medicare.gov/hospitalcompare/Data/Hospital-overall-ratings-calculation.html

2. Kurian N, Maid J, Mitra S, Rhyne L, Korvink M, Gunn LH. Predicting Hospital Overall Quality Star Ratings in the USA. Healthcare (Basel). 2021 Apr 20;9(4):486.

3. Yaraghi N., Wang W., Gao G.G., Agarwal R. How online quality ratings influence patients’ choice of medical providers: Controlled experimental survey study. J. Med. Int. Res. 2018;20

4. Centers for Medicare and Medicaid Services 2021 Quality Payment Program (QPP);2021 Available online: https://www.cms.gov/files/document/2021-qpp-performance-information-medicare-care-compare-presentation-slides.pdf-0

5. Tamara Konetzka R, Yan K, Werner RM. Two Decades of Nursing Home Compare: What Have We Learned? Medical Care Research and Review. 2021;78(4):295-310.

6. Harris Y., Clauser S. B. Achieving improvement through nursing home quality measurement. Health Care Financing Review. 2002;23(4), 5–18.

Procedural anxiety in children is a common and challenging phenomenon, often occurring during medical procedures such as vaccinations, blood draws, and diagnostic tests [1]. Common contributors include fear of pain, unfamiliar environments, and separation from caregivers. Cognitive factors, such as age-related development, also play a significant role in shaping a child’s response to medical procedures. The emotional distress associated with these procedures not only affects the child’s immediate well-being but can also have long-term implications for their attitude towards healthcare. Further, by alleviating a child’s anxiety, healthcare providers are better able to complete their procedures with ease [1]. Healthcare providers should focus on effective strategies to reduce procedural anxiety in children which may include environmental, behavioral, pharmacological, or technological interventions.

The first essential step in mediating a child’s procedural anxiety is performing an accurate evaluation of the patient’s emotional state and level of distress [1]. Assessment involves a clinician making observations of a child’s behavioral cues, responsiveness, and willingness to engage with the clinician. Parent anxiety level can also play a significant role in these interactions.

Creating a child-friendly and supportive environment is a fundamental part of a broader strategy to reduce procedural anxiety in children [3]. This includes modifications such as colorful and engaging décor and age-appropriate toys. Practices may wish to involve child life specialists who can help create a more comfortable atmosphere. Further, interacting with parents to reduce parental anxiety can also reduce any anxiety a parent may inadvertently transfer to their child [1]. Pre-procedural education for parents is essential to prepare them for supporting their child effectively. Providing information about the procedure in an age-appropriate manner as well as helping parents to avoid use of fear-inducing words, like needle or shots, can also contribute to reducing procedural anxiety [2].

Cognitive-behavioral interventions focusing on changing thought patterns and behaviors associated with anxiety in children before and during the procedure may also effectively reduce procedural anxiety. Techniques such as distraction, arousing curiosity, guided imagery, and relaxation exercises have shown promise in reducing procedural anxiety [2, 3, 4]. For example, pointing out a color or item in the room for a child to focus on can distract from the procedure. Often, technology such as a parent phone or iPad with interactive games can be used as a distraction technique to shift a child’s focus away from the procedure. In some cases, pharmacological interventions such as intranasal or oral anxiolytics based on the child’s age, medical history, and the nature of the procedure may be considered [1].

Procedural anxiety in children is a multifaceted phenomenon, but utilizing a combination of environmental modifications, parental involvement, cognitive-behavioral and technological interventions, and when necessary, pharmacological approaches can significantly reduce anxiety levels. By performing comprehensive assessments of a child’s anxiety and employing these techniques, healthcare providers can contribute to a positive healthcare experience for children, promoting their overall well-being and future engagement with healthcare.

References

1. Krauss BS, Krauss BA, Green SM. Managing Procedural Anxiety in Children. New England Journal of Medicine. 2016;374(16):e19.

2. Cohen LL. Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics 2008;122:Suppl 3:S134-9.

3. Corrie E. Chumpitazi, Cindy Chang, Zaza Atanelov, Ann M. Dietrich, Samuel Hiu‐Fung Lam, Emily Rose, Tim Ruttan, Sam Shahid, Michael J. Stoner, Carmen Sulton, Mohsen Saidinejad, . (2022) Managing acute pain in children presenting to the emergency department without opioids. Journal of the American College of Emergency Physicians Open 3:2.

4. Bandstra NF, Skinner L, Leblanc C, et al. The role of child life in pediatric pain management: a survey of child life specialists. J Pain. 2008;9(4):320‐329.

Hemodynamics, or the measure of blood flow throughout the body, plays a significant role in surgical outcomes. Hemodynamic problems can result in complications such as hypertension, hypotension, and irregular heartbeat [1]. Unfortunately, surgery can trigger hemodynamic issues and, thus, endanger patients’ lives. Surgery’s impact on hemodynamics contributes to the 1 to 4% postoperative mortality rate reported in developed countries [2]. The postoperative mortality rate is even more striking among high-risk patients. Although they represent just 10% of surgical procedures performed under anesthesia, high-risk patients suffer 80% of perioperative deaths [3]. Research indicates that hemodynamic optimization could lower the death rate among high-risk patients [3].

Various aspects of surgery impact hemodynamics. For instance, anesthetic agents can be of particular concern because they lower heart rate and blood pressure [4]. This can be true regardless of whether patients receive reduced levels of anesthetic agents [4]. Even at lower doses, anesthesia can still impair peripheral neural function and have profound effects on the body’s hemodynamic responses [4]. Therefore, anesthesiologists are forced to strike a difficult balance between pain management and hemodynamic stability — both of which are crucial to a successful operation.

Another way that surgery can impact hemodynamics comes in the form of preoperative anxiety. Such anxiety is characterized by feelings of apprehension, nervousness, tension, fear, and discomfort before an operation [5]. Studies have found that high preoperative anxiety can affect hemodynamics by increasing mean heart rate, arterial pressure, and systolic blood pressure [5]. Helping patients control high preoperative anxiety is thus a way to ensure better hemodynamics during a procedure.

Lastly, the technique that a surgeon opts to use can also have significant implications for a patient’s hemodynamics. For instance, Parachuri and colleagues found that modified linear endoventricular patch plasty contributes to marked improvements in hemodynamic performance during surgical ventricular restoration, compared to another common technique, endoventricular circular patch plasty [6]. Surgeons should consider hemodynamics as early as the preoperative phase when they are weighing different surgical methods.

There are other ways that surgery can affect hemodynamics as well. Thus, it is clear that medical professionals must be proactive in addressing hemodynamic issues. One cornerstone of surgery is hemodynamic monitoring. Specifically, medical professionals should track articular and ventricular blood pressure every five minutes [7]. While non-intensive monitoring in the form of a blood pressure cuff is standard practice, high-risk patients may require more intensive monitoring techniques, such as arterial lines and Swan-Ganz catheters [Blair]. Providers should also use vasoconstrictors and fluids to maintain blood flow and perfusion pressure in safe zones, but in doing so, they should similarly make sure to avoid volume overload [2].

Admittedly, there continues to be significant disagreement among medical practitioners about the best way to optimize hemodynamics [2]. Nevertheless, hemodynamic optimization is associated with decreased time in the intensive care unit, increased cost-effectiveness, and better patient outcomes [3, 8]. Therefore, taking steps before and during surgery to properly manage hemodynamics is of the utmost importance.

References

[1] M. J. London, “Hemodynamic Management During Anesthesia in Adults,” UpToDate, Updated July 13, 2023. [Online]. Available: https://www.uptodate.com/contents/hemodynamic-management-during-anesthesia-in-adults.

[2] J. Fellahi et al., “Perioperative Hemodynamic Optimization: From Guidelines to Implementation—An Experts’ Opinion Paper,” Annals of Intensive Care, vol. 11, no. 58, pp. 1-10, April 2021. [Online]. Available: https://doi.org/10.1186/s13613-021-00845-1.

[3] M. Cannesson et al., “Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists,” Critical Care, vol. 15, no. R197, pp. 1-11, August 2011. [Online]. Available: https://doi.org/10.1186/cc10364.

[4] T. Abbott and G. L. Ackland, “The Relationships between Anesthesia Hemodynamics and Outcomes,” in Perioperative Hemodynamic Monitoring and Goal Directed Therapy. Cambridge, United Kingdom: Cambridge University Press, 2014, ch.26, pp. 224-30. Accessed October 4, 2023. [Online]. Available: https://www.cambridge.org/core/books/perioperative-hemodynamic-monitoring-and-goal-directed-therapy/relationships-between-anesthesia-hemodynamics-and-outcome/E013D60714A976C872D32261CFD7DFA4.

[5] M. Tadesse et al., “The hemodynamic impacts of preoperative anxiety among patients undergoing elective surgery: An institution-based prospective cohort study,” International Journal of Surgery Open, vol. 42, pp. 1-11, June 2022. [Online]. Available: https://doi.org/10.1016/j.ijso.2022.100490.

[6] V. Rao Parachuri & S. M. Adhyapak, “The Impact of Surgical Technique on Cardiac Hemodynamics Following Surgical Ventricular Restoration,” in Ventricular Geometry in Post-Myocardial Infarction Aneurysms. London: Springer-Verlag, 2012, ch.9, pp. 95-111. Accessed October 4, 2023. [Online]. Available: https://doi.org/10.1007/978-1-4471-2861-8_9.

[7] G. J. Blair, “Hemodynamic Monitoring in the Operating Room,” Medscape, Updated March 11, 2022. [Online]. Available: https://emedicine.medscape.com/article/2500066-overview.

[8] J. M. Silva-Jr. et al., “Impact of perioperative hemodynamic optimization therapies in surgical patients: economic study and meta-analysis,” BMC Anesthesiology, vol. 20, no. 71, pp. 1-12, 2020. [Online]. Available: https://doi.org/10.1186%2Fs12871-020-00987-y.

There are two common meanings of hemodynamics. Sometimes, when they say “hemodynamics,” people are referring to the fundamental measures of cardiovascular function [1]. Other times, it describes how well the blood flows through the veins and arteries of the body [1, 2]. As the latter definition is the more technical one and, thus, more consistent with professional usage, this article will center on hemodynamics as the description of blood flow.

How Does Blood Flow Through the Body?

As the heart beats, it pushes blood into the vessels, which creates a pressure difference between the atrial inlet and the ventricular outlet [3, 4, 5]. As occurs with all fluids, blood moves from high-pressure to low-pressure zones [6]. Therefore, as pressure increases in a given area, blood flow away from that area increases [4]. This is how blood flows from the heart to the arteries, capillaries, veins, and the heart once more [6].

Along with pressure, systemic resistance also affects hemodynamics [4]. The more resistance that blood vessels pose to the blood, the more difficult it will be for blood to pass through those vessels [4]. Consequently, the shape and size of vessels can impede or promote hemodynamic stability as well [4].

What Conditions Affect Hemodynamics?

Many medical conditions can impact hemodynamic stability. Cardiovascular conditions, such as age-related vascular disease and pulmonary hypertension, can impede blood flow [4]. Anxiety and stress can also have a negative effect on the body’s hemodynamics, given how these conditions are often associated with elevated blood pressure which, in turn, increases the load borne by the heart [4]. Substances that affect blood pressure, like aldosterone and angiotensin (I and II), may have an effect as well [4].

That said, it is important to dispel a common misconception. While high blood pressure can compromise hemodynamic instability, the measure of hemodynamics depends on more than just blood pressure [1, 2]. Therefore, the two concepts —blood pressure and hemodynamics— are not synonymous and should not be conflated [2].

What Are the Symptoms of Hemodynamic Instability?

The cardiovascular system is vital to the body and is linked to several other organ systems as well. Hemodynamic instability is a potentially dangerous situation that must be monitored and treated as best as possible. Common symptoms of hemodynamic instability include decreased urine output; cold or blue legs, feet, arms, or hands; chest pain; shortness of breath; restlessness; low blood pressure; abnormal heart rate; confusion; and loss of consciousness [7]. Because many of these symptoms are associated with other medical conditions as well, medical professionals may use hemodynamic monitoring tests to verify whether hemodynamic

instability is the true cause of their patient’s symptoms [8]. It is a non-invasive procedure that can be done in around three hours and permits professionals to identify and address problem areas [8].

Why Are Hemodynamics Important?

Blood plays several key roles in the body. It regulates metabolism, enables the immune system to protect against foreign bodies, and boosts energy [5]. Hemodynamic instability compromises the blood’s ability to supply these benefits [2]. As a result, it is a serious condition that warrants treatment.

References

[1] J. Fletcher, “What to Know About Hemodynamic Instability,” Medical News Today, Updated March 29, 2023. [Online]. Available: https://www.medicalnewstoday.com/articles/hemodynamic-instability.

[2] “Hemodynamics,” Cleveland Clinic, Updated August 9, 2022. [Online]. Available: https://my.clevelandclinic.org/health/body/24013-hemodynamics.

[3] “How Does Blood Flow Through Your Body,” Cleveland Clinic, Updated April 30, 2019. [Online]. Available: https://my.clevelandclinic.org/health/articles/17059-how-does-blood-flow-through-your-body.

[4] J. D. Pollock et al., “Physiology, Cardiovascular Hemodynamics,” StatPearls, Updated March 13, 2023. [Online]. Available: https://www.ncbi.nlm.nih.gov/books/NBK470310/.

[5] M. Thiriet, “Hemodynamics: An Introduction,” in PanVascular Medicine. Berlin, Germany: Springer-Verlag Berlin Heidelberg, 2015, ch.14, pp. 413-83. Accessed September 26, 2023. [Online]. Available: https://doi.org/10.1007/978-3-319-50610-4_3.

[6] “Physiology of Circulation,” National Cancer Institute. [Online]. Available: https://training.seer.cancer.gov/anatomy/cardiovascular/blood/physiology.html.

[7] “Hemodynamic Instability,” University of Miami Health System. [Online]. Available: https://umiamihealth.org/en/treatments-and-services/pediatrics/critical-care-(pediatrics)/hemodynamic-instability.

[8] “Hemodynamics Test,” Cleveland Clinic, Updated August 10, 2022. [Online]. Available: https://my.clevelandclinic.org/health/diagnostics/17094-hemodynamic-test.

Extubation, the process of removing a patient’s endotracheal tube after surgery, is a critical step in the perioperative care of patients undergoing surgical procedures. The timing and location of extubation have been topics of debate, especially in regard to operating room productivity [1]. Traditionally, extubation has been performed in the operating room (OR) immediately following surgery, but there have been studies demonstrating the role and efficacy of extubating patients in the post-anesthesia care unit (PACU) or recovery room [1,2]. In addition to safety, factors that come into play with extubation outside of the OR include patient outcomes, cost-effectiveness, and resource utilization.

Extubation in the OR has been the standard practice for decades. It offers several advantages, including rapid emergence, as extubating in the OR allows for immediate assessment of the patient’s airway, breathing, and circulation, and any complications can be promptly addressed. Further, the OR is a controlled environment equipped with advanced monitoring equipment and skilled anesthesia providers who can manage potential complications such as airway obstruction or hemodynamic instability [1].   

 On the other hand, in recent years, extubation in the recovery room has gained popularity for a variety of reasons, as an alternative to in the OR. Extubation in the OR often requires the presence of an anesthesia provider, which may limit their availability for other cases. Extubating in recovery allows for more efficient use of anesthesia resources and can help streamline the surgical process, potentially reducing OR time, which is essential in high-demand settings [1]. When comparing safety in the OR to safety in the PACU, studies have suggested that extubation in PACU may not only be as safe as in the OR but also may result in less premature extubations and as a result, fewer harmful airway events [1]. Further, studies looking at PACU extubation vs OR extubation in children found no difference in PACU length of stay [3]. Thus, PACU extubation may be more efficient and cost friendly.  

Overall, the evidence suggests that both approaches are safe and result in similar patient outcomes. Studies have shown  respiratory events when extubating during recovery to be infrequent and having a similar incidence as with OR extubation [4]. Although extubation in the OR offers immediate access to medical professionals and equipment in case of complications, extubation in recovery is generally considered safe for low-risk patients undergoing routine surgeries and has begun to be led by anesthetists and nurses in the PACU setting. The cost-effectiveness of extubation in the PACU has demonstrated a reduction in hospital and OR costs, with some hospitals reporting the ability to save more than $1 million in 2 years [4]. Extubation in the operating room and in recovery have differing advantages depending on individual patient needs, surgical complexity, and resource availability. Ultimately, the choice between extubation in the OR and in recovery should be guided by a multidisciplinary approach, considering the specific circumstances of each surgical case and the available resources. 

References 

1. Oviedo P, Engorn B, Carvalho D et al. The impact of routine post-anesthesia care unit extubation for pediatric surgical patients on safety and operating room efficiency. Journal of Pediatric Surgery 2022; 57 (1): 100-103. 

2. Memon Z, Gladney A, Thomas J, Lal S. Nurse Led Extubation in Adult PACU – A Lean Process. Pak J Med Sci. 2022 Jan-Feb;38(1):330.  

3. Kako H, Corridore M, Seo S, Elmaraghy C, Lind M, Tobias JD. Tracheal extubation practices following adenotonsillectomy in children: effects on operating room efficiency between two institutions. Pediatric Anesthesia. 2017 Jun;27(6):591-5.  

4. Oviedo P, Engorn BM, Carvalho D et al. The Impact of Extubation Setting on Operating Room Efficiency, Hospital Costs, and Patient Safety in a Children’s Hospital. Journal of the American College of Surgeons 2021; 233 (5, Supplement 1): S181-S182. 

Postoperative delirium is a common complication following surgery, particularly among elderly patients [1]. Characterized by acute and fluctuating changes in mental status, delirium can lead to serious consequences such as prolonged hospital stays, increased morbidity and mortality, and higher healthcare costs [1,2]. To mitigate these adverse effects, early detection and assessment of postoperative delirium are essential. In recent years, medical researchers and practitioners have developed and refined various tools for assessing and managing delirium in the postoperative setting. 

One such tool is the Confusion Assessment Method (CAM), one of the most widely used tools for assessing delirium in general, including in the postoperative setting [3]. It is a reliable and validated instrument designed to be administered by healthcare professionals [3,4]. CAM evaluates four features of delirium, specifically acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness [3,4]. If the patient meets the criteria for acute onset and inattention, the diagnosis of delirium is established [3,4]. 

Second, the Delirium Rating Scale-Revised-98 (DRS-R-98) is a comprehensive tool used for assessing the severity of delirium in postoperative patients [5]. It evaluates cognitive impairment, fluctuating consciousness, psychomotor behavior, sleep-wake cycle disturbance, and other key features of delirium [5]. The DRS-R-98 provides a more detailed and nuanced assessment of delirium, allowing healthcare professionals to monitor its progression and tailor interventions accordingly [5]. 

Third, the Nursing Delirium Screening Scale (Nu-DESC) is specifically designed to be convenient fornurses, making it a valuable tool in the postoperative setting where nurses play a pivotal role in patient care [6]. The Nu-DESC is a brief and easy-to-administer scale that evaluates six key indicators of delirium: level of consciousness, inattention, disorientation, hallucination or delusion, psychomotor retardation, and psychomotor agitation [6].  

Last, the 4 ‘A’s Test (4AT) is a rapid and reliable screening tool specifically designed for delirium assessment in older adults [7]. It is easy to administer and can be used by healthcare professionals across different disciplines [7]. The 4AT evaluates four domains: Attention, an Abbreviated mental test, Acute change or fluctuation, and Alertness [7]. Its brevity and simplicity make it suitable for use in busy postoperative settings, facilitating early detection and intervention. 

Postoperative delirium poses significant challenges for patients, caregivers, and healthcare systems. However, with the availability of various validated assessment tools, healthcare professionals can promptly identify and manage delirium, leading to improved patient outcomes. The Confusion Assessment Method (CAM), Delirium Rating Scale-Revised-98 (DRS-R-98), Nursing Delirium Screening Scale (Nu-DESC), and 4 ‘A’s Test (4AT) are four essential instruments that play a crucial role in the early detection and management of postoperative delirium. By incorporating these tools for assessing delirium into routine clinical practice, healthcare providers can enhance patient safety, reduce complications, and promote a smoother recovery process for postoperative patients. 

References 

1. Ho, M., Nealon, J., Igwe, E. et al. (2021). Postoperative delirium in older patients: A systematic review of assessment and incidence of postoperative delirium. Worldviews on Evidence‐Based Nursing, 18(5), 290-301. 

2. Oh, S., & Park, J. (2019). Postoperative delirium. Korean journal of anesthesiology, 72(1), 4-12. 

3. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A., & Horwitz, R. (1990). Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Annals of internal medicine, 113(12), 941-948. 

4. Waszynski, C. (2004). Confusion assessment method (CAM). Medsurg Nursing, 13(4), 269. 

5. Sepulveda, E., Franco, J., Trzepacz, P. et al. (2015). Performance of the Delirium Rating Scale-Revised-98 against different delirium diagnostic criteria in a population with a high prevalence of dementia. Psychosomatics, 56(5), 530-541. 

6. Barnes, C., Webber, C., Bush, S. et al. (2019). Rating delirium severity using the nursing delirium screening scale: a validation study in patients in palliative care. Journal of Pain and Symptom Management, 58(4), e4-e7. 

7. Hou, L., Zhang, Q., Cao, L. et al. (2022). Diagnostic accuracy of the 4AT for delirium: A systematic review and meta-analysis. Asian Journal of Psychiatry, 103374. 

Different types of anesthesia used during surgical procedures may have detrimental effects on cognitive functioning. Studies indicate the effects of anesthetics on the nervous system can impact our brains’ abilities to process and understand information, especially for patients who are already experiencing cognitive decline (5). Factors that impact a patient’s level of cognitive risk include the type of anesthesia that is used for the procedure, the specific analgesic drugs a patient receives, and how the anesthetics are administered. Furthermore, a patient’s age, lifestyle factors, and preexisting comorbidities can also influence their level of cognitive risk.

Patients who undergo surgical procedures may experience a condition called postoperative cognitive dysfunction (POCD), a state of cognitive impairment after a surgical procedure that affects a patient’s executive functioning and memory (1). Most patients who experience postoperative cognitive dysfunction recover within a period of weeks to months, but some patients may suffer from long-term cognitive decline. 

Current scientific knowledge indicates that, among the different types of anesthesia, general anesthesia poses a higher level of cognitive risk. General anesthesia targets receptor proteins in the central nervous system to modify the activities of neurons (5). Patients who undergo general anesthesia can experience lasting cognitive issues, especially with children and the elderly. For example, studies have demonstrated that general anesthesia may have a correlation with cognitive dysfunction in the early postoperative period (6). Studies in rats and non-human primates have also suggested that early exposure to general anesthesia when animals are young can have long-term effects on memory, behavior, and cognitive functioning (5). 

In comparison to general anesthesia, regional anesthesia is considered to pose a lower level of cognitive risk. In one study of patients undergoing elective surgery, those who received regional anesthesia experienced a lower risk of developing dementia than patients who received either inhalation or non-inhalation general anesthesia (3). Accordingly, current scientific knowledge is that regional anesthesia is one of the types of anesthesia with lower cognitive risk. 

The type of analgesic drugs that are used during a procedure and the ways they are administered can also impact a patient’s level of cognitive risk. For example, using multimodal anesthesia, wherein a patient receives a combination of intravenous medications instead of inhalation anesthesia, may reduce a patient’s likelihood of postoperative cognitive dysfunction (2). Similarly, avoiding the use of opioids for pain management postoperatively may protect patients against cognitive decline (2). Narcotics, especially morphine agents, may increase the risk of postoperative cognitive dysfunction, so avoiding them whenever possible can help protect patients’ cognitive function. 

Studies on postoperative cognitive dysfunction continue to dispute the causes behind why some patients experience cognitive decline postoperatively. Aging in particular is a significant factor that has been shown to increase a patient’s vulnerability to the inflammatory effects of surgical procedures and the effects of anesthesia on the nervous system (4). Furthermore, patients who are already on a path of cognitive decline may be more susceptible to postoperative cognitive dysfunction. For example, those with Alzheimer’s disease can be more strongly affected by the neurotoxic effects of surgical stress and anesthesia, which may quicken the rate of cognitive decline (4). Overall, there are many factors that affect cognitive risk after anesthesia, and among the modifiable ones, research suggests that considering different anesthesia types and agents can improve outcomes. 

References 

1. Belrose, Jillian C, and Ruediger R Noppens. “Anesthesiology and cognitive impairment: a narrative review of current clinical literature.” BMC anesthesiology vol. 19,1 241. 27 Dec. 2019, doi:10.1186/s12871-019-0903-7 

1. Subramaniam, Balachundhar and Preeti Upadhyay. “Reducing your risk of changes in thinking following surgery.” Harvard Health Blog, Harvard Health Publishing, May 22 2020. www.health.harvard.edu/blog/reducing-your-risk-of-changes-in-thinking-following-surgery-2020052219898 

2. Sun, Mingyang et al. “Dementia risk after major elective surgery based on the route of anaesthesia: A propensity score-matched population-based cohort study.” EClinicalMedicine vol. 55 101727. 4 Nov. 2022, doi:10.1016/j.eclinm.2022.101727 

3. Vacas, Susana et al. “Cognitive Decline Associated With Anesthesia and Surgery in Older Patients.” JAMA, 10.1001/jama.2021.4773. 2 Aug. 2021, doi:10.1001/jama.2021.4773 

4. Wu, Lingzhi et al. “Lasting effects of general anesthetics on the brain in the young and elderly: “mixed picture” of neurotoxicity, neuroprotection and cognitive impairment.” Journal of anesthesia vol. 33,2 (2019): 321-335. doi:10.1007/s00540-019-02623-7 

5. Zywiel, Michael G et al. “The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review.” Clinical orthopaedics and related research vol. 472,5 (2014): 1453-66. doi:10.1007/s11999-013-3363-2 

Orthopedic surgery patients have the highest risk of developing a surgical site infection (SSI) after an operation (2). Luckily, the risk of infection after orthopedic surgery can be reduced by following infection prevention measures before, during, and after surgery. These prevention measures include screening surgery candidates for risk factors, properly administering prophylactic antibiotics, and implementing institutional practices for infection prevention.

A crucial first step for infection prevention after orthopedic surgery is thoroughly evaluating orthopedic surgery candidates for modifiable risk factors in the preoperative period. Modifiable risk factors include malnourishment, tobacco and alcohol use, and mental health conditions (1). Identifying these risk factors allows physicians to properly address these issues prior to the procedure.  

Patients who have comorbid conditions such as rheumatoid arthritis, cardiovascular disease, and diabetes also have a higher risk of developing an infection (1). While these risk factors may not be modifiable, evaluating a patient for comorbid conditions allows the patient’s care team to provide specific interventions and lower the risk of infection as much as possible. 

One of the most important measures for infection prevention after orthopedic surgery is the proper administration of prophylactic antibiotics during the procedure. The CDC recommends that prophylactic antibiotics be initiated within one-to-two hours before the surgery begins and continued throughout the procedure (5). Using the proper type of antibiotics for the particular procedure is crucial to this step (5). Furthermore, antibiotics should be discontinued within 24 hours of surgery completion, since administering them for too long can result in antibiotic resistance (5). 

Hospitals and other medical facilities can implement systemized, institutional approaches to prevent infection that are practiced by every care team. Protocols such as hand washing, patient risk assessment, and infection surveillance are likely to be part of this approach (4). Other prevention measures such as shaving the surgical site, nasal decolonization, and monitoring blood glucose levels can also be implemented before, during, or after surgery to minimize infection risk (2). However, antibiotic prophylaxis remains the most important step for preventing SSI. 

Surgical site infections can have lasting consequences for patients, including increased hospital length of stay, higher medical costs, and higher rates of morbidity and mortality (6). SSIs result in around 4 million additional days in the hospital and $2 billion in health care costs annually (5). Considering that orthopedic surgery patients have the highest risk for SSIs, orthopedic surgeons, anesthesiologists, and other care team members involved with orthopedic surgeries should take extra precautions for infection prevention. Taking proper steps preoperatively, intraoperatively, and postoperatively can have a significant effect on ensuring patient safety and promoting fast recoveries. 

References 

1. Antonelli, Brielle and Antonia F. Chen. “Reducing the risk of infection after total joint arthroplasty: preoperative optimization.” Arthroplasty, vol.1, no. 4, 1 Aug 2019. doi:10.1186/s42836-019-0003-7 

2. Copanitsanou, Panagiota. “Recognizing and preventing surgical site infection after orthopaedic surgery.” International Journal of Orthopaedic and Trauma Nursing, vol. 37, May 2020, pp. 100741. doi: 10.1016/j.ijotn.2019.100751 

3. Nagata, Kosei et al. “Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery.” JANA Network Open, vol. 5, no. 4, 2022. doi:10.1001/jamanetworkopen.2022.6095 

4. Perry, Kevin and Arlen D. Hanssen. “Orthopaedic Infection: Prevention and Diagnosis.” Journal of the American Academy of Orthopedic Surgeons, vol. 25, pp. S4-S6, Feb 2017. doi:10.5435/JAAOS-D-16-00634  

5. Salkind, Alan R. and Kavitha C. Rao. “Antibiotic Prophylaxis to Prevent Surgical Site Infections.” American Family Physician, vol. 38, no. 5, 2011, pp. 585-590. www.aafp.org/pubs/afp/issues/2011/0301/p585.html 

6. Tucci, G et al. “Prevention of surgical site infections in orthopedic surgery: a synthesis of current recommendations.” European Review for Medical and Pharmacological Sciences, vol. 23, no. 2, 2019, pp. 224-239. doi:10.26355/eurrev_201904_17497