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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 

The use of regional nerve blocks in the management of perioperative pain has gained popularity in recent years. Also referred to as “preventive analgesia,” regional nerve blocks are a safe and effective method of pain management, where the blockade of specific nerves can lead to a reduction in postoperative pain and opioid consumption [1,2]. The timing of regional nerve block is an important consideration for proper analgesia.

During surgery, nociceptive signals initiated by tissue injury induce a state of central nervous system hyperactivity which causes patients to experience pain [3]. This central sensitization is thought to be the underlying mechanism of persistent postoperative pain [3]. Failure to control postoperative pain has been associated with prolonged hospital stays, increased healthcare costs, weakening of the immune system, and development of chronic pain [5]. The two main modalities of regional nerve blocks, single-shot and continuous, have both been shown to be a successful methods of controlling postoperative pain, specifically pain associated with mobilization, which is commonly the most difficult pain to alleviate [3]. 

One factor that influences the timing of the regional nerve block is the type of nerve block being used [2,4]. Continuous nerve blocks delivered through an indwelling catheter have been shown to have a small but significant advantage over single-shot nerve blocks in controlled postoperative pain in some studies [5]. A 2022 study comparing the benefits of a single-shot femoral nerve block versus a continuous femoral nerve block found that patients who received the former had a 50% reduction in the need for postoperative manipulation after total knee arthroplasty [5]. However, the superiority of continuous versus single-shot nerve blocks in pain management remains debated [5].  

Another factor that influences the timing of the regional nerve block is the type of surgery being performed [2,4]. In upper limb surgeries, a continuous brachial plexus block (CIBPB) is often given before or after the induction of anesthesia [4]. Some institutions have even beguan to explore initiating CIBPB postoperatively for pain control, although no significant difference between preoperatively initiated CIBPB and postoperatively initiated CIBPB was measured [4]. The choice of timing depends on the anesthesiologist’s preference, patient clinical status, and the surgery being performed [4]. In contrast, for lower limb surgeries, a femoral nerve block is typically administered after the induction of anesthesia due to the anatomical location of the nerve under the inguinal canal and discomfort that patients can experience if the block is performed while they are awake [5]. 

Furthermore, the timing of regional nerve block administration before surgery remains an area of controversy partially due to concerns about rebound pain when the effects of the block wear off [2]. The phenomenon of rebound pain has only started to be explored in recent literature [2]. A 2017 study sought to explore this concept by interviewing patients who received a peripheral nerve block before ankle surgery [2]. All patients received a single-shot popliteal sciatic and saphenous nerve block as primary anesthesia using ropivacaine 0.75% [2]. Patients were told to expect a minimal block duration of 12 hours [2]. The results of the study found that most patients generally expressed satisfaction with the peripheral nerve block regardless of their postoperative pain profile [2]. Mental alertness, increased mobility, and the ability to eat without nausea were advantages emphasized in patient interviews [2]. Some did experience “excruciating” pain when the single-shot block wore off, and it appears that nocturnal cessation of the blocks’ effect worsened the issue [2]. 

Given the current lack of consensus on the ideal timing of regional nerve block administration, anesthesiologists should use evidence-based clinical judgement and patient preference to make decisions on whether to administer a nerve block before or after induction of anesthesia, and whether to use a single-shot or continuous mode of analgesia. Further research is needed to establish the optimal timing of regional nerve blocks. 

References 

1. Richebé, P., Rivat, C., & Liu, S. (2013). Perioperative or postoperative nerve block for preventive analgesia: should we care about the timing of our regional anesthesia?. Anesthesia & Analgesia, 116(5), 969-970. 

2. Henningsen, M., Sort, R., Møller, A., & Herling, S. (2018). Peripheral nerve block in ankle fracture surgery: a qualitative study of patients’ experiences. Anaesthesia, 73(1), 49-58. 

3. Lavand’homme, P. (2011). From preemptive to preventive analgesia: time to reconsider the role of perioperative peripheral nerve blocks?. Regional Anesthesia and Pain Medicine, 36(1), 4-6. 

4. Kim, H. J., Kim, H., Koh, K. et al. (2022). Initiation Timing of Continuous Interscalene Brachial Plexus Blocks in Patients Undergoing Shoulder Arthroplasty: A Retrospective Before-and-After Study. Journal of Personalized Medicine, 12(5), 739. 

5. Freccero, D., Van Steyn, P., Joslin, P. et al. (2022). Continuous Femoral Nerve Block Reduces the Need for Manipulation Following Total Knee Arthroplasty. JBJS Open Access, 7(3). 

Physician assistants or PAs are medical professionals that make up a critical part of the healthcare workforce, especially in primary care. While physician assistants aren’t medical doctors, they may perform many of the services traditionally provided by MDs, including physical exams, ordering and interpreting tests, and advising patients on preventative health care (1). The role of physician assistants in primary care is becoming increasingly important due to a shortage of medical doctors specializing in primary care (3). As the population in the United States ages and more people gain access to insurance coverage, physician assistants are expected to make up more of the share of providers that provide routine primary care to patients (1). 

The role of the physician assistant was first conceptualized in the 1960s to address the shortage of medical professionals in primary care (2). Since then, the number of PAs in the medical field has increased, but the percentage of PAs working in primary care has gone down (2). Research indicates that physician assistants who choose to work in primary care share many of the demographic characteristics of medical students who become primary care doctors. PA and MD students that identify as women, are older, and come from lower-income socioeconomic backgrounds are more likely to work in the primary care field, perhaps because they better understand the healthcare needs of medically underserved communities and minority groups (2). 

Furthermore, studies have found that physician assistants are more likely to work in non-teaching hospitals and provide care to Medicaid recipients, uninsured patients, and younger patients (1). PAs are also more likely to work in smaller medical facilities in remote areas that would otherwise be classified as medically underserved communities without their presence (1). 

Physician assistants and nurse practitioners may deliver care that is more preventative compared to traditional doctors, who tend to address pre-existing health issues or complex cases (1). Long-term trends indicate that physician assistants and nurse practitioners may become the main primary care providers in the future, allowing MDs to perform more managerial roles and focus on in-patient care in hospitals.

Working with a physician assistant can provide multifarious benefits for medical doctors and clinics. For example, PAs can allow medical clinics to handle larger patient caseloads and give doctors the ability to lower their workload (3). The presence of a PA may decrease waiting times and increase the quality of care since medical facilities will be less overburdened. As a result, doctors can focus their energy on more complex cases and patients can experience more attentiveness and preventative care during their visits. 

While doctors report a high level of support for the PA profession, some MDs consider physician assistants to be time-consuming and expensive for healthcare facilities due to increased administrative tasks and a higher volume of low-revenue patients (3). Recently, the national organization for physician assistants rebranded its organization to be called the American Academy of Physician Associates (5). This internal change in the name of the profession reflects a desire for PAs to be viewed as mid-level healthcare providers rather than “assistants” that simply provide help to physicians. The name “physician assistant” can cause confusion amongst patients, since, in many cases, PAs no longer work under the direct supervision of a physician in the same clinic. However, doctors are still required to meet regularly with PAs and review sample patient charts in some states (5). 

Physician assistants continue to advocate for more autonomy in their scope of practice to fill in existing gaps in primary care and move towards more prevention-focused healthcare methodologies while maintaining a team-based approach to healthcare collaborating with doctors. Evidence suggests that prioritizing primary care and encouraging more physician assistants to work within the field helps increase the accessibility of medical care and results in lower medical costs for patient populations (6). 

References 

1. Cawley, James F. “Physician Assistants and Their Role in Primary Care.” Virtual Mentor, 2012, vol. 14, no. 5, pp. 411-414, doi: 10.1001/virtualmentor.2012.14.5.pfor2-1205. 

2. Coplan, Bettie et al. “Physician Assistants in Primary Care: Trends and Characteristics.” Annals of Family Medicine, Jan 2013, vol. 11, no. 1, pp. 75-79, doi: 10.1370/afm.1432  

3. Halter, Mary et al. “The contribution of Physician Assistants in primary care: a systematic review.” BMC Health Services Research, 18 June 2013, vol. 13, no. 223, doi: 10.1186/1472-6963-13-223 

4. Jaspen, Bruce. “Physician Assistant Demand Rivals That of Primary Care Doctors.” Forbes, 19 Feb 2016, www.forbes.com/sites/brucejapsen/2016/02/19/physician-assistant-demand-rivals-the-need-for-primary-care-doctors/ 

5. Rau, Jordan. “Physician assistants want to be called physician associates, but doctors cry foul.” NPR, 3 Dec 2021, www.npr.org/sections/health-shots/2021/12/03/1059916872/physician-assistants-want-to-be-called-physician-associates-but-doctors-cry-foul 

6. van Erp, R.M.A. et al. “Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review.” International Journal of Integrated Care, 12 Feb 2021, vol. 21, no. 6, doi: 10.5334/ijic.5485.s110.5334/ijic.5485.s1doi.org/10.5334/ijic.5485.s1 

Healthcare mergers and acquisitions (or M&As) occur when two or more healthcare organizations join their operations, resulting in a larger entity. These types of mergers can take on many different forms, including mergers between insurance companies, hospitals, pharmaceutical companies, and other healthcare businesses. There has been an increase in M&A activity in the healthcare industry in recent years. This trend is predicted to persist into 2023, with standalone facilities often being absorbed by larger, more established players (1). In line with current laws that aim to regulate and limit negative effects of such large movements on the general public, healthcare M&As are carefully scrutinized by the U.S. Department of Justice (DOJ).

The DOJ plays a key role in regulating healthcare M&As. The DOJ’s Antitrust Division in particular is responsible for making sure that M&As do not reduce competition or result in anticompetitive behavior across the healthcare industry. To this end, the division reviews proposed M&As to estimate whether they would harm healthcare recipients by reducing the quality of care, inflating prices, or reducing innovation in the healthcare space. 

When the DOJ concludes that a proposed healthcare merger might harm competition, it may take action to require certain conditions be met before approving it or simply block the merger. For example, the DOJ may require the divestment of certain assets or business lines to prevent the merged entity from accumulating too much market power. 

Recently, the DOJ has been particularly active in reviewing healthcare M&As—partially a result of the increasing consolidation in the healthcare industry, which has fueled concerns about the potential for increased healthcare costs and reduced competition. 

In 2023, the Antitrust Division withdrew three outdated antitrust policy statements linked to enforcement in healthcare markets: the Department of Justice and FTC Antitrust Enforcement Policy Statements in the Health Care Area (Sept. 15, 1993), Statements of Antitrust Enforcement Policy in Health Care (Aug. 1, 1996), and Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program (Oct. 20, 2011) (2). Following careful review, the division had assessed that the withdrawal of the three statements would the best way to promote continued competition and transparency. The statements were found to be overly permissive as regards information sharing and were no longer effectively fulfilling their aims of providing guidance to the public on relevant healthcare competition issues. The broad goal was to increase transparency around the division’s enforcement policies in healthcare markets (3). The Federal Trade Commission is expected to follow the DOJ’s lead (2). However, some critics continue to argue that the DOJ has not been sufficiently aggressive in preventing anticompetitive behavior and challenging healthcare mergers. 

Overall, healthcare M&As are complex transactions requiring deep and thorough consideration and regulatory oversight. The DOJ’s mission in reviewing mergers is an essential protection against anticompetitive behavior, ultimately ensuring that consumers continue to have access to affordable, high-quality healthcare services. 

The healthcare industry is in a state of constant evolution, but understanding the role of the DOJ in healthcare M&As is important for appropriate planning (1). 

References  

1. Top 3 healthcare M&A trends for 2023 | Healthcare IT News [Internet]. [cited 2023 Mar 16]. Available from: https://www.healthcareitnews.com/blog/top-3-healthcare-ma-trends-2023 

2. DOJ withdraws certain health care antitrust enforcement guidance | AHA News [Internet]. [cited 2023 Mar 16]. Available from: https://www.aha.org/news/headline/2023-02-03-doj-withdraws-certain-health-care-antitrust-enforcement-guidance 

3. Justice Department Withdraws Outdated Enforcement Policy Statements | OPA | Department of Justice [Internet]. [cited 2023 Mar 16]. Available from: https://www.justice.gov/opa/pr/justice-department-withdraws-outdated-enforcement-policy-statements