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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 

Prostate surgery can be carried out to treat prostate cancer, an enlarged prostate or benign prostatic hyperplasia (BPH), urinary continence, or erectile dysfunction in some cases ¹. The goal of anesthesia for prostate surgery is to minimize pain before, during, and after surgery.  

There are multiple different approaches for prostate surgery, depending on the goal, which will require different anesthesia approaches. In a traditional open surgery or open approach, a surgeon will make an incision through the skin to excise out the prostate and nearby tissues. Either a radical retropubic or a radical perineal approach can be used during open prostate surgery. For both approaches, a patient can be under general anesthesia or spinal or epidural anesthesia.

Regional anesthesia and analgesia may favor minimal residual disease following removal of a primary tumor due to how it affects the body. A retrospective review of patient medical records looked at records from patients receiving open prostatectomy with general anesthesia. This study identified that, after adjusting for tumor size and date of surgery, among other factors,  using epidural analgesia with general anesthesia instead of postoperative opioids with general anesthesia was linked to a substantially lower risk of biochemical cancer recurrence after prostate surgery ².  

A recent retrospective study revealed that combined spinal epidural anesthesia seems to be suitable and efficient for patients undergoing open radical retropubic prostatectomy. This specific approach reduces the average time in the operating unit and the length of the hospital stay ³. 

Laparoscopic surgery is a minimally invasive prostate surgery method that has become more widespread due to advancing technology and techniques. Two main approaches can be used tfor laparascopic prostate surgery. A laparoscopic radical prostatectomy requires multiple small cuts for the insertion of small surgical instruments, after which a surgical camera is inserted. In a robotic-assisted laparoscopic radical prostatectomy, a surgeon directs a robotic arm while viewing a computer monitor, providing maneuverability and precision. 

While any induction agent can be used for anesthesia, anesthetic management of prostate surgery patients needs to consider medical co-morbidities and medically optimize patients prior to surgery. Research has found that side effects remain minimal with robotic-assisted laparoscopic prostatectomy: Anesthetic and perioperative complications are rare. However, these do include a 1.3% incidence of postoperative anemia, postoperative pulmonary emboli, and, seemingly most commonly, corneal abrasions ⁴.  

Meanwhile, prostate laser surgery, endoscopic surgery, transurethral resection of the prostate (TURP), or transurethral incision of the prostate are additional surgical approaches that can help with urine flow. While TURP remains the surgical gold standard to treat benign prostatic hyperplasia, perioperative-associated morbidity remains high, ranging from 18% and 26%. In addition, between 1% and 8% of TURP procedures are complicated by TURP syndrome ⁵. The symptoms of TURP syndrome and bladder perforation may be masked under sedation and general anesthesia ⁶, and regional anesthesia may be warranted ⁷. 

Research has found that open prostatectomy may incur fewer complications if the prostate is very large (>100 g); prostatic size may be preemptively assessed by transrectal ultrasound scanning, endoscopic inspection, or manual examination ⁸. 

In any case, it is important after the surgery to keep the surgical wound clean, not drive, not do any high-energy activity, avoid sitting for more than 45 minutes, and take pain medications as prescribed. 

Additional research is required in order to validate and elucidate the links between anesthesia for prostate surgery and certain clinical outcomes. For example, prospective randomized trials to assess the link between substituting epidural analgesia for postoperative opioids and the substantially lower risk of cancer recurrence are required. This research will continue to help select the best anesthesia approach depending on clinical context. 

 
References 

1. What You Need to Know About Prostate Surgery. Available at: https://www.healthline.com/health/prostate-surgery. (Accessed: 3rd February 2023) 

2. Biki, B. et al. Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: A retrospective analysis. Anesthesiology (2008). doi:10.1097/ALN.0b013e31817f5b73 

3. Kofler, O. et al. Anesthesia for Open Radical Retropubic Prostatectomy: A Comparison between Combined Spinal Epidural Anesthesia and Combined General Epidural Anesthesia. Prostate Cancer (2019). doi:10.1155/2019/4921620 

4. Danic, M. J. et al. Anesthesia considerations for robotic-assisted laparoscopic prostatectomy: A review of 1,500 cases. in Journal of Robotic Surgery (2007). doi:10.1007/s11701-007-0024-z 

5. Hahn, R. G. Fluid absorption in endoscopic surgery. British Journal of Anaesthesia (2006). doi:10.1093/bja/aei279 

6. Demirel, I., Ozer, A. B., Bayar, M. K. & Erhan, O. L. TURP syndrome and severe hyponatremia under general anaesthesia. BMJ Case Rep. (2012). doi:10.1136/bcr-2012-006899 

7. Mebust, W. K. et al. Transurethral prostatectomy: Immediate and postoperative complications. Cooperative study of 13 participating institutions evaluating 3,885 patients. J. Urol. (2002). doi:10.1016/S0022-5347(05)65370-0 

8. O’Donnell, A. M. & Foo, I. T. H. Anaesthesia for transurethral resection of the prostate. Contin. Educ. Anaesthesia, Crit. Care Pain (2009). doi:10.1093/bjaceaccp/mkp012 

Recently identified as belonging to the filovirus genus, the Marburg virus (MARV) is another aggressive infectious agent with similar epidemiology to the Ebola virus (EBOV). There have been sporadic cases of MARV in Africa over the last decade, but the most recent cases occurred in Ghana this summer. Although this was Ghana’s first time encountering cases of Marburg virus, the quick response of medical practitioners at the clinic in the Ashanti region where the first case was identified was a key step in interrupting the spread of MARV throughout the region.²  

Ghana’s supposed patient zero was a 26-year-old male who eventually succumbed to the disease 3 days after his symptoms started on June 24, 2022. His symptoms included fever, malaise, epistaxis, bleeding from the mouth, and subconjunctival hemorrhage. On June 28, 2022, a 51-year-old male reported to the hospital with the same symptoms; he died the same day. Blood samples from both victims were tested using reverse transcriptase-polymerase chain reaction (RT-PCR) at the Noguchi Memorial Institute for Medical Research (NMIMR). NMIMR confirmed MARV as the cause of death. Further investigation by the Pasteur Institute in Senegal verified the results. According to the investigation conducted, animal contact played no role in these two cases. The evidence supports human to human transmission; the primary route is direct exposure to the blood or bodily fluids of an infected person. Contact tracing was used to identify 90 individuals who were exposed; they were quarantined and monitored.¹ In total, 198 people were tested for MARV and all presented with negative results.³ Dr. Kasalo, W.H.O. representative to Ghana, credits the success of quelling this outbreak to “early alert and response, strong surveillance, community involvement and participation, and coordinated efforts”.² W.H.O. declared an end of the Marburg virus outbreak September 16, 2022. ²  

Historically, MARV outbreaks on the continent have been moderate, regularly reporting less than 400 cases per incident. In 1980, Kenya reported 2 cases of MARV with fever and malaise. Seven years later, one additional case was reported in Kenya. From 1998-2000, the Democratic Republic of Congo dealt with 154 cases, but the worst outbreak happened in Angola between 2004-2005. A total of 374 cases were reported in this outbreak. Finally, Uganda had the most recent MARV cases and these periodically emerged from 2007-2017. No more than 15 cases were reported per outbreak in Uganda.¹ 

The CDC states that preventative measures against Marburg virus are poorly defined since no vaccine or antiviral drugs exist. Avoiding fruit bats, the natural host of the virus is recommended to prevent zootrophic transmission and early identification and isolation of a human host also prevents transmission. People at highest risk for contracting MARV are veterinarians working with non-human primates, laboratory workers handling the virus and travelers visiting regions of Africa endemic to fruit bats. To prevent infection in such settings, wearing personal protective clothing like gloves, masks, and gowns is recommended. Avoiding fecal matter from the host bats and infected humans is necessary, especially in the clinical setting. Rapid testing is recommended by the CDC to control the spread. ⁴ 

References 

1.  Jack Wellington, Ayça Nur, Aderinto Nicholas, Olivier Uwishema, Hassan Chaito, Olutola Awosiku, Yusuf Jaafer Al Tarawneh, Jana Abdul Nasser Sharafeddine, Chinyere Vivian Patrick Onyeaka, Helen Onyeaka, “Marburg virus outbreak in Ghana: An impending crisis,” Annals of Medicine and Surgery, Volume 81, 2022,104377,ISSN 2049-0801 

2. Sayibu Ibrahim Suhuyini “Beating Marburg virus outbreak: Ghana’s journey to victory” https://www.afro.who.int/countries/ghana/news/beating-marburg-virus-outbreak-ghanas-journey-victory  

3. Mensah, Kent “Ghana Marburg Outbreak Declared Over” https://www.voanews.com/a/ghana-marburg-outbreak-declared-over-/6750533.html 

4. Center for Disease Control and Prevention “Marburg” https://www.cdc.gov/vhf/marburg/index.html  

Minor surgery is generally defined as a surgical procedure which does not require general anesthesia and can be performed electively and in an outpatient setting. Of note, there is no clear official delineation between major and minor surgeries, but minor surgeries are less invasive and less risky (Newsome et al., 2021). Patients undergoing any surgeries are often required to fast from fluid and food beforehand. This, however, can lead to dehydration and place them at risk of organ injury and failure. Administering intravenous (IV) fluids may have positive effects. Conversely, fluid overload may decrease pulmonary function and gut motility (Brandstrup, 2006). Most research on fluid therapy during surgery focuses on major surgery. However, less is understood on the value of IV fluids during minor surgery and how they may affect a patient’s clinical course.

A study found that patients who received 2 liters of IV fluids intra- and postoperatively recovered quicker from the effects of surgery and anesthesia compared to patients without fluids. This was a group of patients undergoing ambulatory gynecologic laparoscopy surgery. Though this is a small volume of IV fluids, it appeared to have immediately measurable effects on patients postoperatively. The authors hypothesized that this was due to a correction of  dehydration. In terms of patient satisfaction, 93% of patients who had intravenous fluids felt the most recent anesthetic experience was better than past ones (Keane & Murray, 2007).  Other trials testing different intravenous fluid volumes on the outcomes of outpatient surgery found similar improvements in self-reported symptoms such as drowsiness and dizziness. In general, the volume of fluids given was approximately the same as the deficit from fasting, which may point to a benefit to replacing fluid losses from fasting. However, this research did not show if IV fluids would be beneficial in minor surgery in terms of external loss of fluid during an operation (Brandstrup, 2006).  

However, patient satisfaction, though important, is a subjective assessment of IV fluids during minor surgery. In two groups of 15 patients undergoing minor gynecologic surgery, there was no obvious clinical benefit of IV fluids administration (Ooi et al., 1992). This study attempted to use objective testing including two tests of psychomotor function. There was no significant difference between postoperative motor reaction times. Notably, the patients in this study were healthy and underwent a short duration of anesthesia. Fluids and hydration may be more important for longer surgeries. 

Furthermore, the benefit of IV fluids during minor surgery may depend on a patient’s risk level. Preoperative administration of 2mL/kg for every hour patients had fasted from fluids decreased incidence and severity of postoperative nausea and vomiting. However, this was for patients scheduled for diagnostic gynecologic laparoscopy, which is typically a less urgent procedure compared to other situations that would require minor surgery (Maharaj et al., 2005). Other factors that may influence recovery include nature and duration of the procedure, individual patient risk, and the anesthesia method used (Ooi et al., 1992).  

Ooi et al. brought up an interesting point in their study: perhaps further research may focus on the benefits of oral fluids versus IV fluids in minor surgery. Oral fluids offer a more cost-effective solution, and patients are often deprived of fluids a long period before minor surgeries (Ooi et al., 1992). Clear fluids may be safe for patients in limited volumes closer to the surgery start time. Another topic of research may focus on the effects of fluid overload compared to hypovolemia. This topic may fuel further investigation into more carefully assessing role of fluids during minor surgery.  

References 

Brandstrup B. Fluid therapy for the surgical patient. Best Pract Res Clin Anaesthesiol. 2006;20(2):265-283. doi:10.1016/j.bpa.2005.10.007 

Keane PW, Murray PF. Intravenous fluids in minor surgery. Their effect on recovery from anaesthesia. Anaesthesia. 1986;41(6):635-637. doi:10.1111/j.1365-2044.1986.tb13059.x 

Maharaj CH, Kallam SR, Malik A, Hassett P, Grady D, Laffey JG. Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients. Anesth Analg. 2005;100(3):675-682. doi:10.1213/01.ANE.0000148684.64286.36 

Newsome K, McKenny M, Elkbuli A. Major and minor surgery: Terms used for hundreds of years that have yet to be defined. Ann Med Surg (Lond). 2021;66:102409. Published 2021 May 25. doi:10.1016/j.amsu.2021.102409 

Ooi LG, Goldhill DR, Griffiths A, Smith C. IV fluids and minor gynaecological surgery: effect on recovery from anaesthesia. Br J Anaesth. 1992;68(6):576-579. doi:10.1093/bja/68.6.576

Intravenous lidocaine is widely used for its effect on postoperative pain and recovery. In addition, concern about opioid risks in the postoperative period has galvanized the use of nonopioid analgesic adjuncts.¹ However, if used inappropriately and incorrectly, intravenous lidocaine can have fatal consequences – therefore, it is extremely important to administer intravenous (IV) lidocaine for surgical pain according to a careful, well-informed protocol.

The decision to administer intravenous lidocaine or not depends on the type of surgery and individual patient factors, including but not limited to the presence of any existing condition that affects pain management and risk (such as pre-existing chronic pain). This decision mainly focuses on three priorities. First, is intravenous lidocaine safe? Second, does intravenous lidocaine effectively reduce postoperative pain and speed up recovery? Third, how is intravenous lidocaine licensed for use?²

In general, while perioperative IV lidocaine infusion is indeed effective at reducing pain, evidence supporting its use varies according to the surgical procedure. However, the benefits of intravenous lidocaine are clear in certain clinical contexts. For example, it prevents airway reactivity on emergence in smokers and quenches cerebral hemodynamic responses to airway manipulation.³ It may also reduce anesthetic requirements by approximately one-third in specific situations.⁴ It may further reduce neuropathic pain by inhibiting the activity of injured afferent nerves.⁵ Finally, following laparoscopic nephrectomy, it can reduce the need for postoperative morphine, ameliorating postoperative pain management and recovery.⁶

In general, notable guidelines have been developed to ensure the appropriateness, safety and efficacy of intravenous lidocaine for surgical pain.  

First and foremost, the use of IV lidocaine for acute surgical pain should be approved by the local hospital and medication governance committee or equivalent. When possible, consent should also be obtained by patients.  

As regards its administration, certain researchers recommend an initial dose not exceeding 1.5 mg/kg, calculated using the patient’s ideal body weight and provided as an infusion over 10 minutes. Thereafter, researchers recommend an infusion not exceeding 1.5 mg/kg/h for no more than 24 hours, subject to re-assessment.  

Furthermore, intravenous lidocaine should not be used in conjunction with any other local anesthetic interventions. Therefore, intravenous lidocaine should not be administered within 4 hours of any nerve block. Conversely, no nerve block should be performed within 4 hours of discontinuing an intravenous lidocaine infusion. 

Outside the operating theater and recovery room, patients receiving intravenous lidocaine should be monitored to quickly address complications, if any arise. Particular attention should be paid to patients who have an existing comorbidity.²

In the end, however, the approach selected for the use of intravenous lidocaine should be approved by hospital health governance systems, and the individual clinical decision should be carried out following properly informed consent on behalf of the patient. 

In conclusion, IV lidocaine may be a key pillar of a pain management strategy for surgical pain. However, it needs to be very carefully delivered. In the meantime, additional research in the form of further randomized control trials with a large sample size⁷ is warranted in order to corroborate and specify current protocols.

References 

1. Dunn, L. K. & Durieux, M. E. Perioperative Use of Intravenous Lidocaine. Anesthesiology (2017). doi:10.1097/ALN.0000000000001527 

2. Foo, I. et al. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia (2021). doi:10.1111/anae.15270 

3. Hamill, J. F., Bedford, R. F., Weaver, D. C. & Colohan, A. R. Lidocaine before endotracheal intubation: Intravenous or laryngotracheal? Anesthesiology (1981). doi:10.1097/00000542-198111000-00016 

4. Kaba, A. et al. Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology (2007). doi:10.1097/00000542-200701000-00007 

5. Kirillova, I. et al. Effect of local and intravenous lidocaine on ongoing activity in injured afferent nerve fibers. Pain (2011). doi:10.1016/j.pain.2011.02.046 

6. Tauzin-Fin, P. et al. Benefits of intravenous lidocaine on post-operative pain and acute rehabilitation after laparoscopic nephrectomy. J. Anaesthesiol. Clin. Pharmacol. (2014). doi:10.4103/0970-9185.137269 

7. Yue, H., Zhou, M., Lu, Y., Chen, L. & Cui, W. Effect of intravenous lidocaine on postoperative pain in patients undergoing intraspinal tumor resection: Study protocol for a prospective randomized controlled trial. J. Pain Res. (2020). doi:10.2147/JPR.S249359

Surgery in the prone position, or lying face down, as opposed to supine where the patient is lying on their back with their face up, is used when a surgery requires access to anatomical structures posteriorly. This can include access to the posterior head, neck, or spine during a spinal surgery or even for access to the upper urinary tracts during urological surgeries [1].

Prone surgery is associated with many complications that often stem from the prolonged and increased pressure on anterior organs. Increased abdominal pressure causes excess pressure to build on the inferior vena cava, the major vein which returns blood from the body back to the heart. This results in a back-up of blood in the body and thus, less blood returning to the heart. Further, the pressure on the chest wall leads to decreased output from the heart which results in a subsequent drop in blood pressure. This drop in blood pressure can be dangerous in the setting of surgery. Additionally, respiratory rate is affected in prone surgery, which can lead to further decreases in cardiac output and oxygenation [2]. Some of the potential cardiovascular complications of prone surgery include hypovolemia and cardiac arrest [1]. Increased bleeding is also a common complication of the prone position, especially in spinal surgery, as damage to engorged veins can cause greater bleeding than damage to normal veins [2].

Prone positioning can also increase intraocular pressure [3]. Malpositioning of the patient can lead to direct pressure on the eye for an extended period, which can lead to irreversible visual loss. While postoperative vision loss is commonly described in journals, the true rate of incidence remains low [1]. However, while rare, it is necessary for both surgeons and anesthesiologists to watch for adequate patient eye protection during prone surgeries to avoid this potentially devastating complication.  

There are many preoperative risk factors that play a role in postoperative complications of prone surgery. In terms of postoperative vision loss, older patients who have an elevated intraocular pressure at baseline typically are at higher risk for vision loss [3]. Hypertension, diabetes, obesity, anemia, atherosclerosis, and history of smoking are all risk factors for postoperative complications [5].

Ideally in a prone surgery, positioning will maximize ventilation of the patient while minimizing risk of bleeding and damage to vital organs [2]. Over the years, special operating tables and other devices such as chest rolls and bolsters have been designed to promote ideal prone positioning, decrease pressure on the abdomen and chest, and lower complications associated with prone positioning. Further, careful positioning can prevent vision loss by changing the degree of the bed so that the head is above the heart. This allows for less venous pooling of blood in the eye and orbit which can help to decrease intraocular pressures [4]. Reducing the length of time patients are in prone positioning can also help to decrease complications. Surgeries that are longer than 6.5 hours are considered prolonged, and it may be beneficial to use a series of shorter surgeries to reduce risks of complications. On the other hand, risks of multiple surgeries may outweigh the risks of one prolonged prone surgery [3,5]. Overall, for preventing complications of prone surgery, it is important to monitor fluids, using IV fluids when necessary to replace intravascular volume, monitor blood loss and hemoglobin level, and optimize blood pressure within 20-25% of baseline blood pressure [5,6].  

References 

1. Kwee, Melissa M., et al. “The Prone Position during Surgery and Its Complications: A Systematic Review and Evidence-Based Guidelines.” International Surgery, vol. 100, no. 2, Feb. 2015, pp. 292–303, www.ncbi.nlm.nih.gov/pmc/articles/PMC4337445/, 10.9738/intsurg-d-13-00256.1. 

2. Schonauer, Claudio, et al. “Positioning on Surgical Table.” European Spine Journal, vol. 13, no. S01, 22 June 2004, pp. S50–S55, 10.1007/s00586-004-0728-y. 

3. ‌van Wicklin, Sharon Ann. “Systematic Review and Meta-Analysis of Prone Position on Intraocular Pressure in Adults Undergoing Surgery.” International Journal of Spine Surgery, 14 Apr. 2020, p. 7029, 10.14444/7029. 

4. Ozcan, Mehmet S., et al. “The Effect of Body Inclination during Prone Positioning on Intraocular Pressure in Awake Volunteers: A Comparison of Two Operating Tables.” Anesthesia & Analgesia, vol. 99, no. 4, Oct. 2004, pp. 1152–1158, 10.1213/01.ane.0000130851.37039.50.  

5. ‌Shifa, Jemal, et al. “A Case of Bilateral Visual Loss after Spinal Cord Surgery.” Pan African Medical Journal, vol. 23, 2016, 10.11604/pamj.2016.23.119.8443.  

6. Lee, Lorri A., et al. “The American Society of Anesthesiologists Postoperative Visual Loss Registry.” Anesthesiology, vol. 105, no. 4, 1 Oct. 2006, pp. 652–659, 10.1097/00000542-200610000-00007.  

The Telehealth Modernization Act was passed in 2022, modifying requirements for the coverage of telehealth services under Medicare. It effectively extends certain flexibilities initially authorized during the COVID-19 public health emergency. Endorsed by a number of professional organizations, from the American Association of Orthopedic Surgeons (AAOS) (1) to the American Hospital Association (AHA) (2), the legislation has a number of critical implications.

In April 2020, at the beginning of the pandemic, over 40% of Medicare fee-for-service primary care visits were carried out through telehealth, and over 10 million beneficiaries accessed telehealth services from mid-March through early July of 2020 (3). While regulatory coverage restrictions have long prevented telehealth services for many of the nation’s roughly 61 million Medicare beneficiaries, the COVID-19 pandemic acutely highlighted the importance of access to telehealth care.

Among other elements, the bill allows (1) federally qualified health centers and rural health clinics to act as the location of the health care practitioner; (2) the home of a beneficiary to act as the location of the health care beneficiary for all services; and (3) all types of practitioners to provide telehealth services, as assessed by the Centers for Medicare and Medicaid Services (4).  

The Telehealth Modernization Act applies to a full spectrum of health care. In addition to providing Medicare recipients many additional telehealth services, the act will 1) help patients continue to access telehealth from varied health care workers, from speech language pathologists to physical therapists, and 2) help Medicare patients receiving services ranging from home dialysis to hospice care keep receiving this care through telehealth. 

The most important implication of the Telehealth Modernization Act is the increased flexibility of – and therefore access to – health care. Permanently eradicating geographic and originating site restrictions, the Telehealth Modernization Act will reduce access barriers that have continuously increased in recent times. Relatedly, it will enable greater access to high-quality health care services for vulnerable populations, in particular among seniors.  

In addition to ensuring access to essential care for patients, the increased use of telehealth helps address certain workforce pressures, including those that arose as a result of an overwhelmed healthcare system during the COVID-19 pandemic.  

Many opportunities and challenges remain to be addressed in view of a telehealth-centric future, however (5). First, patient trust and security are top priorities (6). One study found that ensuring that health services provision meets patients’ needs at all times depends not only on a certain degree of flexibility in care delivery modalities and interprofessional collaboration, but also healthy, sustained relationships with patients. Second, and relatedly, it will be important to ensure that patients receive the right amount of empathic, personalized care, crucial to a good patient experience and patient well-being. As many have experienced, virtual interactions so far have major differences compared to in-person ones. To this end, guidelines and training are needed, as well as careful attention to technological challenges and interpersonal relationship needs (7).  

Overall, telehealth has been beneficial for millions of Americans, especially during the pandemic (3). While continued research is required to ensure that its key provisions are implemented in the most smooth and efficient way possible, the Telehealth Modernization Act will surely continue to positively reshape healthcare delivery.  

References 

1. AAOS’ Advocacy Efforts Focus on Access to Quality Care [Internet]. [cited 2022 Jul 25]. Available from: https://www.aaos.org/aaosnow/2022/may/advocacy/advocacy01/ 

2. AHA Comments to Modernization Subcommittee of the Healthy Future Task Force Re: Telehealth | AHA [Internet]. [cited 2022 Jul 25]. Available from: https://www.aha.org/lettercomment/2022-03-04-aha-comments-modernization-subcommittee-healthy-future-task-force-3-4-22 

3. Scott, Schatz, Shaheen Introduce Bipartisan Legislation to Increase Access to Telehealth in the Midst of the Pandemic | U.S. Senator Tim Scott of South Carolina [Internet]. [cited 2022 Jul 25]. Available from: https://www.scott.senate.gov/media-center/press-releases/scott-schatz-shaheen-introduce-bipartisan-legislation-to-increase-access-to-telehealth-in-the-midst-of-the-pandemic 

4. H.R.1332 – 117th Congress (2021-2022): Telehealth Modernization Act | Congress.gov | Library of Congress [Internet]. [cited 2022 Jul 25]. Available from: https://www.congress.gov/bill/117th-congress/house-bill/1332 

5. Blandford A, Wesson J, Amalberti R, AlHazme R, Allwihan R. Opportunities and challenges for telehealth within, and beyond, a pandemic. The Lancet Global Health. 2020. doi: 10.1016/S2214-109X(20)30362-4. 

6. Hale TM, Kvedar JC. Privacy and security concerns in telehealth. Virtual Mentor. 2014. doi: 10.1001/virtualmentor.2014.16.12.jdsc1-1412. 

7. Breton M, Sullivan EE, Deville-Stoetzel N, McKinstry D, DePuccio M, Sriharan A, et al. Telehealth challenges during COVID-19 as reported by primary healthcare physicians in Quebec and Massachusetts. BMC Fam Pract. 2021; doi: 10.1186/s12875-021-01543-4. 

Viral shedding refers to the expulsion of live virus from an organism in which the virus has successfully replicated.¹ Shedding can occur via several different mechanisms, such as budding, whereby viral particles exit the host cell membrane by surrounding themselves with molecules from the membrane, and apoptosis, whereby viral particles force cells to undergo cell death and can then be released into the extracellular space.² The amount of viral shedding by infected individuals depends on the virus in question, the stage of infection, and the host’s immunity against the virus, including if they have been vaccinated.

 Vaccination can protect individuals from viral infection such that even upon exposure to a virus, the individual’s vaccine-induced immunity kills the infectious agent before it can replicate and cause illness. In reality, breakthrough infections can also occur, in which vaccinated individuals contract a viral illness. Vaccinated individuals who contract breakthrough infections may nevertheless have better outcomes than unvaccinated individuals who become infected. Variants of SARS-CoV-2, such as the Delta variant, have caused breakthrough infections, but it has been found that people vaccinated against COVID-19 are much less likely than unvaccinated individuals to develop severe symptoms.³ 

Does this mean that fully vaccinated individuals are also less likely to transmit the virus to others – do they shed less virus? Dr. Jiwon Jung and other South Korean researchers recently published their findings on this very question. In a recent Journal of the American Medical Association paper, Jung et al. reported on their study of the transmissibility of COVID-19 according to vaccination status.⁴ The study involved two cohorts of vaccinated and unvaccinated individuals. The first cohort was subject to a secondary transmission study: the contacts of the cohort members were tracked, and their COVID-19 infections were recorded. The second cohort underwent a viral kinetics shedding study: patients submitted saliva samples each day of the study, and the viral load in the samples was measured using polymerase chain reaction (PCR). 

The results from both cohorts indicate that vaccinated individuals with breakthrough infections shed less virus than unvaccinated infected patients. The risk of secondary transmission was significantly lower in the breakthrough group than in the non-breakthrough group. Additionally, while patients in the breakthrough and non-breakthrough had a similar initial viral load after infection, fully vaccinated patients had a shorter duration of viral shedding compared to partially vaccinated and unvaccinated individuals. 

Though convincing, the study, as its authors acknowledge, has several limitations. Perhaps most significantly, viral shedding was only measured by the amount of virus in saliva samples. Due to “logistical challenges,” nasopharyngeal swab samples were not used, though they could have enabled more accurate data on viral shedding, especially given the incomplete data regarding the amount of viral shedding at different body sites over the course of infection.⁵ Furthermore, the study only tracked nosocomial secondary transmission – that is, infections originating in a hospital – which may bias the results. Finally, the cohort 1 study began before the emergence of the infectious Delta variant but concluded after it was widespread. The study did not control for SARS-CoV-2 variant, and the conclusions drawn from it are therefore limited. Nevertheless, this important study hopefully paves the way for future research into viral shedding in vaccinated individuals. 

References 

1. Yan, D. et al. Characteristics of Viral Shedding Time in SARS-CoV-2 Infections: A Systematic Review and Meta-Analysis. Front. Public Health 9, (2021), DOI: 10.3389/fpubh.2021.652842 

2. Badu, K. et al. SARS-CoV-2 Viral Shedding and Transmission Dynamics: Implications of WHO COVID-19 Discharge Guidelines. Front. Med. 8, (2021), DOI: 10.3389/fmed.2021.648660 

3. CDC. COVID-19 Vaccination. Centers for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness/why-measure-effectiveness/breakthrough-cases.html (2020). 

4. Jung, J. et al. Transmission and Infectious SARS-CoV-2 Shedding Kinetics in Vaccinated and Unvaccinated Individuals. JAMA Netw. Open 5, e2213606 (2022), DOI:10.1001/jamanetworkopen.2022.13606 

5. Congrave-Wilson, Z. et al. Change in Saliva RT-PCR Sensitivity Over the Course of SARS-CoV-2 Infection. JAMA 326, 1065–1067 (2021), DOI: 10.1001/jama.2021.13967