Regional Anesthesia is Associated with Improved Survival and Decreased Recurrence in Ovarian ...

294 Pages·2010·8.79 MB·English

Abstract 1

Regional Anesthesia is Associated with Improved Survival and
Decreased Recurrence in Ovarian Cancer Patients

Presenting Author: Gildasio S. De Oliveira, Jr., M.D.
Presenting Author’s City, State: - Chicago, Il

Introduction: The deleterious effects of surgery and anesthesia in cancer patients have been postulated
for a long time. It has been demonstrated in animals that surgery and anesthesia may promote
metastasis and accelerate the progression of several tumor types. Stress response, opioids and volatile
anesthetic drugs can cause perioperative immune suppression and promote a negative effect on the
outcome of cancer patients. Regional Anesthesia can blunt the stress response, decreased the use of
volatile anesthetics and the consumption of opioids which can lead to a favorable outcome in those
patients.

Methods: We performed a retrospective analysis of patients undergoing primary cytoreductive surgery to
evaluate if the presence of epidural anesthesia and/or analgesia would have a positive impact on cancer
recurrence and survival. Data extracted from patient's medical records included age, height ,weight,
medical history , cancer staging, cancer grading, cell type, surgical duration, blood loss during the
procedure , preoperative CA125, surgeon performing the operation, presence of perioperative transfusion,
number of units transfused and the presence of epidural anesthesia and analgesia . Baseline data was
analyzed using independent sample t test, Mann-Whitney U test, Pearson's Chi square or
Fisher's exact test as appropriate. Time to event data was analyzed using Kaplan-Meier curves and
log-rank test. Cox regression multivariate analysis was used to adjust for possible confounding factors.

Results: We studied 182 patients that were divided into patients who receive perioperative epidural (55
patients) and the ones who did not receive perioperative epidural(127 patients).Groups had no difference
among baseline characteristics except for the number of units transfused which was higher in the non-
epidural group; 1[0-2] vs. the epidural group ;0[0-1] p=0.03. The epidural group had an increase time to
recurrence (p=0.008, log-rank test) and increased survival (p=0.01, log-rank test) when compared to the
non-epidural group. When adjusting for confounding factors ( Age ,ASA, CA125, stage, grade, surgical
duration, transfusion and number of units transfused) the epidural was still found to be a predictor for less
recurrence(p=0.009) and higher survival(p=0.01) ,estimated hazard rate of 0.54[034-0.85] and 0.50[0.28-
0.89] respectively.

Discussion: We demonstrated in this retrospective analysis that the perioperative use of epidural
anesthesia and analgesia is associated with decreased recurrence and increased survival in ovarian
cancer patients. This positive association is possibly due to a better preservation of the immune system
function with the use of epidural.
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Abstract 2

A Multicenter, Randomized, Triple-Masked, Placebo-Controlled Trial of
The Effect of Ambulatory Continuous Femoral Nerve Blocks on Discharge-
Readiness Following Total Knee Arthroplasty In Patients on General
Orthopaedic Wards

Presenting Author: Brian M. Ilfeld, M.D., M.S.
Presenting Author’s City, State: - La Jolla, CA
Co-Authors: Vanessa J. Loland, M.D. - University of California San Diego - San Diego, CA
John F. Donovan, M.D. - Alta Bates Summit Medical Center - Oakland, CA
Linda T. Le, M.D. - University of Florida - Gainesville, FL
Edward R. Mariano, M.D., MAS - University of California San Diego - San Diego, CA

Background: A previous investigation reported a 4-day ambulatory continuous femoral nerve block
(cFNB) decreased the time required to reach 3 important discharge criteria by 53% compared with an
overnight, hospital-only cFNB following total knee arthroplasty (TKA, p<0.001). However, a major
limitation of that study was the artificial research environment: (1) all subjects convalesced in a
specialized, stand-alone clinical research center often with a single nurse per patient; (2) a single
anesthesiologist cared for all subjects; and (3) the 3 physical therapists involved in the study were
specially trained to optimize the study protocol, including ambulation distances.1 Consequently, it is
problematic generalizing results from this single trial to the more than half-million patients who undergo
TKA each year in the U.S. We therefore designed this prospective clinical trial to retest the hypothesis
that an extended ambulatory cFNB shortens the time until 3 specific, predefined readiness-for-discharge
criteria are met following TKA; and to allow inference of the results to the general population by using
standard orthopaedic hospital wards in multiple centers with a wide range of healthcare providers.

Methods: Preoperatively, all patients received a cFNB with perineural ropivacaine 0.2% from surgery until
the following morning, at which time they were randomized to either continue perineural ropivacaine
(n=39) or switch to saline (n=38). The primary endpoint was the time to attain three discharge criteria
(adequate analgesia, independence from intravenous opioids, and ambulation ≥ 30 meters). Patients
were discharged with their cFNB and a portable infusion pump, and catheters were removed on
postoperative day 4.

Results: Patients given 4 days of perineural ropivacaine attained all 3 criteria in a median (25th-75th
%iles) of 47 (29-69) h, compared with 62 (45-79) h for those of the control group receiving ropivacaine
only until the morning following surgery (Estimated ratio=0.80, 95%CI: 0.66-1.00; p=0.028; Fig. 1).
Compared with subjects receiving saline, patients randomized to ropivacaine met the discharge criterion
for analgesia in 20 (0-38) vs. 38 (15-64) h (p=0.009; Figs. 2-3); for intravenous opioid independence in 21
(0-37) vs. 33 (11-50) h (p=0.061); and ambulation in 40 (25-68) vs. 45 (25-66) h (P=0.780). There were 4
falls in 3 patients receiving ropivacaine, versus 0 in controls (p=0.240).

Conclusions: In the previous study using the artificial environment of a stand-alone clinical research
center,1 subjects with a 4-day cFNB met three discharge criteria in 25 (21-47) h, compared with 71 (46-
89) h for those of the control group with an overnight, hospital-only infusion. Providing the extended cFNB
thus resulted in a far greater decrease in time until discharge readiness (46 h, or 53%; p<0.001) than
found for subjects of the current study (15 h, or 20%; p=0.028). That the benefit was greater in a highly-
controlled environment is not surprising. Our current results reflect a country-wide diversity of practice that
is probably more representative of what clinicians can generally expect from an extended, ambulatory
cFNB.

References:
1. Ilfeld et al. Anesthesiology 2008; 108: 703-13
2. Kurtz et al. JBJS 2005; 87: 1487-97
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Abstract 3

Perioperative Pulmonary Circulatory Changes During Bilateral Total Hip
Arthroplasty

Presenting Author: Matthew C. Rade, B.A.
Presenting Author’s City, State: - New York, NY
Co-Authors: George Go, B.S. - Hospital for Special Surgery - New York, NY
Yan Ma, Ph.D. - Hospital for Special Surgery - New York, NY
Nigel E. Sharrock, M.B., Ch.B. - Hospital for Special Surgery - New York, NY
Stavros G. Memtsoudis, M.D., Ph.D. - Hospital for Special Surgery - New York, NY

Background: The transient and rarely clinically relevant effect of bone and cement embolization during
unilateral joint arthroplasty is a known phenomenon. However, available studies do not address events
surrounding bilateral total hip arthroplasties, during which embolic load is presumably doubled. To
elucidate events surrounding this increasingly utilized procedure and assess the effect on the pulmonary
hemodynamics in the intra- and postoperative period, we studied 24 subjects undergoing cemented
bilateral total hip arthroplasty during the same anesthetic session.

Materials and Methods: Twenty four patients without previous pulmonary history undergoing cemented
bilateral total hip arthroplasty under controlled epidural hypotension were enrolled. Pulmonary artery
catheters were inserted and hemodynamic variables were recorded at baseline, 5 minutes after the
implantation of each hip joint, 1 hour and 1 day postoperatively. Mixed venous blood gases and complete
blood counts were analyzed at every time point.

Results: An increase in pulmonary vascular resistance was observed after the second but not the first hip
implantation when compared to values at incision. Pulmonary vascular resistance remained elevated 1
hour postoperatively (Figure 1). Pulmonary artery pressures were significantly elevated on post operative
day 1 compared to baseline values. The white blood cell count increased in response to the second hip
implantation but not the first compared to incision (P<0.003).

Conclusion: The embolization of material during bilateral total hip arthroplasty is associated with
prolonged increases in pulmonary artery pressures and vascular resistance, particularly after the second
side. The performance of bilateral procedures should be cautiously considered in patients with diseases
suggesting decreased right ventricular reserve.
Abstract 4

Intrathecal Clonidine Decreases Propofol Sedation Requirements During
Spinal Anaesthesia In Infants

Presenting Author: Rajeev Subramanyam, D.N.B., M.D., M.N.A.M.S.
Presenting Author’s City, State: - Chandigarh, Karnataka
Co-Authors: Yatindra Batra Kumar, M.D., M.N.A.M.S., F.A.M.S. - Postgraduate Institute of Medical
Education and Re - Chandigarh, Chandigarh
Rakesh S. V., M.B.B.S. - Postgraduate Institute of Medical Education and Re - Chandigarh, Chandigarh
Nidhi Panda B., M.D. - Postgraduate Institute of Medical Education and Re - Chandigarh, Chandigarh
Lokesh V. C., M.D. - Postgraduate Institute of Medical Education and Re - Chandigarh, Chandigarh

Background: Propofol is a popular agent for providing procedural sedation in paediatric population
during lumbar puncture and spinal anaesthesia. Adjuvants like clonidine and fentanyl are administered
intrathecally to prolong the duration of spinal anaesthesia and to provide post - operative analgesia in
infants. We studied the propofol requirement after intrathecal administration of clonidine or fentanyl in
infants undergoing lower abdominal surgeries.

Methods: Institutional review committee approval and parents written informed consent was obtained. 65
ASA I infants undergoing elective lower abdominal surgery under spinal anaesthesia were enrolled in this
prospective randomised double blinded study (Figure 1). A bolus of 2-3 mg/kg of propofol bolus was
administered for lumbar puncture. Sedation was assessed using a six point sedation score (0 to 5) and a
five point reactivity score (0 to 4) based on a behavioural score. After achieving a sedation and reactivity
score of 3 - 4, the infants were positioned laterally in knee chest position. Lumbar puncture was
performed and test drug was administered based on random assignment into one of the four groups.
Bupivacine was administered according to body weight (<5kg = 0.5 mg/kg; 5–10 kg = 0.4 mg/kg).
Group B received intrathecal bupivacaine alone. Group BC received 1Î1⁄4g/kg of intrathecal clonidine with
bupivacaine, group BF received 1Î1⁄4g/kg of fentanyl with bupivacaine and patients in group BCF received
1Î1⁄4g/kg each of clonidine and fentanyl with bupivacaine. Further intraoperative sedation was maintained
with propofol infusion at 25-50Î1⁄4g/kg/min. The propofol dose requirements in each of the groups were
measured. Sedation and reactivity scores were noted.
Analysis was performed with multiple ANOVA with Bonferroni correction as appropriate. Nominal data
was analyzed with chi-square. P<0.05 was considered statistically significant.

Results: The mean ± SD infusion requirement of propofol decreased from 35.5 ± 4.5 in group B to
33.4 ± 5.4 µg/kg/min in group BF and further decreased significantly to 16.7 ± 6.2 µg/kg/min
(P<0.05) and 14.8 ± 4.9 µg/kg/min (P<0.05) in group BC and BCF respectively (Figure 2). There were
no statistically significant differences between BC and BCF groups. The mean sedation and reactivity
scores were significantly higher in groups BC and BCF (P<0.05) as compared to groups B and BF (Figure
3).

Conclusion: Our study show that the dose requirement of propofol sedation reduces with intrathecal
adjuvants. The reduction was significant with the addition of clonidine and clonidine – fentanyl
combination as opposed to bupivacaine alone or with fentanyl. There was no significant difference in
propofol infusion requirement with the use of bupivacaine alone or with fentanyl.
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Abstract 5

Does Patient Perception of Pain Control Affects Patient’S Satisfaction
Across Various Units in a Tertiary Teaching Hospital?

Presenting Author: Artemus Flagg, M.D.
Presenting Author’s City, State: - Baltimore, MD
Co-Authors: Ashlea Barrett, project manager Service - Johns Hopkins University - Baltimore, MD
Kanupria Kumar, M.D. - Johns Hopkins University - Baltimore, MD
Shawn Sumida, M.D. - Johns Hopkins University - Baltimore, MD
Marie Hanna, M.D. - Johns Hopkins University - Baltimore, MD

Introduction: Patients’ reports of satisfaction are receiving greater attention as a result of the rise in
pay-for-performance and the public release of data from the Hospitals Consumer Assessments of
Healthcare Providers and Systems (HCAHPS) survey. Some US News articles published in October 2009
highlight the facts that Patients surveyed give some of America's best hospitals a poor satisfaction
scores. Among those surveys are questions on pain management during their hospitalization.

This article examines the relationship between patient's perception of pain control during their
hospitalization and their overall satisfaction. It also examines the variable difference in pain control
reports among different services and different floor units in the same hospital.

Methods: This project is exempt from the Johns Hopkins IRB. We used the hospital already existing
HCAHPS survey for Patients discharged between January 1, 2008 and June 30, 2009(18 month). We
analyze the two pain related questions in the survey, questions asking patients how well their pain was
controlled and how often hospital staff did everything they could to help controlling their pain. We used t-
tests to compare pain control measures to overall satisfaction by inpatient adult service line, surgical
service line and surgical nursing unit line. We examined relationships between each pain control question
and the proportion of patients who give their overall hospital experience high scores (9 or 10).

Result: A Chi-Squared analysis performed to determine if there was a significant difference in the results
(% always) show significant difference by service line in both questions less than 0.05 (figure1). A
correlation of r=0.7105 and r=0.6367 was found between the 2 pain questions and patient’s
satisfaction question especially with the question concerning staff doing everything to control patient’s
pain(Table 2)

Discussion: The results showed that patients are more likely to rate their overall experience high (9 or
10) if they perceive that their care providers did everything they could to help control the pain rather than
the pain actually being well controlled.

When looking at the entire hospital and more specifically surgical patients, staff doing everything they
could to help with pain was more strongly correlated to overall satisfaction than the actual pain being
controlled (Table 2). For the entire hospital, the correlations were stronger when looking at the results by
service line as compared to nursing unit, however when limiting the results to surgical patients the
correlations are stronger by nursing unit (0.7105 by unit and 0.6484 by service line).

Correlations of actual pain control to overall satisfaction are moderate for the surgical patients (0.6367 by
unit and 0.6091 by service line), but not very strong for the hospital’s aggregate results (0.4198 by
unit and 0.5290 by service line).

Conclusion: Patient perception of pain control is directly related to patients overall satisfaction scores.
These data will encourage different hospital units and especially surgical units to effectively address pain
management and work in changing the culture towards better pain control.