Heuristics, Overconfidence, and Experience With Management of Neuromuscular Block: Self-Correction Is Unlikely No abstract available

Intraoperative Methadone Reduces Pain and Opioid Consumption in Acute Postoperative Pain: A Systematic Review and Meta-analysis BACKGROUND: Methadone is a potent opioid exerting an analgesic effect through N-methyl-D-aspartate receptor antagonism and the inhibition of serotonin and noradrenaline reuptake. It has also been used in several procedures to reduce postoperative pain and opioid use. This meta-analysis aimed to determine whether the intraoperative use of methadone lowers postoperative pain scores and opioid consumption in comparison to other opioids. METHODS: Double-blinded, controlled trials without language restrictions were included from MEDLINE, Embase, LILACS, The Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL via EBSCOhost. The included studies tracked total opioid consumption, postoperative pain scores, opioid-related side effects, and patient satisfaction until 72 hours postoperatively. Mean difference (MD) was used for effect size. RESULTS: In total, 476 articles were identified and 13 were considered eligible for inclusion in the meta-analysis. In 486 patients (7 trials), pain at rest (MD, 1.09; 95% confidence interval (CI), 1.47–0.72; P < .00001) and at movement (MD, 2.48; 95% CI, 3.04–1.92; P = .00001) favored methadone 24 hours after surgery. In 374 patients (6 trials), pain at rest (MD, 1.47; 95% CI, 3.04–1.02; P < .00001) and at movement (MD, 2.03; 95% CI, 3.04–1.02; P < .00001) favored methadone 48 hours after surgery. In 320 patients (4 trials), pain at rest (MD, 1.02; 95% CI, 1.65–0.39; P = .001) and at movement (MD, 1.34; 95% CI, 1.82–0.87; P < .00001) favored methadone 72 hours after surgery. A Trial Sequential Analysis was performed and the Z-cumulative curve for methadone crossed the monitoring boundary at all evaluations, additionally crossing Required Information Size at 24 and 48 hours at rest. Methadone group also showed lower postoperative opioid consumption in morphine equivalent dosage (mg) at 24 hours (MD, 8.42; 95% CI, 12.99–3.84 lower; P < .00001), 24–48 hours (MD, 14.33; 95% CI, 26.96–1.91 lower; P < .00001), 48–72 hours (MD, 3.59; 95% CI, 6.18–1.0 lower; P = .007) postoperatively. CONCLUSIONS: Intraoperative use of methadone reduced postoperative pain scores compared to other opioids, and Trial Sequential Analysis suggested that no more trials are required to confirm pain reduction at rest until 48 hours after surgery. Methadone also reduced postoperative opioid consumption and led to better patient satisfaction scores through 72 hours postoperatively compared to other opioids. Accepted for publication July 23, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Felipe C. Machado, MD, PhD, Anesthesia Department, Universidade de Sao Paulo, Av Dr Eneas de Carvalho Aguiar, 155, Prédio dos Ambulatórios 8 andar, Setor Azul, CEP (zip): 05403-000, Cerqueira César, São Paulo, Brazil. Address e-mail to felipe.chiodini@hotmail.com. © 2019 International Anesthesia Research Society

Dantrolene Should Be Readily Available Wherever Malignant Hyperthermia Triggering Drugs Are Stocked No abstract available

In Response No abstract available

Development of a Risk Score to Predict Postoperative Delirium in Patients With Hip Fracture BACKGROUND: Post–hip fracture surgery delirium (PHFD) is a significant clinical problem in older patients, but an adequate, simple risk prediction model for use in the preoperative period has not been developed. METHODS: The 2016 American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File was used to obtain a cohort of patients ≥60 years of age who underwent hip fracture surgery (n = 8871; randomly assigned to derivation [70%] or validation [30%] cohorts). A parsimonious prediction model for PHFD was developed in the derivation cohort using stepwise multivariable logistic regression with further removal of variables by evaluating changes in the area under the receiver operator characteristic curve (AUC). A risk score was developed from the final multivariable model. RESULTS: Of 6210 patients in the derivation cohort, PHFD occurred in 1816 (29.2%). Of 32 candidate variables, 9 were included in the final model: (1) preoperative delirium (adjusted odds ratio [aOR], 8.32 [95% confidence interval {CI}, 6.78–10.21], 8 risk score points); (2) preoperative dementia (aOR, 2.38 [95% CI, 2.05–2.76], 3 points); (3) age (reference, 60–69 years of age) (age 70–79: aOR, 1.60 [95% CI, 1.20–2.12], 2 points; age 80–89: aOR, 2.09 [95% CI, 1.59–2.74], 2 points; and age ≥90: aOR, 2.43 [95% CI, 1.82–3.23], 3 points); (4) medical comanagement (aOR, 1.43 [95% CI, 1.13–1.81], 1 point); (5) American Society of Anesthesiologists (ASA) physical status III–V (aOR, 1.40 [95% CI, 1.14–1.73], 1 point); (6) functional dependence (aOR, 1.37 [95% CI, 1.17–1.61], 1 point); (7) smoking (aOR, 1.36 [95% CI, 1.07–1.72], 1 point); (8) systemic inflammatory response syndrome/sepsis/septic shock (aOR, 1.34 [95% CI, 1.09–1.65], 1 point); and (9) preoperative use of mobility aid (aOR, 1.32 [95% CI, 1.14–1.52], 1 point), resulting in a risk score ranging from 0 to 20 points. The AUCs of the logistic regression and risk score models were 0.77 (95% CI, 0.76–0.78) and 0.77 (95% CI, 0.76–0.78), respectively, with similar results in the validation cohort. CONCLUSIONS: A risk score based on 9 preoperative risk factors can predict PHFD in older adult patients with fairly good accuracy. Accepted for publication July 15, 2019. Funding: This publication was supported in part by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through grant No. KL2TR001874 (M.K.). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. Reprints will not be available from the authors. Address correspondence to Minjae Kim, MD, MS, Department of Anesthesiology, Columbia University Medical Center, 622 W 168th St, PH 5, Suite 505C, New York, NY 10032. Address e-mail to mk2767@cumc.columbia.edu. © 2019 International Anesthesia Research Society

Misinterpretation of USP 797 Continues No abstract available

Decoupling Complexity in Perioperative Systems No abstract available

In Response No abstract available

Intraoperative Awareness With Recall: A Descriptive, Survey-Based, Cohort Study BACKGROUND: Unintended intraoperative awareness with recall (AWR) is a potential complication of general anesthesia. Patients typically report recollections of (1) hearing sounds or conversations, (2) being unable to breathe or move, (3), feeling pain, and/or (4) experiencing emotional distress. The purpose of the current study was to identify and further characterize AWR experiences identified through postoperative surveys of a large unselected adult surgical cohort. METHODS: This is a substudy of a prospective registry study, which surveys patients on their health and well-being after surgery. Responses to 4 questions focusing on AWR were analyzed. Patients who reported AWR with pain, paralysis, and/or distress were contacted by telephone to obtain more information about their AWR experience. The interview results for patients who received general anesthesia were sent to 3 anesthesiologists, who adjudicated the reported AWR episodes. RESULTS: Of 48,151 surveys sent, 17,875 patient responses were received. Of these respondents, 622 reported a specific memory from the period between going to sleep and waking up from perceived general anesthesia and 282 of these reported related pain, paralysis, and/or distress. An attempt was made to contact these 282 patients, and 149 participated in a telephone survey. Among the 149 participants, 87 endorsed their prior report of AWR. However, only 22 of these patients had received general anesthesia, while 51 received only sedation and 14 received regional anesthesia. Three anesthesiologists independently adjudicated the survey results of the 22 general anesthesia cases and assigned 6 as definite AWR, 8 as possible AWR, and 8 as not AWR episodes. Of the 65 patients who confirmed their report of AWR after regional or sedation anesthesia, 37 (31 with sedation and 6 with regional anesthesia) had not expected to be conscious during surgery. CONCLUSIONS: The complication of AWR continues to occur during intended general anesthesia. Many reports of AWR episodes occur in patients receiving sedation or regional anesthesia and relate to incorrect expectations regarding anesthetic techniques and conscious experiences, representing a potential target for intervention. Accepted for publication June 24, 2019. Funding: The study was supported by departmental resources (to Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys [SATISFY-SOS]) and a Barnes-Jewish Hospital Foundation (BJHF) grant 7937–77 from the Barnes-Jewish Hospital Foundation, St Louis, Missouri (to M.S.A.). Conflicts of Interest: See Disclosures at the end of the article. The study was presented, in part, at the annual meeting of the International Anesthesia Research Society, May 18, 2019, Montreal, Quebec, Canada. Reprints will not be available from the authors. Address correspondence to Anna Maria Bombardieri, MD, PhD, Department of Anesthesiology, Washington University School of Medicine in St Louis, 660 S Euclid Ave, Campus Box 8054, St Louis, MO 63110. Address e-mail to annamariabombardieri@wustl.edu. © 2019 International Anesthesia Research Society

Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study BACKGROUND: District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs. METHODS: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision. RESULTS: Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment. CONCLUSIONS: Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists—measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies—are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA. Accepted for publication July 1, 2019. Funding: The Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project is funded by the European Union Horizon 2020 Programme for Research and Innovation, under grant agreement No. 733391. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Jakub Gajewski, PhD, Institute of Global Surgery, Royal College of Surgeons in Ireland, Lower Mercer St, Dublin 2, Ireland. Address e-mail to jakubgajewski@rcsi.ie. © 2019 International Anesthesia Research Society