“Obstructive sleep apnea affects 40 million adults in the United States and is associated with an increased complication risk among patients undergoing surgery,” said Stavros Memtsoudis, MD, PhD, Anesthesiologist-in-Chief and Chair of the HSS Department of Anesthesiology, Critical Care & Pain Management. “Guidelines on the perioperative management of OSA patients undergoing surgery are backed by limited evidence. Current recommendations include preoperative screening for OSA and preoperative initiation of CPAP therapy. However, it remains unclear how often this recommendation is followed and how much it reduces complication risks.”

This information is especially important as healthcare systems shift from inpatient to outpatient hip and knee replacement surgery, where patients cannot be monitored as closely for perioperative complications.

To evaluate whether CPAP use among OSA patients prior to surgery led to improved outcomes compared with those patients who did not use CPAP, the researchers extracted more than 100,000 cases of outpatient hip and knee replacement surgeries performed between 2018 and 2022 from the Merative MarketScan national claims data (representing patients and their dependents with employer-sponsored healthcare coverage). The primary outcome of interest was a visit to the emergency department within one day post-discharge, which acted as a stand-in to represent post-discharge complications. The researchers conducted three comparisons: 1) patients with OSA who used a CPAP machine before surgery, compared with patients who did not; 2) patients with OSA who did not use a CPAP machine before surgery, compared with patients without OSA; and 3) patients with OSA who used CPAP before surgery, compared with patients without OSA.

The researchers found that OSA patients who underwent CPAP therapy before hip and knee replacement surgery (19% of 123,349 total hip/knee procedures studied) experienced fewer emergency department visits within one day after discharge compared with OSA patients who did not receive CPAP therapy before surgery. In addition, pre-surgical CPAP use in patients with OSA lowered their risk for complications to a similar level as patients without OSA.

“These findings are significant as they support the notion that adhering to these guidelines can benefit OSA patients undergoing surgery,” said Jashvant Poeran, MD, PhD, Director of Research in the HSS Department of Anesthesiology, Critical Care & Pain Management.  “While we had anticipated these results based on the guidelines, this is the first study to demonstrate this on such a large scale.”

This study offers key insights for both patients and clinicians on ways to reduce the risk of complications after surgery.

“It informs patients with OSA to engage in conversations with their perioperative physicians about strategies to lower their complication risk, including the preoperative initiation of CPAP therapy,” said Dr. Poeran. “Additionally, this research highlights the advantages of preoperative initiation of CPAP therapy. We believe that this study strengthens the evidence supporting the benefits of preoperative CPAP therapy and will encourage both patients and clinicians to consider its increased use.”

While further validation of these findings is necessary, particularly in other surgical cohorts such as elective general surgery, these findings represent a significant advancement in recognizing the benefits of preoperative initiation of CPAP therapy.

“These findings could influence care by emphasizing the importance of preoperative identification of OSA patients who are scheduled for surgery and subsequent initiation of CPAP therapy,” Dr. Poeran said.

In addition to replicating these findings in other surgical cohorts, future research should also examine subgroups of patients in which preoperative CPAP therapy may be even more beneficial. “These subgroups might include patients with multiple risk factors, such as OSA and obesity or other chronic conditions, as well as those with varying needs for opioid management.”

“Follow-up studies could investigate looking at other recommendations outlined in the guidelines such as preoperative screening for OSA and enhanced monitoring. This increased monitoring is crucial as hospital stays shorten and more and more surgeries are performed in an outpatient setting without an overnight stay and the subsequent opportunity to monitor these patients,” Dr. Poeran concluded.

Reference

1. Jashvant Poeran MD PhD, Haoyan Zhong MPA, Alex Illescas MPH, Lisa Reisinger MD, Crispiana Cozowicz MD, Periklis Giannakis MD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA. “Preoperative CPAP Use is Associated with Improved Outcomes in Patients with Obstructive Sleep Apnea Undergoing Orthopedic Surgery.” Presented at: Society of Anesthesia and Sleep Medicine (SASM) 14th Annual Meeting, October 18, 2024; Philadelphia, PA.

“The ASRA research awards recognize HSS’s tireless pursuit of patient safety and innovative treatments in pain management,” said Stavros Memtsoudis, MD, PhD, MBA, Chief of Anesthesiology, Critical Care and Pain Management at HSS and principal investigator of one of the award-winning studies, “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia: A National Observational Study.” “These accolades validate our leadership in research, reinforcing our efforts to enhance safety standards and improve patient outcomes in pain management through evidence-based practices and multidisciplinary collaborations.”

The ASRA Research Committee selects three out of the top 10 highest-scoring scientific abstracts that have met all ASRA Pain Medicine abstract submission requirements and ASRA Pain Medicine membership to be Best of Meeting Abstract winners.

The Patient Safety Award was created in the spirit of Alice Romie to recognize exemplary patient safety work. Alice was an advocate for patient safety who contributed to standardizing medication safety and educating peers about this issue and who passed away from breast cancer in May 2021.

The two Best of Meeting award-winning studies were titled “Effects of Perioperative Dronabinol Use in Total Knee Arthroplasty” and “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia: A National Observational Study.” 

Dronabinol is a synthetic tetrahydrocannabinol (THC) agent that is FDA-approved to treat nausea and vomiting from chemotherapy and to stimulate appetite in patients with HIV or AIDS. Prior studies suggest that cannabinoids may also have pain-relieving properties. While cannabis contains both THC and cannabidiol (CBD), the plant is federally illegal, so it is difficult to study its effects in a hospital setting. As a legal alternative, researchers sought to examine whether 5mg of perioperative dronabinol twice a day could reduce pain and opioid consumption 24 to 48 hours after total knee arthroplasty compared with placebo.

While there were no statistically significant differences in opioid consumption compared with placebo, this study adds to the literature on the effects of THC (in the form of dronabinol) in the perioperative period. Further research examining different dosing regimens of dronabinol for acute pain is warranted.

“In an attempt to decrease perioperative use of opioids in view of the opioid epidemic, it has become even more important to study drugs such as the cannabinoids known to have potential analgesic properties,” said HSS anesthesiologist and lead study author Kethy Jules-Elysee, MD. “Dronabinol was not effective in decreasing pain or opioid consumption in this study with such a rigorous design. However, it was well tolerated. Future studies looking at patients with a history of cannabis use or chronic opioid use should be done, and different dosages of dronabinol should be explored.” Researchers at HSS are also conducting a pilot study examining CBD (Epidiolex) in bilateral total knee replacements.

In the study “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia,” researchers examined whether glucagon-like peptide-1 (GLP-1) medications might affect aspiration or pneumonia risk in patients undergoing surgery. The medications mimic hormones produced in the gut that reduce appetite and cause the body to release insulin, and they are commonly prescribed for diabetes management or weight loss. 

“The increased prescribing of these medications in recent years is likely to result in an increase in patients scheduled for surgery that are on these medications,” said Dr. Memtsoudis. “In a cohort (using MarketScan commercial claims 2017 to 2021 data) of lower extremity joint replacement, hysterectomy, appendectomy and cholecystectomy surgery, preoperative GLP-1 use appears not to be associated with odds of perioperative aspiration or pneumonia. This information may help guide clinical decision-making regarding the use of GLP-1 medications in the preoperative period. However, further research and consideration of broader implications would be necessary before implementing any policy changes.”

In the study that won the 2024 ASRA Patient Safety Award, “Is Spinal Anesthesia Safe in Patients with a History of Guillain-Barré Syndrome Undergoing Orthopedic Surgery?” researchers examined whether regional anesthesia, which has many safety and pain management benefits compared with general anesthesia, is safe for patients with Guillain-Barré syndrome. 

“Guillain-Barré Syndrome (GBS) is a rare autoimmune disorder which results in acute demyelination of the peripheral nervous system, typically after some sort of symptomatic infection,” explained David Lee, MD, an anesthesiologist at HSS and lead study author. “As such, the issue of whether to perform a neuraxial anesthetic technique in these patients has remained a controversial topic due to fears that a spinal may predispose this patient population to worsening neurological symptoms or result in a recurrence of GBS. Because there are many positive benefits to performing a neuraxial anesthetic technique versus general anesthesia, such as decreased mortality, decreased postoperative nausea and vomiting (PONV), and reduced incidence of deep-vein thrombosis, we sought to examine our experience with GBS patients undergoing lower extremity orthopedic procedures over the past 10 years using EPIC to see whether there were any differences in recovery or neurological outcome after administration of a spinal anesthetic.”

In this observational retrospective chart review of 103 patients with a documented history of GBS who underwent some type of lower extremity orthopedic procedure at HSS from 2014 to 2023, 79 patients received a spinal anesthetic and 18 received a general anesthetic. The researchers found no appreciable difference between the groups in postoperative neurological outcomes, length of stay in the post-anesthesia care unit, or length of hospital stay. Similarly, there were also no appreciable differences between the groups in terms of time to achieving physical therapy milestones or incidence of postoperative nausea and vomiting.   

“Because the incidence of GBS is rare (the CDC estimates 3,000 to 6,000 cases per year), the total volume of cases in this study represents a small fraction of the 41,500-plus orthopedic surgeries performed annually at HSS, 85 percent of which are done with a regional anesthetic technique,” said Dr. Lee. “These findings should give both patients and clinicians some measure of assurance that neuraxial anesthetic techniques can be safely performed in someone who has had prior GBS. Larger longitudinal studies would be beneficial to corroborate these findings, so new policies and ASRA guidelines can be established with confidence with regards to the use of neuraxial anesthesia in patients with a prior history of GBS.”

“HSS's commitment to researching new techniques for better outcomes is evident in its dedication to advancing patient care through rigorous scientific inquiry and clinical innovation,” said Dr. Memtsoudis. “By exploring emerging technologies and refining procedural techniques, HSS remains at the forefront of anesthesia administration, pain management, and critical care, ensuring that patients receive the highest standards of care.”

In addition to these three award-winning studies, HSS also presented 20 abstracts and either lectured at or moderated more than 25 sessions, workshops, problem-based learning discussions, poster sessions, and special interest group meetings at this year’s ASRA conference.

References

1. Thor P, Perlstein M, Illescas A, Lauzadis J, Sheetz M, Tailor M, Puglisi A, Popovic M, Oxendine J, Lin Y, Kirksey M, YaDeau J, Kumar K, Baaklini L, Liu J, Cheng S, Mayman D, Jerabek S, Westrich G, Cushner F, Cross M, Sculco P, Sculco T, Ast M, Gonzalez-Della Valle A, Sideris A, Jules-Elysee KM. “Effects of Perioperative Dronabinol Use in Total Knee Arthroplasty.” Presented at: 49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 21-23, 2024; San Diego, CA.

2. Jashvant Poeran, Yhan Colon Iban, Haoyan Zhong, Alex Illescas, Crispiana Cozowicz, Lisa Reisinger, Jiabin Liu, Stavros Memtsoudis. “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia: A National Observational Study.” Presented at: 49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 21-23, 2024; San Diego, CA.

3. Tra BM, Haidar J, Lauzadis, J, Illescas A, Lee D. “Is Spinal Anesthesia Safe in Patients with a History of Guillain-Barré Syndrome Undergoing Orthopedic Surgery?” Presented at: 49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 21-23, 2024; San Diego, CA.

Dr. Memtsoudis succeeds Gregory A. Liguori, MD, who has led the department with distinction for the past 21 years. As Chief Emeritus, Dr. Liguori will focus on his practice at HSS, continue to chair the Credentials Committee and teach as a Professor at Weill Cornell Medicine, and maintain his roles on the Medical Board, Physician Practice Committee, and MIAC.

Dr. Zhou will succeed Interim Chair Matthew E. Fink, MD, who will return full-time to his role as Chairman of the Department of Neurology at Weill Cornell Medicine and Neurologist-in-Chief at NewYork- Presbyterian Hospital/Weill Cornell Medical Center.  Dr. Fink accepted HSS’ request to serve as interim leader following the retirement of Dale J. Lange, MD, who led the department for 13 years.  Dr. Zhou will lead the continued advancement of HSS’ Neurology Department in collaboration with Weill Cornell Medicine Neurology.

"Drs. Fink and Ligouri have provided instrumental support for their clinical colleagues exemplifying excellence in medicine—HSS is grateful for their leadership," said Bryan T. Kelly, MD, MBA, President and CEO, HSS. "We are thrilled to have the expertise and stewardship of Dr. Zhou and Dr. Memtsoudis in advancing translational and clinical research programs that will serve the needs of all of our patient populations. Their collaborative approaches to musculoskeletal health will strengthen our multidisciplinary services and further improve patient care and recovery."

"HSS is recognized as a leader in musculoskeletal health because of the unparalleled number of talented and accomplished experts who call it home," said Douglas Padgett, MD, Surgeon-in-Chief and Medical Director at HSS. "The appointments of Dr. Memtsoudis and Dr. Zhou embody our tradition of strong leaders committed to addressing pain and movement challenges, continuing the advancement of our rich clinical pipeline toward improved health and wellness for everyone."

Stavros Memtsoudis, MD, PhD, MBA

Dr. Memtsoudis is board-certified in anesthesiology and critical care medicine. He earned his medical degree and PhD from Georg-August-University Medical School, in Goettingen, Germany, in 1999, and his MBA from the University of Massachusetts in 2018. Dr. Memtsoudis joined HSS after completing subspecialty training in critical care medicine, cardiac care, and thoracic anesthesiology. He is widely recognized for his clinical expertise in the perioperative care of orthopedic patients with advanced cardiovascular and pulmonary disease as well as his prolific research into perioperative care. During the height of COVID-19, elective surgeries, such as hip and knee replacements, were canceled to accommodate patients requiring hospital admission. Dr. Memtsoudis was instrumental in leading musculoskeletal medical teams at HSS in managing critical care patients.   

As a senior scientist, Dr. Memtsoudis directs research initiatives on cardiopulmonary physiology and population-based outcomes research. His findings have been published in more than 380 peer-reviewed articles. Due to his prominence in the field of perioperative research, Dr. Memtsoudis has won several prestigious research awards, frequently lectures on the topic, and serves on anesthesia and pain medicine boards nationally and internationally. 

"Excellence and continuity of patient care are our highest priorities at HSS," said Dr. Memtsoudis. "I have the pleasure of being a member of an incredible team of experts, and I'm equally passionate about working alongside internationally prominent clinician-

scientists who prioritize delivering the highest-quality care to all our patients."

Dr. Memtsoudis's new role is effective immediately.

Lan Zhou, MD, PhD

Dr. Zhou is a nationally renowned neuromuscular specialist with a long history of clinical and academic accomplishments. She earned her medical degree from Shanghai Medical University School of Medicine in China (now Fudan University Medical Center) in 1989 before completing her PhD in developmental biology at the University of Cincinnati College of Medicine in 1995. Previously, Dr. Zhou served as a staff neurologist at Cleveland Clinic, an associate professor of neurology, neurosurgery, and pathology at Icahn School of Medicine at Mount Sinai, and a professor of neurology and neurotherapeutics and pathology at the University of Texas Southwestern Medical Center. She comes to HSS from Boston University School of Medicine, where she has served as a professor of neurology and pathology and Vice Chair for Research in the Department of Neurology. 

Dr. Zhou cares for patients with neuromuscular diseases and regularly performs and interprets nerve, muscle, and skin biopsies as part of her practice. She has special interests in small-fiber neuropathy, inflammatory myopathy, myasthenia gravis, and neuromuscular pathology. Additionally, she is recognized as an outstanding educator and muscle research scientist. She runs a National Institutes of Health–funded research program to study muscle inflammation, fibrosis, and regeneration associated with skeletal muscle injury and repair. In her new role at HSS, she will establish a clinical diagnostic neuromuscular pathology laboratory.

"I'm honored to take on this new role, building upon and developing new programs that will continue to serve the diverse patient communities at HSS," said Dr. Zhou. "My passion is to make a meaningful impact in the lives of patients and families living with neuromuscular diseases and to work with musculoskeletal teams to develop effective treatments to help them live better."

Dr. Zhou's new role is effective March 1, 2024. 

“The utility of interventions in a general population of patients might be difficult to show, but might differ by subgroups, with certain patients deriving benefit when others do not,” said Stavros G. Memtsoudis, MD, PhD, MBA, an anesthesiologist at HSS and lead author of the study. “In this study, we tried to identify which subgroups might benefit most from peripheral nerve blocks in terms of a reduction in complications after joint arthroplasty.”

These findings demonstrate that comorbidities may be a factor with a greater effect on complication risk than other factors, such as age, and that peripheral nerve blocks alone may not be sufficient to consistently influence outcomes in patients with comorbidities.

These findings may also demonstrate that there may be a specific optimal baseline patient population for whom peripheral nerve blocks have the greatest impact on improving surgical outcomes: patients who are older but do not have many comorbidities. This study could help clinicians determine which surgical patients may benefit most from peripheral nerve blocks and which candidates may need additional measures to improve their outcomes.

Many total joint arthroplasty (TJA) patients are at risk for poorly controlled pain and complications. The number of these surgeries performed increases each year, underscoring the importance of finding solutions. To find out how uniformly peripheral nerve blocks can improve perioperative outcomes and pain relief in TJA patients, the researchers conducted a population-based analysis using data from TJA surgeries in the United States from January 2006 to December 2019.

Patients were divided into nine groups based on age and number of comorbidities. Age was broken down as follows: Young (Y) = younger than 65 years; Middle (M) = 65 to 75 years; and Old (O) = older than 75 years. Comorbidities were categorized as: no pre-existing comorbidity (Group 1); 1 or 2 comorbidities (Group 2); and 3 or more comorbidities (Group 3). This led to a breakdown of nine groups total: Y1, Y2, Y3, M1, M2, M3, O1, O2, and O3.

The sample included more than 2.8 million TJA cases performed in 887 hospitals. Of those, 15.5% received a peripheral nerve block. The overall rate of peripheral nerve blocks increased from 9.5% in 2006 to 18.9% in 2019. Peripheral nerve blocks were used least often in young patients with more than 3 comorbidities (13.9%) and used most often in middle-aged patients with no comorbidities (16.3%). Peripheral nerve blocks were associated with a significant reduction in the odds of respiratory complication, acute renal failure, delirium, ICU admission, high opioid consumption during hospitalization, and prolonged length of stay.

The results showed reduced odds of respiratory complications for the O1 and Y2 groups, reduced odds of acute renal failure in the Y1, O1, and M2 groups, and reduced odds of delirium in O1. The risk for ICU admission was reduced in those who received peripheral nerve blocks in all ages with no comorbidities, as well as in the Y2 and O2 groups, compared with those who did not receive a peripheral nerve block. Peripheral nerve blocks also reduced the odds of a prolonged length of stay in the Y1, M1, Y2, M2, and Y3 groups. Odds of high opioid use in patients who received a peripheral nerve block versus no peripheral nerve block were significantly reduced in all groups except for Y3 and O3.

“While peripheral nerve blocks might have the advantage of providing superior pain control versus systemic modalities as well as reducing opioid consumption, a reduction in complications might be expected in those without comorbidities,” Dr. Memtsoudis said. “However, given that peripheral nerve blocks still provide better pain control and reduce opioid use, all patients should be considered for peripheral nerve blocks.”

“Older patients without major comorbidities might represent a subgroup in which the beneficial effects of peripheral nerve blocks are most likely to be expected,” he noted. “This might be the case because major comorbidities are a bigger determinant of complications, with peripheral nerve blocks being less likely to be able to exert a substantial effect.”

Future research should include further examination of the benefits of peripheral nerve blocks. “Many questions remain unanswered, including quantification of attributable risk reduction of peripheral nerve blocks and which peripheral nerve blocks provide the biggest effect,” Dr. Memtsoudis concluded.

Reference

1. Haoyan Zhong MPA, Marko Popovic BS, Jashvant Poeran MD PhD, Crispiana Cozowicz MD, Alex Illescas MPH, Jiabin Liu MD PhD, Stavros G Memtsoudis MD PhD MBA FCCP. “Does the impact of peripheral nerve blocks vary by age and comorbidity subgroups? A nationwide population based study.” Presented at: 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 20-22, 2023; Hollywood, FL.

These recommendations were created in a follow-up project conducted after the first recommendations made by the ICAROS group in 2019. ICAROS part 2 included a systematic review and meta-analysis of 122 studies comprising more than 1 million cases, investigating how the use of peripheral nerve blocks correlated to major complications such as mortality as well as cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.

“ICAROS part 1 examined the impact of the choice of anesthetic technique for surgery, and experts determined that the evidence suggested that neuraxial anesthesia was associated with better outcomes in joint arthroplasty patients compared to general anesthesia,” said Dr. Memtsoudis. “Part 2 concerns itself with another aspect of regional anesthesia procedures commonly performed for postoperative pain management, namely peripheral nerve blocks. Neuraxial anesthesia is temporary and provides conditions to perform surgery. Peripheral nerve blocks are longer-acting and are being used for pain control.”

“This work is of utmost importance as it provides evidence-based recommendations that improve patient outcomes if implemented widely. Currently, only a minority of patients receive these nerve blocks in the setting of joint arthroplasty,” Dr. Memtsoudis said.

Analysis showed that use of peripheral nerve blocks during surgery in comparison with no peripheral nerve block resulted in a significantly lower risk of complications (95% confidence interval), including: 70% reduced odds of cognitive dysfunction in THA, 48% reduced odds in TKA; 64% reduced odds of respiratory failure in THA, 63% reduced odds in TKA; 16% reduced odds of cardiac complications in THA, 17% reduced odds in TKA; 45% reduced odds of surgical site infections in THA, 14% reduced odds in TKA; 26% reduced odds of thromboembolism in THA, 10% reduced odds in TKA; and 16% reduced odds of blood transfusion in THA, 14% reduced odds in TKA.

Based on these findings, the international consensus group of practitioners strongly recommend that peripheral nerve blocks be used during total hip and total knee replacement surgeries for improved outcomes, except when contraindications prevent their use. Other factors that institutions should consider when determining anesthetic techniques include the skills of providers and the resources available at a given practice location.

“The group assembled and the process used to analyze the literature and come up with these recommendations has been of the highest quality,” Dr. Memtsoudis noted. “The data spoke for itself, thus making it easy for the experts to draw conclusions and make recommendations. These recommendations are solidly founded on evidence and will hopefully affect change worldwide to improve patient outcomes for millions of patients undergoing hip and knee arthroplasty. It will hopefully also lead to more research, such as which specific nerve blocks are best for which patients.”

Adds Dr. Memtsoudis, “We are contemplating expansion of our work to include other patient populations such as pediatric patients as well as other procedures once the pandemic related restrictions are behind us.”

Reference:

Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu JB, Soffin E, et al. “Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.” Reg Anesth Pain Med. 2021;0:1-15. doi:10.1136/rapm-2021-102750

Researchers at Hospital for Special Surgery (HSS) sought to compare characteristics and outcomes of hip fracture patients admitted during the COVID-19 outbreak to patients admitted before the outbreak. They also examined characteristics and outcomes of hip fracture patients with and without the virus. Their findings were presented at the 2021 Spring American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual Meeting.¹

“Studying this topic is important because events that stress the healthcare system, like this pandemic, allow us to gain rare insights into what happens to medical care when resources become scarce,” said principal investigator Stavros Memtsoudis, MD, PhD, MBA, an anesthesiologist at HSS.

Dr. Memtsoudis and colleagues compared patient and healthcare characteristics, COVID-19 diagnoses and outcomes for hip-fracture patients from March to April 2019 and March to April 2020. Observed outcomes included length of hospital stay, admission to an intensive care unit (ICU), use of mechanical ventilation, 30-day readmission, discharge disposition and postoperative complications.

The number of hip fracture cases during the COVID-19 surge decreased by 50% compared with the same time period during the previous year. “One of the major takeaways from this study was we saw that fractures were more commonly treated nonoperatively, and how outcomes differed,” Dr. Memtsoudis noted. During the pandemic, hip fracture patients were discharged earlier and were less likely to be admitted to the ICU.

Other factors did not differ before and after COVID-19, including in-hospital mortality rate, 30-day readmission rate, use of mechanical ventilation, and complication rate.

Hip-fracture patients with COVID-19 stayed in the hospital longer, had higher rates of complications during surgery, increased rates of mortality, and more frequently received nonsurgical treatment.

These results show two main considerations for hospitals. As society begins to return to more normal activities, rates of hip fracture are likely to increase back to pre-COVID-19 levels. Hospitals should be prepared and have plans for treating hip fracture patients with COVID-19, as well as protecting non-COVID-19 patients from exposure.

Additionally, findings that demonstrate shorter length of stay in the hospital, less use of the ICU, and earlier home discharge did not compromise outcomes and deserve further study. This raises the question of whether the strategies of care for hip fracture patients used before the pandemic should be adjusted.

“These results should make us reevaluate our practice going forward to make sure we do not waste resources but also affirm interventions that truly are beneficial,” Dr. Memtsoudis concluded.

Reference

1. Haoyan Zhong MPA, Jashvant Poeran MD PhD, Jiabin Liu MD PhD, Lauren A. Wilson MPH, Stavros G. Memtsoudis MD PhD MBA FCCP. “Hip Fracture Characteristics and Outcomes During COVID 19: A Large Retrospective National Database Review.” Presented at: 46th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), May 13-15, 2021; Orlando, FL.

Previously available information suggests that oral, IV and topical TXA are all effective at reducing blood loss and drastically reducing blood transfusion rates during and after surgery, but research with direct comparisons for each method is limited.

“TXA in orthopedic surgery has become the standard of care. However, the most efficient, efficacious and cost effective method of administration remains unknown,” said principal investigator Stavros Memtsoudis, MD, PhD, MBA, an anesthesiologist at HSS. “The oral administration of TXA is logistically easier, thus reducing the risk of drug errors in the OR. It is also less costly. We are performing this study to identify if oral TXA is also equally efficacious at preventing blood loss. If this is the case, oral administration of the drug preoperatively as a one-time dose could become the standard of care.”

Dr. Memtsoudis and colleagues randomized 199 patients between ages 18 and 80 undergoing total hip or total knee replacement to receive either oral TXA (1950 mg) two hours before surgery or IV TXA (1 g) at the start of the procedure. The primary outcomes observed were blood loss and transfusion rates.

In patients who underwent total hip replacement, the estimated blood loss calculated in the post anesthesia care unit (PACU) for oral TXA was 534 ± 285 mL, versus 676 ± 550 for IV TXA. On postoperative day one, estimated blood loss was 769 ± 257 mL for oral TXA and 798 ± 302 ml for IV TXA.

In patients who underwent total knee replacement, estimated blood loss in the PACU was 289 ± 219 mL for oral TXA, and was 486 ± 670 mL for IV TXA. On postoperative day one, estimated blood loss was 716 ± 288 mL for oral TXA versus 846 ± 659 mL for IV TXA.

No patients received transfusions during surgery. One patient who received IV TXA received a transfusion after surgery.

“Given our interim results, it seems that the oral version of TXA is equally as effective as intravenous administration. This translates to improvements in efficiency, cost and safety, all of which are important for patients, clinicians and policy makers,” Dr. Memstoudis said. “The research seems rather clear at this point. However, a uniform translation into policy is what is needed, as there seems to be limited translation of best evidence into practice.”

Complete results of this study will be analyzed later this year.

Reference

1. Julia F. Reichel, BA, Marko Popovic, BS, Danya DeMeo, BS, Carrie Freeman, BS, Marisa Wong, BA, Haoyan Zhong, MPA, Jiabin Liu, MD, PhD, Stephen C. Haskins, MD, David H. Kim, MD, Kethy M. Jules-Elysee, MD, Meghan A. Kirksey, MD, PhD, Ellen M. Soffin, MD, PhD, Daniel B. Maalouf, MD, MPH, Sean Garvin, MD, Jonathan C. Beathe, MD, Kathryn DelPizzo, MD, Alexandra Sideris, PhD, Stavros G. Memtsoudis, MD, PhD, MBA. “The Effect of Oral Versus Intravenous Tranexamic Acid on Perioperative Blood Loss in Joint Arthroplasty Patients.” Presented at: 46th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), May 13-15, 2021; Orlando, FL.

HSS Researchers Find Duloxetine May Reduce Opioid Use and Improve Pain Management After Total Knee Replacement

• Anesthesiologist Jacques Ya Deau, MD, PhD and colleagues investigated using duloxetine after surgery to reduce pain and opioid use. They found that duloxetine, given on the day of surgery and once daily for 14 days afterwards, reduced opioid use by about 30%. Patients receiving duloxetine were also more satisfied with their pain management.

Study Identifies Risk Factors for Pediatric Opioid Dependence After Surgery

• Anesthesiologist Kathryn (Kate) DelPizzo, MD and colleagues identified risk factors for persistent opioid use after surgery in pediatric patients. Understanding risk factors for opioid dependence could help develop strategies to prevent long-term opioid use in this vulnerable population.

Knowledge Gaps on Opioid Use and Pain Relief After Surgery Offer Opportunities for Improving Patient Education

• Anesthesiologist Bradley Lee, MD and colleagues identified gaps in patient knowledge about pain management and opioid use before total hip replacement, including misconceptions about how much pain relief to expect from opioids after surgery, how to use multiple modes of pain relief, and proper opioid storage and disposal. Improving patient education about opioids and pain management could lead to improvements in pain control and functional outcomes after surgery.

Interim Study Results Suggest Oral Tranexamic Acid (TXA) Is Equally Effective as Intravenous TXA in Preventing Blood Loss in Joint Replacement Surgery

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA and colleagues examined the efficacy and safety of oral TXA for joint replacement surgery. Using oral TXA versus intravenous TXA could translate to improvements in efficiency, cost and safety.

HSS Study Examines Hip Fracture Patient Characteristics and Outcomes Pre- and Post-COVID-19 Outbreak

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA and colleagues sought to compare characteristics and outcomes of hip fracture patients admitted during the COVID-19 outbreak to patients admitted before the outbreak. They also examined characteristics and outcomes of hip fracture patients with and without the virus.

TXA is widely used to minimize blood loss during total joint replacement surgeries. This reduction in blood loss and the reduced need for blood transfusions can have additional benefits for patients. “There is evidence suggesting that bleeding, the formation of hematomas and the need for blood transfusions is associated with infections,” said HSS anesthesiologist Stavros G. Memtsoudis, MD, PhD, MBA, lead author of the study. “Therefore, we evaluated if the use of TXA, which has been shown to reduce bleeding, actually relates to decreased infection risk.”

A single-institution study published in The Journal of Arthroplasty in March 2020 found that total joint arthroplasty patients who received TXA had a reduced risk of periprosthetic joint infections.² Researchers at HSS sought to validate these findings using a large population-based database.

Using the Premier Healthcare database, they examined patients who underwent elective inpatient total hip or knee arthroplasty between 2012 and 2016. Out of 931,692 total joint arthroplasty patients, the overall incidence of periprosthetic joint infections was 0.14% (n=1269). Of the total number of total joint arthroplasty patients, 45.2% received TXA on the day of surgery.

After adjusting for various patient and hospital-related factors, the use of TXA was associated with 40% lower odds of a periprosthetic joint infection within 90 days of surgery (OR 0.60 CI 0.53, 0.68). The researchers also found that the odds of developing a periprosthetic joint infection within 90 days of surgery was approximately eight times higher with hematoma formation (OR 8.08 CI 5.59, 11.68).

While the incidence of periprosthetic joint infections in total joint arthroplasty patients is already relatively low, administration of TXA during the procedure appears to have a protective effect.

“TXA is effective in reducing blood loss, and by doing so can reduce downstream complications, including infections,” explained Dr. Memtsoudis. Given that it is known to prevent hematomas, and hematoma formation was associated with significantly increased odds of joint infections, the researchers believe this is likely the reason why TXA may reduce risk for infection.

The researchers concluded that patients who are considered at high risk of postoperative joint infection may benefit from administration of TXA.

“HSS is well-known for its extremely low infection rates,” noted Dr. Memtsoudis. “Interestingly, our anesthetic practice has always focused on reducing blood loss, most prominently through the use of controlled hypotension in hip arthroplasty patients. We believe that this contribution to perioperative care has significantly influenced our positive outcomes.”

Dr. Memtsoudis is recognized by his peers as going above and beyond for patient safety and was the recipient of the physician Marion Hare Patient Safety Champion Award in 2019.

“The ultimate goal of any perioperative clinician is to allow patients to undergo surgery and get them back to living their life without complications,” he said. “While we always prepare to treat adverse events, my philosophy has always been to prevent them in the first place. Therefore, research needs to focus on identifying risk factors and those at risk and the development of interventions that will prevent them.”

References

1. Lauren Wilson, MPH, Haoyan Zhong, MA, Jashvant Poeran, MD, PhD, Jiabin Liu, MD, PhD, Stavros G. Memtsoudis, MBA, MD, PhD. “A3070. Tranexamic Acid Use During Total Joint Arthroplasty Is Associated With Reduced Odds Of Periprosthetic Joint Infection.” Presented at: 2020 American Society of Anesthesiologists® (ASA) Annual Meeting, October 2-5, 2020; virtual meeting.

2. Yazdi H, Klement MR, Hammad M, et al. Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty. The Journal of Arthroplasty. 2020;35(3):840-844.

HSS is the world’s largest academic medical center specialized in musculoskeletal health, spanning orthopedics, rheumatology and related disciplines. The HSS Research Institute maintains 20 laboratories dedicated to solving debilitating orthopedic and rheumatic conditions such as arthritis, bone and soft tissue injuries, autoimmune diseases, and musculoskeletal pain and deformities. There, more than 300 dedicated personnel focus on tissue repair, improving surgical outcomes, autoimmunity and inflammation, genomics, new treatments, and precision medicine.

“HSS has a long history of contributing to the collective base of clinical and basic science knowledge and finding healthcare solutions for complex conditions,” said Louis A. Shapiro, President and CEO, HSS. “We’re proud that through the joint efforts of our institution and philanthropic support, we will have the ability to make a strong impact on this growing and vital area of research.”

“As experts in inflammatory disorders and in the development of interventions for overactive immune responses, the clinicians and researchers at HSS are well-positioned to investigate many of the adverse effects of COVID-19,” says Lionel B. Ivashkiv, MD, Chief Scientific Officer at the HSS Research Institute. “This includes studying the causes of these adverse effects as well as how to prevent and treat them.”What follows are descriptions of the first group of funded projects in basic/translational research:

Activation of pDCs by SARS-CoV-2 and Its Impact on Macrophage Response

Principal Investigator: Franck Barrat, PhD

Co-Investigator: Marie-Dominique Ah Kioon, PhD

This project will study cell types that are responsible for cytokine storm syndrome — the hyperactive immune response seen in people with COVID-19 — by looking at how certain immune cells are activated by SARS-CoV-2. Research in mice infected with SARS-CoV, a coronavirus similar to the one that causes COVID-19, has suggested that plasmacytoid dendritic cell precursors (pDCs) are key to the immune response to infection. These pDCs activate macrophages, which in turn secrete cytokines. In the SARS-CoV research, depletion of pDCs appeared to protect the mice from lethal lung injury. Using blood samples from donors, the investigators will study the pathway by which pDCs activate macrophages and look at ways to therapeutically block that process.

Inhibiting RNA Polymerase II Transcription Complexes in Macrophages to Target COVID-19–Associated Cytokine Storm

Principal Investigator: Inez Rogatsky, PhD

Co-Investigators: Steven Josefowicz, PhD, and Robert P. Fisher, MD, PhD

This pilot project will dissect the role of macrophages in SARS-CoV-2-induced acute respiratory distress syndrome (ARDS), the main driver of COVID-19-associated mortality. We will test small-molecule inhibitors of RNA Polymerase II (Pol II) transcription complexes for their ability to modulate type I interferon and inflammatory pathways in monocytes/macrophages. This research will be done using cultured macrophages as well as donor blood and blood from COVID-19 patients.

Mechanisms of Cytokine Storm in Patients with COVID-19

Principal Investigator: Mary K. Crow, MD

Co-Investigators: Mikhail Olferiev, MD, and Lionel B. Ivashkiv, MD

The objectives of this study are to describe the process of the cytokine storm in people with COVID-19 and to identify biologic predictors of a favorable outcome in patients with severe cases of the disease. The project aims to characterize immune cell populations seen in COVID-19 patients who experience cytokine storm and compare them to those patients who do not, to compare the immune response before and after patients are given the anti-inflammatory drug anakinra, and to identify measures that suggest patients are more likely to decline and eventually require mechanical ventilation. The research will employ blood samples from HSS patients who are being treated for COVID-19 at New York–Presbyterian Hospital and who meet certain other qualifications.

What follows are descriptions of the first group of funded projects in the areas of clinical and health outcomes research:

Response to and Recovery from TKA in Patients with Antibodies to SARS-CoV-2

Principal Investigator: Miguel Otero, PhD

Co-Investigators: Meghan Kirksey, MD, PhD, and Peter K. Sculco, MD

It is unknown if people who have been exposed to COVID-19 may be at higher risk of experiencing an abnormal immune response following surgery, resulting in poor outcomes. This study will evaluate the response to and recovery from total knee arthroplasty (TKA) in people who have antibodies to COVID-19 — a marker of exposure. This study will include both patients who have COVID-19 antibodies and those who don’t, to act as controls. Patients will be followed for six weeks after surgery and evaluated for the presence of certain immune markers in the blood, as well as symptoms of inflammation including pain and stiffness in the joint.

SARS-CoV-2 Exposure and the Role of Vitamin D Among Hospital Employees

Principal Investigator: Emily M. Stein, MD, MS

Co-Investigators: Theresa T. Lu, MD, PhD; Andy O. Miller, MD; Jeri Nieves, PhD; and Alana Serota, MD

It is unknown if people with vitamin D deficiency may be more likely to become infected with COVID-19. This study will investigate vitamin D status and associated immune markers as risk factors for COVID-19 infection in a cohort of healthcare workers. Healthcare workers are at higher risk of contracting COVID-19 than the general population, making them a good group to study. Vitamin D is critical for immune function and is known to be protective against respiratory-tract infection and tuberculosis. This prospective, observational study will follow healthcare workers at HSS and at other healthcare facilities for one year, to determine whether levels of vitamin D and certain immune cells in the blood make someone more susceptible to COVID-19 infection.

Association of Immunomodulatory Medication Use and Social Determinants of Health with COVID-19 Infection in Systemic Rheumatic Disease Patients in New York City

Principal Investigator: Medha Barbhaiya, MD, MPH

Co-Investigators from HSS: Lisa Mandl, MD, MPH; Catherine MacLean, MD, PhD; Vinicius Antao, MD, PhD; Jane Salmon, MD; and Mayu Sasaki, MPH

Other Co-Investigators: Candace Feldman, MD, MPH (of Brigham and Women’s Hospital); Debra D’Angelo, MS (of Weill Cornell Medicine)

Using data from the INSIGHT Clinical Research Network, a central repository containing longitudinal electronic health data for residents of New York City, investigators will assemble a cohort of patients being treated with immunomodulatory medications for rheumatic disease. This patient population will then be used to study the effect of these medications on COVID-19 incidence and outcomes. Retrospective data will be used to evaluate the incidence and severity of COVID-19 in these patients. Patients will also be studied prospectively to determine whether there’s a relationship between COVID-19 infection and future rheumatic disease as well as to study connections between infection and future psycho-social issues.

Assessment of Surgical Outcomes in the COVID-19 Pandemic Era

Principal Investigator: Andy O. Miller, MD

Co-Investigators: Scott A. Rodeo, MD, and Mark Fontana, PhD

Investigators will implement a patient registry to evaluate how COVID-19 affects outcomes and complication rates after orthopedic surgery. This registry, along with COVID-19 screening procedures, will provide the tools to address specific research questions. Among these questions are determining the incidence of current and prior infection among the HSS surgical population, the clinical features associated with current and prior infections in this patient population, and whether COVID-19 status affects short-term complication rates.

What follows is a description of an integrated multidisciplinary study being undertaken jointly by the Adult Reconstruction and Joint Replacement (ARJR) Perioperative Research Group, Anesthesiology and Rheumatology:

Prediction and Prevention of Postoperative Blood Clots in COVID-19 Patients

Principal Investigators: Friedrich Boettner, MD; Kethy M. Jules-Elysee, MD; Lisa A. Mandl, MD, MPH

Co-Investigators: ARJR surgeons: Alejandro Gonzalez Della Valle, MD; Jason Blevins, MD; David J. Mayman, MD; Peter K. Sculco, MD; Geoffrey H. Westrich, MD and Thomas P. Sculco, MD

Medicine/Rheumatology: Medha Barbhaiya, MD, MPH; Doruk Erkan, MD, MPH; Deanna Jannat-Khah, DrPH

Pathology: Thomas W. Bauer, MD, PhD

Anesthesiology: Stavros G. Memtsoudis, MD, PhD, MBA; Alexandra Sideris, PhD

ARJR: Amethia Joseph, MHA; Ethan Krell, MS

Weill Cornell Medicine: Raymond David Pastore, MD

Recent literature suggests that one of the major complications seen in people with COVID-19 is thrombosis (the formation of blood clots) due to endothelial dysfunction, persistent inflammation and potentially antiphospholipid antibodies. As elective surgeries resume, those with prior exposure to SARS-CoV-2 will inevitably present for treatment, and some may have perioperative management considerations related to their risk of deep-vein thrombosis. This project will use, a noninvasive device that can determine clotting risks, to investigate whether people who have had COVID-19 have a more dysfunctional endothelium preoperatively and at 24 hours after surgery. The investigators will measure antiphospholipid antibodies and inflammatory markers, and evaluate the prevalence of asymptomatic post-operative deep-vein thrombosis in people who undergo TKR and have SARS-CoV-2 antibodies.

COVID-19 Translational Research Core at HSS

Principal Investigator: Theresa Lu, MD, PhD

Co-Investigators: Jessica Andrés-Bergós, PhD; Miguel Otero, PhD and Emily M. Stein, MD, MS

The COVID-19 Translational Research Core (TRC) was designed to fill critical gaps in the resources needed to promote the broad range of COVID-19–related clinical and translational research at HSS. The TRC will provide consultation on the design and implementation of COVID-19 research in the areas of orthopedics, rheumatology and metabolic bone disease; support for a COVID-19 biobank; and technical expertise and facilities required for clinical and translational researchers working on COVID-19–related projects. The TRC staff will help to acquire, house, and track biospecimens from investigator-initiated COVID-19–related research studies.

ERAS protocols aim to use evidenced-based techniques to improve clinical outcomes and reduce costs by lessening patients’ stress response before surgery and optimizing recuperation. Techniques can include reducing nausea, early mobilization, oral nutrition and improvement of analgesia.

Though ERAS protocols were initially developed more than 20 years ago for colorectal surgery, there is evidence of their positive effects for additional procedures. ERAS for spine and total joint replacement surgeries has not been well studied.

In an opinion piece published in the Journal of the American Medical Association in early 2019, Stavros Memtsoudis, MD, PhD, MBA, an anesthesiologist at HSS, cautioned against the use of ERAS protocols in specific surgeries without evidence to support them. He contended that doing so could cause lengthy protocols with as many as 20 components that are not supported by evidence, possible drug interactions, and potentially increased risks for patients or increased costs for hospitals in cases for which patient outcomes cannot be meaningfully improved. Dr. Memtsoudis concluded that ERAS protocols should be studied further to develop a basis of evidence supporting them for specific surgeries.

Since then, Dr. Memtsoudis and colleagues have conducted studies examining ERAS protocols for use in spine surgery¹ and in total joint replacement.²

ERAS in Spine Surgery

For their retrospective cohort study, the researchers identified 119,144 posterior lumbar fusion surgeries in the national Premier Healthcare Database of HSS patients from 2006 to 2016. The ERAS practices they examined were use of multimodal anesthesia, use of tranexamic acid, day zero antiemetic use, day zero steroid use, day zero or day one physical therapy, avoidance of Foley catheters, avoidance of patient-controlled analgesia and avoidance of wound drains. Cases were classified as high ERAS if greater than five practices were used, medium ERAS if three to five practices were used and low ERAS if less than three practices were used.

Overall, 10% of cases were high ERAS, 83% were medium ERAS and 7% were low ERAS. The researchers found that compared with low ERAS, medium and high ERAS cases were associated with significantly lower odds for any complication as well as for cardiopulmonary complications specifically. Length of stay was also improved in medium and high ERAS cases, but minimal differences were seen for average hospitalization cost.

ERAS in Total Joint Replacement

For this retrospective cohort study, researchers identified 1,539,713 patients from the Premier Healthcare Database having elective total hip or knee arthroplasty between 2006 and 2016. ERAS practices examined included use of regional anesthesia, use of multimodal anesthesia, use of tranexamic acid, day zero antiemetic use, day zero steroid use, day zero or one physical therapy, avoidance of Foley catheters, avoidance of patient-controlled analgesia and avoidance of wound drains. Cases were categorized as high ERAS if greater than six ERAS practices were used, medium ERAS if five to six practices were used or low ERAS if less than five ERAS practices were used.

The researchers found that 21% of cases were high ERAS, 58% were medium ERAS and 21% were low ERAS, with use of ERAS practices increasing over time for both hip and knee replacement surgeries. Similar to the results of the spine study, medium and high ERAS cases showed lower odds for any complication as well as for cardiopulmonary complication specifically, and improved the average length of stay incrementally as more ERAS components were used. Minimal effects were seen on the average hospitalization cost. A more profound impact from ERAS protocols was seen after 2013.

While these studies support use of ERAS protocols in orthopedic spine and total joint replacement surgeries, future studies should examine additional ERAS components.

“What these studies answer is that there is a benefit to having a certain amount of interventions within ERAS protocols,” Dr. Memtsoudis said. “In order to actually improve outcomes and recovery, you need to make sure that a minimum number of these aspects are being addressed. You can’t just do one part and ignore the other aspects. It seems that protocols that focus around making patients mobile and facilitating rehabilitation are the ones that are most effective.”

“However, we still need to determine if there is a ceiling effect,” he added. “Is there a point where it no longer adds benefit to add more of those aspects? Also, what medications are most useful and independently helpful when we look at multimodal pain management? Those are the issues that still need to be looked into.”

References

1. Megan Fiasconaro MS, Ellen M. Soffin MD PhD, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Janis Bekeris MD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Exploring Enhanced Recovery Components in Spine Surgery: A Retrospective Study.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

2. Megan Fiasconaro MS, Ellen M. Soffin MD PhD, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Jiabin Liu MD PhD, Janis Bekeris MD, Stavros G. Memtsoudis MD PhD MBA FCCP. “The Association Between Enhanced Recovery Components and Perioperative Outcomes in Total Joint Arthroplasty.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

Although uncommon, the development of depression and anxiety after surgery has been documented across various surgical cohorts and can potentially cause long-term health issues or even disability. However, there is limited research on this topic in orthopedic surgery.

Researchers from HSS led by anesthesiologist Stavros G. Memtsoudis, MD, PhD, MBA, are presenting three studies on this topic at the 2019 American Society of Anesthesiologists (ASA) Annual Meeting.

“Anesthesiologists have to keep in mind that what we do in the operating room or in the hospital may affect long-term outcomes, and anxiety and depression are issues that have been coming up more and more,” Dr. Memtsoudis said. “There are many causes, but having or developing chronic pain is one of the reasons why patients may not fulfill their expectations of what their life should be like after surgery.”

It is well known that acute pain that is not effectively managed has the potential to develop into chronic pain.

“If patients can’t return to their normal lives because they continue having pain, or if they develop anxiety or depression, then we haven’t really achieved our goal,” he added. “This research helps to remind us that what we do surrounding surgery may really affect things down the line, and we need to take more responsibility for those complications that happen perhaps not right away but weeks later.”

The three studies investigated potential risk factors for new-onset depression and anxiety after spine surgery, including posterior lumbar fusion (PLF) and anterior cervical discectomy and fusion (ACDF), and joint replacement, including total hip arthroplasty (THA) and total knee arthroplasty (TKA). They also examined whether obstructive sleep apnea (OSA) affected occurrence of new-onset depression or anxiety or risk factors.

The researchers analyzed patients who underwent surgery between 2012 and 2015 and who were identified with the Truven Health MarketScan database (which includes inpatients and outpatients from various hospitals across the United States).

New-Onset Depression and Anxiety after Spine Surgery

There were 16,277 patients who had PLF or ACDF procedures between 2012 and 2015 without coding or prescriptions indicating depression or anxiety before spine surgery.¹ After surgery, 12.3% of patients (n=2,006) experienced either new-onset depression (n=563), anxiety (n=1,251) or both (n=192).

Risk factors included younger age, female sex, previous history of psychoses/neurological disorders, chronic opioid use and higher income.

New-Onset Depression and Anxiety after Total Joint Replacement

There were 106,260 total joint replacements identified in the database between 2012 and 2015 (34.3% TKA, 65.7%THA).² Researchers found that 3.6% of patients (n=2,642) developed new-onset depression and 4.8% of patients (n=3,886) developed new-onset anxiety.

New-onset depression and anxiety were also significantly more likely after TKA compared with THA; patients undergoing TKA experienced 20% greater odds of new-onset depression and 40% greater odds of new-onset anxiety compared with patients undergoing THA.

“The reasons why new-onset depression and anxiety are more prevalent after TKA compared with THA are speculative, because with these database studies, we can’t determine causality,” Dr. Memtsoudis explained. “However, TKA is commonly a more painful procedure. It doesn’t quite replace a joint as physiologically as a hip replacement. So increased pain and not meeting expectations as well may underlie that finding.”

Chronic opioid use was associated with significantly higher odds of developing depression or anxiety after surgery. The strongest relationship was between chronic postoperative opioid use and new-onset depression and anxiety: Those who chronically used opioids after surgery had 2.4 times greater odds of developing new-onset depression and 2.9 times greater odds of developing new-onset anxiety compared with those who did not use opioids chronically after surgery.

“There are multiple reasons why chronic opioid use might be a risk factor for new-onset depression and anxiety after surgery,” Dr. Memtsoudis said. “One has actually been shown to happen on a molecular level, which is opioids interacting in the brain in a way that can produce anxiety.”

“On the other hand, it may not be current opioid use that causes depression in patients,” he continues. “Do people start getting depressed because they have chronic pain, or do they start having chronic pain when they’re depressed? Either way, I think that disrupting the cycle by finding patients at increased risk will at least allow us to screen for these problems and perhaps treat them early enough to prevent long term complications.”

Obstructive Sleep Apnea and New-Onset Depression and Anxiety after Surgery

Although trends were similar between patients with and without OSA, more significant results were found in patients without OSA, suggesting that OSA has a limited effect on new-onset depression and anxiety after surgery.³

Researchers found that in patients with or without OSA undergoing either spine surgery (PLF or ACDF) or total joint replacement (TKA or THA), risk factors for new-onset depression and anxiety six months after surgery included peripheral vascular disease, hyperthyroidism, paralysis, drug abuse and psychoses. Chronic opioid use increased the risk for complications. Higher income level was also associated with higher anxiety risk: Patients without OSA had 3% higher odds for developing new-onset anxiety if their annual household income was between $45,000-$60,000, and 19% higher odds if their annual household income was greater than $60,000.

“I think that there are multiple explanations for why higher income might be an increased risk factor for new-onset depression and anxiety,” Dr. Memtsoudis said. “It has been described in other fields that patients with higher income often have better access to healthcare. So someone who develops a problem is probably more likely to seek medical advice. So it may just be bias, a surrogate marker of access to better access to healthcare.”

“Additionally, patients with higher income may be more worried about potential loss of that income. Alternatively or additionally it may also be that patients who make more money have higher expectations,” he added.

Because of the observed relationship between chronic opioid use and new-onset depression and anxiety after surgery (particularly in patients whose chronic opioid use begins after surgery), Dr. Memtsoudis and colleagues recommend closely monitoring these patients to ensure they receive adequate and appropriate pain treatment.

“The most important takeaway is that this problem does exist. We need to find out if there is a causal relationship and who is at risk,” he said. “We also need to screen for these problems. It would be beneficial to put protocols in place that allow us to identify as early as possible patients who might develop depression, and find a mechanism to treat it. This may require better expectation management before surgery, or teaching patients coping skills or even referral to a specialist to identify the best course of treatment.”

References

1. Megan Fiasconaro MS, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Janis Bekeris MD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Postoperative depression and anxiety in posterior lumbar fusion and anterior cervical discectomy and fusion.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

2. Megan Fiasconaro MS, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Janis Bekeris MD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA FCCP. “New onset anxiety and depression as a function of chronic opioid use following total joint arthroplasty.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

3. Janis Bekeris MD, Lauren Wilson MPH, Jiabin Liu MD PhD, Jashvant Poeran MD PhD, Megan Fiasconaro MS, Stavros G. Memtsoudis MD PhD MBA FCCP. “OSA depression anxiety.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

As the demand for spine surgeries — specifically anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) — continues to rise, it is important to understand changes in the patient populations undergoing these procedures.

“The assumption in medicine is that as knowledge advances, clinicians and treatments get better and better, and therefore complications should decrease,” said Stavros Memtsoudis, MD, PhD, MBA, an anesthesiologist at HSS. “It’s one of those untested theories that people rarely question because they feel like it’s a logical conclusion. Studies that look into whether that’s true are really rare.”

A decade ago, Dr. Memtsoudis and colleagues conducted studies of patients who had undergone joint replacements and spine surgeries to examine whether complications had decreased between 1998 and 2008 and found that they did not. They also found that while mortality either decreased or remained stable, many other complications measured either stayed the same or increased.^2,3 “We also found that the average comorbidity burden, meaning how sick a patient is when they show up for surgery, also went up,” he said. “Our conclusion at the time was, we may be getting better at identifying complications and taking care of them, as evidenced by lower mortality rates, but the fact that patients are sicker makes it more likely that complications will occur, resulting in no change overall or sometimes worsening outcomes. We decided we wanted to repeat this study 10 years later.”

As a follow-up, the researchers identified 236,856 cases of ACDF surgery and 170,238 cases of PLF surgery in the national Premier Healthcare database of HSS patients between 2006 and 2016. They examined patient and hospital characteristics, patient comorbidities and postoperative complications, including blood transfusions; cardiovascular, pulmonary, renal or wound complications; hemorrhage; stroke; sepsis; thromboembolism; delirium; inpatient falls and mortality.

The median age of patients undergoing these surgeries increased significantly from 2006 to 2016, from 51 to 57 years for ACDF and from 58 to 61 years for PLF.

Comorbidities in these patients also increased, from 61% to 76% in ACDF and from 75% to 81% in PLF. However, despite patients’ increased age and higher rates of comorbidities, overall rates of complications and blood transfusions were stable in ACDF and decreased in PLF.

“The decrease in complications may be because we’ve developed protocols specifically to prevent some of the complications, including new interventions, or that we may be better at appropriately screening patients for surgeries,” Dr. Memtsoudis explained.

However, when evaluating complications individually, acute renal failure and inpatient falls were found to have significantly increased in both ACDF and PLF patients. Hemorrhage/hematoma and wound complications also increased in ACDF. All other postoperative complication rates remained stable or declined in PLF.

“This may be because patients are getting older,” Dr. Memtsoudis said. “Not only is the population aging in general, but surgeons are also getting more and more comfortable extending certain procedures to older patients. We know that age is a risk factor for inpatient falls. If people fall, they’re also more likely to have wound complications.”

He added that as patients get sicker, they are also more likely to have conditions such as diabetes, obesity or hypertension. These comorbidities, which raise the risk of wound infections and complications, have increased.

The increase in hematoma complications may be due to the increasing potency of anticoagulant medications that clinicians use to prevent blood clots, Dr. Memtsoudis explained.

“This study encourages us to step back and try to find further answers,” he added. “We want to be sure that it’s not something that we are doing that increases these complication rates. Currently we’re looking at a study balancing the risk of hematomas and bleeding that requires transfusions with the benefits of preventing blood clots, specifically, pulmonary embolisms and deep vein thrombosis.”

Results from this work suggest that other follow-up research is needed, including identifying risk factors for infections and what causes renal failure in some patients.

“This study also allows hospital administrators to keep an eye on trends, where resources need to be allocated, and to attack the problems that need attacking,” Dr. Memtsoudis concluded.

References

1. Lauren A. Wilson MPH, Megan Fiasconaro MS, Jiabin Liu MD PhD, Janis Bekeris MD, Jashvant Poeran MD PhD, David H. Kim MD, Federico Girardi MD, Andrew Sama MD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Trends in comorbidities and complications among patients undergoing inpatient spine surgery.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

2. M. Kirksey, Y. L. Chiu, Y. Ma, A. G. Della Valle, L. Poultsides, P. Gerner, S. G. Memtsoudis. “Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008.” Anesthesia & Analgesia, 2012;115(2), 321-327.

3. M. Pumberger, Y. L. Chiu, Y. Ma, F. P. Girardi, M. Mazumdar, S. G. Memtsoudis. “National in-hospital morbidity and mortality trends after lumbar fusion surgery between 1998 and 2008.” The Journal of bone and joint surgery. British volume, 2012;94(3), 359-364.

If found to be beneficial with minimal side effects, CBD could be especially useful in patients with comorbidities that put them at increased risk of harm from opioids, such as obstructive sleep apnea (OSA).

In recent years, clinicians and researchers have increasingly focused on relieving pain after surgery using multiple nonopioid pain management approaches, referred to as multimodal analgesia. The technique can lessen the amount of opioids patients take for pain relief, or even eliminate the need for opioids altogether.

“Sleep apnea is directly impacted by medications that are respiratory depressants. Any of the drugs we use during an anesthetic, including opioids, will decrease respiratory function and make it easier for patients to collapse their airway, which is really the one feature that makes up sleep apnea,” explained Stavros Memtsoudis, MD, PhD, MBA, a lead researcher on the study who is an anesthesiologist at HSS and president of the SASM. “Because of that, there is always concern about using opioids in patients with sleep apnea, that you’re going to make their symptoms worse, which can potentially lead to significant complications.”

“There’s an increasing awareness of this problem. Therefore, anesthesiologists try to avoid opioids by utilizing alternative approaches such as peripheral nerve blocks. In addition to that, we use nonopioid analgesics to achieve pain control without impacting respiration,” he said. “CBD, by virtue of its anti-inflammatory action, could potentially have some pain-relieving properties, without having the depressant effects of opioids.”

To examine surgeons’ current knowledge about CBD’s clinical uses and their interest in CBD as a potential recovery method after surgery, researchers designed an anonymous 11-item questionnaire and distributed it to surgeons at HSS.

A total of 94 clinicians, mostly joint arthroplasty orthopedists or sports medicine specialists with less than 5 years to more than 25 years in practice, completed the questionnaire. The survey results showed:

• 86% of surgeons were familiar with CBD, though only 4% said they were very familiar
• No surgeons thought CBD harmed the recovery process; 28% thought of it as a useful adjunct to recovery; 68% said they did not know if it was useful
• Of those who said they thought CBD was a useful adjunct, 64% thought it was either moderately or very useful
• 77% of surgeons said they would agree to the use of CBD during recovery if suggested by a patient or another provider
• 83% of surgeons expressed interest in learning more about CBD; 88% expressed interest in further study of CBD;
• 85% were open to recommending it if it is shown to be opioid and/or NSAID sparing;81% would direct a patient to use CBD as part of a multimodal analgesia recovery plan if shown to be beneficial with minimal side effects
• 24% of surgeons listed concerns with CBD including safety and/or a lack of clinical data

“We found that the surveyed surgeons expressed generally positive attitudes toward the use of CBD and expressed a desire for further study to address safety and efficacy of CBD in their patients,” said HSS researcher Alexandra Sideris, PhD. “CBD has never been studied before for recovery from surgery, mainly due to regulatory barriers precluding surgeons and clinicians from studying this compound within a hospital. Recent legislative changes are giving researchers and clinicians the opportunity to study CBD, and we are now taking advantage of that opportunity.”

Reference

1. Alexandra Sideris PhD, Valeria Rotundo BA, Kethy M Jules-Elysee MD, Jawad Saleh PharmD, Stavros G. Memtsoudis MD PhD MBA. “Cannabidiol as part of multimodal pain management? A survey of surgeons’ attitudes and knowledge.” Presented at 9th Annual Society of Anesthesia and Sleep Medicine Meeting (SASM), October 17-18, 2019; Orlando, FL.

These conclusions are the result of a year-long consensus project and a final conference in December 2018 at HSS, based on meta-analyses of the published evidence examining how the type of anesthesia affects perioperative outcomes in THA and TKA.

"We recommend that regional anesthesia be used for THA and TKA when there are no contraindications or special circumstances prohibiting its use," said Stavros G Memtsoudis, MD, PhD, MBA, anesthesiologist within the Department of Anesthesiology, Critical Care & Pain Management at HSS and leader of the project and chair of the steering committee of the Anesthesia-Related Perioperative Outcomes Consensus Project.

"Millions of people annually have hip and knee arthroplasty in the world, with more than a million per year in the United States alone. There are a number of studies published suggesting regional anesthesia is beneficial, but only a minority of patients are receiving it," Dr. Memtsoudis said. "There hasn’t been a comprehensive review of the evidence and there hasn’t been a randomized controlled trial big enough to answer questions regarding outcomes definitely. We therefore felt that we needed to take on this project and provide guidance. We felt that we were the most equipped group to do so because we publish many of the population-based studies on the topic."

The steering committee convened a consensus group of 45 experts in anesthesiology and orthopedic surgery from 19 different countries to systematically analyze existing literature and produce a consensus statement. Multiple sensitivity analyses were performed to ensure data was consistent, regardless of the methodological approach used.

Consequently, Dr. Memtsoudis and colleagues conducted a systematic review according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement that included 35 randomized controlled trials and 59 observational studies.

Based on their findings, the ICAROS Group made the following recommendations:

Anesthesia Recommendation for THA:

• Neuraxial anesthesia is recommended as the primary anesthetic technique for primary unilateral THA when there are no significant contraindications or special circumstances preventing its use. 
• Strength of recommendation: Strong 
• Level of evidence: Low to moderate

Results supporting recommendation:

• Neuraxial anesthesia in total hip arthroplasty was associated with a lower risk for complications for most outcomes compared with general anesthesia. 
• Combined neuraxial anesthesia and general anesthesia was also associated with better perioperative outcomes compared with general anesthesia alone, but the extent and range of benefits was less than the use of neuraxial anesthesia alone.

Anesthesia Recommendation for TKA:

• Neuraxial anesthesia is recommended as the primary anesthetic technique for TKA when there are no contraindications. This recommendation is based on results showing several benefits of neuraxial anesthesia on post-TKA outcomes as well as no evidence of worse outcomes. 
• Strength of recommendation: Weak, due to less robust evidence for TKA than THA 
• Level of evidence: Low

Results supporting recommendation:

• Use of neuraxial anesthesia for TKA may minimize several important outcomes, including pulmonary, thromboembolic, cardiac, and infectious complications. 
• When neuraxial anesthesia is used, resource utilization is reduced, including ICU admission, length of hospital stay, and readmission. 
• Neuraxial anesthesia and neuraxial anesthesia plus general anesthesia were associated with equivalent complications after TKA compared with general anesthesia. 
• Several caveats apply to these conclusions, including that well-designed, adequately powered prospective randomized controlled trials are lacking on this subject. 
• Data from studies of combined TKA/THA show more positive outcomes associated with neuraxial anesthesia than studies of TKA alone. A stronger positive influence of neuraxial anesthesia on THA outcomes should therefore be investigated further.

"These recommendations will help clinicians and patients choose the most evidence-based anesthesia approach to improve outcomes," said Dr. Memtsoudis. "Institutions will have to take into account their expertise and resources available, and the goal to increase use of neuraxial anesthesia in THA and TKA may be one that we’ll have to work on, as not everyone can switch immediately," Dr. Memtsoudis noted.

"This consensus is an example of what happens when you bring experts throughout the world together to achieve a common goal, and utilize cutting-edge methodology to underline the robustness of your outcomes," Dr. Memtsoudis concluded.

Members of the steering committee included: Dr. Stavros Memtsoudis (HSS), Dr. Dace Bekere (Ans. Research Volunteer), Dr. Janis Bekeris (2018-2019 HSS Perioperative Research Fellow), Dr. Crispiana Cozowicz (2015-2018 HSS Perioperative Research Fellow), George Go (HSS), Rie Goto (HSS), Mary Hargett (HSS), Bridget Jivanelli Gato (HSS), Dr. Rebecca Johnson (Mayo Clinic-MN), Dr. Jiabin Liu (HSS), Dr. Edward Mariano (Stanford-CA), Dr. Lukas Pichler (2017-2018 HSS Perioperative Research Fellow), Dr. Ellen Soffin (HSS).

Reference:

Memtsoudis SG, Bekeris J, Cozowicz C, Bekere D, Liu JB, Soffin E, Johnson R, Mariano ER, Goto R, Jivanelli B, Go G, Hargett M on behalf of the ICAROS Group. “Recommendations for Anesthetic Care of Patients undergoing Primary Hip and Knee Arthroplasty: Statement from the International Consensus on Anesthesia Related Outcomes after Surgery (ICAROS) Group.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

HSS Training in Ghana Expands Physician Knowledge and Use of Regional Anesthesia During Surgery

• Anesthesiologists Swetha R. Pakala, MD, and Mark A. Brouillette, MD, presented research showing that the Global Health Initiative increased physician knowledge, clinical skills and use of peripheral nerve blocks for extremity surgeries at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.

HSS Provides New Recommendations for Anesthesia Use During Total Joint Replacement

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA, and colleagues who participated in a year-long consensus project published their recommendations for the type of anesthesia that should be used during total hip replacement and total knee replacement.

Minority, Low Socioeconomic Status Pediatric Patients Getting Ambulatory/Sports-Related Surgeries Are Less Likely to Receive Regional Anesthesia

• Anesthesiologist Kate DelPizzo, MD, found that in New York state, younger pediatric patients, as well as minorities and those with low socioeconomic status, are less likely to receive regional anesthesia during ambulatory surgeries. She emphasized that this disparity in care must be addressed.

Cautious Approach Recommended for Determining Same-Day Discharge After Total Joint Replacement

• Although the overall risk for complications is low, anesthesiologist Jiabin Liu, MD, PhD, found that same-day discharge after total joint replacement may increase the risk for cardiac and pulmonary complications. He urges a measured approach and case-by-case consideration in recommending same-day discharge for patients.

While some components of ERAS have long been a part of medical practice in the United States, such as early oral intake or goal-directed fluid management, the concepts underlying ERAS originally began in Europe. The goal of these comprehensive patient care movements was to treat undesirable perioperative pathophysiologic processes in a way that would accelerate patient recovery. 

Initially, protocols were developed specifically for various diseases and surgeries after rigorous study of the ways in which metabolic injury and physical interventions affect recovery, and after scientific evaluation of how effective certain measures are at hastening patient recovery.

Most of the available ERAS data involve gastrointestinal surgery, while, due to significant lag time between publication of evidence and adoption into practice, there is a lack of quality research on adopting these principles in other surgeries.

"Surgeries vary vastly in terms of invasiveness, resulting metabolic injury, and the organ systems affected," explained Dr. Memtsoudis. "Therefore, ERAS recommendations for one surgery are not necessarily applicable to others."

While it is certainly encouraging that ERAS measures in Europe have significantly reduced hospital length of stay (LOS) to durations similar to those seen in the United States, there is financial pressure in the United States to reduce LOS, both from managed care programs and due to the shift towards performing minor procedures in ambulatory settings. This means that the push to enact ERAS procedures in the United States is often driven not by measures of patient recovery such as complications, readmissions, or quality of life, but on a desire to reduce cost.

This has resulted in the formation of international ERAS specialty societies, whose protocols and alleged successes have been published and applied to various surgical settings. While these procedures are often extrapolated from those previously published in other settings and incorporate aspects supported by literature, the majority of these publications lack scientific rigor: for example, they may use data from cohort studies instead of clinical trials, include components of ERAS with minor effectiveness, or include small numbers of highly selected patient populations that often lack or only have limited external validity.

ERAS procedures created in this way may also have other problems, including adding interventions with only the assumption that they will provide benefit, resulting in unwieldy protocols including as many as 20 components;²being unable to determine the incremental effects or benefits of drugs added to protocols, which may be unsafe because it is impossible to determine potential drug interactions or the effects of various interventions; and that because it is likely that a ceiling effect exists in which outcomes cannot be meaningfully improved further, patients are exposed to unnecessary risks and healthcare systems are left with increased cost from ineffective interventions.

The focus on LOS may also be misguided in its ability to actually reduce costs. A recent study showed that total joint arthroplasties with a decreased LOS coincided with increased spending post-discharge.³And while most patients may prefer shorter hospital stays, focusing on LOS ignores the reality that much of rehabilitation occurs not in hospitals, but in other acute care settings such as skilled nursing facilities.

"ERAS was founded as an evidence-based science whose outcomes were patient-centered. It should not be replaced with the empiric addition of poorly-studied interventions and medications whose success is measured with outcomes that are primarily economic in nature," Dr. Memtsoudis said.

"To curb this issue, more high-quality research evaluating the individual and cumulative benefit of various aspects of ERAS protocols for specific patient populations needs to be conducted. Additionally, frequent re-evaluation is needed to replace components that may become either obsolete or can be replaced with better or more cost effective alternatives," he concluded.

References
¹Memtsoudis S. Enhanced Recovery After Surgery in the United States: From Evidence-Based Practice to Uncertain Science? JAMA. 2019. doi: 10.1001/jama.2019.1070
²ERAS Society. List of Guidelines. http://erassociety.org/guidelines/list-of-guidelines/. Accessed December 4, 2018.
³Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472(1):188-193. doi: 10.1007/s11999-013-3034-3

Stavros G. Memtsoudis, MD, PhD, MBA, director of Critical Care Services within the Department of Anesthesiology, Critical Care & Pain Management at HSS, explains that regional anesthesia (versus general) can help reduce the need for opioids after surgery.

Dr. Memtsoudis' recent research, published in the journal Anesthesiology earlier this year, found that surgical patients who received at least two other forms of pain medication (such as acetaminophen and a NSAID) along with an opioid did better overall.

Dr. Memtsoudis says that those coming out of surgery should "have realistic expectations - they can't expect to go home from the hospital feeling absolutely pain-free. But, they should be able to read without being distracted by pain".

Read the full article at ConsumerReports.org.

According to the article, findings indicated that IV acetaminophen is not as effective as alternative nonopioid analgesic options.

Dr. Memtsoudis said that the results are reflective of a widespread tendency to turn to any treatment that's said to reduce opioid utilization and its side effects in the wake of the ongoing opioid crisis, regardless of whether the evidence is there to support it.

"Reducing opioids is certainly an important goal, and anything that can help with that is welcome. But IV acetaminophen, as it is currently used, doesn't seem to have any benefits over oral administration," he added.

This article appeared in the October 2018 print issue.

"Multimodal pain management has been heralded for years because it may be associated with improved pain management and reduced opiate consumption. But we wanted to take it one step further. We wanted to know if the number and type of analgesic modes are associated with reduced complications, opioid prescriptions and resource utilization," said Dr. Memtsoudis.

According to the article, Dr. Memtsoudis and his team reviewed surgical data from 2006 to 2016. Findings indicated that patients who received two modes of analgesia experienced fewer respiratory complications and a decrease in opioid prescriptions.

"While multimodal therapy is safe, all these medications have their own risks and side effects—it's not just opioids…. because opioids have a legitimate role to play in pain management. I don't think we should be trying to eliminate them altogether. Instead, I caution moderation when it comes to use of these agents," Dr. Memtsoudis noted.

Read the full article at anesthesiologynews.com.

Additional Coverage:

• Becker's Spine Review: Multimodal analgesia best at managing pain, complications after arthroplasty — 5 findings

Dr. Memtsoudis explained that CNBs manage pain more effectively than painkillers, and are a way to help patients without resorting to opioids.

"Recent developments are certain to increase the trend toward CNBs, the most notable being the increasing popularity of same-day total joint replacements," Dr. Memtsoudis wrote.

This article appeared in the July 2018 print issue.

"The purpose of this study was to identify the utilization patterns of multimodal pain management in patients undergoing joint arthroplasty in the United States," said Dr. Memtsoudis.

Dr. Memtsoudis explained that multimodal pain management improves pain control while also lowering the use of opioids and adverse effects.

Findings indicated that patients who received more than two modes experienced fewer complications and length of hospital stay.

The full interview originally appeared at secure-hwcdn.libsyn.com.

The local anesthetic is designed to provide pain control for up to three days.

Dr. Memtsoudis said "local anesthesia is one mode that has been proposed as being part of a multimodal approach to reducing opioid consumption. But we found that adding liposomal bupivacaine to the mix did not add significant benefit."

According to the article, the study reviewed data from 88,830 total knee replacements between 2013 and 2016.

"It does not seem to be the silver bullet physicians have been hoping for," Dr. Memtsoudis noted.

Read the full article at healthleadersmedia.com.

Due to the impact of OSA on breathing function, patients affected by this condition are at increased risk from the effects of anesthetic medications and specifically opioid drugs delivered during surgery, explained the investigators at the 2018 World Congress on Regional Anesthesia and Pain Medicine poster presentation.

"Multimodal analgesia has become increasingly popular, but there is a lack of large-scale population-based data on the practice and impact of these techniques on patients with OSA," said co-author and presenter Crispiana Cozowicz, MD, a perioperative research fellow within the Clinical Research Division of the Department of Anesthesiology, Critical Care & Pain Management at HSS.

Dr. Cozowicz and a team of researchers looked at opioid dose and post-operative outcomes in 181,182 patients undergoing total hip or total knee replacements enrolled in the Premier Perspective database from 2006 to 2016. Multimodal analgesia was defined as opioid use with the addition of one, two, or more non-opioid pain relief modes including peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, non-steroidal anti-inflammatories (NSAIDs), COX-2 inhibitors, or ketamine.

The prevalence of multimodal analgesia strategies was 88.5 percent, and the use of multimodal analgesia increased over time, reported the investigators. Increasing modes of analgesia were associated with a significant decrease in opioid dose prescription. Most importantly, the need for postoperative mechanical ventilation, representing life-threatening respiratory failure as well as critical care admissions decreased in patients who received multiple types of pain relief. Furthermore, the use of multimodal pain management strategies was associated with reduced hospital length of stay.

"Multimodal analgesia may significantly decrease postoperative opioid consumption and severe complications in patients with OSA," said Stavros Memtsoudis, MD, PhD, FCCP, and senior scientist and anesthesiologist within the Department of Anesthesiology at HSS.  

Reference

Crispiana Cozowicz MD, Lukas Pichler MD, Jashvant Poeran MD PhD, Nicole Zubizarreta MPH, Madhu Mazumdar PhD, Stavros G. Memtsoudis MD PhD FCCP. "Multimodal analgesia in OSA is associated with reduction in severe respiratory complications, critical care admissions and resource utilization in orthopedic surgery." Presented at: 2018 World Congress on Regional Anesthesia and Pain Medicine, April 19 – 21; New York, NY.

Neuraxial anesthesia, a type of regional anesthesia that targets nerves at the spinal level, is used in many ambulatory knee surgeries, explained the investigators. Anesthesiologists use a neuraxial block combined with sedative medication to keep the patient calm. But, more sedative use is linked to its own set of side effects, thus making it important to investigate how to keep exposure down.

"Using headphones or audiovisual devices may not only lower anxiety but can limit sedation requirements during surgery under neuraxial anesthesia," said Stavros Memtsoudis, MD, PhD, FCCP, principal investigator and senior scientist within the Department of Anesthesiology, Critical Care & Pain Management at Hospital for Special Surgery (HSS). Neuraxial anesthesia is a type of regional anesthesia that targets nerves specific to the surgery site.

"Reducing or eliminating sedation may lead to improved perioperative care," explained Dr. Memtsoudis.

To determine if audiovisual devices could impact anxiety levels in patients who received minimal sedation, the investigators randomized 26 patients undergoing primary, ambulatory arthroscopic meniscectomy using neuraxial anesthesia with audiovisual device (n=13) and without an audiovisual device (n=13).

Patients received 2 mg of midazolam before placement of the regional anesthetic medication and could request more sedation at any time, noted the researchers. To gauge satisfaction, patients answered questionnaires and anesthesiologists and surgeons provided feedback on their experience with the audiovisual devices.

No differences in post-operative pain scores or opioid use were observed between the two groups, and no complications occurred. Among the patients, 5 who received no audiovisual device and 2 patients with an audiovisual device requested additional sedative. No difference was seen in either state or trait anxiety scores between groups either before or after surgery. Patients in both groups reported equally high satisfaction following surgery. Providers reported a positive experience with audiovisual device use.

"We demonstrated that performing ambulatory knee surgery under regional anesthesia in awake patients is feasible – with and without the use of audiovisual devices," said Dr. Memtsoudis. "Future studies should use greater sample sizes to determine if use of these devices can reduce sedative medication use and have an impact on outcomes."

References

Pichler L, Lee KL, DeMeo D, Fields K, Moerwald EE, Cozowicz C, Memtsoudis SG. "The feasibility of awake ambulatory knee surgery under regional anesthesia with and without the use of audiovisual devices." Presented at: 2018 World Congress on Regional Anesthesia and Pain Medicine; April 19-21.

In pill form, acetaminophen is a common over-the-counter medication used to treat minor aches and pains. Its intravenous use, however,  was only relatively recently approved by the FDA in 2010, explained principal investigator Stavros G. Memtsoudis, MD, PhD, anesthesiologist and senior scientist at Hospital for Special Surgery (HSS).

Since its approval, intravenous acetaminophen use has been widely adopted as part of a multimodal analgesic approach meant to lower overall opioid consumption and decrease adverse outcomes associated with those medications.  It is also an expensive drug, adds Dr. Memtsoudis, who previously published research into its pricing in a 2015 issue of Regional Anesthesiologists and Pain Medicine. Additionally, there is not much data to back up the efficacy of intravenous acetaminophen in treating acute pain caused by orthopedic procedures in comparison to other more established and less costly alternatives.

These factors –  the limited data demonstrating its analgesic effectiveness, its high cost and its rapidly expanding use – spurred the researchers to investigate the impact intravenous acetaminophen has on postoperative pain control specifically in spine surgeries that have traditionally required high opioid use to treat postoperative pain.

Using data from 117,269 lumbar/lumbosacral spinal fusion patients enrolled in the Premier Healthcare Database from 2011 through 2014, the investigators evaluated an association between intravenous acetaminophen use with opioid use and opioid-related complications in surgeries that usually require a high dose of opioid medication.

The research team found that in 19 percent (n=22,208) of cases, at least one dose of intravenous acetaminophen was used.  Although the scientists did find a link between intravenous acetaminophen use on postoperative day 0 and 1 and opioid use, length of stay, and cost of hospitalization, the association did not coincide with a consistent pattern of significantly reducing the odds for complications, explains Crispiana Cozowicz, co-author and perioperative research fellow within the Department of Anesthesiology, Critical Care and Pain Medicine at HSS. When compared with the outcomes seen in administering other nonopioid analgesics - pregabalin/gabapentin, specifically – the impact of intravenous acetaminophen was minimal at best.

"We could not show that perioperative intravenous acetaminophen reduces inpatient opioid prescriptions and subsequently reduced odds for adverse outcomes," says Dr. Memtsoudis. "It remains to be determined if and under what circumstances intravenous acetaminophen has a meaningful clinical role in everyday practice."

According to the article, Dr. Memtsoudis and his colleagues reviewed data from more than 1.5 million joint replacement surgeries from 2006-2016.

"While our data suggest that practicing multimodal analgesia not only reduces opioid consumption but also reduces perioperative complications, we should also acknowledge that opioids do have a role to play in perioperative care. However, this role needs to be carefully defined, and our reliance on this drug class should be reduced as much as possible," said Dr. Memtsoudis.

This article originally appeared on Medscape.com.

In addition to reduced risk, findings indicated that patients who received more than two types of pain management had fewer respiratory complications and shorter hospital stays.

"Patients need to be aware that there are ways to treat their pain during and after surgery in addition to opioids," said Dr. Memtsoudis.

"If the doctor prescribes more than one type of medicine for your pain, it may reduce your need for opioids," he added.

This article originally appeared at health.com.

Findings indicated that multimodal analgesia (MMA) contributed to a decrease in opioid prescriptions and the average length of hospital stay for patients.

Additionally, Dr. Memtsoudis noted that the study was not designed to deduct why hospital stays might be shorter, but he believes one reason could be a reduction in complications.

"The use of MMA may also represent a practice which is closely linked with programs whose goal is to accelerate recovery, i.e. enhanced recovery after surgery (ERAS) programs. These practices are known to incorporate new knowledge faster and more systematically and thus MMA may be one of the drivers of reduced [length of stay]," he said.

Dr. Memtsoudis added, "now that we have linked MMA to better clinical and economic outcomes, the need for wider adoption of MMA becomes an ethical one. Knowing that this approach may be best for our patients, why don't we use it in everyone (barring contraindications such as allergies and others)?"

Read the full article at mdmag.com

According to the article, total hip replacement patients who received more than two methods of pain relief along with opioids had up to an 18.5 percent decrease in opioid prescriptions.

"While opioids have an important role to play perioperatively, their utilization and our reliance on this drug class should be minimized to improve outcomes. This is especially important as we are trying to understand if perioperative opioid exposure may contribute to the ongoing opioid epidemic," said Dr. Memtsoudis.

Read the full article at medpagetoday.com

HSS anesthesiologist Stavros G. Memtsoudis, MD, PhD, agreed with the study's findings and noted that they reflect a practice that is already in use.

However, he noted that the research supports the claim that aspirin is a safe, efficient and effective way to provide anticoagulation.

Read the full article at medpagetoday.com