What follows are highlights from these studies:

HSS Study Uses Machine Learning to Predict Risk of Long-Term Pain After Knee Replacement Surgery

A new study led by researchers at HSS used a type of AI known as machine learning (ML) to identify key clinical and biological factors that raise a person’s risk of having persistent pain after total knee arthroplasty (TKA). Risk factors included elevated levels of certain inflammatory cytokines (proteins) in the blood, severe preoperative pain, and a longer period of tourniquet use in the operating room.

“These findings highlight the importance of incorporating biological markers like cytokine levels with patient-specific pain profiles and what the surgeon does during the operation to more accurately predict the risk of long-term pain after surgery,” says Meghan Kirksey, MD, PhD, an anesthesiologist at HSS and senior author of the study.

ML is a specialized approach that uses algorithms and statistical models to analyze patterns in large amounts of data to learn, predict, and make recommendations.

“Machine learning is allowing us to look at patient and clinician information in new ways,” says Alexandra Sideris, PhD, Director of the HSS Pain Prevention Research Center and a coauthor of the study. “It gives us a multidimensional approach to understanding patients’ pain experience that we didn’t have in our arsenal even five or 10 years ago.”

One in five people has significant knee pain months after having TKA, also known as total knee replacement surgery. “The lingering pain greatly affects their daily activities and quality of life, so that’s why it’s an important focus for us,” explains Dr. Sideris.

Persistent postoperative pain (PPP) is typically flagged when a patient has lasting pain at the site of the operation that is above a four on a scale of zero to 10 and severely impacts their activities of daily living three to six months after surgery.

The researchers used four different ML models to analyze data from a previously published study that collected comprehensive clinical information and blood samples from 160 patients before and after TKA at HSS. The new study identified key predictors associated with PPP beyond risk factors that were already known such as sex (women tend to have a higher risk), preexisting pain, and mental health issues like anxiety and depression.

The findings showed that having high blood levels of an inflammatory marker called TARC immediately after surgery raises the risk of PPP. “This molecule hasn’t been extensively studied in pain, but the evidence shows that it was consistently associated with persistent pain six months after surgery across all four ML models we tested,” notes Dr. Kirksey.

Other top predictors of PPP that emerged from the analysis included a higher preoperative pain score at rest, longer tourniquet time (a tourniquet is a device that squeezes the leg to help clear the area of blood flow during surgery), and higher blood levels of other inflammatory cytokines right after surgery.

In this study, researchers entered 318 clinical and biological characteristics collected from patients in the older study and asked each of the ML models to figure out the most important features associated with pain after TKA. The researchers also evaluated the accuracy of the ML models they used and found that XGBoost was the most informative.

“To my knowledge, this is the first study that looked at all of this information and tried to make sense of the best ML approach to use,” says Dr. Sideris. “What is exciting to us is that there was one feature – TARC – that consistently popped up across all four models and it wasn’t on anybody’s radar beforehand…this gives us hope that ML can help us identify with high integrity targets that haven’t been studied before.”

The researchers note that more research is needed to know if their findings can be used to impact clinical care. “Our goal is to be able to use these tools and data to tailor pain management strategies, prevent long-term complications, and personalize treatment decisions,” says Dr. Kirksey.

HSS AI Analysis Reveals What Patients Are Googling About Local Anesthesia

A new study by researchers at HSS used AI to systematically evaluate the types of questions that patients are Googling related to regional (local) anesthesia, identify websites that are frequently presented in search results, and assess the quality of the information provided.

“We knew that patients frequently search for information about anesthesia online, but we wanted to know exactly what they were looking for so that we could proactively address these topics and concerns in our conversations in the clinic and our patient education materials,” says Jashvant Poeran, MD, PhD, Director of Research in the Department of Anesthesiology, Critical Care and Pain Management at HSS and lead author of the study.

The analysis found that most patients’ questions focused on risks, complications, and details surrounding medications, awareness during sedation, nerve block duration, and the recovery process. The study also found that while the overall quality of information accessed during Google searches was accurate, the source of that information was not always clear.

Anesthesiologists see patients in the clinic for a short period to prepare them for surgery and manage expectations.

“There’s so much information being conveyed during that limited time that sometimes patients forget what to ask, or they don’t even know what they should be asking during the visit,” explains Dr. Poeran. “Our study results will help us anticipate some of their questions and give us a starting point when we sit down with them so it’s not so much of a guessing game.”

The researchers entered seven search terms into Google Web Search: “regional nerve block,” “regional anesthesia,” “peripheral nerve block,” “pain block,” “neuraxial anesthesia,” “epidural anesthesia,” and “spinal anesthesia.” The top 200 questions in the “People Also Ask” section and its associated websites were collected, totaling 1,400 question and website combinations.

The authors then used AI to categorize themes and assess website quality. They found that most questions pertained to facts around risks and complications, comparisons between different techniques and approaches, technical details, and indications.

“We were expecting questions around risks and complications, but it was surprising that so many patients were looking at technical details, specifically around sedation,” notes Dr. Poeran. “They were not always aware that you can be awake for a peripheral nerve block, for example.”

Because patients’ questions are linked to specific websites, researchers also wanted to know where patients were being referred to and how reliable the information presented was. The AI analysis found that 55% of websites were academic, 19% were government, and 11% were public/social media sources. Information on government and academic/hospital websites scored the highest in terms of accuracy, and medical practice websites scored the lowest.

Dr. Poeran cautioned that some patients’ questions are nuanced, and online information can bias a person in the wrong direction.

“For example, if you ask whether regional anesthesia is better than general anesthesia you will be able to get generic information about those approaches online, but you need to talk to your doctor to get a more personalized recommendation based on your specific circumstances,” says Dr. Poeran.

While the study revealed important questions, it’s not all-encompassing. “There will be questions that aren’t captured by this study, but anesthesiologists can use this data to guide their consultations with patients scheduled for surgery, provide more-informative patient education materials, and refer them to the most reliable websites for more information,” notes Dr. Poeran.

He plans to continue leveraging AI in his future research endeavors.

“Based on the information we gathered, we will update our educational materials with the questions we now know patients ask most often and may even provide it in different languages and reading levels,” says Dr. Poeran. “We can then use AI to see how that information is perceived and understood by patients, study differences in search terms entered in different languages, etc.”

The medication, suzetrigine (JOURNAVX®), was FDA-approved in January 2025 and became available at HSS in April 2025. It is the first non-opioid pain reliever released in more than 25 years.

Alexandra Sideris, PhD, Director of the Pain Prevention Research Center at HSS, and Faye Rim, MD, FAAPMR, a physiatrist and pain management specialist within the Department of Anesthesiology, Critical Care & Pain Management, co-led the study.

One advantage of the new medication is that it works differently from standard over-the-counter pain relievers and stronger medications like opioids.

“What's exciting about this new medication is that it is targeting pain signal on the nerves outside of the brain, so you're presumably getting to the acute pain source right at the time where that happens,” Dr. Sideris said. "Early studies also suggest that it's devoid of those classical addictive properties that opioids have.”

It’s even more targeted than local anesthetics, which block pain messengers known as sodium channels. Instead, suzetrigine blocks just one sodium channel, Nav1.8, which means patients should experience fewer side effects and more targeted pain relief.

HSS was an early adopter in New York City to add suzetrigine to its formulary, and Dr. Rim was instrumental in bringing it to surgical patients. Patients managed by the Perioperative Pain Service often have complex needs that opioids alone may not be able to meet. Some patients may have other conditions that contraindicate the use of opioids. suzetrigine presents a novel, non-habit-forming option that can either replace or augment opioid use after surgery.

For this study, the team evaluated 103 HSS patients who took suzetrigine after undergoing a variety of surgical procedures, but primarily joint arthroplasty or spine surgery. Eight patients (7.8%) experienced at least one adverse reaction during admission, likely related to the drug, and ended up stopping the medication. The remaining 95 patients (92.2%) generally tolerated it well.

“The longer-term goal is to see if adding on suzetrigine actually decreases your need for opioids or if it is an effective option for patients undergoing major orthopedic surgery who cannot tolerate opioids,” Dr. Sideris said.

Pain has historically been a challenging area for drug development, in part because preclinical models do not always predict human response.

“Unfortunately, many things that work in animals just haven't translated into humans, and it's been a quest to understand [why],” Dr. Sideris said.

But this drug’s novel approach makes it an exciting advance in the field and one that HSS pain researchers were eager to capitalize on. This initial study gives a first look at how suzetrigine is tolerated in surgical patients at HSS, with an ongoing study in patients undergoing total hip replacements, and more research planned in patients knee, and spine surgery. Further studies will evaluate who may benefit from the medication the most, and who is more likely to require additional support. Currently, it is not a first-line medication, but Dr. Rim anticipates that will change as the drug becomes more widely available and additional evidence emerges on its efficacy in various surgical populations.

“We need to look more carefully at why certain patients may not do as well on this medication as we think they would,” she said. “It’s not a panacea, but it's definitely promising.”

She added that HSS was an obvious choice for the medication’s early adoption due to the institution’s reputation for cutting-edge science and advanced care.

“HSS is known for being innovative and this falls in line with that,” Dr. Rim said. “We want to try to utilize anything that's safe and effective within an arsenal to make sure patients recover well and become functional.”

The study demonstrated the importance of monitoring accurate dosage and highlighted the need for additional long-term studies to better understand the role of cannabidiol in post-surgery pain management. 

The pilot study, conducted over four years, followed 36 patients who received cannabidiol as a part of their treatment following surgery. Previous surveys at HSS and other institutions have shown that many patients are using cannabidiol to self-medicate, creating challenges for providers. To ensure safety, only relatively healthy patients were enrolled due to the demanding and invasive nature of the surgery. 

“These patients experience significant pain after surgery and often require high doses of opioids,” said Alexandra Sideris, PhD, Director of the Pain Prevention Research Center at HSS and one of the co-authors of the study. “We approached this study knowing that if we were going to study a cannabis constituent to try to see if there is any benefit, we need to start with a population that could significantly benefit from adding on an additional medication. It is very painful to have both knees replaced.” 

According to internal HSS data, this specific patient population showed a clear need for better pain control. The study team performed a blinded study, dividing patients into three groups. Some patients did not receive any CBD; instead, they were given the placebo solution. The other two groups received 400 milligrams or 800 milligrams of CBD. Patients received their first dose right before they went into surgery. They then received three additional doses on the evenings of the subsequent postoperative days—for a total of four doses. The study team monitored how many opioids were required throughout the first 72 hours after surgery. 

“What we found after completing the study is that patients who were randomized or received the 400-milligram dosage actually had 30% lower opioid requirements compared to the group receiving 800 milligrams. We found a lower dose seemed to help but the higher does did not. This suggests the importance of finding the right balance when determining the appropriate dose,” said Dr. Sideris. “CBD appears to be promising, but we have to be very careful in terms of the doses we give to patients.” 

The study further showed that patients in the 400-milligram group reported lower pain scores at every time point measured, with nearly a two-point difference compared to the other groups. According to Dr. Sideris, the 800-milligram group had much higher opioid-related distress scores, which suggested the higher dose did not decrease opioid requirements but caused more side effects for patients. The side effects persisted for up to a week and included dizziness and fatigue. 

“Moving forward, we are planning to pursue more studies where we hope to focus on the lower dose of 400 milligrams and include a larger cohort of patients. Our data suggests that the side effects profile and the fact that we didn’t see any signal for decreased opioid needs or pain suggests that we probably don’t want to go into 800 milligrams for designing a larger study,” said Kethy M. Jules-Elysee, MD, an anesthesiologist at HSS and one of the co-authors of the study. 

Poster Details: 
Title: Effects of cannabidiol (CBD) oral solution in patients undergoing bilateral total knee arthroplasty: a randomized, controlled, parallel, triple blind, pilot study 

Co-authors: Chan W, Liu J, Baaklini L, Kirksey M, Illescas A, Waldman S, Jules-Elysee K, Sideris A 
William Chan1,3, Jiabin Liu1,2,3, Lila Baaklini1,2,3, Meghan Kirksey1,2,3, Alex Illescas1, Seth Waldman1,2, Kethy Jules-Elysee1,2, Alexandra Sideris1,2,3 

Study: Prevalence of cannabidiol use in patients undergoing sports medicine procedures on the knee, shoulder, or hip: A survey study 

Researchers set out to determine the prevalence of cannabidiol (CBD) use in patients scheduled to undergo a sports medicine procedure at HSS. “We know that managing post-operative pain with opioids carries risks, including addiction. A promising alternative gaining attention is cannabidiol, a non-intoxicating derivative of the cannabis plant that is federally legal in the United States,” said Alexandra Sideris, PhD, director of the Pain Prevention Research Center at HSS. The study was presented at the 50th Annual ASRA Meeting in Orlando, Florida on May 1. 

Reports from the National Survey on Drug Use and Health indicate that adults ages 18-35 are the most frequent self-reporters of cannabis use. “Our study aimed to shed light on the prevalence of self-medication with CBD in adults scheduled for elective sports medicine surgery on the knee, hip or shoulder, evaluating the effects in this patient population,” Dr. Sideris explained. 
Researchers emailed anonymous surveys to 470 patients between September 2024 and December 2024. Out of 159 respondents, 39% of patients reported having tried CBD. Approximately one-third indicated that they used CBD on an as-needed basis, primarily for pain or to help them sleep. Most patients used gummies, and 44% purchased them from a dispensary. One-third of the respondents indicated that CBD was either moderately or very helpful. 

“At HSS, ongoing data collection and analysis will further elucidate the perceived efficacy of cannabidiol and the potential for changes to prescription medication use with the incorporation of CBD,” Dr. Sideris noted. 

With respect to the President’s Choice award, she commented, “It is an honor to have one of the top professional organizations in the field of regional anesthesia and pain medicine highlight the collaborative work of our department's Pain Prevention Research Center. The award reflects our dedication to innovations in patient care and underscores the greater scientific community's acknowledgements of our efforts.” 

Study: Opioid Consumption During Hospitalization Across Manual, Computer- and Robotic-Assisted Total Hip Replacement

In the second study to win a President’s Choice award, HSS researchers found that patients who had robotic-assisted total hip replacement (THR) surgery needed less opioid medication during hospitalization compared to patients who had computer-assisted or manual THR. The research was presented at the ASRA meeting on May 2. 

“Effective pain management while limiting opioid consumption following total hip replacement is imperative, as it facilitates immediate postoperative function and leads to better long-term outcomes,” said Periklis Giannakis, MD, a research fellow at HSS. “While patient characteristics are important factors associated with pain control, surgical technique is also relevant. We aimed to determine if the way hip replacement was performed had an effect on the need for opioid medication after surgery.” 
Analyzing a multi-institutional database with almost 100,000 hip replacement cases, Dr. Giannakis and colleagues found that robotic-assisted hip replacement was associated with the lowest total opioid consumption during hospitalization. He noted that while the exact mechanism is unknown, reduced soft tissue trauma and a more precise robotic-assisted surgery may contribute to less acute inflammation and less pain immediately after the procedure. 

Regarding his President’s Choice award, Dr. Giannakis commented, “Receiving President’s Choice recognition is a great honor for me and a testament to the collaboration and important research that we conduct at HSS.” He notes that future collaborative studies between the Department of Anesthesiology, the Pain Prevention Research Center and the Adult Reconstruction and Joint Replacement Service at HSS will seek to obtain more specific data, such as which robotic- and computer-assisted systems were used, with the ultimate goal of optimizing postoperative pain control. 

References: 
Prevalence of cannabidiol use in patients undergoing sports medicine procedures on the knee, shoulder, or hip: A survey study 
Authors: Sophia Madjarova BA, Arjun Khorana BS, William Chan MEng, Answorth Allen MD, Riley Williams MD, Benedict Nwachukwu MD, MBA, Alexandra Sideris PhD. 
Opioid Consumption During Hospitalization Across Manual, Computer- and Robotic-Assisted Total Hip Arthroplasty 
Authors: Periklis Giannakis, MD, Juliet E. Rowe, MPH, Lisa Reisinger, MD, Alex Illescas, MPH, Alexandra Sideris, PhD, Crispiana Cozowicz, MD, Junying Wang, MPH, Sophia T. Zhuang, Jiabin Liu, MD, PHD, Lazaros Poultsides, MD, PHD, Robert G. Marx, MD, Alejandro Gonzalez Della Valle, MD, Jashvant Poeran, MD, PhD, Stavros G. Memtsoudis, MD, PhD, MBA. 
 

“It is an honor to have one of the top professional organizations in the field of regional anesthesia and pain medicine highlight the collaborative work of our department's Pain Prevention Research Center,” said Alexandra Sideris, PhD, director of the Pain Prevention Research Center at HSS. “The award reflects our dedication to innovations in patient care and underscores the greater scientific community's acknowledgement of our efforts.” 

More than one million people undergo knee replacement surgery each year in the United States, and those numbers continue to rise, Dr. Sideris notes. “There is a need to better understand patients’ individual pain trajectories, and one of the most exciting approaches is to leverage artificial intelligence. With our huge patient database at HSS, machine learning can analyze factors such as age, gender, BMI, and presurgical pain levels to predict which patients are at greater risk of severe pain after surgery,” she said. Armed with this information, the care team can tailor personalized pain management plans to meet patients’ needs. 

The HSS researchers had several goals: utilize machine learning to identify pain archetypes following total knee replacement; determine important features for predicting pain outcomes; and classify patients at risk of severe pain in the immediate postoperative period. The retrospective study included 17,200 patients who had total knee replacements at HSS from April 1, 2021, to October 31, 2024. 

“Using unsupervised machine learning, we identified two distinct pain archetypes in patients who underwent total knee replacement, which corresponded to those who experienced severe, difficult to control pain after surgery and those whose pain was relatively well controlled,” explained Justin Chew, MD, PhD, a clinical fellow at HSS who presented the study at the ASRA meeting on May 1. “We then utilized supervised machine learning to determine the most significant predictive factors for severe pain. In our study, risk factors included younger age, greater physical/mental impairment, higher BMI, and preoperative opioid or gabapentinoid use.” 

Dr. Sideris notes that ongoing and future studies at HSS will continue to leverage AI with the goal of improving patient outcomes. While the award-winning study focused on the immediate postoperative period, she said additional studies will follow patients’ pain trajectory and recovery over longer periods of time to determine which strategies doctors can employ before surgery, intraoperatively and in the immediate postoperative period to manage pain in high-risk patients. 

Reference: 
Classification and stratification of patient pain archetypes following total knee arthroplasty: a machine learning approach 
Justin Chew, MD, PhD, Junying Wang, Alexandra Sideris, PhD, Victoria Xu, Daniel Maalouf, MD, MPH, Stavros Memtsoudis, MD, PhD, MBA, Jashvant Poeran, MD, PhD, Jiabin Liu, MD, PhD. 

“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.

“We are implementing and perfecting initiatives that cover the full spectrum of opioid risk,” said Seth Waldman, MD, MBE, anesthesiologist and co-chair of the HSS Controlled Substances Task Force. “Our strategy encompasses the entire structure of the opioid life cycle. We are tackling this issue at every level to positively impact our community.”

HSS is a national leader in orthopedics, ranked No. 1 in the nation by U.S. News & World Report in its “Best Hospitals 2023-2024” survey.¹ HSS performed more than 28,000 surgical cases in 2022. Orthopedic surgery is associated with significant perioperative pain and has been identified as a risk for long-term opioid use and misuse, making it crucial for HSS to tackle this issue.2,3

In late 2017, HSS launched an interdisciplinary Controlled Substances Task Force to prevent and mediate potential problems with opioid medications. HSS has also taken strides to tackle pain management that spans the care continuum.

“Opioid stewardship has had a tremendous impact on prescribing culture at HSS,” said Bobby Stack, MS, assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the task force. “Large-scale initiatives have not only had direct effects on opioid safety at the hospital, including reduced prescribing, distribution of disposal packets, safety warnings, and patient education, but have also inspired departments and individuals to take initiative in pushing for smaller improvements.”

The Controlled Substances Task Force has achieved substantial results in curbing the opioid crisis in six key areas:

Further Reducing Opioid Prescribing
Since 2017, HSS has been implementing initiatives to reduce opioid prescribing across the hospital. These efforts have resulted in continued improvements to the efficacy of post-operative pain control, as seen by continuously improving patient satisfaction scores, as well as a reduction of roughly 1 million pills prescribed per year.

Expanding HSS Patient Education Content
HSS has continued to expand its patient education content with articles and videos covering a range of topics including safe opioid use and disposal, how to taper off opioids, and educating patients about what to expect regarding pain management after surgery. The task force is now branching out to more nuanced topics, including safe pain management for children and adolescents, safety tips for opioids and benzodiazepines, how to use naloxone, and more. Content is made available to patients through their MyHSS patient portal, as well as through QR codes in their discharge paperwork. This content is also on the HSS website and YouTube channel, with top-performing articles reaching nearly 10,000 views per month.

Offering CME Courses for Providers and Personalized Prescriber Training
Over the last six years, HSS has developed and implemented ongoing, personalized training to providers to help them prescribe appropriate amounts of opioid pills for their patients’ situations. Ongoing oversight by a multi-specialty committee tracks whether the training was effective based on provider compliance, and provides follow-up education as needed. HSS also offers numerous CME hours’ worth of educational content for new doctors, ongoing content for existing providers to meet New York State and federal prescribing requirements, as well as regular presentations and webinars focused on new developments and quality assurance in safe opioid prescribing. 

Providing Safe Opioid Disposal Methods to Patients and Staff
HSS was one of the first hospitals in the United States to distribute free prescription disposal products to patients at discharge. Since 2017, HSS has been sending every surgical patient home with DisposeRx®, a small packet of powder mixed with water and any leftover prescription pills to render them unusable. DisposeRx, Inc has also partnered with HSS on initiatives to hand out disposal products on site, as well as to mail every HSS employee a DisposeRx® packet as part of HSS’ annual Opioid Awareness Month initiatives. Our goal is to get as many safe disposal products into the community as we can. HSS also provides a safe drop-off location on campus for unused medications.

Distributing Naloxone and Providing Training for Overdose Emergencies
HSS is a proud participant in the New York State Opioid Overdose Prevention Program (OOPP). We provide free naloxone kits to high-risk surgical patients and make kits available to HSS staff upon request. This year, for Opioid Awareness Month in September, we are training staff in how to administer naloxone and focusing on an initiative to distribute naloxone kits to as many staff as we can. The more naloxone is available in the community, the more lives can potentially be saved.

Expanding Our Research

Starr Foundation Grant

In late 2019, HSS received a $3 million grant from the Starr Foundation to establish the C.V. Starr Endowed Chair in Pain Management. This grant has enhanced existing pain management studies and funded new studies, expediting the translation of research findings into practice, improving safe prescribing practices, and exploring alternatives to opioids.

Seth A. Waldman, MD, Co-Chairman of the HSS Controlled Substances Committee and Advisor of Opioid Prescribing Practices at HSS, is the inaugural holder of the chair. The grant funds a full-time PhD researcher dedicated to these topics, Alexandra Sideris, PhD

Pain Prevention Research Center (PPRC)

Founded in 2023, the Pain Prevention Research Center (PPRC) at HSS is unique in its focus and commitment to studying the prevention of pain and outcomes associated with pain. The PPRC’s goals include identifying innovative approaches to prevent pain; conducting high-quality research on the prevention of pain and its adverse effects; and expediting the development of therapies for those who suffer from pain.

Future Plans

Building on its well-rounded strategy for tackling the opioid epidemic, the HSS Opioid Task Force has future plans to both refine and expand its initiatives.

“We are working on evolving our methods to better identify patients at high risk for issues with controlled substances and pain management,” said Dr. Waldman. “We are developing new tools for preoperative screening to figure out which patients are at high risk for dependence or addiction, as well as which patients may need non-standardized pain management techniques or preventive strategies as part of their care. This information will help us to proactively provide more targeted and effective treatments and optimization throughout the patient’s clinical experience.”

“We are also working on developing media that will go beyond basic education about safe use, tapering, and disposal to delve into topics that we might not otherwise be discussing,” Ms. Stack said.

Moving forward, one of HSS’s major goals is to continue educating others about what we have learned about opioid management and education, so it becomes the standard of care at other hospitals and facilities. HSS also plans to keep learning from experts in the field to continue improving on a bio-psycho-social approach to pain management.

Seth Waldman, MD, MBE, is an anesthesiologist and co-chair of the HSS Controlled Substances Task Force. He is the Advisor for Opioid Prescribing Practices at HSS, the C.V. Starr Endowed Chair in Pain Management, a physician consultant to the U.S. Department of Justice and Drug Enforcement Administration, a consultant for the HSS Clinical Ethics Service, and a Pain Management Physician for the New York Giants.

Roberta (Bobby) Stack, MS, is an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force.

References

1. https://health.usnews.com/media/best-hospitals/BH_Methodology_2023-2024
2. Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS Journal. 2019 Feb; 15(1):57-65. doi: 10.1007/s11420-018-9652-2
3. Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017 Nov;125(5):1704-1713. doi: 10.1213/ANE.0000000000002433

“The feeling of fear is very natural, and every single one of us knows that feeling,” said Stephanie Cheng, MD, DABMA, FAAMA. Dr. Cheng is an anesthesiologist at HSS and developed HSS’s protocols for using acupuncture in the operating room. “For some people, that fear can become irrational and develop into PTSD. Although exact numbers are unknown, reported estimates for the incidence of PTSD in the United States are approximately 6%, with women having twice the rate of men.

“For patients with nosocomephobia, it can make getting care in the hospital setting very hard,” she continues. “We don’t even know how many of these ‘unseen patients’ are out there because they just don’t come to the hospital.”

Current treatments for nosocomephobia include techniques such as cognitive behavioral therapy, exposure therapy, hypnotherapy, and medications.

“It’s worth noting that acupuncture isn’t even listed as a treatment on many patient information websites, despite it being well researched in PTSD patient populations,” Dr. Cheng said. “While acupuncture has been well studied with outpatient PTSD patients, specifically in the military, using it in the operating room is almost unheard of. Our study shows that offering acupuncture to patients is something that can help them feel more in control of the situation and get through surgery successfully.”

For these case studies, two patients were interviewed about their nosocomephobia and their prior hospital experiences. Using Dedoose software, six reviewers coded the interview transcripts line-by-line. The reviewers labeled meaningful words, phrases, and sentences, and created more than 600 codes. The reviewers grouped similar codes to identify themes, and then conducted a thematic analysis to generalize the study’s themes and construct its theoretical framework.

This analysis demonstrated how nosocomephobia affected patients’ perceptions of surgery and helped identify their individual fears. The researchers diagrammed the thought process of the patients to show how they considered whether they felt comfortable enough to get surgery. The appraisal process included three steps: experiencing the stressor (surgery), how they would be able to cope (acupuncture), and their mental state about whether they believed they could go through with the surgery (reappraisal).

In the case of these two patients with nosocomephopbia, acupuncture was a safe, non-invasive way for them to manage their preoperative anxiety and undergo elective surgery.

“Our research is based on a limited number of cases and makes it difficult to draw any major conclusions. We need to study more patients who have a major fear of hospitals and who need surgery and see whether offering acupuncture intraoperatively can successfully get those patients through surgery,” Dr. Cheng explained. “We also need to make more patients and doctors aware that this modality is available, and that it can be really helpful to patients suffering with PTSD.”

“If the addition of intraoperative acupuncture can prove to be helpful for patients who have a fear of hospitals, then we can really change the quality of life of a segment of the population that has historically been difficult to treat. The unseen patient can finally be seen,” Dr. Cheng concluded.

Reference

1. Pa Thor PhD, Andrew Moreno MS, MD, Haoyan Zhong MS, Miriam Sheetz BS, Marko Popovic BS, Sabrina M. Strickland MD, Michael P. Ast MD, Stephanie I. Cheng MD, DABMA, FAAMA. “A Qualitative Analysis of Intraoperative Acupuncture for Nosocomephobia: The Unseen Patient.” Presented at: 6th World Congress on Regional Anaesthesia & Pain Medicine, September 6-9, 2023, Paris, France.

“Usually for hip arthroscopy, the anesthesiologist performs a type of neuraxial block; in this case, a femoral nerve block or fascia iliaca block,” said Lisa Reisinger, MD, a research fellow at HSS and one of the authors of the study. “With these blocks, there is an adverse effect of quadriceps weakness leading to elevated fall risk and prolonged hospital stay.”

“PENG and LFCN are both motor-sparing blocks, but neither provide adequate pain relief for hip arthroscopy on their own,” Dr. Reisinger explained. “The purpose of this study was to evaluate whether these nerve blocks performed at the same time would lead to adequate analgesia with opioid-sparing effects and earlier discharge. While these are two commonly used techniques, it is not yet common to use them together for hip arthroscopy.”

Twenty-six patients who received only the PENG block and 86 patients who received both the PENG and LFCN blocks were matched to a control group of 112 patients who received only a neuraxial block using propensity score matching (1:1) and a caliper of 0.2, to match patients by American Society of Anesthesiologists classification, gender, and age.

The primary examined outcome was average opioid consumption in the PACU. Secondary outcomes included maximum numerical rating scale (NRS) pain score, intravenous (IV) rescue analgesia, and PACU readiness for discharge times.

The combination of a PENG block and LFCN block showed a significant reduction in average opioid consumption (more than 40% less) and earlier PACU discharge times (more than 1.7 hours earlier) compared with neuraxial alone.

There were also significantly lower severe pain scores in the PENG/LFCN group than the neuraxial alone group, which was demonstrated with the PENG/LFCN group using significantly less IV rescue analgesia and having lower maximum NRS pain scores. The PENG block alone did not demonstrate a significant pain relief benefit compared with the control group, although it did decrease the amount of time to discharge.

These results demonstrate that using both the PENG and LFCN nerve blocks may provide the best pain relief, reduce opioid use, and reduce discharge times compared with PENG block alone or neuraxial analgesia alone.

“Patients are looking for alternatives to minimize narcotic use after surgery,” said David Kim, MD, an anesthesiologist at HSS and lead author of the study. “This study offers an opioid-sparing alternative for ambulatory hip arthroscopy.”

“The next stage of research should be focusing on whether PENG/LFCN combination provides any longer-term outcome benefits to our patients, such as functional outcomes, post-discharge opioid consumption, etc.,” said Jiabin Liu, MD, an anesthesiologist and one of the authors of the study.

“Most blocks have a duration of 24 to 48 hours,” Dr. Kim added. “The next focus should be on methods for lengthening the duration beyond that.”

Reference

1. Lisa Reisinger, MD, Genewoo Hong, MD, JD, Edward Lin, MD, Sang Jo Kim, MD, Jonathan Beathe, MD, Douglas Wetmore, MD, Jiabin Liu, MD, David H Kim, MD. “Pericapsular nerve group block combined with a lateral femoral cutaneous nerve block decreases opioid consumption after hip arthroscopy: a retrospective cohort study.” Presented at: 6th World Congress on Regional Anaesthesia & Pain Medicine, September 6-9, 2023, Paris, France.

HSS is nationally ranked No. 1 in orthopedics (for the 14th consecutive year), and No. 2 in rheumatology by U.S. News & World Report (2023-2024). It is also the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS was ranked No. 1 worldwide in orthopedics for a third consecutive year in 2023. HSS physicians serve as team doctors for the New York Giants, New York Knicks, New York Liberty, New York Mets, Long Island Nets and other professional sports teams. 

“We are pleased to make better quality care more convenient for the Long Island community,” said Mark Drakos, MD, medical director of HSS Long Island. “HSS Southampton responds to a steady increase in demand for our highly specialized orthopedic care from eastern Long Island.”

HSS Southampton is the second outpatient location on Long Island for HSS, which completed a major expansion and renovation of its longstanding offices in Uniondale, in Nassau County in 2022. Physicians at the Southampton location will offer expertise in sports medicine, foot and ankle surgery, hand surgery, pain management, physiatry, spinal care and orthopedic trauma. They are the same physicians who see patients at the main hospital in New York City.

“Our team strives to ensure every patient’s experience across all HSS facilities is consistent and exceptional,” said John Finger, senior vice president, HSS Regional Markets. “We look forward to continuing to serve active communities on Long Island by expanding our physical and digital reach to advance their musculoskeletal health and overall quality of life.”

Individuals who are candidates for orthopedic surgery would go to the Upper East Side hospital. “Long Island residents who have surgery in New York City are pleased to have the convenience of scheduling their pre-operative visits and post-operative care on Long Island,” Dr. Drakos noted.

HSS Southampton is located at 56 Flying Point Road in Southampton. In addition to Long Island, HSS has outpatient locations throughout New York, in New Jersey, in Connecticut and in Florida. More information is available at www.hss.edu/longisland.

The BrightPoint^TM Epidural Needle Guidance System, Lumoptik’s first product, is a low cost, easy to use device which can help clinicians better perform epidurals using the standard-of-care Loss of Resistance (LOR) technique. BrightPoint^TM utilizes a specialized reflectometer that shows the clinician the color of the tissue at the tip of the needle in real time while inside the patient, thus providing an additional, objective indication that the needle is in the correct position. BrightPoint^TM is designed to work as part of the LOR technique, in combination with standard needles and syringes and can help clinicians perform LOR epidurals more safely and reliably than traditional methods.

“HSS looks forward to working with Lumoptik to evaluate and assess the BrightPoint^TM Epidural Needle Guidance System and work on new uses for Lumoptik’s innovative platform technology,” said Michael P. Ast, MD, chief medical innovation officer and a joint replacement surgeon at HSS. “This partnership is a great example of HSS being able to leverage all areas of its expertise, including anesthesia, in improving musculoskeletal care.”

The HSS Innovation Institute played a central role in bringing together the appropriate HSS skillsets and expertise to optimize the collaboration with Lumoptik. “Our mission to advance patient care through new technologies and partnerships aligns with the potential of Lumoptik’s technology and our anesthesia team to drive this new innovation forward,” said Doug Leach, vice president of Device Innovation at HSS.

“Using epidural anesthesia with patients who have musculoskeletal disease can be particularly challenging given the impact that arthritis and injury can have on the spine,” said Michael Singleton, MD, an anesthesiologist at HSS. “I am excited to see Lumoptik’s use of technology in an area that is ripe for modernization.”

“We are very pleased that a world class clinical organization like HSS sees the opportunity for our BrightPoint^TM Epidural System to potentially become the standard of care. We also look forward to working with them to develop additional high value medical products based on our platform technology. We believe this will be a fruitful relationship for both HSS and Lumoptik,” said Frank Lyman, CEO of Lumoptik.

About Lumoptik

Lumoptik, Inc. is a medical device company that has developed the BrightPoint^TM Epidural System to assist physicians with needle placement during epidural procedures for childbirth, spine/back pain and surgical procedures such as knee and hip replacements. Over 11 million epidural procedures are performed in the US each year with over 30 million performed worldwide. BrightPoint^TM is a platform technology with multiple potential medical uses in orthopedics, pain management, neurology, vascular access and urology. Lumoptik is a private company with a diverse investor base. For further information, please visit www.lumoptik.com or contact Frank Lyman, CEO at frank.lyman@lumoptik.com.

Hip arthroscopy is one of the fastest growing orthopedic procedures in the United States, and despite being minimally invasive, it is a painful procedure for which analgesia can be difficult to manage. 

“Hip arthroscopy is becoming a more popular procedure performed at free standing ambulatory surgery centers (ASC). It is important to provide optimal analgesia to help combat against the over reliance on opioids for pain relief and also to facilitate discharge and patient satisfaction,” said Dr. David Kim, anesthesiologist at HSS.

A review of the literature for opioid-sparing options has not revealed a clearly superior regimen for managing pain after this surgery. 

Because ultrasound has become more common to perform nerve blocks, novel motor-sparing blocks have been introduced, such as the PENG and LFCN. When performed separately, these blocks have been shown to provide suboptimal pain relief or to cause quadriceps weakness, if a high volume of injectate spreads to the femoral nerve. Case studies have been written on combining these nerve blocks, but this is the first prospective randomized controlled trial conducted to validate this finding.

Investigators identified 1,559 patients who had elective hip arthroscopy at HSS between January 2019 to December 2020. Of that group, 268 received both a neuraxial anesthetic and a peripheral nerve block; 86 received a PENG and an LFCN block; and 26 received a PENG block, only. A control group of 112 patients received no blocks. 

The primary outcome was total opioid consumption in the PACU. Secondary outcomes included average numeric rating scale (NRS) pain scores, maximum NRS pain scores, length of PACU stay, incidence of postoperative nausea and vomiting, and admissions to the hospital for pain management. 

Patients who received both a PENG and LFCN block required significantly less opioids in the PACU (15 mg [15,15] vs 22.5 mg [15 34]). They were also discharged earlier than the control group (2.4 hours [1.8,3.4] versus 4.1 [3.5,4.9]); 2.72 hours versus 4.42 hours, p <0.001). The combined PENG/LFCN group also used less intravenous rescue opioids than the control group (0 mg [0,0] versus 0 mg [0,2], p = 0.0099), and the highest NRS pain scores showed a significant difference in the PENG/LFCN group vs control group (7 [5,8] versus 7 [6,8], p = 0.0437). The group who received the PENG block alone did not show a significant difference in opioid reduction, but was discharged from the PACU earlier than the control group (3.35 hours [2.7,4.3]versus 4.9 hours [3.8,5.7], p = 0.0023).

These results demonstrate the combined PENG and LFCN block could be an opioid-sparing method of pain relief after hip arthroscopy. “PENG combined with a lateral femoral cutaneous nerve block decreased opioid consumption, and facilitated expedient discharges,” Dr. Kim noted.

Dr. Kim concluded “Follow up research should include a prospective randomized controlled trial comparing PENG, PENG with lateral femoral cutaneous nerve block, and no blocks, with primary focus on analgesia and motor strength.”

Reference

1. David H Kim MD, Genewoo Hong MD, JD, Edward Lin MD, Sang Jo Kim MD, Jonathan Beathe MD, Douglas Wetmore MD, Stavros Memtsoudis MD PhD MBA, Jiabin Liu MD PhD. “Pericapsular Nerve Group block combined with a lateral femoral cutaneous nerve block decreases opioid consumption after hip arthroscopy: a retrospective cohort study.” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

Because patients with hip fractures have significant comorbidities, they are often at a higher risk of experiencing adverse effects from opioids. Using nerve blocks for pain relief in these patients can help to not only reduce pain, but also opioid use and confusion. Some emergency medicine and acute pain societies are attempting to increase the use of ultrasound guided regional anesthesia.

“This was the first attempt to look at how hip fracture patients are treated with local anesthetics prior to surgery. It is a descriptive study from a nationally representative database,” explained Alexander Stone, MD, regional anesthesia/acute pain medicine (RA/APM) fellow at HSS, who received one of three Resident/Fellow Travel Awards from ASRA for this study. 

The researchers identified hip fracture patients in the Premiere Healthcare Database, excluding patients under 18 years of age, who had missing data on sex or on discharge date. The researchers identified the use of injectable local anesthetics from medication billing records and physician order entry on the day of admission. 

This study included 864,416 patients with an emergency admission due to a hip fracture from 2009-2019 from 1,012 different hospitals. Of these patients, 1,126 (0.11%) underwent surgery on the day of hospital presentation.

From 2009-2019 the rates of local anesthetic use on the day of admission increased as follows: 

• Bupivacaine (13.3% to 18.6%)
• Ropivacaine (2.0% to 8.4%)
• Mepivacaine (0.05% to 0.14%)
• Lidocaine (28.4% to 41.0%)

Limitations of the study include the inability to tell from medical reports whether the medication was administered as a nerve block, field block, or local infiltration. Additionally, investigators could not determine who administered the medication.

These results show a trend towards increased use of local anesthetics before surgery in patients with hip fracture. There was an increase in the use of sustained pain relief being started early in admissions, specifically with longer acting anesthetics such as bupivacaine and ropivacaine. 

“The primary takeaway is that it appears more hip fracture patients are being treated with longer-acting local anesthetics prior to surgery. This could reflect changes in opioid sparing and multimodal analgesia practices,” Dr. Stone noted. “It is important for anesthesiologists to be aware of this, and for increased communication and collaboration between specialties to reduce the risk of local anesthetic toxicity.”

When discussing follow-up research, Dr. Stone said more detailed information about this topic is needed. 

“This study is not granular, which is a limitation of using large administrative databases. To address this, we have created a survey for ASRA members to better assess how common it is for patients to receive nerve blocks in the setting of the emergency department,” Dr. Stone said.

If you are an ASRA member and would like to participate, click here to go to the survey.

Reference

1. Alexander B. Stone MD, Haoyan Zhong MPA, Jashvant Poeran MD PhD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA. “Injected local anesthetic use for hip fracture patients on the day of hospital presentation: a national database analysis.” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

The U.S. Food & Drug Administration recently approved liposomal bupivacaine for use in interscalene nerve blocks. Liposomal bupivacaine is an extended-release formulation of bupivacaine that theoretically sustains pain relief up to 72 hours. However, there is a lack of randomized controlled trials comparing liposomal bupivacaine with placebo (saline) or with “standard” bupivacaine. 

Investigators aimed to determine whether liposomal bupivacaine actually prolongs pain relief compared with standard bupivacaine plus dexamethasone as a regional anesthetic technique. HSS has been using standard bupivacaine with perineural dexamethasone as an adjuvant in order to lengthen pain relief from nerve blocks up to 30 hours, as there are several meta-analyses and systematic reviews supporting its safe and effective use in upper extremity blockade. This study is the first randomized controlled trial comparing the two drugs as injectates in nerve blocks.

Study on prolonging nerve blocks is imperative, as “prolonging analgesia with adjuvants may be key in decreasing opioid use after surgery,” said Dr. David Kim, anesthesiologist at HSS.

The study was conducted from August 2019 to March 2021 in 112 patients undergoing ambulatory shoulder surgery. Participants were divided into two groups: 56 patients who received a mixture of 5 mL of 0.5% standard bupivacaine with 133 mg of liposomal bupivacaine; and 55 patients who received a mixture of 15 mL of 0.5% standard bupivacaine with 4 mg of dexamethasone. 

The primary outcome was average numerical rating scale (NRS) pain scores at rest over a period of 72 hours, but the researchers also examined analgesic block duration, motor and sensory resolution, opioid use, and NRS pain scale scores when resting and moving on days 1, 4 and 7 after surgery. They also examined patient satisfaction, readiness for PACU discharge, and adverse side effects related to the interscalene block. 

The results indicated that the pain score after 72 hours in the liposomal bupivacaine group was non-inferior to the bupivacaine with dexamethasone group (mean (SD), 2.4 (1.9) versus 3.4 (1.9), mean difference (95%CI), -1.1 (-1.8, -0.4), p <0.001 for noninferiority). Additionally, there was also no significant difference in the length of pain relief between the two groups. Furthermore, there was no difference in opioid consumption, readiness for PACU discharge, or adverse events. 

“Liposomal bupivacaine is noninferior to preservative-free dexamethasone when used as an adjuvant for the interscalene nerve block,” Dr. Kim noted. “Even though there was a statistically significant difference in the pain scores, the differences are unlikely to be clinically relevant. As practicing clinicians, it was important for us to investigate interventions that provide meaningful clinical differences, not to only look for statistical significance in numbers.”

Dr. Kim concluded “Follow up research should include a large prospective randomized controlled trial comparing liposomal bupivacaine and preservative-free dexamethasone on total shoulder arthroplasties.”

Reference

1. Danya A. DeMeo BS, Ejiro Gbaje MPH, Jacques T. YaDeau MD PhD, Kethy M. Jules-Elysee MD, Yi Lin MD PhD, Enrique A. Goytizolo MD, David Kim MD, Richard L Kahn MD, Stephen C. Haskins MD, David J. Mayman MD, Douglas E. Padgett MD, Thomas P. Sculco MD, Chad M. Brummett MD, Geoffrey Westrich MD. “Interscalene brachial plexus block with liposomal bupivacaine versus standard bupivacaine with perineural dexamethasone: a noninferiority trial.” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

“If not properly treated, pain after TKA can be severe. Currently, in addition to other analgesic medications (multimodal analgesia), many patients receive two long-lasting nerve blocks (ACB and IPACK) as well as PAI by the surgical staff,” said HSS anesthesiologist Jacques Ya Deau, MD, PhD. “Previous studies have shown that patients with a PAI do better when the nerve blocks are added to their pain management therapy.”

However, “we thought that it may not be necessary to do the PAI, given the theoretically nearly-complete analgesia provided by the two nerve blocks. It's best to avoid unnecessary procedures,” Dr. Ya Deau added.

The researchers randomized 94 patients undergoing primary TKA into either a PAI group or a placebo group. Patients in the PAI group received a deep injection consisting of: 

• 30 mL of bupivacaine 0.25%, with 1:200,000 epinephrine
• 8 mg of Morphine
• 40 mg of Methylprednisolone
• 500 mg of Cefazolin
• Normal saline to bring total volume to 64 mL

They also received a superficial injection of 20 mL of bupivacaine, 0.25%.

Both groups received the standardized multimodal analgesia protocol of intraoperative sedation consisting of: 

• midazolam and propofol
• a mepivacaine spinal (60 mg)
• adductor canal block (comprised of 15 mL bupivacaine 0.25%, with 1 mg of preservative-free dexamethasone)
• IPACK block (comprised of 25 mL bupivacaine 0.25%, with 2 mg of preservative-free dexamethasone)
• intraoperative ketamine (50 mg)
• ketorolac (15 mg)

Postsurgical pain relief included:

• IV ketorolac, followed by oral meloxicam
• IV, then oral acetaminophen
• 60 mg of oral duloxetine daily
• 5-10 mg of oral oxycodone by mouth every 4 hours as needed. Opioids were adjusted according to patient needs.
• In the recovery room, IV hydromorphone was available for breakthrough pain. 

The researchers examined numerical rating score (NRS) pain with movement and opioid consumption. They found no significant difference between the PAI and placebo groups. NRS pain with movement the day after surgery in the ACB/IPACK/No PAI group was noninferior to the ACB/IPACK/PAI group, and there was no significant difference in cumulative opioid consumption from the PACU to postop day 2 between the groups. 

These results indicate that PAI may not provide a benefit in patients undergoing TKA with a multimodal pain relief plan that already includes ACB and IPACK blocks. “In the context of multimodal analgesia, the two nerve blocks provided excellent pain relief. There was no additional benefit from adding a PAI,” Dr. Ya Deau said. 

The researchers noted that these results may not be generalizable to different surgeries or to patients with different underlying conditions or baseline characteristics. 

Dr. Ya Deau added that looking towards future research, it is important to investigate how to improve pain relief after the nerve blocks wear off a few days after surgery.

“Currently, most TKA patients have excellent pain relief during the first few days. This is the acute pain phase, when otherwise pain would be most severe,” Dr. Ya Deau said. “Unfortunately, some of these patients have more pain than is desirable once discharged. We need to continue trying to improve pain management on days 3-14 after surgery,” he concluded.

Reference

1. Justas Lauzadis, PhD; Douglas Padgett, MD; Geoffrey Westrich, MD; Ejiro Gbaje, MPH; Fred Cushner, MD; Richard L. Kahn, MD; Yi Li n, MD; Enrique A. Goytizolo, MD; David J Mayman, MD; David H. Kim, MD; Kethy M. Jules Elysee, MD; Jacques T. YaDeau , MD, PhD. “Does Periarticular Injection reduce pain after knee arthroplasty among patients receiving peripheral nerve blocks?” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

Endothelial injury, or damage to the lining of the blood vessels, can be a major cause of blood clots after surgery. It has also been found in patients infected with COVID-19. 

Investigators aimed to gain insights into whether the risk of endothelial dysfunction continues after an infection with COVID-19 resolves, and if there is a need for more aggressive Deep Vein Thrombosis (DVT) prophylaxis in TKR patients with a history of COVID-19 infection. Aggressive DVT prophylaxis consists of pharmacologic and nonpharmacologic measures to diminish the risk of deep vein thrombosis and pulmonary embolism.

“Previous studies have demonstrated endothelial dysfunction in patients with active COVID-19 infection as manifested by higher rates of thromboembolic events. Consequently, therapeutic anticoagulation is recommended for hospitalized patients with acute and significant disease from the virus,” said HSS anesthesiologist Kethy Jules-Elysee, MD. “It remains unknown to what extent this predisposition to endothelial dysfunction persists upon resolution of active COVID-19 infection, implying a possible need for higher level of thromboprophylaxis in these patients postoperatively.”

She continued “Postoperative thrombosis is always a concern in patients undergoing total knee arthroplasty (TKA). This has been attributed to endothelial dysfunction from Virchow's triad. Given the projected increase in demand of TKA surgeries and the continued rise of COVID-19 cases, it is significantly important to assess the risks of postoperative thrombosis in the setting of both TKA and previous COVID-19 infection.”

Fifty-three patients with SARS-CoV-2 antibodies were identified for the case group and 48 patients without SARS-CoV-2 for the control group; all had received a primary TKR for knee osteoarthritis. Endothelial function was analyzed non-invasively via a reactive hyperemia procedure with a VENDYS-II device, once before surgery and once on postoperative day 1. Endothelial function was quantified using the vascular reactivity index (VRI) ranging between 0 (poor) to 3.5 (excellent). 

There was no significant difference between the average pre- and postoperative VRI in both patient groups, nor was there a significant difference in VRI scores before surgery vs after surgery. 

“Findings suggest no increased risk of DVT after TKA in SARS-CoV-2 IgG positive patients,” Dr. Jules-Elysee noted.

Postoperative VRI was not correlated with the duration or severity of COVID-19 infection. Decreased postoperative VRI was also not associated with increased length of hospital stay.

These results indicate that more aggressive DVT prophylaxis is likely not needed in TKR patients who have fully recovered from COVID-19.

When considering follow-up studies, Dr. Jules-Elysee noted “Since patients with a history of severe or prolonged infection with COVID-19 were not included in the study, further research on these patients is needed.”

Reference

1. Kethy Jules-Elysee, Carola Hanreich, Friedrich Boettner, Anna Jungwirth-Weinberger, Alison Zhao, Robyn Schultz, Ilya Bendich, Lisa Mandl. “Risk of thromboembolic events as measured by endothelial function is not elevated in total knee replacement patients with history of COVID disease.” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

“Total knee replacements are one of the most common operative procedures in the United States and often very painful, so there’s a great need to explore non-opioid pain relief techniques for this type of surgery,” said Stephanie Cheng, M.D., DABMA, lead author of the study and assistant attending anesthesiologist at the Hospital for Special Surgery and assistant professor of clinical anesthesiology at Weill Cornell Medicine, both located in New York City. “Acupuncture is extremely safe and can help reduce pain with few unwanted side effects, but it has not been well researched as part of surgical anesthesia.”

The study included 41 patients undergoing primary total knee replacement at the Hospital for Special Surgery. All patients received the institution’s standard opioid-sparing multimodal analgesic protocol, with the addition of electroacupuncture – a modified form of traditional acupuncture that applies a small electric current to thin needles that are inserted at known acupuncture points on the body. The acupuncture was administered during surgery by Dr. Cheng, who is board certified in medical acupuncture, to eight specific points in the ear to provide targeted pain relief in the knee.

With the addition of acupuncture, the majority of patients had a significant reduction in postoperative opioid use, compared to historical controls. Sixty-five percent of patients maintained a low-dose opioid regimen (15 oxycodone pills or less) from induction of anesthesia to 30 days after surgery, while 7% of patients remain completely opioid-free. Historically, only 9% of patients outside of the study maintained a low-dose or opioid-free regimen post-surgery. All patients studied discontinued opioid use after 30 days following surgery.

“Our study shows that if a trained medical acupuncturist is available to perform acupuncture in the operating room, it can help patients with postoperative pain recovery,” said Dr. Cheng. “Most studies fail to incorporate nontraditional techniques, such as acupuncture, to help decrease the dependance on opioid medications for postoperative pain control.”

In the context of the opioid epidemic, achieving low-dose perioperative opioid consumption is critical to reducing the risk of long-term opioid use in patients. With acupuncture being commonly used outside of the hospital as an effective therapy for pain management and treatment for a range of health issues and symptoms, it’s time to consider its benefits inside the hospital as well, Dr. Cheng said. “Additional research is needed to further define acupuncture’s effects and encourage its use in all aspects of disease treatment.”

ABOUT THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 54,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.

For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/madeforthismoment. Join the ANESTHESIOLOGY^® 2021 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES21.