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Objectives: Medication errors are common during transitions of care. The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition of care interventions on the reduction of medication errors after hospital discharge., Methods: A systematic search was conducted to detect published reports of randomized trials using the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews, and Google Scholar inclusive to July 1, 2015. Search terms included pharmacist, medication, errors, readmission, transition, and discharge. A priori main outcomes included medication errors and health-care resources utilization (hospital readmission and/or emergency room visits). Quantitative analysis was performed using a random effect method., Results: Thirteen randomized trials examining 3503 patients were included in the final analysis. The aggregate effect of the 10 studies evaluating the effect of pharmacists intervention on the incidence of medication errors during transitions of care favored pharmacist over control with an odds ratio (95% confidence interval [CI]) of 0.44 (0.31-0.63). The overall effect of 4 studies evaluating the effect of a pharmacist intervention on the incidence of emergency room visits compared with control favored the pharmacist intervention, odds ratio (95% CI) of 0.42 (0.22-0.78), number needed to treat (95% CI) of 6.2 (3.4-31.4)., Conclusions: Pharmacist transition of care intervention is an effective strategy to reduce medication errors after hospital discharge. In addition, a pharmacist intervention also reduces subsequent emergency room visits. Hospitals should consider implementing this intervention to improve patient safety and quality during transitions of care., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is a paucity of data regarding risk stratification of pediatric patients presenting for low-risk skin and soft tissue surgery., Aims: We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30-day readmission in a cohort of children undergoing low-risk skin and soft tissue surgery., Methods: The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two-year period. The primary outcome was a 30-day postoperative complication composite. The secondary outcome was unplanned 30-day readmission., Results: The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound-related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30-day readmission., Conclusion: Pediatric patients with American Society of Anesthesiologists classification ≥3 and nutritional deficiency undergoing low-risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30-day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications., (© 2018 John Wiley & Sons Ltd.)

Background: Poor health literacy affects over 90 million Americans. The primary aim of the study was to evaluate a possible association between health literacy and decision conflict in surgical patients., Methods: Patients undergoing a diverse number of elective surgeries were enrolled in the study. Health literacy was measured using the Newest Vital Sign instrument and decision conflict using the low literacy version of the Decision Conflict Scale., Results: 200 patients undergoing elective surgeries were included in the study. Patients who had greater health literacy scores had lower decision conflict scores, Spearman's rho = - 0.43, P < 0.001. Following propensity-score matching to account for potential covariates, the median (IQR) decision conflict score was 20 (0 to 40) for patients with poor health literacy compared to 0 (0 to 5) for patients with adequate literacy, P < 0.001., Conclusions: Poor health literacy is associated with greater decision conflict in patients undergoing elective surgical procedures. Strategies should be implemented to minimize decision conflict in poor health literacy patients undergoing elective surgical procedures.

Introduction: Intraoperative systemic esmolol has been shown to reduce postsurgical pain. Nonetheless, it is unknown whether the use of intraoperative systemic esmolol can improve patient-reported postsurgical quality of recovery. The main objective of the current investigation was to evaluate the effect of intraoperative esmolol on postsurgical quality of recovery. We hypothesized that patients receiving intraoperative esmolol would report better quality of postsurgical recovery than the ones receiving saline., Methods: The study was a prospective randomized double-blinded, placebo-controlled, clinical trial. Healthy female subjects undergoing outpatient hysteroscopic surgery under general anesthesia were randomized to receive intravenous esmolol administered at a rate of 0.5 mg/kg bolus followed by an infusion of 5 to 15 μg/kg/min or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included postoperative opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test., Results: Seventy subjects were randomized and 58 completed the study. There was not a clinically significant difference in the global QoR-40 scores between the esmolol and saline groups at 24 hours, median (interquartile range) of 179 (171-190) and 182 (173-189), respectively, P = .82. In addition, immediate post-surgical data in the post-anesthesia care unit did not show a benefit of using esmolol compared to saline in regard to pain scores, morphine consumption, and postoperative nausea and vomiting., Conclusions: Despite current evidence in the literature that intraoperative esmolol improves postsurgical pain, we did not detect a beneficial effect of intraoperative esmolol on patient-reported quality of recovery after ambulatory surgery. Our results confirm the concept that the use of patient-centered outcomes rather than commonly used outcomes (e.g., pain scores and opioid consumption) can change the practice of perioperative medicine.

Few systemic drug interventions are efficacious to improve patient reported quality of recovery after ambulatory surgery. We aimed to evaluate whether a single dose systemic acetaminophen improve quality of recovery in female patients undergoing ambulatory breast surgery. We hypothesized that patients receiving a single dose systemic acetaminophen at the end of the surgical procedure would have a better global quality of postsurgical recovery compared to the ones receiving saline. The study was a prospective randomized double blinded, placebo controlled, clinical trial. Healthy female subjects were randomized to receive 1 g single dose systemic acetaminophen at the end of the surgery or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test. The association between opioid consumption and quality of recovery was evaluated using Spearman rho. P < .05 was used to reject the null hypothesis for the primary outcome. Seventy subjects were randomized and sixty-five completed the study. Patients' baseline characteristics and surgical factors were similar between the study groups. There was a clinically significant difference in the global QoR-40 scores between the acetaminophen and the saline groups, median (IQR) of 189 (183 to 194) and 183 (175 to 190), respectively, P = .01. In addition, there was an inverse relationship (Spearman's rho= -0.33) between oral opioid consumption at home (oral morphine equivalents) and 24 hour postoperative quality of recovery, P = .007. A single dose of systemic acetaminophen improves patient reported quality of recovery after ambulatory breast surgery. The use of systemic acetaminophen is an efficacious strategy to improve patient perceived quality of postsurgical recovery and analgesic outcomes after hospital discharge for ambulatory breast surgery., (© 2017 Wiley Periodicals, Inc.)

Background: Maximising patient comfort during and after surgery is a primary concern of anaesthetists and other perioperative clinicians, but objective measures of what constitutes patient comfort in the perioperative period remain poorly defined. The Standardised Endpoints in Perioperative Medicine initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials., Methods: We undertook a systematic review to identify measures of patient comfort used in the anaesthetic, surgical, and other perioperative literature. A multi-round Delphi consensus process that included up to 89 clinician researchers was then used to refine a recommended list of outcome measures., Results: We identified 122 studies in a literature search, which were the basis for a preliminary list of 24 outcome measures and their definitions. The response rates for Delphi Rounds 1, 2, and 3 were 100% (n=22), 90% (n=79), and 100% (n=13), respectively. A final list of six defined endpoints was identified: pain intensity (at rest and during movement) at 24 h postoperatively, nausea and vomiting (0-6 h, 6-24 h, and overall), one of two quality-of-recovery (QoR) scales (QoR score or QoR-15), time to gastrointestinal recovery, time to mobilisation, and sleep quality., Conclusions: As standardised outcomes will support benchmarking and pooling (meta-analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery., (Copyright © 2018 British Journal of Anaesthesia. All rights reserved.)

Objective: To compare the incidence in postsurgical persistent pain following breast cancer surgery in women receiving intravenous lidocaine compared to saline using validated pain instruments in accordance with the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations., Methods: The study was a randomized, double-blinded, placebo-controlled, clinical trial. Subjects were randomized into Group 1 (1.5 mg/kg bolus of intravenous lidocaine followed by a 2 mg/kg/hour infusion) or Group 2 (normal saline at the same bolus and infusion rate). Patients were evaluated at 3 and 6 months for the presence of chronic persistent postsurgical pain., Results: One hundred forty-eight patients were included in the study analysis. There were no differences in quality of recovery, pain burden, or opioid consumption between groups at 24 hours. Pain (yes/no) at 6 months attributed to surgery was reported in 29% of Group 2 vs. 13% of Group 1 patients (P = 0.04); however, only 3 subjects (5%) in Group 1 and 2 subjects (3%) in Group 2 met IMMPACT criteria for persistent postoperative pain (P = 0.99)., Discussion: Perioperative infusion of lidocaine has been reported to decrease the incidence of postsurgical pain at 3 and 6 months following mastectomy using dichotomous (yes/no) scoring. Although intravenous lidocaine reduced the reported incidence of pain at rest at 6 months, pain with activity, pain qualities, and the physical or emotional impact of the pain were unaffected. Future studies evaluating postsurgical persistent pain should adhere to the IMMPACT recommendations in order to more accurately describe the effect of an intervention on persistent pain., (© 2017 World Institute of Pain.)

Background: The "July Effect" refers to a theoretical increase in complications that may occur with the influx of inexperienced interns and residents at the beginning of each academic year in July., Objectives: We endeavored to determine if a July Effect occurs in plastic surgery., Methods: Plastic surgery procedures were isolated from the National Surgical Quality Improvement Program registry. Cases involving residents were grouped as either having occurred within the first academic quarter (AQ1) or remaining year (AQ2-4). Groups were propensity matched using patient/operative factors and procedure type to account for baseline differences. Univariate and multivariate regression analyses assessed differences in overall complications, surgical and medical complications, individual complications, length of hospital stay, and operative time. A comparison group comprised of procedures without resident involvement was also analyzed., Results: There were 5967 cases with resident involvement, 5156 of which successfully matched. Both univariate and multivariate regression analyses revealed no significant differences between AQ1 and AQ2-4 in terms of overall, surgical, medical and individual complications, or length of hospital stay. There was a statistically significant, albeit not clinically significant, increase in operative time by 10 minutes per procedure during AQ1 in comparison to AQ2-4 (P = 0.001). For procedures lacking resident participation, there were no differences between AQ1 and AQ2-4 in terms of these outcomes., Conclusions: A July Effect was not observed for plastic surgery procedures in our study, conceivably due to enhanced resident oversight and infrastructural safeguards. Patients electing to undergo plastic surgery early in the academic year can be reassured of their safety during this period., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com)

Background: The knowledge regarding appropriate dosage of local anaesthetics for peripheral nerve blocks in children is very scarce. The main objective of the current investigation was to evaluate dosing patterns of local anaesthetics in children receiving peripheral nerve blocks across multiple paediatric hospitals in the USA. We also sought to estimate the incidence of local anaesthetic systemic toxicity., Methods: This is an observational study using the Pediatric Regional Anesthesia Network (PRAN) database. Data on every peripheral nerve block in patients aged <18 years placed from April 1, 2007 to May 31, 2015 were examined as a subset of the PRAN protocol. Data were examined for the type and dose of local anaesthetic and for the presence of local anaesthetic systemic toxicity., Results: In total, 40 121 peripheral nerve blocks in children were analysed. Individual analyses of block type demonstrated large local anaesthetic dose variability with a five- to 10-fold spread depending on the block type. Two patients developed local anaesthetic systemic toxicity, resulting in an estimated incidence (95% CI) per blocks performed of 0.005% (0.001-0.015%). None of the patients had any short- or long-term complications or sequelae., Conclusions: We detected a large variability in the local anaesthetic dosing practices for peripheral nerve blocks in children across multiple hospitals in the USA. Nonetheless, the risk of local anaesthetic systemic toxicity was very low. Due to the lack of dose findings studies, our results suggest the need to develop practice guidelines to minimize variability of regional anaesthesia practices in children., (Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background and Objectives: Dosage of local anesthetics (LAs) used for regional anesthesia in children is not well determined. In order to evaluate and come to a consensus regarding some of these controversial topics, The European Society of Regional Anaesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) developed a Joint Committee Practice Advisory on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia., Methods: Representatives from both ASRA and ESRA composed the joint committee practice advisory. Evidence-based recommendations were based on a systematic search of the literature. In cases where no literature was available, expert opinion was elicited., Results: Spinal anesthesia with bupivacaine can be performed with a dose of 1 mg/kg for newborn and/or infant and a dose of 0.5 mg/kg in older children (>1 year of age). Tetracaine 0.5% is recommended for spinal anesthesia (dose, 0.07-0.13 mL/kg). Ultrasound-guided upper-extremity peripheral nerve blocks (eg, axillary, infraclavicular, interscalene, supraclavicular) in children can be performed successfully and safely using a recommended LA dose of bupivacaine or ropivacaine of 0.5 to 1.5 mg/kg. Dexmedetomidine can be used as an adjunct to prolong the duration of peripheral nerve blocks in children., Conclusions: High-level evidence is not yet available to guide dosage of LA used in regional blocks in children. The ASRA/ESRA recommendations intend to provide guidance in order to reduce the large variability of LA dosage currently observed in clinical practice.

Objective: The main objective of the current investigation was to evaluate the effect of propofol used as anesthetic maintenance compared to sevoflurane on global post-surgical quality of recovery in female patients undergoing ambulatory gynecological surgery., Design: The study was a prospective randomized double blinded, controlled, clinical trial., Interventions: Healthy female subjects were randomized to receive propofol or sevoflurane as anesthetic maintenance., Measurements: The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24h after surgery. Other data collected included opioid consumption, pain scores and time to hospital discharge. P<0.05 was used to reject the null hypothesis for the primary outcome., Main Results: Ninety subjects were randomized and sixty seven completed the study. Patient's baseline characteristics and surgical factors were not different between study groups. There was not a clinically significant difference in the global QoR-40 scores between the sevoflurane and the propofol groups, median (IQR) of 175 (163 to 181) and 176 (163 to 184), respectively, P=0.97. There was an inverse relationship (ρ=-0.42) between the opioid consumption in PACU (IV morphine equivalents) and 24h postoperative quality of recovery (P<0.001) and an inverse relationship (ρ=-0.48) between the oral opioid consumption at home (oral morphine equivalents) and 24h postoperative quality of recovery, P<0.001., Conclusions: Our current results do not support the use of total intravenous anesthesia as an efficacious strategy to improve global quality of recovery after ambulatory surgery. Opioid consumption in the PACU is an earlier surrogate that can be utilized to identify ambulatory patients with a high likelihood to develop poor global quality of recovery and who may benefit from more efficacious strategies to improve global quality of recovery., Trial Registration: ClinicalTrial.gov; url: http://www.clinicaltrials.gov; registration identified: NCT 01755234., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Current literature is controversial regarding the importance of obese BMI classifications as a risk factor for pulmonary complications after outpatient surgery. The objective of the current investigation was to evaluate predictors of pulmonary outcomes after outpatient surgery and to assess the importance of BMI weight classifications in risk assessment., Study Design: Patients with "outpatient" recorded as their inpatient/outpatient status in the 2012 to 2013 NSQIP database were included. The primary outcome of interest was the occurrence of a new pulmonary complication (eg pneumonia, pulmonary embolism, unplanned intubation, or ventilator-assisted respiration for greater than 48 hours) within 30 days of surgery., Results: There were 444,532 cases included in the final analysis. There were 996 (0.22%; 99% CI 0.21% to 0.24%) all-cause pulmonary complications. Binary logistic regression identified BMI as an independent predictor of a pulmonary complication, unadjusted odds ratio 1.091 (99.75% CI 1.026 to 1.160) per 5 kg/m 2 change in BMI, p < 0.001. Adjusted odds of a pulmonary complication with a BMI of 35 to 39.99 kg/m 2 was 1.44 (99.75% CI 1.01 to 2.06; p = 0.002) and with a BMI of 40 to 49.99 kg/m 2 was 1.68 (99.75% CI 1.13 to 2.50; p < 0.001) compared with a BMI of 18.5 to 24.99 kg/m 2 ., Conclusions: Obese classes II and III were associated with an independent risk of a pulmonary complication. The risk associated with obesity was low compared with the risk associated with advanced age, prolonged surgical duration, and the risk of comorbidities including congestive heart failure, COPD, and renal failure., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

We evaluated blood bupivacaine concentrations in children having a single-shot sciatic and continuous femoral blocks after anterior cruciate ligament repair. Dried blood spot samples were analyzed for bupivacaine levels at 0, 5, 15, 30, 60, and 120 minutes and 4, 24, and 48 hours. The highest 99% upper confidence interval limit was 135 ng/mL at the 4-hour evaluation point. The 99% upper confidence interval was below potentially toxic levels (1500 ng/mL) across all sampling times. The risk of local anesthetic toxicity in pediatric patients receiving single-shot sciatic and continuous femoral nerve blocks is very low.

Objective: The use of pneumoperitonium and the placement of patients in Trendelenburg position are commonly cited reasons for the potential development of intraoperative regurgitation of gastric contents and the need for an endotracheal tube in laparoscopic surgery. The main objective of the current investigation was to evaluate the presence of regurgitation of gastric contents in the oropharynx of patients having laparoscopic gynecological surgery with a laryngeal mask airway (LMA)., Design: Prospective, observational clinical investigation., Interventions: Not applicable., Measurements: Healthy subjects having a laparoscopic gynecological surgery under general anesthesia with a ProSeal LMA were included in the study. An insufflation pressure of 15 mm Hg was established as the maximum intra-abdominal pressure for the pneumoperitonium, and patients were placed in Trendelenburg position at a 15° angle. The pH of secretions extracted from subjects' hypopharynx was measured at multiple time points during the surgical procedure. A pH of oropharynx secretions ≤4.1 indicated the regurgitation of gastric contents., Main Results: Eighty subjects were recruited and completed the study. The median (range) of pH measurements at any time (T3-T9) was 6.5 (5.5-7.0). The median (range) for the lowest pH for each subject was 6.0 (5.5-7.0). The lowest detected pH in the hypopharynx was not correlated (Spearman ρ) with total surgical time (P = .9), total pneumopertitonium time (P = .17), or total Trendelenburg position time (P = .47)., Conclusions: Our current results suggest that the use of an LMA in healthy patients undergoing laparoscopic gynecological surgery may be safe. Future studies to confirm or refute our findings are warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objectives: A single-dose adductor canal block can provide postoperative analgesia for patients undergoing total knee arthroplasty (TKA). The purpose of this study was to assess postoperative opioid consumption after ultrasound-guided single-injection bupivacaine compared with saline adductor canal block for patients undergoing TKA., Methods: After institutional review board approval, written informed consent was obtained from patients (>18 years old) undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 10 mL of bupivacaine 0.25% with epinephrine 1:300,000 or 10 mL of normal saline. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. Personnel blinded to group allocation recorded pain scores and opioid consumption every 6 hours. Pain burden, area under the numeric rating score for pain, was calculated for 36 hours. The primary outcome was postoperative IV/IM morphine (mg morEq) consumption at 36 hours after surgery., Results: Forty (28 women/12 men) subjects were studied. Postoperative opioid consumption was reduced in the bupivacaine 48 (39 to 61) mg morEq compared with saline 60 (49 to 85) mg morEq, difference -12 (-33 to -2) mg morEq (P = 0.03). Pain burden at rest was decreased in the bupivacaine 71 (37 to 120) score · hours compared with saline 131 (92 to 161) score · hours, difference -60 (-93 to -14) score · hours (P = 0.009)., Conclusions: Adductor canal blockade with bupivacaine 0.25% with epinephrine 1:300,000 effectively reduces pain and opioid requirement in the postoperative period after TKA. Adductor canal blockade is an effective pain management adjunct for patients undergoing TKA.

Study Objective: Diphenhydramine is an antihistamine with previously demonstrated analgesic and antiemetic properties. However, it is unknown if the beneficial perioperative properties of diphenhydramine can translate to a better quality of postsurgical recovery. The main objective of the current investigation was to investigate dose-ranging effects of diphenhydramine on quality of recovery after surgery., Setting: Tertiary hospital in the United States., Design: A prospective, randomized, double-blind trial., Intervention: Saline, diphenhydramine 25 >mg, or diphenhydramine 50 mg given intravenously before induction., Measurements: The primary outcome was global Quality of Recovery-40 at 24hours. Postoperative pain, nausea, opioid consumption, and discharge time were also evaluated., Main Results: Ninety subjects were randomized, and 75 completed the study. The median (interquartile range) Quality of Recovery-40 scores were not different among study groups: 164 (151-189), 169 (159-181), and 172 (157-185) for the saline, 25-mg diphenhydramine, and 50-mg diphenhydramine groups, respectively (P=.74). Postoperative nausea was decreased in the 50-mg group, 3 of 24 (12.5%), compared with the saline group, 12 of 27 (44%), P=.01. There was an inverse linear association between postoperative opioid consumption and quality of recovery (R(2)=0.37, P<.001)., Conclusions: Diphenhydramine does not provide dose-ranging improvements on postoperative quality of recovery after ambulatory laparoscopic gynecologic surgery. Our results support a recent concept that not all postoperative nausea and vomiting symptoms are clinically important. Future studies evaluating postoperative nausea and vomiting should include patient-centered outcomes to validate the clinical importance of the examined interventions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine the feasibility of providing streamlined same-day evaluation and surgical management of children with recurrent otitis media or chronic serous otitis media who meet criteria for tympanostomy tube (TT) placement., Study Design: Retrospective matched case series., Setting: Tertiary care children's hospital., Methods: A comparison group (age, sex, insurance product) was utilized to determine if the same-day process decreased facility time and surgical time for the care episode. A parent satisfaction survey was administered., Results: Thirty children, with a median age of 16 months (range, 12-22 months), participated in the same-day surgery process for TT. Twenty-one patients (70.0%) were male, and these patients were matched to a comparison group (similar age, sex, and insurance product) having non-same-day (routine) TT placement. The same-day patients spent significantly less time in clinic for the preoperative physician visit (average, 15 minutes) when compared with the non-same-day patients (average, 51.5 minutes; P < .001). The operative experience for the same-day patients was similar to the non-same-day patients (average, 145 vs 137 minutes, respectively; P = .35), but the overall experience was significantly shorter for the same-day patients (average, 151 vs 196 minutes for comparisons; P < .001). All parents surveyed in the same-day group were satisfied with the efficiency of the experience., Conclusion: The same-day surgery process for management of children who meet the criteria for TT placement is a model of improved efficiency of care for children who suffer from otitis media., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Prior studies have examined the static effect of intravenous ketamine on the BIS Index for sedation but it remains unknown if the BIS Index is a reliable method to track sedation levels in the presence of ketamine. The major objective of the current investigation was to compare the BIS Vista Index ability to track varying depths of sedation as determined by OASS scores in a standardized anesthetic regimen with and without ketamine. The study was a randomized, double blinded clinical trial. Patients undergoing breast surgery under sedation with propofol were randomized to receive ketamine (1.5 μg kg min(-1)) or saline. Infusion data was used to estimate propofol plasma concentrations (Cp). The main outcome of interest was the correlation between the BIS Vista Index with the OASS score. Twenty subjects were recruited and fifteen completed the study. Four hundred fifty-five paired data points were included in the analysis. Model performance (Nagelkerke R(2)) of the multinomial logistic regression model was 0.57 with the c-statistic of 0.87 (95 % CI 0.82-0.91). Compared to awake the odds ratio for BIS values predicting moderate sedation in the saline/propofol group 1.19 (95 % CI 1.12-1.25) but only 1.06 (95 % CI 1.02-1.1) in the ketamine/propofol group (P = 0.001). There was no difference in the odds for BIS values to predict deep sedation between groups (P = 0.14). The BIS monitor can be used to monitor sedation level even when ketamine is used with propofol as part of the sedation regimen. However, ketamine reduces the value of the BIS in predicting moderate sedation levels.

Background: Currently, there is limited evidence to support the safety of neuraxial catheters in neonates. Safety concerns have been cited as a major barrier to performing large randomized trials in this population. The main objective of this study is to examine the safety of neuraxial catheters in neonates across multiple institutions. Specifically, we sought to determine the incidence of overall and individual complications encountered when neuraxial catheters were used for postoperative analgesia in neonates., Methods: This was an observational study that used the Pediatric Regional Anesthesia Network database. Complications and adverse events were defined by the presence of at least 1 of the following intraoperative and/or postoperative factors: catheter malfunction (dislodgment/occlusion), infection, block abandoned (unable to place), block failure (no evidence of block), vascular (blood aspiration/hematoma), local anesthetic systemic toxicity, excessive motor block, paresthesia, persistent neurologic deficit, and other (e.g., intra-abdominal misplacement, tremors). Additional analyses were performed to identify the use of potentially toxic doses of local anesthetics., Results: The study cohort included 307 neonates with a neuraxial catheter. There were 41 adverse events and complications recorded, resulting in an overall incidence of complications of 13.3% (95% confidence interval, 9.8%-17.4%). Among the complications, catheter malfunction, catheter contamination, and vascular puncture were common. None of the complications resulted in long-term complications and/or sequelae, resulting in an estimated incidence of any serious complications of 0.3% (95% confidence interval, 0.08%-1.8%). There were 120 of 307 patients who received intraoperative and/or postoperative infusions consistent with a potentially toxic local anesthetic dose in neonates. The incidence of potentially toxic local anesthetic infusion rates increased over time (P = 0.008)., Conclusions: Neuraxial catheter techniques for intraoperative and postoperative analgesia appear to be safe in neonates. Further studies to confirm our results and to establish the efficacy of these techniques across different surgical procedures are required. We suggest that each center that uses neuraxial anesthesia techniques in neonates closely evaluate the dose limits for local anesthetic agents and develop rigorous quality assurance methods to ensure potentially toxic doses are not used.

Background: Transfer of patient care among clinicians (handovers) is a common source of medical errors. While the immediate efficacy of these initiatives is well documented, sustainability of practice changes that results in better processes of care is largely understudied., Aims: The objective of the current investigation was to evaluate the sustainability of a protocolized handover process in pediatric patients from the operating room after cardiac surgery to the intensive care unit., Methods: This was a prospective study with direct observation assessment of handover performance conducted in the cardiac ICU (CICU) of a free-standing, tertiary care children's hospital in the United States. Patient transitions from the operating room to the CICU, including the verbal handoff, were directly observed by a single independent observer in all phases of the study. A checklist of key elements identified errors classified as: (1) technical, (2) information omissions, and (3) realized errors. Total number of errors was compared across the different times of the study (preintervention, postintervention, and the current sustainability phase)., Results: A total of 119 handovers were studied: 41 preintervention, 38 postintervention, and 40 in the current sustainability phase. The median [Interquartile range (IQR)] number of technical errors was significantly reduced in the sustainability phase compared to the preintervention and postintervention phase, 2 (1-3), 6 (5-7), and 2.5 (2-4), respectively P = 0.0001. Similarly, the median (IQR) number of verbal information omissions was also significantly reduced in the sustainability phase compared to the preintervention and postintervention phases, 1 (1-1), 4 (3-5) and 2 (1-3), respectively., Conclusions: We demonstrate sustainability of an improved handover process using a checklist in children being transferred to the intensive care unit after cardiac surgery. Standardized handover processes can be a sustainable strategy to improve patient safety after pediatric cardiac surgery., (© 2016 John Wiley & Sons Ltd.)

Background: Untreated pain can have instant and prolonged consequences to behavioral and neurologic outcomes in neonates. Although the use of transversus abdominis plane (TAP) block to minimize postsurgical pain has been demonstrated in neonates, no data regarding the safety of this procedure are available for this patient population. For instance, it is unknown whether plasma levels of local anesthetics are safe in neonates after TAP blocks. The main objective of the current investigation was to evaluate plasma bupivacaine concentrations in neonates having an ultrasound-guided TAP block., Methods: The study was a prospective, observational study. After general anesthesia was induced, neonates received an ultrasound-guided TAP block with 0.125% bupivacaine and a total volume of 1 mL/kg. Dried blood spot samples were obtained and analyzed for bupivacaine levels at 0, 5, 15, 30, 60, 120 minutes, 4, and 24 hours after the TAP block., Results: Ten neonates were included in the study. The highest 99% upper prediction limit for blood concentration, 0.38 µg/mL, occurred at the 30-minute interval, but it was significantly lower than potentially toxic plasma levels (1.5-2.0 µg/mL). The highest individual concentration was 0.26 µg/mL and occurred at the 30-minute interval. None of the patients demonstrated any potential signs of local anesthetic toxicity., Conclusions: Our results suggest a low risk of local anesthetic toxicity in neonates after a TAP block. Future studies to determine the efficacy of the TAP block to minimize postsurgical pain in this patient population are warranted.

We surveyed anesthesiology residents to evaluate the predictive effect of prior residence on desired location for future practice opportunities. One thousand five hundred United States anesthesiology residents were invited to participate. One question asked whether they intend to enter academic practice when they graduate from their residency/fellowship training. The analysis categorized the responses into "surely yes" and "probably" versus "even," "probably not," and "surely no." "After finishing your residency/fellowship training, are you planning to look seriously (e.g., interview) at jobs located more than a 2-hour drive from a location where you or your family (e.g., spouse or partner/significant other) have lived previously?" Responses were categorized into "very probably" and "somewhat probably" versus "somewhat improbably" and "not probable." Other questions explored predictors of the relationships quantified using the area under the receiver operating characteristic curve (area under the curve) ± its standard error. Among the 696 respondents, 36.9% (N = 256) would "probably" consider an academic practice. Fewer than half of those (P < 0.0001) would "very probably" consider a distant location (31.6%, 99% CI 24.4%-39.6%). Respondents with prior formal research training (e.g., PhD or Master's) had greater interest in academic practice at a distant location (AUC 0.63 ± 0.03, P = 0.0002). Except among respondents with formal research training, a good question to ask a job applicant is whether the applicant or the applicant's family has previously lived in the area.

Unlabelled: The value proposition of an acellular dermal matrix (ADM) taken from the deep dermis is that the allograft may be more porous, allowing for enhanced integration and revascularization. In turn, this characteristic may attenuate complications related to foreign body reactions, seromas, and infection. However, this is juxtaposed against the potential loss of allograft structural integrity, with subsequent risk of malposition and extrusion. Despite the active use of novel, deep dermal ADMs, the clinical outcomes of this new technology has not been well studied., Methods: This is a prospective study to evaluate surgical and patient-reported outcomes using a deep dermal ADM, FlexHD Pliable. Surgical outcomes and BREAST-Q patient-reported outcomes were evaluated postoperatively at 2- and 6-month time points., Results: Seventy-two breasts (41 patients) underwent reconstruction. Complication rate was 12.5%, including 2 hematomas and 7 flap necroses. One case of flap necrosis led to reconstructive failure. Notably, there were no cases of infection, seroma, or implant extrusion or malposition. Average BREAST-Q scores were satisfaction with outcome (70.13 ± 23.87), satisfaction with breasts (58.53 ± 20.00), psychosocial well being (67.97 ± 20.93), sexual well being (54.11 ± 27.72), and physical well being (70.45 ± 15.44). Two-month postoperative BREAST-Q scores decreased compared with baseline and returned to baseline by 6 months. Postoperative radiation therapy had a negative effect on satisfaction with breasts (P = 0.004) and sexual well being (P = 0.006)., Conclusions: Deep dermal ADM is a novel modification of traditional allograft technology. Use of the deep dermal ADM yielded acceptably low complication rates and satisfactory patient-reported outcomes.

Background: Postsurgical quality of recovery is worse in female than that in male patients. Duloxetine has been used successfully for the treatment of chronic pain conditions, but its use for preventing acute postoperative pain has been limited to a single previous study. More importantly, the effect of preoperative duloxetine on global postoperative quality of recovery has yet to be evaluated. The main objective of the current investigation was to evaluate the effect of perioperative duloxetine on postoperative quality of recovery in women undergoing abdominal hysterectomy., Methods: The study was a prospective, randomized, placebo-controlled, double-blinded trial. Female patients undergoing abdominal hysterectomy were randomized to receive duloxetine (60 mg orally 2 hours before surgery and 24 hours after surgery) or an identical placebo pill. The primary outcome was the quality of recovery-40 score at 24 hours. Secondary outcomes included opioid consumption and postoperative pain scores. A P value <0.05 was used to reject type I error., Results: Seventy patients were recruited, and 63 completed the study. The median difference (95% confidence interval) in global recovery scores (quality of recovery-40) at 24 hours after surgery between the duloxetine and the placebo group was 9 (4-20) (P < 0.001). Total opioid consumption was reduced at 24 hours in the duloxetine group compared with the placebo group, median (interquartile range) of 1 (0-5) mg IV morphine compared with 5.5 (0.5-9) mg IV morphine (P = 0.004). Nausea, vomiting, and time to postanesthesia care unit discharge were not significantly reduced in the duloxetine group compared with placebo., Conclusions: Duloxetine improves postoperative quality of recovery after abdominal hysterectomy. In addition, duloxetine reduces postoperative opioid consumption, even in the presence of a robust multimodal analgesic strategy. Duloxetine seems to be a viable pharmacologic strategy to improve postoperative quality of recovery in female patients undergoing abdominal hysterectomy.

Background and Objectives: Ischemic pain after uterine fibroid artery embolization (UFAE) is often severe. We evaluated the sensory anesthesia extent from thoracic epidural catheter test injection of lidocaine 75 mg with epinephrine 25 μg as a predictor of analgesia effectiveness after UFAE., Methods: One hundred patients were studied. Pinprick and cold insensitivity were assessed from L3 to T4 at 5-minute intervals for 30 minutes after the test dose. Thoracic epidural management was standardized. Total epidural infusate and numeric rating of pain (0-10) scores were recorded., Results: Pinprick or cold insensitivity at T9 to T10 dermatome was present in 94% of patients. Forty-six subjects (45%) achieved a sensory level at or above the T6 dermatome at 30 minutes. Median analgesic consumption in the first hour and at catheter discontinuation was greater in subjects with a sensory level above T6 compared with those below T6: first hour difference, 7 mL (95% confidence interval [95% CI], 0-12 mL; P = 0.02); difference at discontinuation, 21 mL (95% CI, 4-35 mL; P = 0.02). The area under the pain score by time curve for the first 24 hours was greater in patients with sensory levels above T6: difference 32 score · hour (95% CI, 12 score · h - 60 score · h; P = 0.001)., Conclusions: Sensory anesthesia spread above the T6 dermatome 30 minutes after a test dose of 1.5% lidocaine was an independent predictor of the analgesic consumption after UFAE. Pain burden and oral opioid consumption were also increased in subjects who demonstrated a high sensory spread after the test dose.

Background: Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy. We hypothesized that children who received systemic magnesium infusions would have less post-tonsillectomy pain than the children who received saline infusions., Methods: The study was a prospective, randomized, double-blinded, clinical trial. Subjects were randomly assigned using a computer-generated table of random numbers to 1 of the 2 intervention groups: systemic magnesium infusion (initial loading dose 30 mg/kg given over 15 minutes followed by a continuous magnesium infusion 10 mg/kg/h) and the same volume of saline. The primary outcome was pain scores in the postanesthesia care unit (PACU) measured by FLACC (Face, Legs, Activity, Cry, Consolability) pain scores. Pain reduction was measured by the decrement in the area under the pain scale versus 90-minute postoperative time curve using the trapezoidal method. Secondary outcomes included opioid consumption in the PACU, emergence delirium scores (measured by the pediatric anesthesia emergence delirium scale), and parent satisfaction., Results: Sixty subjects were randomly assigned and 60 completed the study. The area under pain scores (up to 90 minutes) was not different between the study groups, median (interquartile range [IQR]) of 30 (0-120) score × min and 45 (0-135) score × min for the magnesium and control groups, respectively (P = 0.74). Similarly, there was no clinically significant difference in the morphine consumption in the PACU between the magnesium group, median (IQR) of 2.0 (0-4.44) mg IV morphine, compared with the control, median (IQR) of 2.5 (0-4.99) mg IV morphine (P = 0.25). The serum level of magnesium was significantly lower in the control group than in the treatment group at the end of the surgery (P < 0.001)., Conclusions: Despite a large number of studies demonstrating the efficacy of systemic magnesium for preventing postsurgical pain in adults, we could not find evidence for a significant clinical benefit of systemic magnesium infusion in children undergoing tonsillectomies. Our findings reiterate the importance of validating multimodal analgesic strategies in children that have been demonstrated to be effective in the adult population.

Age has been shown to be an independent predictor of complications in general surgery patients. In contrast, the effect of age on outcomes after plastic surgery has yet to be confirmed or refuted. The objective of the current investigation was to evaluate a possible association between age and postoperative outcomes after plastic surgery. The 2005-2012 NSQIP database was retrospectively reviewed for all patients undergoing plastic surgery. Patients ≥60 years with procedures under the category of plastic surgery in NSQIP were selected for analysis. The primary outcome of interest was 30-day overall complication rates. Multivariate regression models were constructed to control for potential perioperative confounders. Of the 2,320,920 patients captured in the NSQIP database, 36,819 patients underwent plastic surgery and met inclusion criteria. The incidence of unadjusted overall complications increased with age with an overall complication rate of 9.0% in patients <60 years, 11.6% in patients 60-69 years, 13.2% in patients 70-79 years, and 15.9% in patients 80 or more years (p < 0.001). After adjusting for potential confounders, age was not independently associated with increased overall complications rates in patients 60-69 years (OR = 1.026; 95% CI = 0.927-1.135; p = 0.619) and 70-79 years (OR = 0.933; 95% CI = 0.797-0.919; p = 0.393), although patients 80 years and older experienced more medical complications (OR = 1.626; 95% CI = 1.218-2.172; p = 0.001). Age is not independently associated with overall worse outcomes in patients undergoing plastic surgery. Medical complications and mortality were more likely in extremes of age (>80 years). Age alone should not be included as a decisional factor in patients <80 years old considering plastic surgery., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Clinical trial registries have been created to reduce reporting bias. Study registration enables the examination of discrepancies between the original study design and the final results reported in the literature. The main objective of the current investigation is to compare the original clinical trial registrations and the corresponding published results in high-impact anesthesiology journals. Specifically, we examined the rates of major discrepancies (i.e., involving primary outcome, sample size calculation, or study intervention)., Methods: The 5 highest-impact factor anesthesiology journals (Anaesthesia, Anesthesia & Analgesia, Anesthesiology, British Journal of Anaesthesia, and Regional Anesthesia and Pain Medicine) were screened for randomized controlled trials published in 2013. A major discrepancy was defined as a difference in the content of the manuscript compared with the original entry in a clinical trial registry for at least one of the 3 areas: primary outcome, target sample size, and study intervention. The type of primary outcome discrepancy was further classified as adding/omitting measures or outcomes, downgrading/upgrading from primary to secondary outcomes, or changing the definition of the outcomes measured., Results: Two hundred one articles were included in the final analysis. One hundred thirty of 201 (64%; 95% confidence interval [CI], 57%-71%) published clinical trials were not prospectively registered as recommended by the International Committee of Medical Journal Editors. Registration rates were significantly lower between studies performed in the United States, 15 of 40 (37%), compared with studies not performed in the United States, 92 of 161 (57%), P = 0.03. Fifty-two of 107 (48%; 95% CI, 39%-58%) registered trials had a major discrepancy when the published manuscript was compared with the clinical trial registration. Thirty-one of the 46 (67%; 95% CI, 51%-80%) primary outcome discrepancies had changes in the outcome with characteristics of reporting bias., Conclusions: We detected a high rate of major discrepancies between the published results and the original registered protocols for clinical trial manuscripts in high-impact anesthesiology journals. Future action to reduce the negative impact of reporting bias in the anesthesiology field is warranted.

Background and Objectives: Perioperative modulation of the surgical inflammatory response has been hypothesized as a viable pharmacological preventive target for the development of chronic pain after surgery. The objective of the current investigation was to evaluate an association between intravenous dexamethasone 4 to 20 mg on the day of surgery with self-reported pain in the breast or axilla 3 months or more after mastectomy., Methods: The study was a secondary data analysis of a prospective cohort investigation. Subjects who have undergone mastectomy surgery were evaluated at least 3 months after the surgical procedure for the presence of chronic postsurgical pain using validated pain questionnaires. Binary logistic regression analysis was used to determine the odds of development of chronic postsurgical pain in subjects who did and did not receive perioperative dexamethasone., Results: Three hundred ten patients were included in the study. Fifty-two patients (17%) met the IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) criteria for chronic pain in the breast and/or axillary region. Two hundred eleven (68%) of 310 subjects received perioperative dexamethasone on doses varying from 4 to 20 mg. The incidence of chronic pain in the mastectomy group who received perioperative dexamethasone was not different, 15 (15.2%) of 84 compared with 37 (17.5%) of 211 in the group who did not receive perioperative dexamethasone, difference -2% (95% confidence interval, -10 to 7; P = 0.75)., Conclusions: Perioperative dexamethasone is not associated with a reduction in the incidence and/or severity of chronic postmastectomy pain. In addition, we did not detect a dose-response effect of dexamethasone on the incidence of chronic postsurgical pain.

Objectives: To evaluate whether age is independently associated with greater rate of unanticipated hospital admission within 30 days of ambulatory surgery., Design: Retrospective database study., Setting: The 2012 National Surgical Quality Improvement Project data set., Participants: All individuals with "outpatient" recorded as their status in the data set., Measurements: The primary outcome of interest was all-cause hospital admission in the 30-day period after surgery. Multivariate models were constructed to control for covariate bias. Assessment of interactions of terms in the final model was performed using a conditional tree analysis., Results: The final analysis included 53,667 ambulatory surgical cases. There were 1,370 (2.5%, 99% confidence interval (CI) = 2.4-2.7%) hospital admissions among the cases evaluated. After adjusting for potential confounders, age (<70 vs ≥70) was independently associated with hospital admission (odds ratio = 1.54, 99% CI = 1.29-1.84). A classification tree analysis of the cases without postoperative morbidity identified age (<60 vs ≥60) as an important decision point leading to greater likelihood of admission (P < .001) within 30 days after ambulatory surgery., Conclusion: Even after adjusting for comorbidities, older adults are at greater risk of unanticipated hospital admission within 30 days of ambulatory surgery. Renal failure, chronic obstructive pulmonary disease, current cancer treatment, diabetes mellitus, and history of amputation or revascularization were also associated with greater likelihood of hospital admission. Interventions to improve transitions of care for older adults after ambulatory surgery are needed., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Study Objective: The main objective of the current investigation was to assess the readability of Internet-based patient education materials related to the field of anesthesiology. We hypothesized that the majority of patient education materials would not be written according to current recommended readability grade level., Setting: Online patient education materials describing procedures, risks, and management of anesthesia-related topics were identified using the search engine Google (available at www.google.com) using the terms anesthesia, anesthesiology, anesthesia risks, and anesthesia care., Design: Cross-sectional evaluation., Interventions: None., Measurements: Assessments of content readability were performed using validated instruments (Flesch-Kincaid Grade Formulae, the Gunning Frequency of Gobbledygook, the New Dale-Chall Test, the Fry graph, and the Flesch Reading Ease score)., Main Results: Ninety-six Web sites containing Internet patient education materials (IPEMs) were evaluated. The median (interquartile range) readability grade level for all evaluated IPEMs was 13.5 (12.0-14.6). All the evaluated documents were classified at a greater readability level than the current recommended readability grade, P < .001. Readability grades were not significantly different among different IPEM sources. Assessment by the Flesch Reading Ease test classified all but 4 IPEMs as at least fairly difficult to read., Conclusions: Internet-based patient education materials related to the field of anesthesiology are currently written far above the recommended readability grade level. High complexity of written education materials likely limits access of information to millions of American patients. Redesign of online content of Web sites that provide patient education material regarding anesthesia could be an important step in improving access to information for patients with poor health literacy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Inadequate health literacy affects more than 90 million Americans and it has been associated with adverse outcomes in the medicine field including increased hospitalization rates and greater mortality. Since surgical patients are often required to make complex decisions and adhere to complex instructions, health literacy may have a profound impact in the surgical practice. The main objective of the current study was to systematically evaluate the role of health literacy in surgical patients., Methods: A systematic search was performed to identify studies that evaluated the role of health literacy in the perioperative setting following the PRISMA guidelines. Only studies that examined health literacy using a validated instrument in the perioperative setting were included., Results: Ten studies including data on 1147 patients were included. The median (IQR) number of patients in the included studies was 101 (30 to 152). The majority of studies used the Short Test of Functional Literacy in adults (STOFHLA) to evaluate patients' health literacy. Five studies evaluated the patients preoperatively, four studies evaluated patients in the postoperative period and in one study the time of evaluation in relation to the surgical procedure was not defined. The lowest prevalence of inadequate health literacy was detected in kidney transplant patients, 6 out of 124 (5 %), while the highest prevalence of inadequate health literacy was detected in orthopedic patients having total joint replacement, 86 out of 126 (60 %). Inadequate health literacy in the preoperative period was associated with poor medical information comprehension and it may adversely affect adherence to preoperative medications and even modulate surgical disparities. Inadequate health literacy in the postoperative period was associated with poor comprehension of discharge instructions and worse kidney function in transplant recipients., Conclusions: Health literacy seems to have a very significant impact in the care of surgical patients. More studies to establish the impact of poor health literacy on perioperative outcomes are needed.

Background: Several studies have investigated the selection process for medical students, residents, and fellows across different specialties. Currently, the selection criteria used by pediatric anesthesia program directors to select prospective pediatric anesthesia fellows are unknown., Objective: To evaluate the criteria used by program directors in the selection of prospective pediatric anesthesia fellows in the United States., Methods: Survey responses were solicited from 51 pediatric anesthesia fellowship directors in the United States. Questions evaluated department demographic information, the importance of fellowship selection criteria, and program satisfaction with the Match process., Results: Forty-two of 51 fellowship directors responded to the survey (a response rate of 82%). The personal statement was reported as extremely/very important for 30 of 42 (71%) program directors, while research experience and prior publications were reported as extremely/very important for 16 of 41 (39%) and 16 of 41 (39%) program directors, respectively. Programs that offered all the spots through the Match were smaller, median (IQR) number of fellows of 3 (2-6) compared to the ones that did not offer all the spots through the Match, 8 (2-12), P = 0.03. In contrast, no difference in program directors' satisfaction with the Match was detected between smaller (≤ 3 fellows) and larger programs (>3 fellows), P = 0.25., Conclusion: A minority of pediatric fellowship program directors rated prior research experience as an important factor in the selection of prospective fellows. The lack of emphasis on research qualities for fellows is potentially concerning for the future of our specialty., (© 2015 John Wiley & Sons Ltd.)