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A huge variety of fields and industries depend upon cloud computing based microservice due to its high-performance capability. Also, the merit of container usage is enormous; it enable larger portability, easier and faster deployment and restricted overheads. However, the rapid evolution causes issues in terms of container automation and management, Till now, a number of research works has concentrated on solving the open issues in container automation and management. In fact, container resource allocation is the major key hole for cloud providers since it directly influences the resource consumption and system performance. In this manner, this paper introduces a new optimized container resource allocation model by proposing a new optimization concept. To make the possibility of optimal container resource allocation, a new hybridized algorithm is implanted; namely, Whale Random update assisted Lion Algorithm (WR-LA), which is the hybrid form of Lion Algorithm (LA) and Whale Optimization Algorithm (WOA) is introduced. Moreover, the solution of optimized resource allocation is made by considering objectives like Threshold Distance, Balanced Cluster Use, System Failure, and Total Network Distance, respectively. Finally, the performance of the proposed model is compared over other conventional models and proves its superiority.

OBJECTIVES To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. DESIGN Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. PARTICIPANTS Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. INTERVENTIONS Continuous infusion of dexmedetomidine and ketamine. MEASUREMENTS & MAIN RESULTS The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P

General anesthesia technique can influence not only immediate postoperative outcomes, but also long-term outcomes beyond hospital stay (e.g., readmission after discharge from hospital). There is lack of evidence regarding superiority of total intravenous anesthesia over inhalation anesthesia with regards to postoperative outcomes even in high-risk population including cancer patients. Optimal balanced general anesthetic technique for enhance recovery after elective surgery in adults includes avoidance of routine use preoperative midazolam, avoidance of deep anesthesia, use of opioid-sparing approach, and minimization of neuromuscular blocking agents and appropriate reversal of residual paralysis. Given that the residual effects of drugs used during anesthesia can increase postoperative morbidity and delay recovery, it is prudent to use a minimal number of drug combinations, and the drugs used are shorter-acting and administered at the lowest possible dose. It is imperative that the discerning anesthesiologist consider whether each drug used is really necessary for accomplishing perioperative goals.

Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life, and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to become standard of care for several surgical procedures. In this article, we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress.

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.

Video-assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video-assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video-assisted thoracoscopic surgery. A systematic review was undertaken using procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2-specific inhibitors pre-operatively or intra-operatively and continued postoperatively. Intra-operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first-choice option. A serratus anterior plane block could also be administered as a second-choice option. Opioids should be reserved as rescue analgesics in the postoperative period. ispartof: ANAESTHESIA vol:77 issue:3 pages:311-325 ispartof: location:England status: published

PURPOSE OF REVIEW Ambulatory surgery is associated with improved patient experience while reducing overall costs without compromising patient safety. Patient-centered care is crucial for further expansion and success of ambulatory surgery because it is associated with superior patient experience and improved patient satisfaction. This article discusses the approach to improving patient-centered care and patient-reported outcomes (PROs). RECENT FINDINGS It is necessary to recognize that each patient is different and may have different needs and preferences. Patient education and shared decision-making are critical components of patient-centered care. Shared decision-making emphasizes patient engagement in an effort to improve PROs. Implementation of enhanced recovery after surgery principles in ambulatory surgery is necessary to improve PROs. SUMMARY Delivery of patient-centered care will require modification of the current approach to perioperative care. It is imperative to measure PROs by implementing a comprehensive continuous quality improvement program.

Nociception refers to the process of encoding and processing noxious stimuli. Its monitoring can have potential benefits. Under anesthesia, nociceptive signals are continuously generated to cause involuntary effects on the autonomic nervous system, reflex movement, and stress response. Most available systems depend on the identification and measurement of these indirect effects to indicate nociception-antinociception balance. Despite advances in monitoring technology and availability, their limitations presently override their benefits. Hence, their utility and applicability in present-day anesthesia care is uncertain. Future technologies might allow automated closed-loop multimodal anesthesia systems, which includes the components of hypnosis and analgesic balance for a patient.

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine. ispartof: ANAESTHESIA vol:76 issue:8 pages:1082-1097 ispartof: location:England status: published

This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.

Background Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility. Methods The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses. Results A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77). Conclusions This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study.

The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta-analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta-analyses should critically assess the clinical aspects of the included studies.

Context-awareness develops smart, intelligent IoT devices that can adapt to changing needs and act autonomously on behalf of the user. The main challenge of context-aware internet of things is to interpret the context effectively. There is an abundance of CAIOT in literature. Understanding of the meaning of the context is, however, almost ignored. Misinterpretation of context can lead to an incorrect decision that motivates to develop a system that emphasis context reasoning and decision making using the fuzzy Bayesian approach. The current investigation aims to build a context-aware IoT system using occupancy detection for energy management. The performance evaluation for the proposed system uses data collected in the tutorial room to detect occupancy. Extensive experiments highlight the utility of the proposed approach, which significantly reduces energy than the traditional ON/OFF usage pattern through customer access via mobile phone or personal computer.

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

Background We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume. Methods Data were extracted from the 2007–2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden. Results Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume. Conclusion Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.

Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.

ObjectiveThe aim of this study was to provide an interim safety analysis of the first 30 surgical procedures performed using the Versius Surgical System.BackgroundRobot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is currently undergoing a first-in-human prospective clinical trial to confirm the safety and effectiveness of the device when performing minimal access surgery (MAS).MethodsProcedures were performed using Versius by a lead surgeon supported by an operating room (OR) team. Male or female patients aged between 18 and 65 years old and requiring elective minor or intermediate gynaecological or general surgical procedures were enrolled. The primary endpoint was the rate of unplanned conversion of procedures to other MAS or open surgery.ResultsThe procedures included nine cholecystectomies, six robot-assisted total laparoscopic hysterectomies, four appendectomies, five diagnostic laparoscopy cases, two oophorectomies, two fallopian tube recanalisation procedures, an ovarian cystectomy and a salpingo-oophorectomy procedure. All procedures were completed successfully without the need for conversion to MAS or open surgery. No patient returned to the OR within 24 h of surgery and readmittance rate at 30 and 90 days post-surgery was 1/30 (3.3%) and 2/30 (6.7%), respectively.ConclusionsThis first-in-human interim safety analysis demonstrates that the Versius Surgical System is safe and can be used to successfully perform minor or intermediate gynaecological and general surgery procedures. The cases presented here provide evidence that the Versius clinical trial can continue to extend recruitment and begin to include major procedures, in alignment with the IDEAL-D Framework Stage 2b: Exploration.

Background. The COVID-19 epidemic has resulted in a massive surge in the need for intensive care unit (ICU) care. To avoid being overwhelmed, hospitals had to adapt and support the ICU teams in structured ICU care including involving surgical teams. This work aims at describing the collaborative efforts between the ICU care team and the Surgical Task Force (STF) during a surge of ICU activity in a University Hospital in a French high-density COVID-19 cluster. Study Design. This retrospective single center study analyzed the STF workflow and the ICU population. The study included 55 patients hospitalized in our ICU, ICU-converted step-down units, and post-anesthesia care units. The primary measure was the global daily STF activity. The secondary measure was the daily activity for each of the 5 tasks accomplished by the STF. Results. The STF attempted 415 phone calls for 55 patients’ families, 237 mobilizations of patients requiring prone positions, follow-up of 20 patients requiring medevac, and contribution to ethical discussion for 2 patients. The mean (SD) daily number of successful phones calls, ethical discussions, mobilizations of patients requiring prone positions and medevac follow-up were 18 (7), .1 (.4), 10 (7), and 2 (3), respectively. No actions for discharge summaries writing were required. The maximum number of daily mobilizations for patients requiring prone positions was 25. The maximum number of daily attempted phone calls and successful phone calls were 37 and 26, respectively. Conclusion. Surgeons’ technical and nontechnical skills represented an effective support for ICU teams during the COVID-19 pandemic.

Background The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair. Materials and methods The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions. Results A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used. Conclusions Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.

Regional nerve blocks are an effective method of managing acute pain associated with surgery. The relative benefit of preoperative versus postoperative peripheral nerve blocks is not entirely clear. The primary aim of this study was to determine differences in pain scores in patients undergoing preoperative block versus postoperative block versus no block. We hypothesized that patients receiving preoperative blocks would have reduced pain scores and decreased opioid use in the immediate postoperative period. We conducted a retrospective cohort analysis of 302 consecutive patients undergoing unilateral open reduction and internal fixation of ankle fracture under general anesthesia. We identified 3 groups: preoperative block, postoperative block, or no block. Data obtained from our electronic medical records included demographic information, postanesthesia care unit length of stay, pain scores obtained preoperatively, upon arrival to the postanesthesia care unit, and upon discharge from the postanesthesia care unit as well as intraoperative and postanesthesia care unit opioid utilization. Patients receiving preoperative block had significantly lower pain scores, less intraoperative or postanesthesia care unit opioid use, and shorter postanesthesia care unit dwell time compared with patients receiving postoperative block or no block. Preoperative popliteal sciatic and adductor canal blocks in patients undergoing ankle fracture surgery appears to be more effective than either postoperative block or no block.

In the cloud sector, as the applications used by users are exploited via micro-service pattern, the container allocation seems to be the most vital process. This has further been concentrated with more care for its beneficiary acts like easier employment, limited overheads and higher portability. For the past few decades, various contributions have been made under the container management and allocation as well. Under these circumstances, this study intends to design an optimal resource allocation and management model by incorporating the concept of optimisation, which guarantees optimal container allocation. To make this possible, this study establishes a novel hybrid algorithm, namely velocity-updated grey wolf optimisation (VU-GWO), which is the hybridisation of two renowned algorithms particle swarm optimisation and grey wolf optimization, respectively. More importantly, the solution of optimised resource allocation is influenced by the designing of a novel objective function, which concerns the constraints like balanced cluster use, threshold distance, system failure, and total network distance as well. At last, the performance of the presented scheme is evaluated over other traditional schemes, and the betterment of the proposed model is validated.

Purpose The containerization application is one among the technologies that enable microservices architectures, which is observed to be the model for operating system (OS) virtualization. Containers are the virtual instances of the OS that are structured as the isolation for the OS atmosphere and its file system, which are executed on the single kernel and a single host. Hence, every microservice application is evolved in a container without launching the total virtual machine. The system overhead is minimized in this way as the environment is maintained in a secured manner. The exploitation of a microservice is as easy to start the execution of a new container. As a result, microservices could scale up by simply generating new containers until the required scalability level is attained. This paper aims to optimize the container allocation. Design/methodology/approach This paper introduces a new customized rider optimization algorithm (C-ROA) for optimizing the container allocation. The proposed model also considers the impact of system performance along with its security. Moreover, a new rescaled objective function is defined in this work that considers threshold distance, balanced cluster use, system failure, total network distance and security as well. At last, the performance of proposed work is compared over other state-of-the-art models with respect to convergence and cost analysis. Findings For experiment 1, the implemented model at 50th iteration has achieved minimal value, which is 29.24%, 24.48% and 21.11% better from velocity updated grey wolf optimisation (VU-GWO), whale random update assisted LA (WR-LA) and rider optimization algorithm (ROA), respectively. Similarly, on considering Experiment 2, the proposed model at 100th iteration attained superior performance than conventional models such as VU-GWO, WR-LA and ROA by 3.21%, 7.18% and 10.19%, respectively. The developed model for Experiment 3 at 100th iteration is 2.23%, 5.76% and 6.56% superior to VU-GWO, WR-LA and ROA. Originality/value This paper presents the latest fictional optimization algorithm named ROA for optimizing the container allocation. To the best of the authors’ knowledge, this is the first study that uses the C-ROA for optimization.

STUDY DESIGN Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015. OBJECTIVE Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings. SUMMARY OF BACKGROUND DATA In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge. METHODS The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients. RESULTS A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P

Study objective We examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy. Design Retrospective cohort study. Setting Multi-institutional. Patients Adult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting. Intervention None. Measurements Using the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m2 and Main results There were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m2 ( OR 1.55, 95% CI 1.18–2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications. Conclusion We found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI

Clinical practice parameters have been published with greater frequency by professional societies and groups of experts. These publications run the gamut of practice standards, practice guidelines, consensus statements or practice advisories, position statements, and practice alerts. The definitions of these terms have been clarified in an accompanying article. In this article, we present the criteria for high-quality clinical practice parameters and outline a process for developing them, specifically the Delphi method, which is increasingly being used to build consensus among content experts and stakeholders. Several tools for grading the level of evidence and strength of recommendation are offered and compared. The speciousness of categorizing guidelines as evidence-based or consensus-based will be explained. We examine the recommended checklist for reporting and appraise the tools for evaluating a practice guideline. This article is geared toward developers and reviewers of clinical practice guidelines and consensus statements.

An evidence-based approach to clinical decision-making for optimizing patient care is desirable because it promotes quality of care, improves patient safety, decreases medical errors, and reduces health care costs. Clinical practice recommendations are systematically developed documents regarding best practice for specific clinical management issues, which can assist care providers in their clinical decision-making. However, there is currently wide variation in the terminology used for such clinical practice recommendations. The aim of this article is to provide guidance to authors, reviewers, and editors on the definitions of terms commonly used for clinical practice recommendations. This is intended to improve transparency and clarity regarding the definitions of these terminologies.

Purpose of review The in-person preanesthesia visit serves multiple purposes including identification and optimization of comorbid conditions as well as patient education. However, it imposes a significant burden on patients and healthcare providers. In this review, we define the scope of telemedicine and present the most up-to-date literature supporting its role for the preanesthesia evaluation. The opportunities and challenges are discussed and approaches to implementation of telemedicine in preanesthesia care are offered. Finally, the future of telemedicine as it pertains to preanesthesia care is examined. Recent findings Although telemedicine for preanesthesia practice was proposed almost two decades ago, the COVID-19 pandemic has accelerated its implementation. The potential benefits of telemedicine include improved patient satisfaction as well as the ability to provide cost-effective specialty services while reducing the burden on healthcare providers. Limitations to telemedicine include lack of technology, training, regulatory barriers, and an inability to perform a physical exam. Summary Telemedicine will continue to expand and its application to the preanesthesia evaluation is a clear example of how technology will revolutionize anesthesia practice. In order for telemedicine to continue to expand in the postpandemic period, steps must be taken to ensure that healthcare facilities and providers keep up with the times.

Double walled TiO2 nanotubes have been synthesized by two probe anodization method on highly pure Titanium (Ti) substrate. FESEM and XRD analyses revealed the morphological and structural properties of the as-synthesized double walled TiO2 nanotubes. Investigation of their field emission characteristics in a planar diode configuration at a base pressure of 1 x 10-8 mbar has been done. The turn-on field defined for the emission current density of 10 µA/cm2 is found to be 2.1 V/µm. As the field is increased further to 2.95 V/µm maximum, a current density of 890 µA/cm2 is achieved. Current-time (I-t) measurement at a preset value of 1 µA emission current for the duration of 3 h demonstrates a robust emission current stability. The observed low turn-on field and stable electron emission makes the double walled TiO2 nanotubes a suitable emitter for various electronics devices applications.

Background and Aims With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. [1, 4] The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy. Methods A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken [5]. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020 – assessing post-operative pain using analgesic, anaesthetic and surgical interventions – were identified from MEDLINE, EMBASE and Cochrane Databases. Results Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended (table 1). Some interventions – gabapentinoids and intrathecal opioid administration – although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence (table 2). Conclusions Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations.

Background and Aims Complex spinal procedures are associated with intense pain in the postoperative period. Adequate perioperative pain management has been shown to correlate with improved outcomes including early ambulation and discharge. We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. Methods A systematic review using the PROSPECT methodology was undertaken. RCTs and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. Results Out of 111 eligible studies identified, 31 RCTs and 4 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain were paracetamol, COX-2 specific-inhibitors or NSAIDs, intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfacial plane block, intravenous lidocaine, dexmedetomidine and gabapentin. Conclusions The analgesic regimen should include preoperative or intraoperative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intraoperative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intraoperative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Further qualitative RCTs are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.

ispartof: ANAESTHESIA vol:76 issue:9 pages:1280-1281 ispartof: location:England status: published