Search

Objective To compare pain outcome reports of patients undergoing hip or knee replacement who received single-injection nerve/plexus blocks with plain bupivacaine (BPV) with those of patients who received injections of buprenorphine-clonidine-dexamethasone (BCD) admixed with BPV. Design Prospective, parallel-arm, randomized, double-blind trial. Setting A single veterans’ hospital. Subjects Ninety-eight veterans scheduled for total hip or knee replacement surgery with spinal as the primary anesthetic. Methods Participants were randomized to BPV-BCD or plain BPV groups. They underwent nerve/plexus blocks in the L2–L4 and L4–S3 distributions in advance of joint replacement surgery. The primary outcome was change in pain from baseline during the postoperative day, as assessed by the total pain score on the short-form McGill Pain Questionnaire-v2 (SF-MPQ-2). Secondary outcomes were pain during movement, pain interference, range of motion, mobility, and quality of recovery. Results On postoperative day one, the SF-MPQ-2 total score for the BPV-BCD group demonstrated greater pain reduction than that of the plain BPV group (mean difference 1.8 points, 95% confidence interval 0.6 to 3.0, P = 0.003). The BPV-BCD group also had larger reductions in pain during movement in the surgical joint and less pain interference, along with increased range of hip and knee flexion, compared with the plain BPV group. Outcomes of mobility and quality of recovery were not different between groups. Conclusions Preoperative BPV-BCD blocks in the L2–L4 and L4–S3 nerve distributions for hip and knee replacements led to less pain on postoperative day one and increased knee and hip range of motion, compared with plain BPV blocks. Trial registration ClinicalTrials.gov ID NCT02891798.

One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. The Brigham Spinal Stenosis (BSS) questionnaire was the main outcome. Brigham Spinal Stenosis scales (symptom severity, physical function [PF], and satisfaction [SAT]) were dichotomized as SAT < 2.42, symptom severity improvement ≥ 0.46, and PF improvement ≥ 0.42, and analyzed using logistic regression. Sixty-two percent improved in 2 of 3 BSS scales (ie, success). Baseline characteristics associated with an increased odds of success were-worse BSS PF (odds ratio [OR] 1.24 [1.08-1.42]), greater self-efficacy for PF (OR 1.30 [1.08-1.58]), lower self-efficacy for pain management (OR 0.80 [0.68-0.94]), less apparent leg length discrepancy (OR 0.71 [0.56-0.91]), greater self-reported alcohol problems (OR 1.53 [1.07-2.18]), greater treatment credibility (OR 1.31 [1.07-1.59]), and moderate or severe magnetic resonance imaging-identified central canal stenosis (OR 3.52 [1.06-11.6]) moderate, OR 5.76 [1.83-18.1] severe). Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.

Objective We tested the hypothesis that buprenorphine-clonidine-dexamethasone (BCD) extends perineural analgesia compared with plain bupivacaine (BPV) nerve blocks used for hip and knee replacement surgery. Design Prospective, parallel-arms, randomized, double-blind trial. Setting A single veterans’ hospital. Subjects Seventy-eight veterans scheduled for total hip or knee replacement with plans for spinal as the primary anesthetic. Methods Participants underwent nerve/plexus blocks at L2–L4 and L4–S3 in advance of hip or knee joint replacement surgery. Patients were randomized to receive BPV-BCD or plain BPV in a 4:1 allocation ratio. Patients answered four block duration questions (listed below). Time differences between treatments were analyzed using the t test. Results Significant (P Conclusions BPV-BCD provided 26–39 hours of perineural analgesia in the L2–L4 and L4–S3 nerve distributions after hip/knee replacement surgery, compared with 11–21 hours for plain BPV.

Background Perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population is an uncommon, yet devastating outcome. A combination of emboli and hypoperfusion may cause large vessel occlusions leading to perioperative strokes and mortality. Identifying independent risk factors for perioperative stroke-related mortality may enhance risk-stratification algorithms and preventative therapies. Objectives This study utilised cause-of-death data to determine independent risk scores for common surgical comorbidities that may lead to perioperative stroke-related mortality, including atrial fibrillation and asymptomatic carotid stenosis. Methods This retrospective, IRB-exempt, case–control study evaluated non-cardiovascular, non-neurological surgical patients in a claims-based database. ICD-10-CM and ICD-9-CM codes identified cause of death and comorbidity incidences, respectively. A multivariate regression analysis then established adjusted independent risk scores of each comorbidity in relation to perioperative stroke-related mortality. Results Patients with atrial fibrillation were more likely (1.7 aOR, 95% CI (1.1, 2.8) p = 0.02) to die from perioperative stroke-related mortality than from other causes. No association was found with asymptomatic carotid stenosis. Further, in-hospital strokes (25.9 aOR, 95% CI (16.0, 41.8) p Conclusions Atrial fibrillation, diabetes and in-hospital strokes may be independent risk factors for perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population.

Supplemental material, sj-pdf-1-ppj-10.1177_1750458920911830 for Perioperative stroke-related mortality after non-cardiovascular, non-neurological procedures: A retrospective risk factor evaluation of common surgical comorbidities by Nathan J Reinert, Bansri M Patel, Khaled Al-Robaidi, Xiaotian Gao, Anthony Fabio, Ashutosh Jadhav, Visala S Muluk, Stephen A Esper, Brian S Zuckerbraun and Parthasarathy D Thirumala in Journal of Perioperative Practice

Background and Purpose: Perioperative stroke remains a devastating complication after cardiac surgery and is associated with significant morbidity and mortality. Despite the significant contribution of stroke to perioperative mortality, risk factors for perioperative stroke-related mortality have not been well characterized. Our aim was to identify independent predictors of perioperative stroke-related mortality after cardiac surgery, using the Pennsylvania Health Care Cost Containment Council (PHC4) database which provides information on cause of death. Methods: We retrospectively examined patient medical records from 2012 to 2014 of 3345 patients (ages 18-99) who underwent a cardiac surgical procedure and suffered perioperative (30-day) mortality. Perioperative stroke-related mortality was identified by International Classification of Diseases, Tenth Revision, Clinical Modification cause of death codes. We performed Fisher's exact test and multivariate analysis to identify comorbidities that independently predict perioperative stroke-related mortality. Results: After controlling for all variables with multivariate analysis, we found that patients with carotid stenosis were 4.9 (adjusted odds ratio [aOR], 95% confidence interval [CI] 1.8-12.8) times more likely to die from a stroke than from other causes, when compared to patients without carotid stenosis. Other independent predictors of perioperative stroke-related mortality included in-hospital stroke (aOR 108.8, 95%CI 48.2-245.9), history of stroke (aOR 17.1, 95%CI 3.3-88.4), and age ≥ 80 (aOR 4.9, 95%CI 2.1-11.2). Conclusions: This is the first study to establish carotid stenosis, among other comorbidities, as an independent predictor of perioperative stroke-related mortality after cardiac surgery. Understanding risk factors for mortality from stroke will help enhance the efficacy of preoperative screening, intraoperative neurophysiological monitoring, and potential treatments for stroke. Interventions to manage carotid stenosis and other identified risk factors prior to, during, or immediately after surgery may have the potential to reduce perioperative stroke-related mortality after cardiac surgery.

Objective: The purpose of this study was to delineate the natural history of claudication and determine risk factors for ischemic rest pain (IRP) and ischemic ulceration (IU) among patients with claudication. Methods: We prospectively collected data on 1244 men with claudication during a 15-year period, including demographics, clinical risk factors, and ankle-brachial index (ABI). We followed these patients serially with ABIs, self-reported walking distance (WalkDist), and monitoring for IRP and IU. We used Kaplan-Meier and proportional hazards modeling to find independent predictors of IRP and IU. Results: Mean follow-up was 45 months; statistically valid follow-up could be carried out for as long as 12 years. ABI declined an average of 0.014 per year. WalkDist declined at an average rate of 9.2 yards per year. The cumulative 10-year risks of development of IU and IRP were 23% and 30%, respectively. In multivariate analysis using several clinical risk factors, we found that only DM (relative risk [RR], 1.8) and ABI (RR, 2.2 for 0.1 decrease in ABI) predicted the development of IRP. Similarly, only DM (RR, 3.0) and ABI (RR, 1.9 for 0.1 decrease in ABI) were significant predictors of IU. Conclusion: This large serial study of claudication is, to our knowledge, the longest of its kind. We documented an average rate of ABI decline of 0.014 per year and a decline in WalkDist of 9.2 yards per year. Two clinical factors, ABI and DM, were found to be associated with the development of IRP and IU. Our findings may be useful in predicting the clinical course of claudication. (J Vasc Surg 2001;34:962-70.)

Objective: The purpose of this study was to delineate the natural history of claudication and determine risk factors for death. Methods: We reviewed the key outcomes (death, revascularization, amputation) in 2777 male patients with claudication identified over 15 years at a Veterans Administration hospital with both clinical and noninvasive criteria. Patients with rest pain or ulcers were excluded. Data were analyzed with life-table and Cox hazard models. Results: The mean follow-up was 47 months. The cohort exhibited a mortality rate of 12% per year, which was significantly (P

Purpose: The purpose of this study was to determine the etiologic factors in the progression of carotid stenosis. Methods: We performed prospective serial duplex scan surveillance of 1470 carotid arteries in 905 asymptomatic patients during a 10-year period, with an average follow-up interval of 29 months and an average of 3.0 scans per carotid artery. Vascular laboratory and hospital records were used to collect risk factor information. The data were analyzed with proportional hazards modeling. Results: We examined several demographic, clinical, and laboratory risk factors that were chosen because of their potential relevance to atherosclerotic disease. These factors were analyzed with univariate proportional hazards modeling, in which time to progression of stenosis was the outcome variable. The six significant predictors (P < .05) were age, sex, systolic pressure, pulse pressure (systolic pressure – diastolic pressure), total cholesterol, and high-density lipoprotein (HDL). All, except HDL, were positive predictors of time to disease progression. With multivariate modeling, only pulse pressure and HDL remained as significant independent predictors of stenosis progression. The risk ratio for a 10–mm Hg rise in pulse pressure was 1.12, and the risk ratio for a 10-mg/dL decrease in HDL was 1.20. Conclusion: In this large cohort of patients who were followed prospectively for carotid stenosis, pulse pressure and HDL were found to be the key risk factors for carotid stenosis progression. The fact that pulse pressure superseded systolic pressure in multivariate modeling may shed light on the biology of carotid plaque progression. Further, our identification of these modifiable risk factors may help in the design of therapeutic trials for the prevention of progression of carotid atherosclerosis. (J Vasc Surg 2000;31:31-8.)

Purpose: The purpose of this study was to delineate the natural history of the progression of asymptomatic carotid stenosis. Methods: In a 10-year period, 1701 carotid arteries in 1004 patients who were asymptomatic were studied with serial duplex scans (mean follow-up period, 28 months; mean number of scans, 2.9/patient). At each visit, stenoses of the internal carotid artery (ICA) and the external carotid artery (ECA) were categorized as none (0 to 14%), mild (15% to 49%), moderate (50% to 79%), severe (80% to 99%), preocclusive, or occluded. Progression was defined as an increase in ICA stenosis to ≥50% for carotid arteries with a baseline of

The progression of carotid stenosis may be a better predictor of adverse neurological outcomes than a single measurement of stenosis in asymptomatic patients.Retrospective review of prospectively collected data from a noninvasive vascular surgery laboratory between 1988 and 1997 at a Veterans Affairs Medical Center. A total of 1701 carotid arteries from 1004 asymptomatic patients were prospectively followed by duplex ultrasonographic scanning. Carotid arteries treated with endarterectomy were excluded. The main outcome measures were ipsilateral transient ischemic attack (TIA) and cerebrovascular accident (CVA).The baseline degree of carotid stenosis was less than 50% of artery diameter in 75% of patients. The annual rates of ipsilateral TIA and CVA were each 3.3%. When categorized with respect to carotid artery, the annual rates of ipsilateral TIAs and CVAs were 2.0% and 2.1%, respectively. Univariable Cox proportional hazards modeling showed that both baseline carotid stenosis and progression of stenosis were significant predictors of the composite outcome TIA and CVA, as well as the outcome CVA alone. In multivariable modeling, the progression of carotid stenosis was a highly significant predictor of the composite outcome TIA and CVA (risk ratio [RR], 1.68; P.001) and of CVA alone (RR, 1.78; P.001). However, baseline stenosis was found to be a significant predictor of time to the combined outcome (RR, 1.29; P =.01) but not of CVA alone. Clinical risk factors did not add any additional predictive information.The progression of carotid stenosis assessed by serial duplex scanning is a better predictor of ischemic neurological events than a single measurement of stenosis.

ObjectiveAlthough the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS) have helped to define the role of carotid endarterectomy (CEA) for both symptomatic and asymptomatic lesions, the role of surveillance of the contralateral carotid artery remains unclear. The purpose of this study was to determine the progression of contralateral carotid artery disease with serial duplex ultrasound scans after CEA compared with the recurrent stenosis rate for the carotid artery ipsilateral to the CEA.MethodsFrom January 1990 to December 2000, 473 CEA procedures were performed at a Veterans Affairs Medical Center. From this group we identified 279 patients who had undergone first-time CEA, as well as preoperative duplex scanning and postoperative duplex scanning at least once, in the vascular laboratory. At each visit stenosis of the internal carotid artery (ICA) was categorized as none (0%-14%), mild (15%-49%), moderate (50%-79%), severe (80%-99%), or occluded. Analysis of probability of freedom from progression was determined. Progression was defined as an increase in ICA stenosis 50% or greater or increase to a higher category of stenosis if baseline was 50% or greater. The Cox proportional hazards model was used for data analysis.ResultsMean patient age was 65.7 years (range, 33-100 years). The 1024 carotid duplex ultrasound scanning examinations performed (mean, 3.7; range, 2-13) included the last study done before the index CEA and all studies done after the CEA. Mean follow-up was 27 months (range, 1-137 months). Forty-six patients were found to have contralateral carotid occlusion at initial duplex scanning, and were therefore excluded from the contralateral progression analysis. Contralateral progression was more frequent than ipsilateral recurrent stenosis at long-term follow-up (P < .01). Annual rates of “any progression” and “progression to severe stenosis or occlusion” were 8.3% and 4.4%, respectively, for contralateral arteries, and 4.3% and 2.4%, respectively for ipsilateral arteries. As a result of surveillance, 43 contralateral CEAs (19% of initial cohort) were performed. Carotid stenosis regressed in 25 arteries (10.7%). Baseline clinical and demographic factors did not predict disease progression. Baseline contralateral stenosis did not predict time to “any progression,” but was a strong predictor of “progression to severe stenosis or occlusion” (P < .001).ConclusionsAfter CEA, we identified an 8.3% annual rate of progression of contralateral carotid artery stenosis and a 4.4% annual rate of progression to severe stenosis or occlusion. Baseline contralateral stenosis was significantly predictive of progression to severe stenosis or occlusion. Clinical and demographic factors were not helpful in predicting which patients would have disease progression. These data may help in assessing the cost effectiveness of duplex scanning surveillance after CEA.