Daily Anesthesiology Research Analysis

BACKGROUND: While paravertebral block is a well-established regional anesthetic technique for breast surgery, evidence for fascial plane blocks and combined block approaches is limited. Furthermore, the optimal block approach for mastectomy with expander reconstruction remains unclear. We hypothesized that combining PECS I (interpectoral) nerve blocks with either paravertebral or serratus anterior plane blocks would reduce opioid use after mastectomy with expander reconstruction compared with paravertebral block alone. METHODS: This was a single-center, cluster-randomized, clinically integrated trial. Patients undergoing bilateral mastectomy with immediate expander reconstruction were randomized by month to receive paravertebral, paravertebral plus PECS I, or serratus anterior plane plus PECS I blocks. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain scores and antiemetic use, discharge time, adverse events, chronic pain, and patient-reported quality of recovery. The primary analysis compared the combined block groups, paravertebral plus PECS I and serratus anterior plane plus PECS I blocks, with the paravertebral block group. RESULTS: 1507 patients were randomized between 2019 and 2023: 492 to paravertebral blocks, 446 to paravertebral plus PECS I blocks, and 568 to serratus anterior plane plus PECS I blocks. Rates of high postoperative opioid use were 26%, 27% and 22% respectively, with a non-significant 1.9% lower rate in patients who received any combination block, paravertebral plus PECS I or serratus anterior plane plus PECS I blocks (95% CI -2.7%, 6.5%, p=0.4). There were no significant differences for any secondary outcomes when accounting for multiple testing. CONCLUSION: Paravertebral or serratus anterior plane blocks combined with PECS I blocks were not superior to paravertebral block alone in reducing high opioid use after bilateral mastectomy with expander reconstruction. All three block approaches are acceptable techniques for this procedure. Choice of block should be based on clinician expertise, patient-specific factors, and safety considerations.

INTRODUCTION: The enhanced care model of peri-operative care has evolved to meet increasing surgical demand, aiming to relieve pressure on critical care and prevent unnecessary cancellation of surgery. Despite widespread adoption of these facilities in the UK, no resources currently describe the national landscape of enhanced care or the organisational impacts of their introduction. METHODS: We conducted a UK-wide, retrospective, observational study. At each site, the local structure of enhanced (level 1) and critical care (levels 2-3) services was recorded alongside time-series data describing patient flow and individual details for all referrals to levels 1-3. Multilevel regression was used to explore the relationships between referral to an enhanced care facility and various organisational outcomes. A cluster analysis was performed to group enhanced care units with similar characteristics. RESULTS: Data were collected between September and November 2023. Of 110 participating centres, 70 (63.6%) had a surgical level 1 unit. In total, 5990 patient referrals to levels 1-3 were followed up, of which 3146 (52.5%) were referred to level 1 and 2844 (47.5%) to levels 2-3. Enhanced care patients were younger, with fewer comorbidities, and were undergoing less complex surgery than those referred to critical care. Referral to level 1 rather than levels 2-3 was associated with a reduced likelihood of cancellation (OR 0.50, 95%CI 0.40-0.64, p < 0.001); cancellation due to a lack of bed (OR 0.27, 95%CI 0.19-0.40, p < 0.001); and a shorter duration of hospital stay (incidence risk ratio 0.58, 95%CI 0.55-0.61, p < 0.001). DISCUSSION: Enhanced care services provide a suitable alternative to critical care for high-risk surgical patients in the UK whilst building surgical capacity and system resilience. These facilities are associated with improved organisational outcomes, associations which may reflect both operational efficiency and the lower clinical acuity of the population they serve. Hospitals in the UK have started using something called ‘enhanced care’ to help patients who need surgery. This helps make sure there are enough beds in the intensive care unit and stops surgeries from being cancelled when intensive care is full. Even though many hospitals now use enhanced care, no one has yet described how it works across the country or what it means for hospitals. To find out more, a study was done across the UK. The researchers looked back at what had already happened in many hospitals. They collected information about how hospitals organise their care for patients who need different levels of support after surgery. They also collected details about patients sent to these different care levels to see how it affected things like surgery cancellations and time spent in hospital. The study took place from September to November 2023. Out of 110 hospitals, 70 had a special unit for enhanced care after surgery. In total, the researchers followed 5990 patients who were sent to either enhanced care or critical care. About half of the patients went to enhanced care. These patients were usually younger, healthier, and had simpler surgeries than those sent to critical care. Patients who went to enhanced care were less likely to have their surgery cancelled, especially because of a lack of ICU beds. They also stayed in the hospital for a shorter time. In summary, enhanced care is a good option for patients who need some support after surgery but don't need full critical care. It helps hospitals run more smoothly and treat more patients without delays.

INTRODUCTION: Living with obesity is a risk factor for diabetes, cardiovascular disease and cancer. The 'obesity paradox' suggests patients who are overweight or living with mild obesity experience better outcomes after surgery and critical illness compared with patients living with normal weight. However, little is known about the generalisability and possible mechanisms of the obesity paradox. This study investigated the relationship between BMI and loss of independent living after surgery. METHODS: We analysed adult patients who lived independently before non-cardiac, non-bariatric, non-ambulatory surgery. We used a multivariable restricted cubic spline model, with a BMI of 22.0 kg.m RESULTS: Among 73,813 patients, 9495 (12.9%) were unable to live independently after surgery. Adjusted analyses showed a U-shaped relationship between BMI and adverse discharge, with calculated risk ratios and confidence intervals for each distinct BMI in the cohort compared with our reference weight of 22.0 kg.m DISCUSSION: This study shows a U-shaped relationship between BMI and the risk of postoperative loss of independent living. Patients with mild obesity experienced a lower risk of losing the ability to live independently after surgery. Being very overweight, also called obesity, can increase the chance of getting diseases like diabetes, heart problems and cancer. But some studies have found something called the ‘obesity paradox’. This means that people who are a little overweight or mildly obese sometimes do better after surgery or serious illness than people with a normal weight. Scientists don't yet know why this happens or if it applies to everyone. We looked at how body weight (measured by BMI) affects whether people can still live on their own after surgery. We studied adults who were living on their own before having surgery that didn't involve the heart, weight loss, or bone and joint problems. We used a special model that compared different BMI levels, using a BMI of 22 as the middle point. We focused on whether patients could still live on their own after surgery. If someone died in the hospital or had to go to a care home or nursing facility, that meant they lost independent living. We looked at 73,813 patients. Of these, 9495 (about 13%) could not live independently after surgery. The results showed a U‐shaped pattern between BMI and losing independence. People who were very thin were more likely to lose their independence after surgery. People who were very obese also had a higher risk. But those who were slightly overweight or mildly obese were less likely to lose their ability to live independently. We found that both very low and very high body weight increase the chance of losing independence after surgery. People with mild obesity seemed to recover better and were more likely to keep living on their own.