Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine. However, block duration was longer with plain bupivacaine than ropivacaine. Thus, although dexamethasone prolonged the action of ropivacaine more than that of bupivacaine, the combined effect of dexamethasone and either drug produced nearly the same 22 h of analgesia.

Background Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. Methods Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). Results Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. Conclusions Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

This large cohort study found that epidural use is associated with improved survival in patients with nonmetastatic colorectal cancer undergoing resection but does not support an association between epidural use and decreased cancer recurrence.

Many attempts have been made to increase the duration of local anesthetic action. One avenue of investigation has focused on encapsulating local anesthetics within carrier molecules to increase their residence time at the site of action. This article aims to review the literature surrounding the recently approved formulation of bupivacaine, which consists of bupivacaine loaded in multivesicular liposomes. This preparation increases the duration of local anesthetic action by slow release from the liposome and delays the peak plasma concentration when compared to plain bupivacaine administration. Liposomal bupivacaine has been approved by the US Food and Drug Administration for local infiltration for pain relief after bunionectomy and hemorrhoidectomy. Studies have shown it to be an effective tool for postoperative pain relief with opioid sparing effects and it has also been found to have an acceptable adverse effect profile. Its kinetics are favorable even in patients with moderate hepatic impairment, and it has been found not to delay wound healing after orthopedic surgery. More studies are needed to establish its safety and efficacy for use via intrathecal, epidural, or perineural routes. In conclusion, liposomal bupivacaine is effective for treating postoperative pain when used via local infiltration when compared to placebo with a prolonged duration of action, predictable kinetics, and an acceptable side effect profile. However, more adequately powered trials are needed to establish its superiority over plain bupivacaine.

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Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Frailty is associated with adverse postoperative outcomes, but it remains unclear which measure of frailty is best. This study compared two approaches: the Modified Frailty Index, which is a deficit accumulation model (number of accumulated deficits), and the Hopkins Frailty Score, which is a phenotype model (consisting of shrinking, weakness, exhaustion, slowness, and low physical activity). The primary aim was to compare the ability of each frailty score to predict prolonged hospitalization. Secondarily, the ability of each score to predict 30-day readmission and/or postoperative complications was compared. Methods This study prospectively enrolled adults presenting for preanesthesia evaluation before elective noncardiac surgery. The Hopkins Frailty Score and Modified Frailty Index were both determined. The ability of each frailty score to predict the primary outcome (prolonged hospitalization) was compared using a ratio of root-mean-square prediction errors from linear regression models. The ability of each score to predict the secondary outcome (readmission and complications) was compared using ratio of root-mean-square prediction errors from logistic regression models. Results The study included 1,042 patients. The frailty rates were 23% (Modified Frailty Index of 4 or higher) and 18% (Hopkins Frailty Score of 3 or higher). In total, 12.9% patients were readmitted or had postoperative complications. The error of the Modified Frailty Index and Hopkins Frailty Score in predicting the primary outcome was 2.5 (95% CI, 2.2, 2.9) and 2.6 (95% CI, 2.2, 3.0) days, respectively, and their ratio was 1.0 (95% CI, 1.0, 1.0), indicating similarly poor prediction. Similarly, the error of respective frailty scores in predicting the probability of secondary outcome was high, specifically 0.3 (95% CI, 0.3, 0.4) and 0.3 (95% CI, 0.3, 0.4), and their ratio was 1.00 (95% CI, 1.0, 1.0). Conclusions The Modified Frailty Index and Hopkins Frailty Score were similarly poor predictors of perioperative risk. Further studies, with different frailty screening tools, are needed to identify the best method to measure perioperative frailty.

Background and Objectives Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not. Methods We used the linked federal Surveillance, Epidemiology, and End Results (SEER) Program/Medicare database to identify patients aged ≥66 with nonmetastatic gastric carcinoma diagnosed 1996–2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by CPT codes. Treated recurrence was defined as chemotherapy ≥ 16 months and/or radiation ≥ 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression. Results We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% non-epidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio [OR] 1.40, 95% CI 0.96 to 2.05). Median survival did not differ: 28.1 months (95% CI 24.8 to 32.3) in the epidural versus 27.4 months (95% CI 24.8 to 30.0) in the non-epidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted HR 0.93, 95% CI 0.84 to 1.03). Conclusions There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

EDITOR’S PERSPECTIVE What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.