Perioperative visual loss (POVL) is an uncommon, but devastating complication that remains primarily associated with spine and cardiac surgery. The incidence and mechanisms of visual loss after surgery remain difficult to determine. According to the American Society of Anesthesiologists Postoperative Visual Loss Registry, the most common causes of POVL in spine procedures are the two different forms of ischemic optic neuropathy: anterior ischemic optic neuropathy and posterior ischemic optic neuropathy, accounting for 89% of the cases. Retinal ischemia, cortical blindness, and posterior reversible encephalopathy are also observed, but in a small minority of cases. A recent multicenter case control study has identified risk factors associated with ischemic optic neuropathy for patients undergoing prone spinal fusion surgery. These include obesity, male sex, Wilson frame use, longer anesthetic duration, greater estimated blood loss, and decreased percent colloid administration. These risk factors are thought to contribute to the elevation of venous pressure and interstitial edema, resulting in damage to the optic nerve by compression of the vessels that feed the optic nerve, venous infarction or direct mechanical compression. This review will expand on these findings as well as the recently updated American Society of Anesthesiologists practice advisory on POVL. There are no effective treatment options for POVL and the diagnosis is often irreversible, so efforts must focus on prevention and risk factor modification. The role of crystalloids versus colloids and the use of α-2 agonists to decrease intraocular pressure during prone spine surgery will also be discussed as a potential preventative strategy. Core tip: Perioperative visual loss (POVL) is an uncommon, but devastating complication that remains primarily associated with spine and cardiac surgery. The incidence and mechanisms of visual loss after surgery remain difficult to determine. Ischemic optic neuropathy accounts for the vast majority of these cases, with retinal ischemia, cortical blindness, and posterior reversible encephalopathy observed with low incidence. Recently identified risk factors include obesity, male sex, Wilson frame use, longer anesthetic duration, greater estimated blood loss, and decreased percent colloid administration. POVL is often permanent and untreatable, so prevention is key to limiting its impact. Nickels TJ, Manlapaz MR, Farag E. Perioperative visual loss after spine surgery. World J Orthop 2014; 5(2): 100-106 Available from:

These data suggest that recent metformin ingestion is not associated with increased risk of adverse outcome in cardiac surgical patients. Alternatively, metformin treatment may have beneficial effects.

Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at reducing perioperative morbidity and costs while improving outcomes. To date, spine surgery protocols have been limited in scope, focusing only on specific types of procedures or specific parts of the surgical episode. The authors describe the creation and implementation of one of the first comprehensive ERAS protocols for spine surgery. The protocol is unique in that it has a comprehensive perioperative paradigm encompassing the entire surgical period that is tailored based on the complexity of each individual spine patient.

Background Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores. Methods Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h. Results The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, –6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being –9 (97.5% CI, –23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being –0.4 (97.5% CI; –0.8, 0.1, P = 0.094). Conclusions An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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BACKGROUND: Monitored anesthesia care (MAC) and general anesthesia (GA) with endotracheal intubation are the 2 most used techniques for patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy. We aimed to test the hypothesis that increased arterial oxygen concentration during reperfusion period is a mechanism underlying the association between use of GA (versus MAC) and increased risk of in-hospital mortality. METHODS: In this retrospective cohort study, data were collected at the Cleveland Clinic between 2013 and 2018. To assess the potential mediation effect of time-weighted average oxygen saturation (Spo 2 ) in first postoperative 48 hours between the association between GA versus MAC and in-hospital mortality, we assessed the association between anesthesia type and post-operative Spo 2 tertiles (exposure-mediator relationship) through a cumulative logistic regression model and assessed the association between Spo 2 and in-hospital mortality (mediator-outcome relationship) using logistic regression models. Confounding factors were adjusted for using propensity score methods. Both significant exposure-mediator and significant mediator-outcome relationships are needed to suggest potential mediation effect. RESULTS: Among 358 patients included in the study, 104 (29%) patients received GA and 254 (71%) received MAC, with respective hospital mortality rate of 19% and 5% (unadjusted P value <.001). GA patients were 1.6 (1.2, 2.1) (P < .001) times more likely to have a higher Spo 2 tertile as compared to MAC patients. Patients with higher Spo 2 tertile had 3.8 (2.1, 6.9) times higher odds of mortality than patients with middle Spo 2 tertile, while patients in the lower Spo 2 tertile did not have significant higher odds compared to the middle tertile odds ratio (OR) (1.8 [0.9, 3.4]; overall P < .001). The significant exposure-mediator and mediator-outcome relationships suggest that Spo 2 may be a mediator of the relationship between anesthetic method and mortality. However, the estimated direct effect of GA versus MAC on mortality (ie, after adjusting for Spo 2 ; OR [95% confidence interval {CI}] of 2.1 [0.9-4.9]) was close to the estimated association ignoring Spo 2 (OR [95% CI] of 2.2 [1.0-5.1]), neither statistically significant, suggesting that Spo 2 had at most a modest mediator role. CONCLUSIONS: GA was associated with a higher Spo 2 compared to MAC among those treated by endovascular thrombectomy for AIS. Spo 2 values that were higher than the middle tertile were associated with higher odds of mortality. However, GA was not significantly associated with higher odds of death. Spo 2 at most constituted a modest mediator role in explaining the relationship between GA versus MAC and mortality.

Study design retrospective review. Objective Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery. Methods A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay. Results Following implementation, the rate of blood transfusion decreased by 11.7%( P = .017) and average crystalloid infusion was reduced 680 mL per case( P < .001). Intraoperative blood loss decreased on average 342 mL per case( P = .001) and TXA use increased significantly by 25%( P < .001). Postoperative ICU admissions declined by 8.5%( P = .071); extubation within the OR increased by 13.3%( P = .005). Conclusions This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

Background: During the coronavirus disease 2019 (COVID-19) pandemic, health professions educators who traditionally used a face-to-face mode to deliver education transitioned to virtual formats. With the widespread use of vaccines, restrictions on social distancing requirements have waned. Some educators have reverted to a face-to-face modality, whereas others have maintained a virtual modality. Method: A framework was developed to evaluate the suitability of curricular elements to be presented in a virtual platform to guide educators in modality decision making. Results: Learner motivation, context and content compatibility, social learning community requirements, and technological infrastructure should be considered when planning future curricula delivery. Conclusion: The virtual learning environment must be compatible with content and context. Appropriate technology infrastructure, which includes institutional support, virtual learning platform, and technological support, also must be in place. Hybrid modalities that divide content into face-to-face and virtual components can be used to ease demands on logistics and technology infrastructure limitations. [ J Nurs Educ . 2022;61(9):503–509.]