Abstract 1 Regional Anesthesia is Associated with Improved Survival and Decreased Recurrence in Ovarian Cancer Patients Presenting Author: Gildasio S. De Oliveira, Jr., M.D. Presenting Author’s City, State: - Chicago, Il Introduction: The deleterious effects of surgery and anesthesia in cancer patients have been postulated for a long time. It has been demonstrated in animals that surgery and anesthesia may promote metastasis and accelerate the progression of several tumor types. Stress response, opioids and volatile anesthetic drugs can cause perioperative immune suppression and promote a negative effect on the outcome of cancer patients. Regional Anesthesia can blunt the stress response, decreased the use of volatile anesthetics and the consumption of opioids which can lead to a favorable outcome in those patients. Methods: We performed a retrospective analysis of patients undergoing primary cytoreductive surgery to evaluate if the presence of epidural anesthesia and/or analgesia would have a positive impact on cancer recurrence and survival. Data extracted from patient's medical records included age, height ,weight, medical history , cancer staging, cancer grading, cell type, surgical duration, blood loss during the procedure , preoperative CA125, surgeon performing the operation, presence of perioperative transfusion, number of units transfused and the presence of epidural anesthesia and analgesia . Baseline data was analyzed using independent sample t test, Mann-Whitney U test, Pearson's Chi square or Fisher's exact test as appropriate. Time to event data was analyzed using Kaplan-Meier curves and log-rank test. Cox regression multivariate analysis was used to adjust for possible confounding factors. Results: We studied 182 patients that were divided into patients who receive perioperative epidural (55 patients) and the ones who did not receive perioperative epidural(127 patients).Groups had no difference among baseline characteristics except for the number of units transfused which was higher in the non- epidural group; 1[0-2] vs. the epidural group ;0[0-1] p=0.03. The epidural group had an increase time to recurrence (p=0.008, log-rank test) and increased survival (p=0.01, log-rank test) when compared to the non-epidural group. When adjusting for confounding factors ( Age ,ASA, CA125, stage, grade, surgical duration, transfusion and number of units transfused) the epidural was still found to be a predictor for less recurrence(p=0.009) and higher survival(p=0.01) ,estimated hazard rate of 0.54[034-0.85] and 0.50[0.28- 0.89] respectively. Discussion: We demonstrated in this retrospective analysis that the perioperative use of epidural anesthesia and analgesia is associated with decreased recurrence and increased survival in ovarian cancer patients. This positive association is possibly due to a better preservation of the immune system function with the use of epidural. Additional File #1: Additional File #2: Abstract 2 A Multicenter, Randomized, Triple-Masked, Placebo-Controlled Trial of The Effect of Ambulatory Continuous Femoral Nerve Blocks on Discharge- Readiness Following Total Knee Arthroplasty In Patients on General Orthopaedic Wards Presenting Author: Brian M. Ilfeld, M.D., M.S. Presenting Author’s City, State: - La Jolla, CA Co-Authors: Vanessa J. Loland, M.D. - University of California San Diego - San Diego, CA John F. Donovan, M.D. - Alta Bates Summit Medical Center - Oakland, CA Linda T. Le, M.D. - University of Florida - Gainesville, FL Edward R. Mariano, M.D., MAS - University of California San Diego - San Diego, CA Background: A previous investigation reported a 4-day ambulatory continuous femoral nerve block (cFNB) decreased the time required to reach 3 important discharge criteria by 53% compared with an overnight, hospital-only cFNB following total knee arthroplasty (TKA, p<0.001). However, a major limitation of that study was the artificial research environment: (1) all subjects convalesced in a specialized, stand-alone clinical research center often with a single nurse per patient; (2) a single anesthesiologist cared for all subjects; and (3) the 3 physical therapists involved in the study were specially trained to optimize the study protocol, including ambulation distances.1 Consequently, it is problematic generalizing results from this single trial to the more than half-million patients who undergo TKA each year in the U.S. We therefore designed this prospective clinical trial to retest the hypothesis that an extended ambulatory cFNB shortens the time until 3 specific, predefined readiness-for-discharge criteria are met following TKA; and to allow inference of the results to the general population by using standard orthopaedic hospital wards in multiple centers with a wide range of healthcare providers. Methods: Preoperatively, all patients received a cFNB with perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomized to either continue perineural ropivacaine (n=39) or switch to saline (n=38). The primary endpoint was the time to attain three discharge criteria (adequate analgesia, independence from intravenous opioids, and ambulation ≥ 30 meters). Patients were discharged with their cFNB and a portable infusion pump, and catheters were removed on postoperative day 4. Results: Patients given 4 days of perineural ropivacaine attained all 3 criteria in a median (25th-75th %iles) of 47 (29-69) h, compared with 62 (45-79) h for those of the control group receiving ropivacaine only until the morning following surgery (Estimated ratio=0.80, 95%CI: 0.66-1.00; p=0.028; Fig. 1). Compared with subjects receiving saline, patients randomized to ropivacaine met the discharge criterion for analgesia in 20 (0-38) vs. 38 (15-64) h (p=0.009; Figs. 2-3); for intravenous opioid independence in 21 (0-37) vs. 33 (11-50) h (p=0.061); and ambulation in 40 (25-68) vs. 45 (25-66) h (P=0.780). There were 4 falls in 3 patients receiving ropivacaine, versus 0 in controls (p=0.240). Conclusions: In the previous study using the artificial environment of a stand-alone clinical research center,1 subjects with a 4-day cFNB met three discharge criteria in 25 (21-47) h, compared with 71 (46- 89) h for those of the control group with an overnight, hospital-only infusion. Providing the extended cFNB thus resulted in a far greater decrease in time until discharge readiness (46 h, or 53%; p<0.001) than found for subjects of the current study (15 h, or 20%; p=0.028). That the benefit was greater in a highly- controlled environment is not surprising. Our current results reflect a country-wide diversity of practice that is probably more representative of what clinicians can generally expect from an extended, ambulatory cFNB. References: 1. Ilfeld et al. Anesthesiology 2008; 108: 703-13 2. Kurtz et al. JBJS 2005; 87: 1487-97 Additional File #1: Additional File #2: Additional File #3: Abstract 3 Perioperative Pulmonary Circulatory Changes During Bilateral Total Hip Arthroplasty Presenting Author: Matthew C. Rade, B.A. Presenting Author’s City, State: - New York, NY Co-Authors: George Go, B.S. - Hospital for Special Surgery - New York, NY Yan Ma, Ph.D. - Hospital for Special Surgery - New York, NY Nigel E. Sharrock, M.B., Ch.B. - Hospital for Special Surgery - New York, NY Stavros G. Memtsoudis, M.D., Ph.D. - Hospital for Special Surgery - New York, NY Background: The transient and rarely clinically relevant effect of bone and cement embolization during unilateral joint arthroplasty is a known phenomenon. However, available studies do not address events surrounding bilateral total hip arthroplasties, during which embolic load is presumably doubled. To elucidate events surrounding this increasingly utilized procedure and assess the effect on the pulmonary hemodynamics in the intra- and postoperative period, we studied 24 subjects undergoing cemented bilateral total hip arthroplasty during the same anesthetic session. Materials and Methods: Twenty four patients without previous pulmonary history undergoing cemented bilateral total hip arthroplasty under controlled epidural hypotension were enrolled. Pulmonary artery catheters were inserted and hemodynamic variables were recorded at baseline, 5 minutes after the implantation of each hip joint, 1 hour and 1 day postoperatively. Mixed venous blood gases and complete blood counts were analyzed at every time point. Results: An increase in pulmonary vascular resistance was observed after the second but not the first hip implantation when compared to values at incision. Pulmonary vascular resistance remained elevated 1 hour postoperatively (Figure 1). Pulmonary artery pressures were significantly elevated on post operative day 1 compared to baseline values. The white blood cell count increased in response to the second hip implantation but not the first compared to incision (P<0.003). Conclusion: The embolization of material during bilateral total hip arthroplasty is associated with prolonged increases in pulmonary artery pressures and vascular resistance, particularly after the second side. The performance of bilateral procedures should be cautiously considered in patients with diseases suggesting decreased right ventricular reserve. Abstract 4 Intrathecal Clonidine Decreases Propofol Sedation Requirements During Spinal Anaesthesia In Infants Presenting Author: Rajeev Subramanyam, D.N.B., M.D., M.N.A.M.S. Presenting Author’s City, State: - Chandigarh, Karnataka Co-Authors: Yatindra Batra Kumar, M.D., M.N.A.M.S., F.A.M.S. - Postgraduate Institute