Andrew J Rowlingson

Johns Hopkins University, Baltimore, MD, United States

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Publications (18)71.45 Total impact

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    ABSTRACT: It is unclear whether perioperative epidural analgesia is associated with a decrease in mortality in patients who undergo orthopedic procedures. We examined 35,878 patients' data obtained from a random sample of Medicare beneficiaries who underwent elective total knee replacement. Division of patients into 2 groups was based on presence or absence of billing for postoperative epidural analgesia. Outcomes assessed were death and major morbidity 30 days after surgery. Multivariate regression analysis revealed no between-groups difference in mortality 30 days after surgery. Postoperative epidural analgesia was not associated with lower incidence of mortality or major morbidity in Medicare patients who underwent elective total knee replacement.
    American journal of orthopedics (Belle Mead, N.J.) 11/2008; 37(10):524-7.
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    ABSTRACT: Introduction Currently, there is no standard location for the placement of epidural catheters in patients undergoing abdominal gynaecologic surgery. Methods Adult women undergoing elective gynaecologic surgery with abdominal incision were prospectively enrolled in a randomised double-blind controlled trial comparing postoperative outcomes for lumbar epidural analgesia (LEA) versus thoracic epidural analgesia (TEA). Motor function, proprioception, cold sensation, pain, American Pain Society (APS) Patient Outcome Questionnaire (Modified), Brief Fatigue Inventory (BFI) and Quality of Recovery 9 (QOR9) were assessed. Results A total of 103 patients enrolled with 88 completing the study. There were no significant differences in demographics, pain scores during hospital stay or nausea/vomiting. Motor blockade was less with TEA compared to LEA but was statistically significant only for right knee extension and flexion and straight leg raise. There was a statistically significant decrease in pruritus with LEA. Subgroup analysis by surgical incision demonstrated a statistically significant decrease in pain scores for TEA for vertical incisions extending above the umbilicus only. Pain scores reported by the patients 7 days after surgery were higher both at rest and maximal for TEA. Conclusions Lower abdominal procedures for gynaecologic surgery do not appear to require TEA for optimal care unless upper abdominal incision is used or catheters will remain in place greater than 24 h.
    Acute Pain 01/2007; 9(3):109-118.
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    ABSTRACT: To perform an analysis of the Medicare claims database in patients undergoing lung resection to determine whether there is an association between postoperative epidural analgesia and mortality. Retrospective cohort (database) design. University hospital. We examined a cohort of 3501 patients obtained from a 5% nationally random sample of 1997 to 2001 Medicare beneficiaries who underwent nonemergency segmental excision of the lung (International Classification of Diseases, 9th Revision, Clinical Modification codes 32.3 and 32.4). Patient data were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity (acute myocardial infarction, angina, cardiac dysrhythmias, heart failure, pneumonia, pulmonary edema, respiratory failure, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, somnolence, acute cerebrovascular event, transient organic syndrome, and paralytic ileus) were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. Multivariate regression analysis showed that the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.39; 95% confidence interval, 0.19-0.80; P = 0.001) and 30 days (odds ratio, 0.53; 95% confidence interval, 0.35-0.78; P = 0.002) after surgery. There was no difference between the groups with regard to overall major morbidity. Postoperative epidural analgesia may contribute to lower odds of death after segmental excision of the lung, although the mechanism of such a benefit is not clear from our analysis.
    Journal of Clinical Anesthesia 12/2006; 18(7):515-20. · 1.15 Impact Factor
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    ABSTRACT: To examine, with a large database, the effect of postoperative epidural analgesia (vs systemic analgesia) on mortality after colectomy is unclear. Retrospective cohort (database) design. Medicare beneficiaries undergoing elective colectomy. We examined a cohort of 12817 patients obtained from a 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 who underwent elective partial excision of the large intestine. Patients were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. Multivariate regression analysis revealed that there was no difference between the groups with regard to overall major morbidity; however, the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.35; 95% confidence interval, 0.21-0.59; P < 0.0001) and 30 days (odds ratio, 0.54; 95% confidence interval, 0.42-0.70; P < 0.0001) after surgery. The presence of postoperative epidural analgesia may decrease the odds of death after elective colectomy; however, the mechanism of such a benefit is not clear from our analysis.
    Journal of Clinical Anesthesia 12/2006; 18(8):594-9. · 1.15 Impact Factor
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    ABSTRACT: To perform a meta-analysis of available randomized controlled trials to determine if neuraxial anesthesia would decrease blood loss, compared with general anesthesia. Retrospective analysis. University medical center. The National Library of Medicine's PubMed database was searched from the period of 1966 to December 10, 2003 for all abstracts containing words related to neuraxial anesthesia and general anesthesia. The search was limited to randomized controlled trials and the English language and yielded 667 articles. A total of 66 articles met inclusion criteria and were used for the analysis. Overall, the use of spinal anesthesia resulted in significantly less estimated blood loss (EBL) (P < 0.0001), compared with epidural anesthesia (EA), which, in turn, resulted in significantly less EBL compared with general anesthesia (GA) or combined GA-EA (P < 0.0001). No significant difference between GA and GA-EA was noted when analysis was limited to studies directly comparing GA-EA and GA. Use of spinal anesthesia or EA is associated with a significant decrease in EBL when compared with that for GA or combined GA-EA.
    Journal of Clinical Anesthesia 10/2006; 18(6):427-35. · 1.15 Impact Factor
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    ABSTRACT: Gender is believed to be an independent risk factor for the development of post-dural puncture headache, but there are some of the inconsistencies in the available data. This systematic review examined a total of 18 trials (2,163 males, 1,917 females). The odds of developing a post-dural puncture headache were significantly lower for male than nonpregnant female subjects (odds ratio = 0.55; 95% confidence interval, 0.44-0.67). Although the authors found that nonpregnant female subjects seem to have a higher incidence of post-dural puncture headache than males, the etiology behind these findings is not clear from the current meta-analysis.
    Anesthesiology 10/2006; 105(3):613-8. · 5.16 Impact Factor
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    ABSTRACT: The effect of lumbar puncture needle bevel direction on the incidence of postdural puncture headache (PDPH) is somewhat controversial. We performed a meta-analysis of available trials to determine if bevel direction during lumbar puncture would influence the incidence of PDPH. Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to November 29, 2004) and abstracts from several national meetings (American Society of Anesthesiology, International Anesthesia Research Society, American Society of Regional Anesthesia, Society of Obstetric Anesthesia and Perinatology) for terms related to needle and bevel direction. Inclusion criteria were assessment of the incidence of PDPH after lumbar puncture with a cutting needle (eg, Quincke, Tuohy), comparison of a "parallel" (bevel oriented in a longitudinal or cephalad to caudad direction) to "perpendicular" (bevel oriented in a transverse direction) orientation during needle insertion, randomized trials, and trials primarily in adult populations. Data on study characteristics and incidence of PDPH were abstracted from qualified studies and subsequently analyzed. The search resulted in 52 abstracts from which the original articles were obtained and data abstracted, with ultimately a total of 5 articles meeting all inclusion criteria. Insertion of a non-pencil-point/cutting needle with the bevel oriented in a parallel/longitudinal fashion resulted in a significantly lower incidence of PDPH compared with that oriented in a perpendicular/transverse fashion (unadjusted rates of 10.9% versus 25.8%; odds ratio = 0.29 [95% CI = 0.17-0.50]). Our meta-analysis indicates that with use of a cutting needle, insertion in a parallel/longitudinal fashion may significantly reduce the incidence of PDPH, although the reasons for this decrease are unclear.
    The Neurologist 08/2006; 12(4):224-8. · 1.48 Impact Factor
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    ABSTRACT: To perform a meta-analysis of available randomized trials investigating the analgesic efficacy of periprostatic block with local anesthetic. The National Library of Medicine's PubMed database was searched for the time period 1966 to August 16, 2005 for all relevant articles. Inclusion criteria included subjects undergoing prostate biopsy, trials that were randomized with one arm of the randomization using local anesthetic for periprostatic block before prostate biopsy, and where the assessment of biopsy pain was measured and available in a form compatible for statistical analysis in our meta-analysis. Our search resulted in 107 abstracts, of which a total of 16 articles met all inclusion criteria. There were 660 subjects who received local anesthetics for a periprostatic block and 616 subjects who did not. The weighted mean difference between the groups indicates that subjects receiving local anesthetic periprostatic block would have a statistically lower pain score compared with those who did not (weighted mean difference in visual analogue pain of -1.66 [95% confidence interval -2.03 to -1.29]). Our meta-analysis suggests that periprostatic block with local anesthetic for prostate biopsy might result in significantly lower levels of pain during the biopsy procedure. Because periprostatic block with local anesthetic is relatively easy to administer and does not seem to be associated with increased morbidity, clinicians performing prostate biopsies should consider using this technique on a routine basis.
    Urology 07/2006; 67(6):1224-8. · 2.42 Impact Factor
  • Journal of Clinical Anesthesia 06/2006; 18(3):240-1. · 1.15 Impact Factor
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    ABSTRACT: Although most randomized clinical trials conclude that the addition of continuous peripheral nerve blockade (CPNB) decreases postoperative pain and opioid-related side effects when compared with opioids, studies have included relatively small numbers of patients and the majority failed to show statistical significance during all time periods for reduced pain or side effects. We identified studies primarily by searching Ovid Medline (1966-May 21, 2004) for terms related to postoperative analgesia with CPNB and opioids. Each article from the final search was reviewed and data were extracted from tables, text, or extrapolated from figures as needed. Nineteen articles, enrolling 603 patients, met all inclusion criteria. Inclusion criteria were a clearly defined anesthetic technique (combined general/regional anesthesia, general anesthesia alone, peripheral nerve block), randomized trial, adult patient population (> or =18 yr old), CPNB (or analgesia) used postoperatively (intrapleural catheters were deemed not to be classified as a peripheral nerve catheter), and opioids administered for postoperative analgesia in groups not receiving peripheral nerve block. Perineural analgesia provided better postoperative analgesia compared with opioids (P < 0.001). This effect was seen for all time periods measured for both mean visual analog scale and maximum visual analog scale at 24 h (P < 0.001), 48 h (P < 0.001), and 72 h (mean visual analog scale only) (P < 0.001) postoperatively. Perineural catheters provided superior analgesia to opioids for all catheter locations and time periods (P < 0.05). Nausea/vomiting, sedation, and pruritus all occurred more commonly with opioid analgesia (P < 0.001). A reduction in opioid use was noted with perineural analgesia (P < 0.001). CPNB analgesia, regardless of catheter location, provided superior postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia.
    Anesthesia and analgesia 02/2006; 102(1):248-57. · 3.08 Impact Factor
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    ABSTRACT: Gabapentin is an anticonvulsant that has been shown to be effective in the treatment of neuropathic and inflammatory pain in animal and human studies. The analgesic effect of its perioperative use has not been fully elucidated. This systematic review (meta-analysis) included 12 randomized controlled trials of 896 patients undergoing a variety of surgical procedures that investigated the impact of perioperative administration of gabapentin on postoperative outcome. The pooled visual analog scores for pain at 4 hours and 24 hours were significantly less in those patients who received gabapentin (weighted mean difference [WMD] = -1.57; 95% confidence interval [CI], -2.14 to -0.99 and WMD = -0.74; CI, -1.03 to -0.45, respectively). A concomitant decrease in opioid usage by those patients who received gabapentin was also noted (odds ratio [OR] = -17.84; CI, -23.50 to -12.18). Gabapentin administration was associated with sedation and anxiolysis (OR = 3.28; CI, 1.21-8.87) but not associated with a difference in lightheadedness, dizziness, nausea, or vomiting. Based on this systematic review, perioperative oral gabapentin is a useful adjunct for the management of postoperative pain that provides analgesia through a different mechanism than opioids and other analgesic agents and would make a reasonable addition to a multimodal analgesic treatment plan.
    Regional Anesthesia and Pain Medicine 01/2006; 31(3):237-47. · 3.46 Impact Factor
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    ABSTRACT: The authors performed a meta-analysis and found that epidural analgesia overall provided superior postoperative analgesia compared with intravenous patient-controlled analgesia. For all types of surgery and pain assessments, all forms of epidural analgesia (both continuous epidural infusion and patient-controlled epidural analgesia) provided significantly superior postoperative analgesia compared with intravenous patient-controlled analgesia, with the exception of hydrophilic opioid-only epidural regimens. Continuous epidural infusion provided statistically significantly superior analgesia versus patient-controlled epidural analgesia for overall pain, pain at rest, and pain with activity; however, patients receiving continuous epidural infusion had a significantly higher incidence of nausea-vomiting and motor block but lower incidence of pruritus. In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared to intravenous patient-controlled analgesia.
    Anesthesiology 12/2005; 103(5):1079-88; quiz 1109-10. · 5.16 Impact Factor
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    ABSTRACT: To determine whether a subfascial continuous infusion of local anesthetic in patients undergoing radical retropubic prostatectomy would result in a reduction in postoperative opioid requirements and an improvement in pain scores. This was a prospective, double-blind, placebo-controlled, randomized trial in patients undergoing elective radical retropubic prostatectomy. A small catheter was placed subfascially at the end of surgery and attached to an elastomeric pump that administered either 0.5% bupivacaine or normal saline into the wound at a rate of 2 mL/hr until discharge on postoperative day 3. The outcomes assessed included the dosage of hydromorphone used by a patient-controlled analgesic system, a visual analog scale (VAS) for pain at rest and with activity, a VAS of nausea, and length of hospital stay. A total of 100 patients were successfully randomized, with all patients completing the protocol. No differences were found between the groups with regard to VAS pain at rest, VAS pain with activity, intravenous or oral analgesic consumption, or VAS nausea scores. Continuous subfascial infusion of local anesthetic did not result in a postoperative reduction in opioid requirements or an improvement in pain scores in patients undergoing radical retropubic prostatectomy.
    Urology 09/2005; 66(2):366-70. · 2.42 Impact Factor
  • Christopher L. Wu, Andrew J. Rowlingson, Lee A. Fleisher
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    ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
    Regional Anesthesia and Pain Medicine 04/2005; 30(3):312–313. · 3.46 Impact Factor
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    ABSTRACT: It is unclear whether the severity of postoperative pain may affect patients' quality of recovery in the immediate postoperative period (within 2 weeks of surgery). This was a prospective, observational study in patients undergoing elective radical retropubic prostatectomy. All patients received a standardized intraoperative general or spinal anesthetic followed by intravenous patient-controlled analgesia. Visual analog scores for pain at rest, pain with activity, and nausea along with the QoR, an instrument validated to assess quality of recovery in the postoperative period, and Brief Fatigue Inventory were assessed on postoperative days 1 to 3, 7, and 30. The Epworth Sleepiness Scale was assessed on postoperative days 7 and 30. We found that the severity of pain both at rest and with activity correlated with a decrease in quality of recovery as assessed by the QoR. Our findings suggest that an increase in postoperative pain is correlated with a decrease in a patient's quality of recovery in the immediate postoperative period.
    Regional Anesthesia and Pain Medicine 01/2005; 30(6):516-22. · 3.46 Impact Factor
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    ABSTRACT: Because of the uncertainty and limitations in available randomized controlled trials, we performed an analysis of the Medicare claims database to determine whether an association exists between postoperative epidural analgesia and mortality. A 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 was analyzed to identify patients undergoing segmental excision of the lung (International Statistical Classification of Diseases, Ninth Revision, Clinical Modification codes 32.3 and 32.4), complete pneumonectomy (code 32.5), partial excision of large intestine (codes 45.73 and 45.76), anastomosis of the esophagus (codes 42.5 and 42.6), total knee replacement/revision (codes 81.54 and 81.55), total/radical abdominal hysterectomy (codes 68.4 and 68.6), partial/radical pancreaticoduodenectomy (codes 52.5 and 52.7), partial/complete nephrectomy (codes 55.4 and 55.5), partial/complete cystectomy (codes 57.6 and 57.7), hepatotomy/lobectomy of the liver (codes 50.0 and 50.3), partial/total gastrectomy (codes 43.5 to 43.9), and radical retropubic prostatectomy (codes 60.4 and 60.5). Patients were divided into 2 groups, depending on the presence or absence of postoperative epidural analgesia. The rate of major morbidity and death at 7 and 30 days after surgery were compared. Multivariate regression analyses incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status were performed. The presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38 to 0.73; P = .0001) and 30 days (OR, 0.74; 95% CI, 0.63 to 0.89; P = .0005) after surgery; however, no difference was seen between the groups with regard to overall major morbidity, with the exception of an increase in pneumonia at 30 days for the epidural group (OR, 1.91;[95% CI, 1.09 to 3.34; P = .02). Postoperative epidural analgesia may contribute to lower odds of death after surgery.
    Regional Anesthesia and Pain Medicine 01/2004; 29(6):525-33; discussion 515-9. · 3.46 Impact Factor
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    ABSTRACT: The hypothesis of this study was to determine if the severity of postoperative pain would affect patients' health-related quality of life (HRQL) in the immediate postoperative period (within 2 wk of surgery). We designed this study as a prospective, nonrandomized observational trial in a tertiary academic care center. Patients undergoing elective total hip or knee replacement surgery were eligible. Patients received a standardized intraoperative general or epidural anesthetic followed by IV patient-controlled analgesia or patient-controlled epidural analgesia. Short Form (SF)-12, visual analog scores for pain at rest and pain with activity, nausea, and itching were assessed on postoperative days 1-5, 7, and 14. The severity of pain correlated with a decrease in both the physical and mental component of the SF-12. The severity of nausea correlated with a decrease in the mental but not physical component of the SF-12. The severity of itching did not correlate with a change in the SF-12. Our findings suggest that an increase in postoperative pain will decrease a patient's quality of life in the immediate postoperative period; however, several methodologic issues exist when assessing HRQL in the immediate postoperative period. IMPLICATIONS: Severity of postoperative pain may affect quality of life.
    Anesthesia & Analgesia 11/2003; 97(4):1078-85, table of contents. · 3.30 Impact Factor
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    ABSTRACT: Whether epidural analgesia is a better method than parenteral opioids for postoperative pain control remains controversial. To systematically review the efficacy of postoperative epidural analgesia vs parenteral opioids, the primary alternative technique. Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to April 25, 2002) and other sources for studies related to postoperative epidural analgesia. Inclusion criteria were a comparison of epidural therapy vs parenteral opioids for postoperative analgesia, measurement of pain using a visual analog scale (VAS) or numeric rating scale, randomization of patients to either therapy, and adult patients (> or =18 years). A total of 1404 abstracts were identified, 100 of which met all inclusion criteria. Each article was reviewed and data extracted from tables, text, or extrapolated from figures as needed. Weighted mean pain scores, weighted mean differences in pain score, and weighted incidences of complications were determined by using a fixed-effect model. Epidural analgesia provided better postoperative analgesia compared with parenteral opioids (mean [SE], 19.40 mm [0.17] vs 29.40 mm [0.20] on the VAS; P<.001). When analyzed by postoperative day, epidural analgesia was better than parenteral opioids on each postoperative day (P<.001 for each day after surgery). For all types of surgery and pain assessments, all forms of epidural analgesia provided significantly better postoperative analgesia compared with parenteral opioid analgesia (P<.001 for all), with the exception of thoracic epidural analgesia vs opioids for rest pain after thoracic surgery (weighted mean difference, 0.6 mm; 95% confidence interval, -0.3 to 1.5 mm; P =.12). The complication rates were lower than expected for nausea or vomiting and pruritus but comparable with existing data for lower extremity motor block. Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provided better postoperative analgesia compared with parenteral opioids.
    JAMA The Journal of the American Medical Association 11/2003; 290(18):2455-63. · 29.98 Impact Factor