Hello. This is Francesca Matthews with the Becker's
ASC review podcast.
I'm thrilled to be joined today by Armin
Voskaridjian,
director of anesthesia services at Jefferson Surgery Center
at the Navy Yard. Armin, thank you so
much for being here today.
Oh, thank you for having me, Franchesca.
A lot has gone on since, our last
Becker's,
podcast we did with Alan,
in November,
2024.
For those of you that missed that podcast,
you may wanna go back and take a
quick listen. It's only nineteen minutes long to
that podcast, but we're gonna be I would
like to follow-up with, the information I presented
there. At the time, it was pretty preliminary,
but we've got some
rock hard facts. Now we got some data,
enough for two studies, and I would like
to share that with the Becker's community.
Absolutely.
Very excited to hear all about that. But
just to start us off, could you please
introduce yourself and tell us a little bit
about your background?
Sure. Sure. Again, as you said, my name
is Arman Voskarygian.
I'm a double board certified in internal medicine
and anesthesiology,
physician. I work primarily at a a small
ambulatory surgery center in the Navy Yard in
South Philly.
I trained
mainly in New York. I'm actually going to
my fortieth high school reunion at the end
of this month, so I give a little
shout out to the Bronx High School of
Science, if there are any alumni out there.
I went to college at NYU,
medical school at the State University of New
York downstate in Brooklyn.
Shout out to Brooklyn.
And then I did my, internal medicine residency
in Staten Island
and passed my boards and then did the
anesthesia residency at New York
Hospital Cornell
on the Upper East Side. Stayed there for
two years, as a teaching adjunct.
Did private practice for two years. Did not
like it at all.
And then I came to Philadelphia to be
closer to my family where I worked at
Albert Einstein Medical Center
in North Philly for about ten years.
And then I found this job,
at the Navy Yard,
which was primarily focusing in,
outpatient ambulatory orthopedic
surgery.
We do everything except for joint replacements,
unfortunately.
But, everything else we do, we work on
everything from collarbone fractures,
shoulder cases, rotator cuff repairs,
elbow, wrist,
hip scopes,
knee scopes, ACL repair, MPFL repairs,
quad tendon,
patella tendon,
and foot and ankle cases. Everything from Lisfranc
fractures to,
Achilles tendon repairs.
And,
I became director of the, anesthesia services there
about three years ago now.
So
that's basically my CV in a nutshell.
Excellent. Great. Well, we we do have some
questions here kind of about
ASCs at large and sort of some,
zoomed out large level industry questions, but I
am first interested in,
in these studies that you were discussing. If
you could just enlighten us a little bit
as to what you've been working on.
Sure. So, last time,
I spoke with Becker's,
we we I was bragging about some incredible
results we've been getting.
At this point, we have submitted our first
paper,
to the online journal of sports medicine. This
is our ACL study.
Our, subjects were a 131,
so n equals a 131.
We split that into two groups.
One group getting
liposomal bupivacaine,
with mixed with aqueous bupivacaine,
and then the other group would get liposomal
bupivacaine
with the aqueous bupivacaine
and the additional
preservative free dexamethasone.
Now although the the theory being that the
dexamethasone
would prolong
the effects,
we didn't see
that greater
reflection of prolongation
of effects on the ACL study.
We'll get to that,
in the foot and ankle study. There was
only approximately about twenty four to thirty hours
extra by adding the dexamethasone.
However,
the more stunning result is in both groups,
if you just take the n of a
hundred and thirty one,
seventy seven percent of those hundred and thirty
one patients
took zero narcotics
after their ACL repair surgery, and that includes
quad tendon, patella tendon,
and allograft.
The allografts did the, did the best, obviously.
They're known to have less pain because it's
a cadaveric donor of the ACL
of the, ligament.
And,
those patients usually come out,
complaining of zero to one pain. The ACL
patients came out complaining of about three to
four on average is the score out of
ten,
and they took zero seventy seven percent took
zero narcotics,
and this is now documented. This is gonna
be published. I'm hoping we'll get the results,
the yes or no from the online Journal
of Sports Medicine soon. Of the twenty three
percent of patients that did take narcotics after
their ACL repair surgery,
the average number of pills they took
was less than two five milligram oxycodone pills.
These these are, in my opinion, incredible results.
I think any orthopedic surgeon
would be hard pressed to deny that.
So we're very proud of these results,
that we're getting here.
For the foot and ankle study, we have
not yet submitted that for publishing, but we
have our abstract out. We have the preliminary
data out.
Our end, I believe, was a hundred and
twenty nine patients for the foot and ankle
study. And there, we did notice a significant,
improvement
in the block length duration,
for those that for the group that did
get the dexamethasone,
the preservative free dexamethasone
in the, foot popliteal and saphenous nerve blocks.
So again, two groups of patients, total a
100 and twenty nine.
One group received,
liposomal bupivacaine
with,
aqueous bupivacaine and no dexamethasone,
no preservative free dexamethasone.
The second group received liposomal bupivacaine
plus aqueous bupivacaine
and
preservative free dexamethasone. So one group basically had
no preservative free dexamethasone,
the other group did. And we took all
types of surgeries from
surgeries that the surgeon had requested a block
previously from the anesthesiologist.
So that included everything from Lisfranc fractures
to,
complex bunionectomies,
Achilles tendon ruptures,
trimal bimalleolar,
ankle fractures.
Of those hundred and twenty nine patients,
I believe,
and don't quote me on this, but I
believe the average number of pill takers, narcotic
pill takers in both groups was I'm sorry.
I'll take that back. In the dexamethasone group
was
zero point seven percent.
That just means that out of every hundred
patients,
only seven people took narcotics.
Mhmm. So Yeah. These are remarkable. Yeah. Yeah.
Unbelievable.
And the length, duration,
that the dexamethasone
was able to extend was approximately,
thirty
six to forty hours. But, again, don't quote
me on that. I'd have to look I
don't have the results in front of me
right now, but I did send them to
you, and, I can go over them later
on. But these are un unbelievable
results. This is unheard of right now. The
only thing that comes close to these kinds
of results was when we were placing catheters.
And catheters were
great for what they were accomplishing,
but, unfortunately,
we were only placing them on one of
the two nerves that we blocked, the one
that did the most, lifting, the heavy lifting,
which was the popliteal nerve. We would let
the saphenous nerve go. So patients invariably
had a,
plateau,
of pain control wherein
they felt great when they left the surgery
center. But after twenty four to thirty six
hours when the,
saphenous nerve block wore off and they were
just relying on the catheter for the popliteal
nerve, you'd see a spike in complaints about
pain, obviously, because the, saphenous nerve is now
activated.
And,
but narcotic use would go up. Depends on
the patient, depends on the surgery,
all that taken into account, though, this was
what we were seeing.
And so it was it was it was
good for what it was at the time,
but,
it was not
it was not the best that we could
do. And I believe this is,
going above and beyond providing,
both nerves
with a complete blockade that's lasting us about
six to seven days.
And I'm saying that,
with some hesitation because,
and I'll get to this, a little bit
later.
But, I've modified
my,
use of the liposomal bupivacaine after the first
podcast came out in November.
I got some shout outs from colleagues across
the country,
and the most disconcerting,
comment I was receiving
was that you I'm very fortunate
myself. I'm very fortunate to be able to
use this much liposomal bupivacaine, and we'll get
into the amounts in a moment,
simply because
their
institutions, the pharmacy wouldn't even allow them to
touch liposomal bupivacaine. Or if they did, it
would only be the 10 cc bile, not
the 20 cc bile. So liposomal bupivacaine comes
in two volumes, 10 cc and 20 cc.
And that made me rethink
this is after the studies were already finalized,
but it made me rethink my approach. I
was very fortunate to have an administrator
at our ASC at the Navy Yard, Jefferson
Surgical Center at the Navy Yard,
who
saw the results we were getting, saw the
patients almost taking minimal to zero narcotics,
saw the responses of the surgeons, which were
positive all across the board, and allowed me
to sort of
she didn't complain about my,
liposomal bupivacaine use. And as everybody knows who's
listening, liposomal bupivacaine is definitely expensive.
So another report I'd like to make on
this podcast is that I've reduced the amount
of liposomal bupivacaine
with minimal in both of those blocks, the
foot and ankle and the ACL, with minimal
changes in narcotic use and patient satisfaction and
patient pain scores, but I don't have any
data for that. But I'd be more than
happy to share that if you're interested in
delving, giving me a couple more minutes more.
Yeah. I mean, go go into any more
detail that you feel like is is appropriate.
I, yeah, wanna get the full breadth of
this before we kinda dive into how it
might affect the industry going forward.
Wonderful. Thank you, Francesca. I appreciate it. So
the study for the ACL that is being,
submitted for publication at the online Journal of
Sports Medicine,
in that initial study, we were using thirty
ccs of liposomal bupivacaine. So one twenty c
c vial and one ten c c vial.
In my subsequent,
reevaluation,
I've gotten that down to one twenty c
c vial.
And if anybody wants to reach out to
me, I'd be more than happy to share,
how I'm doing it. You can reach me
on LinkedIn, or I'm sure if you they
can contact me through Becker's as well.
So the ACL,
amount of liposomal bupivacaine was reduced by one
third. So instead of using thirty cc's, I'm
using twenty cc's. For the foot and ankle,
I was using 20 cc's for the study,
of liposomal bupivacaine for a final volume of
30 cc's. I've got that down to now
ten cc's of liposomal bupivacaine,
a final volume of about 21 cc's with
the dexamethasone
in it. Having reduced the amount of bupivacaine,
I'm now administering preservative free dexamethasone
to everyone.
So, basically, what these studies have shown is
that even though the manufacturer,
states that you shouldn't be mixing anything with
liposomal bupivacaine besides aqueous bupivacaine
with the caveats for how much you can
add,
how many milligrams you can add.
I've shown we've shown at the Navy Yard
that you can actually,
add preservative free dexamethasone
without comp compromising the liposomes.
That's the first thing. And then we've shown
that, with adding the preservative free dexamethasone, you
can prolong
the effect of the blocks that you're getting.
And finally,
that you can do this with less liposomal
duplicates than our studies actually showed.
And that's anecdotal, that part, but, I'd be
happy to talk to anybody that's, willing to
talk to me about it. So the ACL,
again, twenty cc's liposomalpivacaine,
and the foot and ankle blocks will get
we're using ten cc's of liposomalpivacaine.
And, to add to that, Francesca, I believe
we discussed this, during the interview we had
a couple of weeks ago. This formulation
where you're mixing the liposomal bupivacaine,
the aqueous bupivacaine, and the preservative free dexamethasone
will work on any of the blocks that
we're doing. So this works for superficial cervical
plexus blocks for clavicle fractures.
It works for the interscalene, and that's the
last study we'll be publishing. That's still underway.
We're still collecting data for that.
So it will work for the interscaling blocks.
It will work
for your,
ACL blocks and, as a side and foot
and ankle blocks, your pops up blocks. As
a side note, the final discovery that we
were able to publish in the ACL study
was that we've added a third infiltration
for ACL
knee surgeries.
In other words, your standard blocks for the
ACL surgeries were your adductor canal block,
done at the apex of the triangle of
the adductor canal,
and your IPAC block for behind the knee
pain. I've added a third block to that,
which is the suprasartorial
infiltration,
and we get into that in the study
as to, how I was motivated to do
that.
And by adding that third block, I think
we've that that is also another strength, and
it's not just a liposomal bupivacaine.
It's by doing these three infiltrations
that you can truly
get superior coverage of blocking the knee. So
the suprasartorial
infiltration,
your adductor canal block at the apex of
the triangle,
and your iPAC infiltration.
I've used this on four total knee replacements.
One of them for a very close friend
of mine, three of them,
at the Rothman Orthopedics actually, all four were
the Rothman Orthopedic Specialty Hospital in Bensalem, Pennsylvania.
And narcotic use was, basically eliminated,
postoperatively
by the patients. And these are patients that
went to rehab,
approximately eight hours after their surgery, six to
eight hours after their surgery.
The PT the physical therapists were pretty impressed
at the results they were getting. And so
this is not a motor block. There's no
motor blockade.
The volumes are kept low, and the satisfaction
and the pain control is superlative.
I can't I can't express how happy we
we are with the results that we've gotten.
Absolutely. And kind of given all that, taking
a step back, what do you see as
the potential
influence of this discovery on,
the ASC industry at large and for outpatient
surgery?
I can only speak from personal observation,
but, what we're seeing is basically,
with the government cutting funding,
for reimbursements for procedures, and then the private
insurance is following suit.
Reimbursements
for anesthesia,
both the CRNA and the anesthesia physician
are,
getting less.
Salaries are going up.
This makes for an impossible scenario. You can't
cut reimbursements
and increase and have an increased cost of
living,
and plus competition
as well,
increase in salaries,
and,
expect
the revenue from your insurance company
reimbursement to cover everything. So what I've been
seeing in our institution
is that, unfortunately, our anesthesia group has had
to ask the ambulatory surgery center
to start paying outside. In other words, paying
the
ambulatory, the anesthesia group separately.
And
the anesthesia group is telling the,
ambulatory surgery center,
you keep the collections
because it's just not enough. And this, unfortunately,
means that the ambulatory surgery center has to
dig into its profits to pay for an
anesthesia group now.
And,
this is,
this is a big strain. It's a big,
it's a big,
chunk of money. This is not,
small amounts of money we're talking about here,
especially if you're running a four to six
room ambulatory surgery center. So
what does this bring? This brings the anesthesia
group saying that we're not just here asking
for reimbursements and and increased reimbursements or increased
money.
This is what we're bringing to you. They
we're bringing to you top of the top
of the top of the line, cutting edge,
anesthesia
nerve blockade for outpatient surgery where your patients
are going home, and they're basically not taking
any narcotics. The surgeons have almost stopped prescribing
narcotics
if if if not severely curtailing their narcotic
prescriptions,
sometimes switching to
lesser, quote, unquote, lesser forms of, narcotics like
tramadol versus,
using oxycodone.
And, some of the patients are not even
taking that.
This is a big
deal,
when it comes to advocating for the group.
The surgeons will be the first person to
advocate for them. Any anesthesia group that adopts
this type of,
for outpatient orthopedic surgery or for perhaps other
types of surgery. This will work for tap
blocks. This will work for,
the surgeons doing infiltrations
when when they're using liposomal bupivacaine,
whether they're general surgeons or OBGYNs.
If they add preservative free dexamethasone
to their liposomal butpivacaine and acryl's butpivacaine mixture,
it's gonna make their blocks last longer. Again,
no data. It needs to be studied. This
needs to be shown to be the case.
Maybe like the ACL study, it'll be shown
that the difference in adding the in the
preservative free dexamethasone
doesn't make a clinically significant difference. But, again,
this is, these are avenues right for,
study in the future. But, again, the anesthesia
group can say, look at what we're doing
with your outpatient ambulatory orthopedic surgeries.
This is what we're bringing. No pain, no
narcotic use to minimal narcotic use. That's a
big draw,
especially in this day and age of,
opioid,
epidemics,
the no pain act that was just passed
for 2025
in congress.
The the this can be only a feather
in the cap of the anesthesia group that
adopts these measures.
Mhmm. Absolutely. I mean, it sounds like a
a win win for, you know, physicians and
for patients, you know, given the the benefit
to,
the added value that anesthesiologists would be bringing
given, you know, this clinical development. And then
it is also the
improvement in patient patient satisfaction and overall outcomes.
Just, yeah, like, that seems win win. When
you mentioned patient satisfaction,
we're going to be start to be reimbursements
are gonna be tied to patient satisfaction scores.
Mhmm. So all of it comes it becomes
one big
box present with a bow tie on top,
and you give that to the anesthesia,
ASC,
provide the administrator.
And, hopefully,
you know, they take it with a grain
of salt, and they see the benefit in
that.
Absolutely.
Yeah.
Great. Yeah. Absolutely. And, you know, taking a
bit of a step back away from, this
development, are what are some other trends that
you're following in health care and in ASCs
today?
So
the to me, these are the number one
and number two issues.
For at least for ambulatory orthopedic surgery centers.
Obviously, what I'm saying is not going to
affect places that do colonoscopies
and endoscopies. That,
that I that is outside of my purview.
We don't do that at my institution. But
any place that does outpatient ambulatory orthopedic surgery
is definitely gonna be benefiting from this. And,
unfortunately, what I see in the future is
is is is this is the trend that
we're seeing. We're going to be seeing more
and more anesthesia groups,
requesting,
their payments directly from the ASC
with cutting into the profits of the ASC,
while the ASC now struggles to make their
collections from the insurance companies for anesthesia services
provided.
This puts an undue burden on the ASC,
unfortunately,
but
I there there's just I don't see how
it's going to change. If
the government keeps cutting reimbursement rates,
and as we know, inflation is constantly there,
as a backdrop to our
yearly lives,
in cost of living is gonna go up.
They're gonna have to be competitive. ASCs are
gonna have to offer,
or an anesthesia groups are gonna have to
keep up with their salaries.
And the salaries are increasing by two to
3% every year, if not more, since some
places,
depending on where you are. And
in order to do that, you're not you
can't depend on reimbursement from the private insurance
companies or the,
government. Obviously, not the government for a long
time. It's not been enough.
But, with the the the the what's really
been impactful in the past couple of years
is that now even the private insurance reimbursement
rates are not enough.
If you're sick and your ASC patient population
starts to change, what was good
two, three, three, four years ago may not
be any good anymore because suddenly the demographics
of who's coming to your surgery center. New
surgeons are onboarded. Old surgeons start to retire.
So the patient demographic
may start to mix also.
And once that happens, you can't rely on
past performance. As we know, past performance is
no indication of future returns.
So,
this is a big stress on ASCs, and
I think we're gonna see a slowing down,
if not already, in the,
upstart of new openings of ASCs around the
country.
Absolutely. This is a big time. This is
an alarm sort of a canary in a
coal mine.
Mhmm. Yeah. Definitely. And I think that that's
echoing concerns I've heard from other ASC leaders
as well.
Kind of on the flip side of, you
know, concerns, this is obviously an incredibly exciting
development.
What else are you excited about right now
in this space?
Oh,
if anything. I I that's what I just
said. Really nothing because everything I just told
you has eclipsed,
my view of,
of the future for it's been a while
now. My head's been my nose has been
in the grindstone, and I'm just now taking,
time to look up and get get some
air. So I I'll I'll defer that question,
to perhaps another interviewee.
Gotcha. Gotcha. No worries. I mean, I can
completely completely understand that. And everything you've discussed
so far is also just kind of so
interconnected between the clinical developments,
you know, outcomes for patients, and then obviously,
the sustainability of, ASCs in the future. So
I can understand how that's definitely, like you
said, just eclipsing everything.
We are kinda close to time here. Is
there anything that we haven't touched on so
far that you would like to mention?
Again, I, if, anybody's interested in the work
we're doing,
obviously, we'll be publishing soon in the online
journal of sports medicine.
We will be submitting the foot and ankle
study, but I we haven't decided which journal
yet to, we're waiting to to hear from,
back from a few. But if anybody has
any questions,
feel free to reach out to me.
You can either do that through LinkedIn or
I'm sure through Becker's ASC.
People can get in touch with me as
well. I would love to share,
my data anecdotal or or otherwise
with anybody interested in bringing this type of
cutting edge,
regional ultrasound guided regional anesthesia to,
their ASC. I it would be my pleasure.
Absolutely.
Alright. Well, that is all I have for
you today, Armin. Thank you so much for
for joining us. Thank you so much. I
appreciate it.
Yes.
Yeah. Yeah. Of course. We're yeah. I'm so
excited to hear more about your findings,
and I look forward to connecting with you
again in the future.
Likewise. Thank you so much. Absolutely. You have
a good one. Thank you. Bye bye. Bye.