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Journal of Cardiothoracic and Vascular... May 2024To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery.
OBJECTIVE
To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery.
DESIGN
Retrospective cohort study.
SETTING
Single academic medical center.
PARTICIPANTS
Patients undergoing isolated CABG over a 5-year period.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01).
CONCLUSIONS
Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.
PubMed: 38876810
DOI: 10.1053/j.jvca.2024.05.012 -
Diving and Hyperbaric Medicine Jun 2024Blood alcohol concentrations above defined levels are detrimental to cognitive performance. Empirical and published evidence suggest that nitrogen narcosis is analogous...
Blood alcohol concentrations above defined levels are detrimental to cognitive performance. Empirical and published evidence suggest that nitrogen narcosis is analogous to alcohol intoxication with both impairing prefrontal cortex function. Nitrogen narcosis is also known to have been a factor in fatal accidents. To examine the effects of nitrogen narcosis, a recent publication used the Iowa Gambling Task tool, to simulate dynamic real-life risky decision-making behaviour. If the reported outcomes are corroborated in larger rigorously designed studies it is likely to provide further evidence that divers may well experience the negative effects of a 'narcotic agent', even at relatively shallow depths. These deleterious effects may occur regardless of diving experience, aptitude or professional status. In 1872, English law made it an offence to be 'drunk' whilst in charge of horses, carriages, cattle and steam engines. Understanding the danger was easy, establishing who is 'drunk' in the eyes of the court required a legal definition. Driving above a 'legal limit' for alcohol was made illegal in the United Kingdom in 1967. The limit was set at 80 milligrams of alcohol per 100 millilitres of blood. It took just short of one hundred years to get from first introducing a restriction to specific activities, whilst under the influence of alcohol, to having a clear and well-defined enforceable law. The question surely is whether our modern society will tolerate another century before legally defining safe parameters for nitrogen narcosis?
Topics: Humans; Diving; Inert Gas Narcosis; Driving Under the Influence; United Kingdom; Alcoholic Intoxication; Blood Alcohol Content
PubMed: 38870957
DOI: 10.28920/dhm54.2.137-139 -
Paediatric & Neonatal Pain Jun 2024Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid...
Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) ( = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18-24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort ( = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort ( = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0-24, 24-48, and 48-72 h. There was a statistically significant difference in median pain scores at 24-48 and 48-72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.
PubMed: 38863457
DOI: 10.1002/pne2.12117 -
Annals of Plastic Surgery Jun 2024Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in... (Comparative Study)
Comparative Study
Local Infiltration Anesthesia Versus Ultrasound-Guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Postanesthetic Care Unit Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty.
BACKGROUND
Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in plastic surgery. The purpose of this study was to analyze the outcomes of these newer anesthetic techniques compared with traditional blind local anesthetic infiltration in patients undergoing breast augmentation.
METHODS
This retrospective institutional review board-approved cohort study compared the outcomes of the different practices of 2 plastic surgeons at the same accredited outpatient surgery center between 2018 and 2022. Group 1 received an intraoperative blind local infiltration anesthetic. Group 2 underwent surgeon-led, intraoperative, ultrasound-guided PEC1 (Pectoralis 1) + SAP (serratus anterior plane) blocks. Patients who underwent any procedure other than primary submuscular augmentation mammoplasty were excluded from the study. The outcomes measured included operative time, opioid utilization in morphine milligram equivalents (MME), pain level at discharge, and time spent in the post anesthetic care unit (PACU).
RESULTS
Sixty patients met the inclusion criteria for each group for a total of 120 patients. The study groups were similar to each other. Patients receiving PEC1 + SAP blocks (group 2) had significantly lower average MME requirements in the PACU (3.04 MME vs 4.52 MME, P = 0.041) and required a shorter average PACU stay (70.13 minutes vs 80.38 minutes, P = 0.008). There were no significant differences in the pain level at discharge, operative time, or implant size between the 2 groups.
CONCLUSIONS
Surgeon-led, intraoperative, ultrasound-guided PEC1 + SAP blocks significantly decreased opioid utilization in the PACU by 33% and patient time in the PACU by 13%, while achieving similar patient pain scores and operating times.
Topics: Humans; Female; Retrospective Studies; Ultrasonography, Interventional; Adult; Nerve Block; Pain, Postoperative; Anesthesia, Local; Mammaplasty; Pain Management; Pectoralis Muscles; Middle Aged; Pain Measurement; Anesthesia Recovery Period; Anesthetics, Local; Cohort Studies
PubMed: 38857002
DOI: 10.1097/SAP.0000000000003948 -
Plastic and Reconstructive Surgery.... Jun 2024Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus...
BACKGROUND
Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction.
METHODS
This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016-2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed.
RESULTS
Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677-0.879]; = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347-0.581]; < 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411-0.629]; < 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452-0.993]; = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785-0.999]; = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different.
CONCLUSIONS
LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.
PubMed: 38855138
DOI: 10.1097/GOX.0000000000005874 -
Plastic and Reconstructive Surgery.... Jun 2024Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients...
BACKGROUND
Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients undergoing tissue expander-based breast reconstruction (TEBR). This study evaluates the effectiveness of an ERAS postoperative protocol for TEBR at a high-volume center.
METHODS
All patients undergoing immediate tissue expander reconstruction after the introduction of ERAS were prospectively included from April 2019 to June 2023. An equivalent number of similar patients were retrospectively reviewed before this date as the non-ERAS control. Data included demographics, operative details, postoperative length of stay, inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation, and complications within 90 days.
RESULTS
There were 201 patients in each cohort with statistically similar demographics. Patients in the ERAS cohort were more likely to undergo prepectoral reconstruction (83.1% versus 4.5%, < 0.001), be discharged by day 1 (96.5% versus 70.2%, < 0.001) and consume lower inpatient milligram morphine equivalent (MME) median (79.8 versus 151.8, < 0.001). Seroma rates (17.4% versus 3.5%, < 0.001) and hematoma incidence (4.5% versus 0%, = 0.004) were higher in the ERAS cohort. Adjusting for implant location, ERAS was associated with a 60.7 MME reduction (β=-60.7, < 0.001) and a shorter inpatient duration by 0.4 days (β =-0.4, < 0.001). Additionally, prepectoral reconstruction significantly decreased MME (β=-30.9, = 0.015) and was the sole predictor of seroma development (odds ratio = 5.2, = 0.009).
CONCLUSIONS
ERAS protocols significantly reduce opioid use and hospital stay after TEBR.
PubMed: 38855130
DOI: 10.1097/GOX.0000000000005879 -
Journal of Shoulder and Elbow Surgery Jun 2024Preoperative opioid users (POU) experience worse outcomes and higher complication rates compared to opioid naïve patients (ONP) following shoulder arthroplasty. This...
BACKGROUND
Preoperative opioid users (POU) experience worse outcomes and higher complication rates compared to opioid naïve patients (ONP) following shoulder arthroplasty. This study evaluates the effects of socioeconomic status (SES), as measured by the distressed communities index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery.
METHODS
A retrospective review of patients who underwent primary shoulder arthroplasty (CPT code 23472) from 2014-2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index (CCI), DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents (MME) was gathered.
RESULTS
Individuals from distressed communities utilized more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared to prosperous, comfortable, and mid-tier respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs 21.3%, p<0.001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs 21.7%, p=0.002).
CONCLUSIONS
Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.
PubMed: 38852706
DOI: 10.1016/j.jse.2024.04.016 -
Journal of Chromatography. A Aug 2024Efficient rare earth element (REE) separations are becoming increasingly important to technologies ranging from renewable energy and high-performance magnets to applied...
Efficient rare earth element (REE) separations are becoming increasingly important to technologies ranging from renewable energy and high-performance magnets to applied radioisotope separations. These separations are made challenging by the extremely similar chemical and physical characteristics of the individual elements, which almost always occupy the 3+ oxidation state under ambient conditions. Herein, we discuss the development of a novel REE separation aimed at obtaining purified samples of neodymium (Nd) on a multi-milligram scale using high-speed counter-current chromatography (HSCCC). The method takes advantage of the subtle differences in ionic radii between neighboring REEs to tune elution rates in dilute acid through implementation of the di-(2-ethylhexyl)phosphoric acid (HDEHP)-infused stationary phase (SP) of the column. A La/Ce/Nd/Sm separation was demonstrated at a significantly higher metal loading than previously accomplished by HSCCC (15 mg, R > 0.85), while the Pr/Nd separation was achieved at lower metal loadings (0.3 mg, R = 0.75 - 0.83). The challenges associated with scaling REE separations via HSCCC are presented and discussed within.
Topics: Countercurrent Distribution; Neodymium; Organophosphates
PubMed: 38852269
DOI: 10.1016/j.chroma.2024.465033 -
Harm Reduction Journal Jun 2024As the opioid public health crisis evolves to include fentanyl and other potent synthetic opioids, more patients are admitted to the hospital with serious complications...
BACKGROUND
As the opioid public health crisis evolves to include fentanyl and other potent synthetic opioids, more patients are admitted to the hospital with serious complications of drug use and frequently require higher levels of care, including intensive care unit (ICU) admission, for acute and chronic conditions related to opioid use disorder (OUD). This patient population poses a unique challenge when managing sedation and ensuring adequate ventilation while intubated given their high opioid requirements. Starting a patient on medications such as buprenorphine may be difficult for inpatient providers unfamiliar with its use, which may lead to undertreatment of patients with OUD, prolonged mechanical ventilation and length of stay.
METHODS
We developed a 7-day buprenorphine low dose overlap initiation (LDOI) schedule for patients with OUD admitted to the ICU (Table 1). Buprenorphine tablets were split by pharmacists and placed into pre-made blister packs as a kit to be loaded into the automated medication dispensing machine for nursing to administer daily. An internal quality review validated the appropriate dosing of split-dose tablets. To simplify order entry and increase prescriber comfort with this new protocol, we generated an order set within our electronic health record software with prebuilt buprenorphine titration orders. This protocol was implemented alongside patient and healthcare team education and counseling on the LDOI process, with follow-up offered to all patients upon discharge.
RESULTS
Here we report a series of 6 ICU patients started on buprenorphine using the LDOI schedule with split buprenorphine tablets. None of the 6 patients experienced precipitated withdrawal upon buprenorphine initiation using the LDOI schedule, and 5/6 patients were successfully extubated during the buprenorphine initiation. Four of six patients had a decrease in daily morphine milligram equivalents, with 3 patients transitioning to buprenorphine alone.
CONCLUSION
Initiating buprenorphine via LDOI was found to be successful in the development of a protocol for critically ill patients with OUD. We examined LDOI of buprenorphine in intubated ICU patients and found no events of acute precipitated withdrawal. This protocol can be used as a guide for other institutions seeking to start critically ill patients on medication treatment for OUD during ICU admission.
Topics: Humans; Buprenorphine; Opioid-Related Disorders; Intensive Care Units; Male; Analgesics, Opioid; Female; Opiate Substitution Treatment; Adult; Middle Aged; Narcotic Antagonists; Intubation, Intratracheal
PubMed: 38849912
DOI: 10.1186/s12954-024-01028-4 -
The Spine Journal : Official Journal of... Jun 2024Perioperative pain management affects cost and outcomes in elective spine surgery.
BACKGROUND CONTEXT
Perioperative pain management affects cost and outcomes in elective spine surgery.
PURPOSE
This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization.
STUDY DESIGN
This was a retrospective comparative study.
PATIENT SAMPLE
Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores.
OUTCOME MEASURES
Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis.
METHODS
Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc.
RESULTS
In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts.
CONCLUSIONS
Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.
PubMed: 38843956
DOI: 10.1016/j.spinee.2024.05.005