Prescription Opioid Use and Satisfaction With Care Among Adults With Musculoskeletal Conditions.

PURPOSE: In the current payment paradigm, reimbursement is partially based on patient satisfaction scores. We sought to understand the relationship between prescription opioid use and satisfaction with care among adults who have musculoskeletal conditions. METHODS: We performed a cross-sectional study using nationally representative data from the 2008-2014 Medical Expenditure Panel Survey. We assessed whether prescription opioid use is associated with satisfaction with care among US adults who had musculoskeletal conditions. Specifically, using 5 key domains of satisfaction with care, we examined the association between opioid use (overall and according to the number of prescriptions received) and high satisfaction, defined as being in the top quartile of overall satisfaction ratings. RESULTS: Among 19,566 adults with musculoskeletal conditions, we identified 2,564 (13.1%) who were opioid users, defined as receiving 1 or more prescriptions in 2 six-month time periods. In analyses adjusted for sociodemographic characteristics and health status, compared with nonusers, opioid users were more likely to report high satisfaction with care (odds ratio = 1.32; 95% CI, 1.18-1.49). According to the level of use, a stronger association was noted with moderate opioid use (odds ratio = 1.55) and heavy opioid use (odds ratio = 1.43) (P <.001 for trend). CONCLUSIONS: Among patients with musculoskeletal conditions, those using prescription opioids are more likely to be highly satisfied with their care. Considering that emerging reimbursement models include patient satisfaction, future work is warranted to better understand this relationship.

Association between sleep apnea and perioperative outcomes among patients undergoing shoulder arthroscopy.

PURPOSE: Sleep apnea is a recognized risk factor for adverse perioperative outcomes in total joint arthroplasty. Nevertheless, little is known about its impact on shoulder arthroscopy, which is a commonly performed ambulatory procedure. Our primary objective was to determine whether sleep apnea was associated with increases in complications and healthcare utilization in this setting. METHODS: We analyzed administrative data collected from 583 U.S. hospitals between 2010-2015 and identified a cohort of 128,932 patients who underwent shoulder arthroscopy. Using a cross-sectional study design, we examined the relationship between sleep apnea and perioperative outcomes including mortality, stroke, myocardial infarction, and pulmonary complications. We also examined a variety of health utilization outcomes. RESULTS: Among patients who underwent shoulder arthroscopy, approximately 6% (7,761 of 128,932) had the diagnosis of sleep apnea. The overall complication rate in these patients was 1.39% (95% confidence interval [CI], 1.33 to 1.45). In a crude analysis, sleep apnea was associated with increases in the majority of systemic complications. In adjusted analyses, sleep apnea was associated with a 4.95 (95% CI, 1.81 to 13.5) times greater odds of acute myocardial infarction and a 4.92 (95% CI, 2.72 to 8.9) times greater odds of pulmonary complications. Sleep apnea was also associated with increased odds of requiring postoperative ventilation, hospital admission, and intensive care unit admission. CONCLUSION: Sleep apnea is associated with an increased risk of complications and resource utilization in patients undergoing shoulder arthroscopy.

A comparison of oxygen saturation data in inpatients with low oxygen saturation using automated continuous monitoring and intermittent manual data charting.

BACKGROUND: The manual collection and charting of traditional vital signs data in inpatient populations have been shown to be inaccurate when compared with true physiologic values. This issue has not been examined with respect to oxygen saturation data despite the increased use of this measurement in systems designed to assess the risk of patient deterioration. Of particular note are the lack of available data examining the accuracy of oxygen saturation charting in a particularly vulnerable group of patients who have prolonged oxygen desaturations (mean SpO2 <90% over at least 15 minutes). In addition, no data are currently available that investigate the often suspected "wake up" effect, resulting from a nurse entering a patient's room to obtain vital signs. METHODS: In this study, we compared oxygen saturation data recorded manually with data collected by an automated continuous monitoring system in 16 inpatients considered to be at high risk for deterioration (average SpO2 values <90% collected by the automated system in a 15-minute interval before a manual charting event). Data were sampled from the automatic collection system from 2 periods: over a 15-minute period that ended 5 minutes before the time of the manual data collection and charting, and over a 5-minute range before and after the time of the manual data collection and charting. Average saturations from prolonged baseline desaturations (15-minute period) were compared with both the manual and automated data sampled at the time of the nurse's visit to analyze for systematic change and to investigate the presence of an arousal effect. RESULTS: The manually charted data were higher than those recorded by the automated system. Manually recorded data were on average 6.5% (confidence interval, 4.0%-9.0%) higher in oxygen saturation. No significant arousal effect resulting from the nurse's visit to the patient's room was detected. CONCLUSIONS: In a cohort of patients with prolonged desaturations, manual recordings of SpO2 did not reflect physiologic patient state when compared with continuous automated sampling. Currently, early warning scores depend on manual vital sign recordings in many settings; the study data suggest that SpO2 ought to be added to the list of vital sign values that have been shown to be recorded inaccurately.

Dysautonomia following breast surgery: Disproportionate response to postoperative hematoma.

Background: Up to 10% of patients undergoing breast surgery suffer from bleeding complications. Some experience severe hypotension and bradycardia of unclear etiology. Similar to the vasovagal hyperstimulation provoked by abdominal insufflation during laparoscopic surgery, we hypothesize that chest wall stretch from postoperative breast hematoma may mechanically stretch the vagus nerve, triggering dysautonomia disproportionate to the degree of blood loss. Methods: A single-institution retrospective review of patients requiring reoperation for hematoma evacuation following breast surgery between 2011 and 2021 was performed. The relationship between hematoma volume and hemodynamic instability, as well as hematoma volume and vasovagal symptoms, was measured. Results: Sixteen patients were identified. Average hematoma volume was 353 mL, and average minimum mean arterial pressure was 64 mm Hg (range: 34-102 mm Hg). Fifty-six percent of patients reported symptoms including dizziness, somnolence, and/or syncope. Accounting for body surface area, patients with larger hematomas had similar minimum mean arterial pressures compared to those with smaller hematomas, 55 and 73 mm Hg, respectively (P = .0943). However, patients in the large hematoma group experienced over 3 times as many vasovagal symptoms, 88% and 25%, respectively (P = .0095). Conclusion: Patients with large hematomas reported significantly more vagal symptoms compared to those with small hematomas despite similar mean arterial pressures. In addition, the trend of lower mean arterial pressures and heart rates more closely resembles vagal hyperstimulation than hypovolemic shock. Early hematoma evacuation to relieve vagal nerve stretch and parasympatholytics to reverse dysautonomia are targeted interventions to consider in this patient population rather than fluids, vasopressors, and blood products that are used in cases of hemodynamic instability due to hypovolemia alone.

Evaluation of a task-specific checklist and global rating scale for ultrasound-guided regional anesthesia.

UNLABELLED: Checklists and global rating scales (GRSs) are used for assessment of anesthesia procedural skills. The purpose of this study was to evaluate the reliability and validity of a recently proposed assessment tool comprising a checklist and GRS specific for ultrasound-guided regional anesthesia. METHODS: In this prospective, fully crossed study, we videotaped 30 single-target nerve block procedures performed by anesthesia trainees. Following pilot assessment and observer training, videos were assessed in random order by 6 blinded, expert observers. Interrater reliability was evaluated with intraclass correlation coefficients (ICCs) based on a 2-way random-effects model that took into account both agreement and correlation between observer results. Construct validity and feasibility were also evaluated. RESULTS: The ICC between assessors' total scores was 0.44 (95% confidence interval, 0.27-0.62). All 6 observers scored "experienced trainees" higher than "inexperienced trainees" (median total score 76.7 vs 54.2, P = 0.01), supporting the test's construct validity. The median time to assess the videos was 4 minutes 29 seconds. CONCLUSIONS: This is the first study to evaluate the reliability and validity of a combined checklist and GRS for ultrasound-guided regional anesthesia using multiple observers and taking into account both absolute agreement and correlation in determining the ICC of 0.44 for interrater reliability. There was evidence to support construct validity.

Incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks: an analysis from a prospective clinical registry.

BACKGROUND AND OBJECTIVES: There are varying reports on the incidence of major morbidity associated with peripheral regional anesthesia. Our objective was to contribute to the knowledge regarding the incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms in the setting of ultrasound-guided peripheral regional anesthesia. METHODS: During an 8-year period, 12,668 patients undergoing peripheral regional anesthesia were evaluated. Using a clinical registry, incidence rates of postoperative neurologic symptoms, local anesthetic toxicity, pneumothorax, and vascular trauma were calculated. Univariate analysis was used to identify risk factors for postoperative neurologic symptoms. We defined postoperative neurologic symptoms as any sensory or motor dysfunction present for more than 5 days and anatomically consistent with the possibility of contribution from the nerve block. RESULTS: The incidence (per 1000 blocks) of adverse events across all peripheral regional anesthetics was 1.8 (95% confidence interval [CI], 1.1-2.7) for postoperative neurologic symptoms lasting longer than 5 days, 0.9 (95% CI, 0.5-1.7) for postoperative neurologic symptoms lasting longer than 6 months, 0.08 (95% CI, 0.0-0.3) for seizure, 0 (95% CI, 0-0.3) for pneumothorax, 0.6 (95% CI, 0.2-1.2) for unintended venous puncture, 1.2 (95% CI, 0.7-2.0) for unintended arterial puncture, and 2.0 (95% CI, 1.2-3.0) for patients having unintended paresthesia during block placement. There were no cardiac arrests. CONCLUSIONS: In the setting of a surgical procedure, ultrasound-guided regional anesthesia is associated with the risk of long-term postoperative neurologic symptoms. Local anesthetic systemic toxicity, however, is extremely uncommon.