Continuing Chronic Buprenorphine Perioperatively is Associated With Reduced Postoperative Opioid Use.

INTRODUCTION: Buprenorphine is a frequently used medication for opioid use disorder and misunderstanding buprenorphine's unique pharmacology has historically complicated perioperative analgesia. The purpose of this study was to evaluate the association of perioperative buprenorphine continuation in patients with substance use disorder on perioperative opioid use. MATERIALS AND METHODS: This was a single-center retrospective study at a level 1 trauma academic medical center. Adult patients using outpatient buprenorphine for medication for opioid use disorder admitted with an operating room booking were included. Patients were grouped (continuation, withheld) retrospectively based upon the decision to continue or omit buprenorphine therapy while admitted. The primary outcome of the study was any use of full mu-opioid agonists during days 1-7 of admission. Secondary outcomes included length of stay and average pain scores during days 1-7 of admission. RESULTS: 43.4% of patients in the continuation cohort used no full mu-opioid agonists during days 1-7 compared to 3.1% of patients in the withheld cohort (P < 0.001). No significant difference in median length of stay was noted (4.7 d [2.8-6.6] versus 6.1 d [4.0-8.2], P = 0.36). There was no statistical difference in average pain scores on postoperative days 1 (5.2 versus 6.9, P = 0.82) and 7 (0 versus 0, P = 0.41). CONCLUSIONS: Perioperative continuation of buprenorphine is associated with reduced use of alternative full mu-opioid agents while admitted without impacting pain scores.

Complications of major aortic and lower extremity vascular surgery.

Atheromatous disease and invasive intervention of the aortoiliac and distal arteries are common. Morbidity and mortality have been reduced through understanding and management of patient risk factors. Complications of this form of treatment affect all organ systems; mortality is most frequently caused by a cardiovascular complication (eg, myocardial infarction). Infection, leading to aortoenteric fistula is a dreaded complication, and paraplegia, though rare, is a devastating outcome. Multiorgan failure and death may result from a systemic inflammatory response syndrome. Vascular surgery for infrainguinal disease also has a significant cardiovascular complication rate. Resulting complications may affect all organs; loss of an extremity may occur. The first part of this article reviews perioperative and postoperative complications of open aortic repair and lower-extremity revascularization and addresses the issue of regional anesthesia for major vascular surgery. The second part reviews endovascular aortic repair (EVAR). EVAR is a new intervention that combines surgery and radiology. Complications of EVAR are similar to open repair, but early results suggest they may be less frequent. New technology leads to new complications; endoleaks, migration of the endoprosthesis, and surgical conversion are unique to EVAR. The benefits of EVAR may be less blood loss, shorter hospitalization, and less cardiovascular stress; the risks may be aneurysm recurrence, prolonged surveillance and repeated secondary procedures. The development of EVAR, the complications, and the anesthesia-related concerns of EVAR, including its use in management of acute abdominal aortic aneurysm are reviewed.

Thrombosis of sirolimus-eluting coronary stent in the postanesthesia care unit.

A 44-yr-old woman with a drug-eluting coronary stent placement two weeks before surgery suffered a myocardial infarction in the postanesthesia care unit immediately after hysterectomy. She had missed only one dose of aspirin and clopidogrel preoperatively. Early recognition of subacute stent thrombosis and urgent percutaneous coronary intervention probably prevented her death. In this case report, we highlight perioperative coronary stent issues and discuss their implications.