An update on the perioperative management of postcraniotomy pain.

PURPOSE OF REVIEW: Pain after craniotomy is often severe and undertreated. Providing adequate analgesia while avoiding medication adverse effects and physiological complications of pain remains a perioperative challenge. RECENT FINDINGS: Multimodal pain management includes regional anesthesia and analgesic adjuncts. Strategies aim to reduce or eliminate opioids and the associated side effects. Many individual pharmacologic interventions have been studied with beneficial effects on acute pain following craniotomy. Evidence has been accumulating in support of scalp blockade, nonsteroidal anti-inflammatory drugs (NSAIDs), dexmedetomidine, paracetamol, and gabapentinoids. The strongest evidence supports scalp block in reducing postcraniotomy pain and opioid requirements. SUMMARY: Improving analgesia following craniotomy continues to be a challenge that should be managed with multimodal medications and regional techniques. Additional studies are needed to identify the most effective regimen, balancing efficacy and adverse drug effects.

Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program.

OBJECTIVE: The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN: A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING: Single-center, major university hospital. PATIENTS: The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS: The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS: An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.