Acute postoperative pain impact trajectories and factors contributing to trajectory membership.

BACKGROUND: Ongoing postoperative pain assessments are vital to optimizing pain management and attenuating the development of poor health outcomes after surgery. This study aimed to characterize acute multidimensional trajectories of pain impact on physical function, sleep, mood, and stress and to examine clinical characteristics and demographics associated with trajectory membership. Additionally, this study compared levels of pain intensity and prescription opioid use at 2 weeks and 1 month postoperatively across acute symptom trajectories. METHODS: Participants (N = 285) undergoing total knee arthroplasty, total hip arthroplasty, and spinal fusion procedures were recruited for this multisite prospective observational study. Longitudinal, joint k-means clustering was used to identify trajectories based on pain impact on activity, sleep, mood, and stress. RESULTS: Three distinct pain impact trajectories were observed: Low (33.7%), Improving (35.4%), and Persistently High (30.9%). Participants in the Persistently High impact trajectory reported pain interfering moderately to severely with activity, sleep, mood, and stress. Relative to other trajectories, the Persistently High impact trajectory was associated with greater postoperative pain at 1 month postoperatively. Preoperatively, participants in the Persistently High impact trajectory reported worse Pain Catastrophizing Scale scores and PROMIS Pain Interference, PROMIS Anxiety, and PROMIS Social Isolation scores than did participants presenting with other trajectories. No statistical differences in opioid use were observed across trajectories. CONCLUSIONS: Variation in acute postoperative pain impact on activity, sleep, mood, and stress exists. Given the complex nature of patients' postoperative pain experiences, understanding how psychosocial presentations acutely change throughout hospitalization could assist in guiding clinicians' treatment choices and risk assessments.

Multidimensional Perioperative Recovery Trajectories in a Mixed Surgical Cohort: A Longitudinal Cluster Analysis Utilizing National Institutes of Health Patient-Reported Outcome Measurement Information System Measures.

BACKGROUND: Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery. METHODS: Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships. RESULTS: Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters. CONCLUSIONS: These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes.

Discrete and Dynamic Postoperative Pain Catastrophizing Trajectories Across 6 Months: A Prospective Observational Study.

OBJECTIVES: To investigate pain catastrophizing presentations up to 6 months postoperatively and subsequent changes in pain intensity and physical function. DESIGN: Prospective observational multisite study. SETTING: Two tertiary care facilities between 2016 and 2019. PARTICIPANTS: Adult patients (N=348) undergoing a mastectomy, thoracic surgery, total knee or hip arthroplasty, spinal fusion, or major abdominal surgery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pain Catastrophizing Scale scores, Defense and Veterans Pain Rating Scale, average pain intensity, and Patient Reported Outcomes Measurement Information System (PROMIS) physical function. RESULTS: Four pain catastrophizing trajectories were identified in 348 surgical patients during the 6 months of postoperative recovery: stable, remitting, worsening, and unremitting. Linear mixed-effects models found that the unremitting trajectory was associated with higher pain intensity over time. The average pain intensity of participants in the remitting trajectory was estimated to decrease at a faster rate over the 6 months after surgery than pain of other trajectories, despite participants reporting high preoperative Pain Catastrophizing Scale and pain scores. Worsening and unremitting trajectories were associated with reduced physical function. Preoperative average pain intensity scores were not associated with postoperative physical function scores, nor were participants' preoperative physical function scores associated with average pain intensity scores postoperatively. Prolonged hospitalization, smoking, and preoperative opioid prescriptions were associated with the unremitting trajectory. CONCLUSIONS: Findings suggest that preoperative pain catastrophizing scores alone may not be adequate for estimating long-term patient-reported outcomes during postoperative rehabilitation. Pain catastrophizing has a dynamic presentation and is associated with changes in pain intensity and physical function up to 6 months postoperatively. Routine assessments can inform the delivery of early interventions to surgical patients at risk of experiencing a pain catastrophizing trajectory associated with suboptimal outcomes during rehabilitation.

A comparison of ultrasound-guided and landmark-based approaches to saphenous nerve blockade: a prospective, controlled, blinded, crossover trial.

BACKGROUND: Blockade of the saphenous nerve is often used for surgeries below the knee. Depending on the approach, success rates vary widely ranging from 33% to 88%. In this prospective volunteer study, we compared 2 ultrasound-guided techniques, the modified vastus medialis and perifemoral saphenous nerve block with a below the knee field block. METHODS: Twenty volunteer adults, in a single-blinded, crossover, prospective trial underwent 3 different saphenous nerve blocks. The primary end point of block success was loss of sensation in the distal two-thirds distribution of the saphenous nerve. Secondary variables included time to perform the block, time to sensory loss, pain during block, and motor weakness. RESULTS: Compared with the below the knee field block success rate (30%), both the modified vastus medialis and perifemoral techniques had significantly higher success rates (80%, difference 50% with confidence interval [CI], 23%-77%, P = 0.009, and 100%, difference 70% with CI, 41%-91%, P < 0.001, respectively). However, the difference when comparing the perifemoral ultrasound technique against the modified vastus medialis ultrasound technique did not show significance (difference 20% with CI, -7% to 49%, P = 0.125). Also, no statistical differences were found with the other variables measured, except the perifemoral technique showed faster block performance times than below the knee field block (P = 0.007). CONCLUSION: In our prospective study, we have demonstrated that ultrasound-guided above the knee saphenous nerve blocks have higher success rates than a below the knee field block and are easily performed in a short amount of time.

Pacific partnership 2010: Anesthesia support aboard the USNS Mercy humanitarian civic assistance.

INTRODUCTION: The USNS Mercy has been integral in providing humanitarian and civic assistance as part of the Department of Defense's ongoing Combatant Commander Theater Security Cooperation Plans. The purpose of this study was to critically assess patient demographics and procedures performed to provide guidance for future missions. METHODS: A retrospective review was performed on a cohort of 825 surgical patients who underwent surgery during a 4-month period during Pacific Partnership 2010. Patient demographics, anesthesia exam findings, comorbidities, and surgical data were compared among the mission sites. RESULTS: Of the 825 patients, the mean age ranged from 39.7 to 24.7 with a statistical difference between Vietnam (39.7, p < 0.0087 for all tests) and the remaining sites. Poorer health by American Society of Anesthesiologist grading was noted in Vietnam (1.61) as compared to patients in Cambodia (1.21, p < 0.001) and Timor-Leste (1.40, p = 0.001). No difference in complication rates was noted. DISCUSSION: The reason for apparent differences in age or health status by site weren't clearly explained, but these differences had no bearing on surgical outcome. CONCLUSION: Analysis of anesthesia data compiled during Pacific Partnership 2010 provided meaningful data for future humanitarian efforts at these sites.

Negative intratracheal pressure produced by esophageal detector devices causes tracheal wall collapse in a porcine cardiac arrest model.

BACKGROUND: Esophageal detector devices (EDDs) impose negative pressure on the trachea or esophagus to verify endotracheal tube (ETT) position. In cardiac arrest, the smooth muscle of the lower esophageal sphincter relaxes in a time-dependent and irreversible manner. If relaxation also occurs in the muscular posterior tracheal wall, it could predispose tracheal invagination or collapse with negative pressure, potentially yielding false-negative (tracheal ETT, EDD indicates esophagus) results. We compared 3 different EDDs in their ability to correctly discriminate tracheal and esophageal intubation. METHODS: ETTs were placed into the trachea and esophagus of 5 domestic swine, and bronchoscopy was used to visualize the trachea while 3 EDDs were tested. Tracheal wall activity was observed before and after induced cardiac arrest. Tracheal ETTs were aspirated with increasing negative force and pressures at initial wall movement and >50% tracheal lumen obliteration were recorded. Measurements were repeated at 4, 8, and 12 minutes postarrest and pressures at tracheal wall collapse pre- and postarrest were determined. EDDs were also tested on esophageal ETTs prearrest and at 6 and 10 minutes postarrest. RESULTS: In a closed system, each EDD generated more than -100 cm H(2)O pressure. Average prearrest pressure at tracheal collapse was -112 cm H(2)O. Average postarrest collapse pressures were -68, -66, and -54 cm H(2)O at 4, 8, and 12 minutes postarrest. One EDD consistently gave equivocal results; the remaining 2 gave accurate results in all subjects. Most observed movement was insufficient to cause device failure although tracheal wall movement was noted in all postarrest EDD trials. Esophageal intubation was correctly determined at all times pre- and postarrest. CONCLUSION: These findings describe a mechanism for false-negative results from decreased posterior tracheal wall tone during cardiac arrest. Further studies are required to elucidate factors contributing to its occurrence and impact on EDD use.

Brief report: effects of positive end-expiratory pressure on internal jugular vein cross-sectional area in anesthetized adults.

We tested whether positive end-expiratory pressure (PEEP) increases right internal jugular vein (RIJV) cross-sectional area (CSA) in 45 ASA physical status I and II adults. All patients received a standardized IV fluid bolus, induction of general anesthesia, tracheal intubation, and mechanical ventilation. We evaluated the CSA of the RIJV using ultrasound without PEEP (control) and with PEEP (10 cm H(2)O) in the supine, level position. Addition of PEEP increased RIJV CSA 0.42 + or - 0.41 cm(2) (mean + or - SD, median 0.34 cm(2), P < 0.001), which represented a 41% mean increase in CSA.

Confirmation of needle cricothyroidotomy using an esophageal detector device in a porcine model.

The difficult intubation is one of the most trying situations encountered in airway management. Transtracheal jet ventilation via needle cricothyroidotomy can provide temporary oxygenation in this critical situation in a minimally invasive fashion. The esophageal detector device (EDD) has been previously shown to be effective in determining the tracheal placement of endotracheal tubes. In this experiment, three commonly available EDDs are utilized to accurately identify 15 of 15 intratracheal placements of a 16-gauge i.v. catheter in five cadaveric domestic swine. The incorporation of EDDs in i.v. catheter placement for needle cricothyroidotomy is shown to be effective and merits further study. Likewise, further investigation is needed to identify a standardized apparatus for needle cricothyroidotomy in emergent situations.

A brief report: the use of high-frequency oscillatory ventilation for severe pulmonary contusion.

BACKGROUND: Severe pulmonary contusions are a common cause of acute respiratory distress syndrome (ARDS) and are associated with significant morbidity. High frequency oscillatory ventilation (HFOV) is a ventilatory mode that employs a lung protective strategy consistent with the ARDSNet low tidal volume ventilation strategy and may result in reduced morbidity. The objective of this report is to examine the impact of HFOV on blunt trauma patients with severe pulmonary contusions who failed or were at a high risk of failing conventional mechanical ventilation. METHODS: We undertook a retrospective chart review of all patients at our institution who received HFOV for severe pulmonary contusions. Patients were placed on HFOV when their mean airway pressure (mP(aw)) surpassed 30 cm H2O and their FIO2 was greater than 0.6. Baseline demographic data including injury severity score (ISS), length of time requiring HFOV, total ventilator days, and inhospital mortality were collected. Serial determinations of oxygenation index (OI) and the PaO2/FIO2 ratio (P/F) were made up to 72 hours after initiation of HFOV. A linear mixed model was used to analyze the slope (beta) of the regression line of P/F versus time and that of OI versus time. RESULTS: Seventeen patients were identified who underwent HFOV for ARDS due primarily to pulmonary contusions. Mean ISS was 36.6, mean APACHE II score was 21.7, and the mean time before initiation of HFOV was 2.0 days. P/F increased significantly after HFOV was initiated (beta = 12.1; 95% confidence interval 7.9 to 16.4, p < 0.001). OI significantly decreased after HFOV implementation (beta = -1.8; 95% confidence interval -2.3 to -1.3, p < 0.001). Mortality rate was 17.6%. CONCLUSIONS: The early use of HFOV appears to be safe and efficacious in blunt trauma patients sustaining pulmonary contusions, and results in a rapid improvement in OI and the P/F ratio.

Acute appendicitis in a patient with undiagnosed pheochromocytoma.

Pheochromocytoma is a rare catecholamine-producing tumor that can cause severe hypertension and other systemic disturbances. A clinical challenge arises when a patient with a previously undiagnosed and untreated pheochromocytoma presents with a surgical emergency. We describe a patient presenting with acute appendicitis in whom surgery was cancelled because of suspected pheochromocytoma. The possibility of mortality associated with surgery in a patient with an undiagnosed pheochromocytoma outweighed the risk of nonoperative management for appendicitis. This case resulted in a nonoperative resolution of appendicitis and an unremarkable recovery once appropriate hypertension treatment was administered.

Dolasetron versus ondansetron as single-agent prophylaxis for patients at increased risk for postoperative nausea and vomiting: a prospective, double-blind, randomized trial.

This study identified 100 ambulatory surgery patients receiving general anesthesia who were at increased risk for postoperative nausea and vomiting (PONV) and randomly assigned them to receive single-agent prophylaxis (12.5 mg of dolasetron or 4 mg of ondansetron) 15 to 30 minutes before the end of surgery. Data were collected in the postanesthesia care unit, and patients completed a questionnaire 24 hours after surgery. No statistically significant difference existed between study groups in demographic features, history of PONV, history of motion sickness, or type and duration of surgery and anesthesia. No statistically significant difference existed in satisfaction with the medication used for PONV prophylaxis (dolasetron, 70.9 of 100 mm; ondansetron, 67.9 of 100 mm; p = 0.69). No statistically significant difference existed in satisfaction with the overall surgical experience (dolasetron, 87.9 of 100 mm; ondansetron, 85.3 of 100 mm; p = 0.36). Costminimization strategies should be considered without fear of substandard care or increased patient dissatisfaction.

Intraocular Pressure During Robotic-assisted Laparoscopic Procedures Utilizing Steep Trendelenburg Positioning.

PURPOSE: To determine the effect of steep Trendelenburg (sTBURG) surgical positioning on intraocular pressure (IOP) during robotic-assisted laparoscopy (RAL) in subjects without previously identified ocular disease. DESIGN: Prospective cohort study. PARTICIPANTS AND CONTROLS: Eighteen patients undergoing RAL with sTBURG and 21 controls undergoing open and laparoscopic cases in horizontal positioning. MATERIALS AND METHODS: Research data derived from an approved Naval Medical Center, San Diego, CA, IRB protocol. A study group undergoing RAL utilizing sTBURG (group 1) was compared with a control group undergoing open surgery in the horizontal position (group 2), and laparoscopic cases in the horizontal position (group 3). An ophthalmologic examination including Snellen visual acuity, IOP, Humphrey Visual Field (HVF) 24-2 with standard Swedish Interactive Thresholding Algorithm, time domain optical coherence tomography (OCT), retinal nerve fiber layer (RNFL) analysis, pachymetry, and dilated fundus examination was conducted preoperatively and at 1 month postoperatively. IOP was measured intraoperatively at discrete time-points. MAIN OUTCOME MEASURES: IOP values, change in OCT RNFL thickness, HVF mean deviation, and HVF pattern standard deviation. RESULTS: Baseline IOP (mm Hg) was similar, 13.7±3.2 for group 1 versus 15.3±3.2 for group 2 and 14.1±2.4 for group 3 (P=0.55). The IOP plateau from 60 minutes until case conclusion occurred at 29.9 mm Hg (95% confidence interval, 27.4-32.5), 19.9 mm Hg (95% confidence interval, 17.6-22.3), and 22.8 mm Hg (95% confidence interval, 20.2-25.4) for group 1, group 2, and group 3, respectively. There were no significant changes in OCT RNFL thickness, HVF mean deviation, and HVF pattern standard deviation. CONCLUSIONS: Significant elevations of IOP are experienced during robotic surgery utilizing sTBURG positioning in patients with healthy eyes, and we recommend a multidisciplinary approach in determining potential risk to those with known ocular disease who are candidates for these procedures.

A Case Report of Post-Operative Jöd-Basedow Phenomennon Following Oral and IV Iodine Contrast Administration.

This is a case of thyrotoxicosis, due to the Jöd-Basedow phenomenon following administration of oral and IV iodinated contrast in a patient with history of gastrointestinal stromal tumor (GIST) and small bowel obstruction. The patient developed atrial fibrillation and had an extended stay in the intensive care unit. Given the aging population with possible subclinical hyperthyroidism, multinodular goiter, and the rise in contrast administration for routine diagnostic studies, this case serves to raise awareness of the risks of "routine" tests administered to our aging patient population.