A comparison of postpartum opioid consumption and opioid discharge prescriptions among opioid-naïve patients and those with opioid use disorder.

BACKGROUND: Management of patients with opioid use disorder during the acute postpartum period remains clinically challenging as obstetricians aim to mitigate postdelivery pain while optimizing recovery support. OBJECTIVE: This study aimed to evaluate postpartum opioid consumption and opioids prescribed at discharge among patients with opioid use disorder treated with methadone, buprenorphine, and no medication for opioid use disorder, as compared with opioid-naïve counterparts. STUDY DESIGN: We conducted a retrospective cohort study of pregnant patients who underwent delivery at >20 weeks' gestation at a tertiary academic hospital between May 2014 and April 2020. The primary outcome of this analysis was the mean daily quantity of oral opioids consumed after delivery while inpatient, in milligrams of morphine equivalents. Secondary outcomes included the following: (1) quantity of oral opioids prescribed at discharge, and (2) prescription for oral opioids in the 6 weeks after hospital discharge. Multiple linear regression was used to compare differences in the primary outcome. RESULTS: A total of 16,140 pregnancies were included. Patients with opioid use disorder (n=553) consumed 14 milligrams of morphine equivalents per day greater quantities of opioids postpartum than opioid-naïve women (n=15,587), (95% confidence interval, 11-17). Patients with opioid use disorder undergoing cesarean delivery consumed 30 milligrams of morphine equivalents per day greater quantities of opioids than opioid-naïve counterparts (95% confidence interval, 26-35). Among patients who underwent vaginal delivery, there was no difference in opioid consumption among patients with and without opioid use disorder. Compared with patients prescribed methadone, patients prescribed buprenorphine, and those prescribed no medication for opioid use disorder consumed similar opioid quantities postpartum following both vaginal and cesarean delivery. Among patients undergoing cesarean delivery, opioid-naïve patients were more likely to receive a discharge prescription for opioids than patients with opioid use disorder (77% vs 68%; P=.002), despite lower pain scores and less inhospital opioid consumption. CONCLUSION: Patients with opioid use disorder, regardless of treatment with methadone, buprenorphine, or no medication for opioid use disorder consumed significantly greater quantities of opioids after cesarean delivery but received fewer opioid prescriptions at discharge.

Impact of pregnancy on airway complications after intubation for COVID-19 infection: A case series.

Coronavirus disease (COVID-19) is associated with severe acute respiratory illness, often requiring intensive care unit admission. Some patients require prolonged intubation and mechanical ventilation. Post-intubation laryngotracheal stenosis occurs in approximately four to 13 % of adult patients after prolonged intubation in the absence of COVID-19 infection. The rate of COVID-19 related post-intubation laryngotracheal stenosis may be higher. Of 339 pregnant patients with COVID-19, we identified seven who required intubation and mechanical ventilation. Four of the seven developed persistent airway complications, and laryngotracheal stenosis, the most severe, was present in three. Each patient had variations in duration of intubation, endotracheal tube size, re-intubation, presence of superimposed infections, and pre-existing comorbidities. We speculate that underlying physiologic changes of pregnancy in addition to the increased inflammatory state caused by COVID-19 are associated with an increased risk of post-intubation laryngotracheal stenosis. Otolaryngology physicians should have a low threshold for considering this pathophysiology when consulting on obstetric patients who have previously been intubated with COVID-19. Otolaryngologists can educate obstetricians when caring for pregnant patients who have laryngotracheal stenosis, especially those who may require emergency airway management for obstetric indications.

On anesthesia and race.

Racial tensions continue to ignite social unrest in the United States. Structural racism is increasingly recognized as a public health issue. It is therefore necessary to continue addressing the interaction of race and medicine, including anesthesiology. While many may overlook the impact that racial discrimination has had on the development of anesthesiology, understanding pain through a racialized lens has always been entwined with this medical specialty since its origins. Considering the first public demonstration of ether anesthesia in 1846 occurred 15 years before the American Civil War (1861-1865), it is naïve to pretend that anesthesia has been insulated from racial prejudice. We increasingly recognize the effects of variables, such as housing and education, which are important as social determinants of health. Across ethnic and racial lines, statistically significant differences persist in pain assessment and analgesia delivery. To understand these irregularities without relying on unsupported theories, we must challenge our current understanding of race in medicine. By reviewing the history of anesthesia through a racialized lens, we may better explore our biases and develop strategies towards racially equitable care. This article focuses on anesthesia's roots on the plantation in the American South, the medical perpetuation of racial disparities, and the challenges we face in healthcare today.