Race/Ethnicity and Sex and Opioid Administration in the Emergency Room.

BACKGROUND: Although racial/ethnic and sex disparities have been examined in health care generally and pain management more specifically, the combined influence of these sociodemographic factors together has not been well documented. The aim of this study was to examine the association between administration of opioid analgesics in the emergency department (ED) and interaction of race/ethnicity and sex. METHODS: We conducted a retrospective cohort study using 2010-2014 Center for Disease Control-National Hospital Ambulatory Medical Care Survey data for patients 12-55 years of age presenting to EDs with a primary diagnosis of appendicitis or gallbladder disease as defined by International Classification of Diseases, Ninth Revision codes. The primary outcome was the receipt of opioid analgesic medications. Secondary outcomes included: receipt of nonopioids, receipt of antiemetic medications, wait time to see a provider, and length of visit in the ED. The association between sex and analgesic receipt within Caucasian non-Hispanic and non-Caucasian groups was evaluated adjusting for pain score on presentation, patient age, emergent status, number of comorbidities, time of visit (month, day of the week, standard versus nonstandard working hours, year), and US region. RESULTS: After exclusions, a weighted sample of 553 ED visits was identified, representing 2,622,926 unique visits. The sample population was comprised of 1,858,035 (70.8%) females and 1,535,794 (58.6%) Caucasian non-Hispanics. No interaction was found in adjusted sampling-weighted model between sex and race/ethnicity on the odds of receiving opioids (P = .74). There was no difference in opioid administration to males as compared to females (odds ratio [OR] = 0.96, 95% CI, 0.87-1.06; P = .42) or to non-Caucasians as compared to Caucasians (OR = 0.99, 95% CI, 0.89-1.10; P = .84). In adjusted weighted models, non-Caucasian males, 123,121/239,457 (51.4%) did not differ from Caucasian non-Hispanic males, 317,427/525,434 (60.4%), on odds of receiving opioids, aOR = 0.88, 95% CI, 0.39-1.99; P = .75. Non-Caucasian females, 547,709/847,675 (64.6%) also did not differ from Caucasian females, 621,638/1,010,360 (61.5%), on odds of receiving opioids, aOR = 1.01, 95% CI, 0.53-1.90; P = .98. Across both sexes, non-Caucasians did not differ from Caucasians on receipt of nonopioid analgesics or antiemetics. Neither wait time to see a provider nor the length of the hospital visit was significantly different between sexes or race/ethnicities. CONCLUSIONS: Based on National Hospital Ambulatory Medical Care Survey data from 2010 to 2014, there is no statistically significant interaction between race/ethnicity and sex for administration of opioid analgesia to people presenting to the ED with appendicitis or gallbladder disease. These results suggest that the joint effect of patient race/ethnicity and sex may not manifest in disparities in opioid management.

Obesity: physiologic changes and implications for preoperative management.

The proportion of patients defined as obese continues to grow in many westernized nations, particularly the United States (USA). This trend has shifted the perioperative management of obese patients into the realm of routine care. As obese patients present for all types of procedures, it is crucial for anesthesiologists, surgeons, internists, and perioperative health care providers alike to have a firm understanding of their altered multi-organ physiology in order to safely prepare the obese patient for an operation. A careful preoperative evaluation may also serve to identify risk factors for postoperative adverse events. Subsequently, preoperative measures may be implemented to mitigate these complications. In this manuscript we address the major considerations for the preoperative evaluation of the severely obese patient.

Administering Labor Analgesia Under General Anesthesia in an Intellectually Disabled Patient.

Maternal intellectual disability presents anesthetic challenges.1 A 19-year-old primigravida with significant intellectual disability presented with preterm premature rupture of membranes at 31 4/7 weeks of gestation and underwent induction of labor for chorioamnionitis. She was unable to tolerate bedside epidural placement. Intrapartum general anesthesia allowed for epidural catheter placement that provided adequate labor analgesia for a vaginal delivery. This report describes a unique approach to providing labor analgesia in the intellectually disabled patient.

Infrastructure Design: A Critical Element in the Care of the Patient With Obesity.

ABSTRACT: The worldwide rate of obesity continues to rise, causing healthcare systems to morph to meet the demands posed by the concomitant increase in comorbidities associated with this condition. Increasing patient weight imposes its own constraints on the safety of patients and providers; therefore, a sound healthcare facility infrastructure is required to properly address the medical needs of patients with obesity. Currently, most healthcare systems-in their attitudes, equipment, and facility design-are ill equipped to meet the needs of this epidemic. In this article, we discuss the facilities and equipment design considerations in providing medical care to patients with obesity. Extending beyond the physical plant, we also touch on organizational elements that enable the healthcare provider to safely care for this challenging patient population. The rising prevalence and disease burden of excess adiposity highlight the obligation to recognize that the design needs common to all of our patients must include the particular needs of the patient with obesity.

How Rescue Echocardiography Changed the Intraoperative Management of an Obese Patient with Refractory Hypotension?

The value of perioperative echocardiography as a rescue tool to complement the clinical assessment of patients who develop hemodynamic instability during noncardiac surgery is becoming increasingly recognized. Several studies have demonstrated the utility of echocardiography in establishing a diagnosis during clinical emergencies. We present the case of an obese patient with refractory hypotension during laparoscopic gynecologic surgery in which rescue transesophageal echocardiography was pivotal in elucidating a diagnosis and changing the course of management.

Strategies for managing oxygenation in obese patients undergoing laparoscopic surgery.

The worldwide trend toward increasing body mass index (BMI) has caused the anesthetic management of overweight, obese, and severely obese patients to become common. The increase in oxygen demand coupled with the anatomic and physiologic changes associated with excess adipose tissue make maintenance of oxygenation a major challenge during induction, maintenance and recovery from general anesthesia. It is crucial for anesthesiologists, surgeons and perioperative healthcare providers alike to have a thorough understanding of the impact of airway management and mechanical ventilation on the respiratory care of the obese in the immediate perioperative setting. In this manuscript we aim to discuss the consequences of obesity, particularly abdominal obesity, on respiratory physiology and provide suggestions on intraoperative ventilatory strategies to maintain oxygenation in the severely obese patient undergoing pneumoperitoneum.

The effects of preoperative, video-assisted anesthesia education in Spanish on Spanish-speaking patients' anxiety, knowledge, and satisfaction: a pilot study.

We studied the effect of an instructional video in Spanish on self-reported anxiety, knowledge about general anesthesia procedures, and satisfaction with the preoperative anesthesia process in patients requiring a Spanish interpreter. This prospective, randomized, nonblinded pilot study took place at Massachusetts General Hospital (MGH), a university-affiliated tertiary-care hospital. Twenty adult, ASA physical status 1, 2, and 3 patients, scheduled for elective surgery (gynecological, orthopedic, and intrabdominal surgery) during general anesthesia were studied. Anxiety, knowledge, and patient satisfaction were assessed using a visual analog scale (VAS). There was a significant reduction in anxiety score in patients who viewed the video compared with those who did not (median reduction 2 vs 0; P = 0.020). There was an increase in satisfaction score in the video group (median increase 2 vs 0; P = 0.046). There was no difference in reported knowledge-improvement scores between the two groups (3.5 vs 4; P = 0.908). In Spanish-speaking patients, the addition of an instructional video in Spanish to a preanesthesia interview decreased anxiety and increased patient satisfaction.

Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004-2007.

To reevaluate and update evidence-based best practice recommendations published in 2004 for anesthetic perioperative care and pain management in weight loss surgery (WLS), we performed a systematic search of English-language literature on anesthetic perioperative care and pain management in WLS published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. We identified relevant abstracts by using key words, retrieved full text articles, and stratified the resulting evidence according to systems used in established evidence-based models. We updated prior evidence-based best practice recommendations based upon interim literature. In instances of controversial or inadequate scientific evidence, the task force reached consensus recommendations following evaluation of the best available information and expert opinion. The search yielded 1,788 abstracts, with 162 potentially relevant titles; 45 were reviewed in detail. Despite more information on perioperative management of patients with obstructive sleep apnea (OSA), evidence to support preoperative testing and treatment or to guide perioperative monitoring is scarce. New evidence on appropriate intraoperative dosing of muscle relaxants allows for greater precision in their use during WLS. A novel application of alpha-2 agonists for perioperative anesthetic care is emerging. Key elements that may enhance patient safety include integration of the latest evidence on WLS, obesity, and collaborative multidisciplinary care into clinical care. However, large gaps remain in the evidence base.

Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery.

OBJECTIVE: To develop evidence-based recommendations that optimize the safety and efficacy of perioperative anesthetic care and pain management in weight loss surgery (WLS) patients. RESEARCH METHODS AND PROCEDURES: This Task Group examined the scientific literature on anesthetic perioperative care and pain management published in MEDLINE from January 1994 to March 2004. We also reviewed additional data from other sources (e.g., book chapters). The search yielded 195 abstracts, of which 35 references were reviewed in detail. Task Group consensus was used to provide recommendations when evidence in the literature was insufficient. RESULTS: We developed anesthesia practice and patient safety advisory recommendations for preoperative evaluation, intraoperative management, and postoperative care and pain management of WLS patients. We also provided suggestions related to medical error reduction and systems improvements, credentialing, and future research. DISCUSSION: Obesity-related comorbidities including obstructive sleep apnea place WLS patients at increased risk for complications perioperatively. Regarding perioperative safety and outcomes, conclusive evidence beyond the accepted standard of care in the reviewed literature is limited. Few reports specifically address the perioperative needs of severely obese patients. In this advisory, we synthesize current knowledge and make best practice recommendations for perioperative care and pain management in WLS patients. These recommendations require periodic review as further medical knowledge and evidence evolve.