Bladder spasms following ambulatory urologic procedures.

INTRODUCTION: Bladder spasm are common complications following cystoscopic urologic procedures. This study aims to determine the incidence and risk factors for bladder spasm after ambulatory cystoscopic urologic procedures. MATERIALS AND METHODS: Medical records of adult patients who underwent urologic procedures in our ambulatory center from May 1st, 2018 through December 30th, 2020, were reviewed. Bladder spasm was identified from the administration of antispasmodic therapy (e.g. oxybutynin) during anesthesia recovery. Multivariable analyses were performed to assess the association between bladder spasm and clinical factors. RESULTS: Included were 2,671 patients, of which 917 (34.3%) developed postoperative bladder spasm, yielding an incidence of 343 (95%CI 325-361) per 1,000 procedures. Risk factors associated with bladder spasm were younger adult age (< 60 years), longer (> 45 minutes) and more complex procedures. Compared to cystoscopy the risk of spasm following transurethral resection of the bladder tumor was OR 4.35 (95%CI 3.22, 5.87) and for transurethral resection of the prostate OR 3.25 (95% CI 2.24, 4.71). Spasm prophylaxis with belladonna and opium suppositories (B&O) was used in 1,158 patients and 384 (33.2%) developed spasms. The use of B&O was not associated with reduction of bladder spasm, OR 0.91 (95%CI 0.75, 1.1, p = 0.318). Postoperative outcomes did not differ between patients who did or did not develop spasms. CONCLUSION: Bladder spasms are common following ambulatory urologic procedures, more so with more extensive procedures. Prophylaxis with B&O was not significantly associated with a lower rate of bladder spasms.

Serotonergic medications, herbal supplements, and perioperative serotonin syndrome.

PURPOSE: Perioperative use of serotonergic agents increases the risk of serotonin syndrome. We describe the occurrence of serotonin syndrome after fentanyl use in two patients taking multiple serotonergic agents. CLINICAL FEATURES: Two patients who had been taking multiple serotonergic medications or herbal supplements (one patient taking fluoxetine, turmeric supplement, and acyclovir; the other taking fluoxetine and trazodone) developed serotonin syndrome perioperatively when undergoing outpatient procedures. Both experienced acute loss of consciousness and generalized myoclonus after receiving fentanyl. In one patient, the serotonin syndrome promptly resolved after naloxone administration. In the other patient, the onset of serotonin syndrome was delayed and manifested after discharge, most likely attributed to the intraoperative use of midazolam for sedation. CONCLUSION: Even small doses of fentanyl administered to patients taking multiple serotonergic medications and herbal supplements may trigger serotonin syndrome. Prompt reversal of serotonin toxicity in one patient by naloxone illustrates the likely opioid-mediated pathogenesis of serotonin syndrome in this case. It also highlights that taking serotonergic agents concomitantly can produce the compounding effect that causes serotonin syndrome. The delayed presentation of serotonin syndrome in the patient who received a large dose of midazolam suggests that outpatients taking multiple serotonergic drugs who receive benzodiazepines may require longer postprocedural monitoring.

Multimodal Analgesic Therapy With Gabapentin and Its Association With Postoperative Respiratory Depression.

BACKGROUND: Gabapentinoids are widely used in perioperative multimodal analgesic regimens. The primary aim of this study was to determine whether gabapentin was associated with respiratory depression during phase-I postanesthesia recovery after major laparoscopic procedures. METHODS: We retrospectively reviewed the electronic health records of 8567 patients who underwent major laparoscopic procedures (lasting ≥90 minutes) from January 1, 2010, to July 31, 2014. We assessed potential associations among patient and perioperative variables and episodes of respiratory depression during phase-I recovery. Multivariable and propensity score-matched analyses were performed to assess potential associations between preoperative gabapentin use and postoperative respiratory depression. RESULTS: The incidence of respiratory depression was 153 (95% confidence interval [CI], 146-161) episodes per 1000 cases. Multivariable analysis showed that gabapentin was associated with respiratory depression (odds ratio [OR], 1.47 [95% CI, 1.22-1.76]; P < .001). These results were confirmed by propensity score-matched analysis among a subset of patients who did not have analgesia supplemented by intrathecal opioids (OR, 1.26 [95% CI, 1.02-1.58]; P = .04). Older patients and those who received more intraoperative opioids had increased risk of respiratory depression. Those who had an episode of respiratory depression had a longer phase-I recovery (P < .001) and an increased rate of admission to a higher level of care (P = .03). CONCLUSIONS: The use of gabapentin is associated with increased rates of respiratory depression among patients undergoing laparoscopic surgery. When gabapentinoids are included in multimodal analgesic regimens, intraoperative opioids must be reduced, and increased vigilance for respiratory depression may be warranted, especially in elderly patients.

Perioperative management of patients with DiGeorge syndrome undergoing cardiac surgery.

OBJECTIVE: DiGeorge syndrome is a genetic disorder with multisystem involvement resulting in craniofacial and cardiac anomalies and parathyroid and immune system dysfunction. This study describes perioperative management of a large cohort of patients with DiGeorge syndrome undergoing cardiac surgery. DESIGN: Retrospective cohort study. SETTING: Major academic tertiary institution. PARTICIPANTS: The medical records of patients diagnosed with DiGeorge syndrome and undergoing cardiac surgery at this institution, from January 1, 1976, to July 31, 2012, were reviewed for phenotypic characteristics and intraoperative and postoperative complications, with specific attention to hemodynamic instability, perioperative perturbations of plasma calcium homeostasis, and airway difficulty. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-two patients underwent 136 cardiac surgical procedures; 47 patients (76%) had multiple operations. Sternotomies for reoperations often were complex (8 complicated by vascular injury or difficulty achieving hemostasis and 5 requiring bypass before sternotomy). Two patients had persistent hypocalcemia intraoperatively, requiring infusion of calcium chloride, and hypocalcemia developed postoperatively in 8 patients. Prolonged mechanical ventilation (>24 hours) was required after 48 procedures (35%), and 25 (18%) required prolonged inotropic support (>72 hours). Infectious complications occurred after 31 procedures (23%). There was no in-hospital or 30-day mortality. CONCLUSIONS: Patients with DiGeorge syndrome often have complex cardiac anomalies that require surgical repair. The postoperative course is notable for the frequent need for prolonged respiratory and hemodynamic support. Patients can develop hypocalcemia and may require calcium supplementation. Immunodeficiencies may be associated with the increased rate of postoperative infections and may dictate the need for specific transfusion management practices.

Prophylactic belladonna suppositories on anesthetic recovery after robotic assisted laparoscopic prostatectomy.

INTRODUCTION: Two prospective trials have demonstrated prophylactic antimuscarinics following prostatectomy reduce pain from bladder spasms. Our practice adopted the routine administration of prophylactic belladonna and opium (B&O) suppositories to patients undergoing robotic assisted laparoscopic radical prostatectomy (RALP). The aim of this study is to determine if this change in clinical practice was associated with improvement of postoperative outcomes. MATERIALS AND METHODS: The medical records of 202 patients that underwent RALP surgery who were or were not administered prophylactic B&O suppositories in the immediate postoperative period were abstracted for duration of anesthesia recovery, pain and analgesic use. RESULTS: Patient and surgical characteristics between groups were similar except B&O group were slightly older (p = 0.04) and administered less opioid analgesics (p = 0.05). There was no difference between groups in the duration of phase I recovery from anesthesia (p = 0.96). Multivariable adjustments for age, body mass index, American Society of Anesthesiologists physical status, and surgical duration were made, and again it was found that suppository administration had no association with phase I recovery times (p = 0.94). The use of antimuscarinic medication for bladder spams in the B&O group was less during phase I recovery (p < 0.01), but was similar during the first 24 hours (p = 0.66). Postoperative sedation, opioid analgesic requirements and pain scales were similar during phase I recovery and the first 24 postoperative hours. Hospital length of stay was similar. DISCUSSION: The introduction of prophylactic B&O suppositories at the immediate conclusion of RALP surgery was not associated with improvements of the postoperative course.

Repeated episodes of difficulty with arousal following general anesthesia in a patient with ulnar neuropathy.

Delayed emergence following general anesthesia may be due to serious life-threatening disorders and deserves prompt evaluation. Rarely, delayed emergence has been attributed to a psychiatric or psychological cause. This report describes an otherwise healthy and mentally sound 52-year-old woman who experienced repeated dissociative episodes following general anesthesia for minor surgical procedures. These episodes lasted for 5 h and resulted in admission to the intensive care unit. The current literature is reviewed to identify commonalities among previously reported cases and to discuss different psychiatric and psychological mechanisms that can play a role in the development of this disorder.

The prevalence of neuropathic pain: clinical evaluation compared with screening tools in a community population.

BACKGROUND: Neuropathic pain is reported to be common based on studies from specialty centers and survey studies. However, few prevalence estimates have been completed in a community population using clinical evaluation. OBJECTIVE: To develop an estimate of the prevalence of neuropathic pain in community-dwelling adults. METHODS: Data from a mailed survey (N = 3,575 community respondents), telephone interview (N = 907), and a clinical examination (N = 205) were linked to estimate the population prevalence of neuropathic pain. Using the clinical examination as the "gold" standard, estimates from several screening tools were developed and adjusted to the Olmsted County, MN adult population. RESULTS: The estimated community prevalence of neuropathic pain from the clinical examination (gold standard) was 9.8%. Most other estimates were lower, including a 3.0% population prevalence using the Berger criteria and 8.8% using the Leeds Assessment of Neuropathic Symptoms and Signs. Only the prevalence rate based on self-report of nerve pain was higher (12.4%). Overlap among the groups each tool identified as having "neuropathic predominant pain" was only modest and the groups had significantly different rates of depressive symptoms, anxiety, limited functional ability, and use of complementary and alternative medicine. CONCLUSIONS: The estimated rates and personal characteristics of community residents with "neuropathic pain" vary widely depending on the tools used to identify neuropathic pain. None of the screening tools compared well with clinical evaluation. The differences in the groups identified by alternative screening methods become of major importance when reporting neuropathic pain epidemiology, studying therapies for neuropathic pain, or attempting to translate neuropathic pain research into clinical practice.

Management of cerebral spinal fluid leak complicating spinal cord stimulator implantation.

Accidental puncture of the dura mater with resultant leakage of cerebral spinal fluid (CSF) and development of postdural puncture headache (PDPH) is a known potential complication of percutaneous placement of spinal cord stimulator (SCS) leads. However, the implications and management strategies for this complication have not been thoroughly reported. We report two cases of SCS lead placement complicated by CSF leak and PDPH.