Patterns of Use of Opioid Sparing Adjuncts for Perioperative Pain Management of Patients on Chronic Opioids.

BACKGROUND: Perioperative pain management of patients on chronic opioids is challenging. Although experts recommend regional anesthesia and multimodal analgesics for their opioid sparing effects, their use and predictors of use are unknown. OBJECTIVES: To examine the patterns and predictors of use of regional anesthesia and multimodal analgesics for perioperative pain control of patients on chronic opioids. A secondary objective was to examine the association of patient and surgical factors with 24-hour postoperative opioid use. STUDY DESIGN: Retrospective cross sectional. SETTING: Single center tertiary care academic hospital. METHODS: We studied patients with chronic opioid use undergoing painful operations such as abdominal, gynecologic, breast, orthopedic, spine, amputation, and laparoscopic surgeries. Chronic opioid use was identified using the narcotic score - a score generated from the state prescription drug monitoring database via the NarxCare platform. A narcotic score >= 320 corresponding to a preoperative home dose of approximately 40 milligram morphine equivalents (MMEs) daily, was chosen as a cutoff since the risk of overdose death increases above 40 MMEs. We reported the use of regional anesthesia and >= 3 multimodal analgesics in this cohort (n = 155) and examined the association of this use with patient and surgical factors such as preoperative narcotic score, age, race, comorbidity index, operative timetime, and intraoperative opioid use. In addition, we examined the association of patient and surgical factors with 24-hour postoperative opioid use. RESULTS: Out of 2470 patients undergoing painful surgeries between July 2017and- December 2018, 155 patients had a narcotic score >= 320. The median narcotic score was 411 (interquartile range (IQR) 351-520), the median preoperative home MME dose was 67.5 (IQR 32-180) mg daily. Regional anesthesia was used in only 9.7% of cases and was associated with intraoperative opioid used, but not the preoperative narcotic score. Patients receiving 1 SD more MMEs intraoperatively had a higher odds of receiving regional anesthesia (OR = 1.57, 95% CI [1.06, 2.32]). Three or more multimodals were used in 83% of cases. Every 10-point increase in narcotic score and every additional hour of operative time was associated with higher odds of receiving >= 3 multimodals (OR = 1.05, 95% CI [1.00, 1.11] and OR = 1.49, 95% CI [1.11, 1.99] respectively). Total 24 hour post-operative opioid dose was associated with narcotic score, with an 8.6 higher mean MME for every 10-point increase in narcotic score (mean difference = 8.6, 95% CI [4.1, 13.1]). It was also moderately associated with age, where patients an year older received 4.7 MMEs less (mean difference = - 4.7, 95% CI [-9.3, -0.5]). LIMITATIONS: This was a single center retrospective observational study. We could not adjust for inter-physician or inter-surgery effect on use of regional anesthesia or multimodal analgesics. Since this was one of the first studies to use narcotic scores to identify patients on chronic opioids, comparing the outcomes of interest to a control group was beyond the scope of the current study. Narcotic scores need to be validated to identify chronic opioid use. CONCLUSIONS: Despite consensus guidelines, regional anesthesia remains underutilized. Multimodals are used frequently and are modestly associated with preoperative narcotic scores.

It Is Just a Blood Patch: Considerations for Patients with Preexisting Intracranial Hypertension.

Epidural blood patches are routine procedures interventional pain physicians perform for postdural puncture headaches (PDPH), whether it be due to the inadvertent wet tap from an epidural or a diagnostic lumbar puncture. Typically, these patients are relatively healthy and an epidural is relatively straightforward. However, there are cases complicated by a neurologic history such as benign intracranial hypertension. Here, we present a case of a patient with benign intracranial hypertension (BIH) that suffered a postdural puncture headache after a diagnostic lumbar puncture, with no documented opening pressure, continued on acetazolamide. There have only been a small number of documented cases of BIH complicated by PDPH. We discuss the medical management of BIH, how it can exacerbate a postdural puncture headache, our definitive management with an epidural blood patch, and our concerns of rebound intracranial hypertension. We demonstrate that treatment of PDPH in BIH is best managed with image-guided blood patches, with smaller volume of autologous blood, and at a slower rate.

The Effectiveness of Ketamine in Pediatric Acute Deafferentation Pain after Spinal Cord Injury.

Deafferentation pain and allodynia commonly occur after spinal cord trauma, but its treatment is often challenging. The literature on effective therapies for pediatric deafferentation pain, especially in the setting of spinal cord injury, is scarce. We report the case of a 12-year-old patient with acute allodynia after a gunshot injury to the spine. The pain was refractory to multiple analgesics, but resolved with ketamine, which also improved the patient's physical function and quality of life, a trend that continued many months after the injury. We suggest that early initiation of ketamine may be effective for acute pediatric deafferentation pain secondary to spinal cord injury, as well as preventing chronic pain states in that population.

Endometriosis Pain Management: a Review.

PURPOSE OF REVIEW: The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis. RECENT FINDINGS: The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Bilateral variations of brachial plexus involving the median nerve and lateral cord: An anatomical case study with clinical implications.

During the routine dissection of upper limbs of a Caucasian male cadaver, variations were observed in the brachial plexus. In the right extremity, the lateral cord was piercing the coracobrachialis muscle. The musculocutaneous nerve and lateral root of the median nerve were observed to be branching inferior to the lower attachment of coracobrachialis muscle. The left extremity exhibited the passage of the median nerve through the flat tendon of the coracobrachialis muscle near its distal insertion into the medial surface of the body of humerus. A variation in the course and branching of the nerve might lead to variant or dual innervation of a muscle and, if inappropriately compressed, could result in a distal neuropathy. Identification of these variants of brachial plexus plays an especially important role in both clinical diagnosis and surgical practice.