Ketamine and Cognitive Behavioral Therapy for Rapid Opioid Tapering With Sustained Opioid Abstinence: A Case Report and 1-Year Follow-up.

BACKGROUND: Ketamine, a potent analgesic and N-methyl-D-aspartate-(NMDA)-receptor antagonist, improves analgesic outcomes in patients with complex regional pain syndrome (CRPS). The NMDA receptor has also been implicated in opioid withdrawal. The use of ketamine to assist with a rapid opioid taper in the setting of CRPS has not been previously described. CASE: We present a case in which a 5-day continuous ketamine infusion was utilized in a robust multimodal analgesia regimen in combination with cognitive behavioral therapy (CBT) to successfully taper a patient with complex regional pain syndrome (CRPS) who was taking 330 mg of daily morphine equivalents completely off of opioids, minimize withdrawal symptoms, and produce sustained results. DISCUSSION: CRPS may involve catecholamine hypersensitivity and central sensitization and can be notoriously challenging to treat by itself even outside of the context of an opioid taper. The patient we describe here received one additional 5-day infusion at 6 months and remained opioid-free while experiencing a major improvement in function and lifestyle that he still maintains. This was possible through a combination of aggressive inpatient management with ketamine as the centerpiece, followed by consistent outpatient CBT to maintain results without the need for a return to opioids. This combination has previously not been described in the setting of a rapid opioid taper and this patient's underlying CRPS made it all the more remarkable.

Systematic criteria for type and screen based on procedure's probability of erythrocyte transfusion.

BACKGROUND: At many hospitals, the type and screen decision is guided by the hospital's maximum surgical blood order schedule, a document that includes for each scheduled (elective) surgical procedure a recommendation of whether a preoperative type and screen be performed. There is substantial heterogeneity in the scientific literature for how that decision should be made. METHODS: Anesthesia information management system data were retrieved from the 160,207 scheduled noncardiac cases in adults of 1,253 procedures at a hospital. RESULTS: Neither assuming a Poisson distribution of mean erythrocyte units transfused, nor grouping rare procedures into larger groups based on their anesthesia Current Procedural Terminology code, was reliable. In contrast, procedures could be defined to have minimal estimated blood loss (less than 50 ml) based on low incidence of transfusion and low incidence of the hemoglobin being checked preoperatively. Among these procedures, when the lower 95% confidence limit for erythrocyte transfusion was less than 5%, type and screen was shown to be unnecessary. The method was useful based on including multiple differences from the hospital's maximum surgical blood order schedule and clinicians' test ordering (greater than or equal to 29% fewer type and screen). Results were the same with a Bayesian random effects model. CONCLUSIONS: We validated a method to determine procedures on the maximum surgical blood order schedule for which type and screen was not indicated using the estimated blood losses and incidences of transfusion.

Forecasting preanesthesia clinic appointment duration from the electronic medical record medication list.

BACKGROUND: When scheduling clinic appointments, scheduling patients expected to have different visit durations for different minutes of time reduces patient waiting time and staff idle time. Maintaining an active medication list is an important (and, in the United States, required) component to the meaningful use of electronic medical records. We hypothesized that the count of medications from the medication list would be a better predictor of the time taken by a nurse practitioner to evaluate the patient preoperatively than the American Society of Anesthesiologists' (ASA) physical status and other demographic variables. METHODS: Using 69,654 preoperative visits, we obtained the number of different medications taken by the patient and demographic variables, including ASA physical status, ASA base units, and body mass index. For each independent variable, we applied transformations and calculated the Pearson correlation giving the largest correlation with the log(10) (duration), which followed a normal distribution. RESULTS: Only 18% of the patients had been evaluated previously at the preoperative facility, making use of the prior ASA physical status ineffective for forecasting. The number of medications was a more accurate predictor of appointment duration than any of the other 8 variables (each Bonferroni corrected P < 0.0001), including ASA physical status. CONCLUSIONS: Schedulers can use the number of medications that each patient is taking when choosing the time for preoperative evaluation. This approach can take schedulers only approximately 10 seconds extra per patient when scheduling the appointment.

New and emerging analgesics and analgesic technologies for acute pain management.

PURPOSE OF REVIEW: Recent advances in drug delivery technology have provided new means of delivering medications with improved efficacy and safety. This review details developments in drug delivery recently made available or in development with the potential to better deliver analgesia. RECENT FINDINGS: Patient-controlled analgesia of intravenous medications was a major advance in drug delivery technology that allowed opioids to be administered more effectively and more safely. Extension of this technology to medications not administered intravenously has further broadened therapeutic options in the treatment of acute pain. Improvements in sustained-release formulations and patient-controlled analgesia modalities that are not catheter-based confer the potential to deliver analgesia less invasively. Receptor-specific antagonists allow opioids to be administered with fewer untoward side effects. SUMMARY: New routes of administration allow familiar medications to be utilized with greater clinical efficacy. Elimination of the need for indwelling catheters may reduce both the frequency of analgesic gaps and catheter-related complications. Physicians need to be familiar with developments in drug delivery technologies to be able to effectively utilize analgesics as part of well designed multimodal regimens to bring effective and well tolerated analgesia to patients with acute pain.

Bypass of an anesthesiologist-directed preoperative evaluation clinic results in greater first-case tardiness and turnover times.

STUDY OBJECTIVE: We evaluated 4 hypotheses related to bypass of an anesthesiologist-directed preoperative evaluation clinics (APEC): 1) first-case tardiness and turnover times increased; 2) turnover times increased more than first-case tardiness; and higher American Society of Anesthesiologists Physical Status (ASA PS) resulted in both an ordered increase among ASA PS and within ASA PS in 3) first-case tardiness; and 4) turnover times. DESIGN: Retrospective observational study using electronic health records. SETTING: One large, teaching hospital. PATIENTS: An average of 14,310 patients per year undergoing elective surgery in the hospital's main opera rating rooms who were not inpatients preoperatively between 2006 and 2016. INTERVENTIONS: None. MEASUREMENTS: Average increases in first-case tardiness and turnover times between patients seen or not seen preoperatively in the APEC. MAIN RESULTS: APEC bypass increased first-case tardiness 2.58 min per case (CI 1.55-3.61; P<0.0001) and turnover times by 7.49 min (CI 6.79-8.19; P<0.0001). The increase in mean turnover time was greater than mean first-case tardiness (difference=4.91 min; CI 3.76-6.06; P<0.0001). Had all patients bypassed the APEC, the increase in total minutes OR- 1 workday- 1 for turnover times would have been larger than the increase in first-case tardiness (difference=5.71, CI 3.17-4.72; P<0.0001). There was an ordered increase with APEC bypass for both first-case tardiness and turnover times with increasing ASA PS (P<0.0001). Within ASA PS, first-case tardiness (all P-values<0.003) and turnover times (all P-values<0.0001) also increased with APEC bypass. All 4 hypotheses were accepted. CONCLUSIONS: Overall and with control for ASA PS, APEC bypass increases first-case tardiness and turnover times. A strategy of selective bypass of ASA PS 1-2 patients would not be effective economically because of substantial delays from ASA PS 2 patients.