Perioperative factors associated with HCAHPS responses of 2,758 surgical patients.

OBJECTIVE: To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey responses. DESIGN: Retrospective analysis. SETTING: Single tertiary care, academic, urban, level-1 trauma center. PARTICIPANTS: Final cohort represents 2,758 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS. EXPOSURES: Responses to four HCAHPS questions were compared against 19 perioperative treatments and events. MEASURES: Positive and negative responses to HCAHPS questions. RESULTS: Patients responding affirmatively with a "9" or "10" to "what number would you use to rate this hospital" were associated with decreased lengths of hospitalization, greater lengths of surgery, decreased intraoperative opioid equianalgesic doses, greater preoperative midazolam doses, shorter post anesthesia care unit (PACU) lengths of stay and decreased last PACU numerical rating scale (NRS) pain scores. Patients responding affirmatively with "yes, definitely" to "would you recommend this hospital to your family" were associated with decreased last PACU NRS pain scores. Patients responding affirmatively with "yes, always" to "How often did the hospital staff do everything to help with your pain" were associated with decreased hospital lengths of stay, decreased chronic benzodiazepine use, greater chronic NSAID use, and decreased PACU lengths of stay. Patients responding affirmatively with "yes, always" to "how often was your pain well controlled" were associated with decreased chronic opioid use, decreased chronic benzodiazepine use, greater chronic NSAID use, increased length of surgery, decreased last PACU NRS pain score, and decreased first PACU NRS pain scores. Subgroup analysis of patients undergoing different types of surgery further characterized factors associated with HCAHPS responses among different surgical populations. CONCLUSIONS: These data suggest that demographic factors, preadmission medications, and PACU pain scores but not analgesic medications are associated with patient satisfaction with regards to both pain management and overall satisfaction.

Spontaneous intracranial hypotension in childhood and adolescence.

OBJECTIVES: To describe the clinical and radiographic manifestations of spontaneous intracranial hypotension, a rarely diagnosed cause of headache in children. STUDY DESIGN: This study included patients 19 years of age or younger evaluated between January 1, 2001, and June 30, 2012, for spontaneous intracranial hypotension. RESULTS: We evaluated 24 children (18 girls and 6 boys) with spontaneous intracranial hypotension (age at onset of symptoms: 2-19 years, mean 14.3 years). Twenty-three patients presented with orthostatic headaches and 1 presented with a nonpositional headache. A generalized connective tissue disorder was diagnosed in 54% of patients. Magnetic resonance imaging showed the typical changes of spontaneous intracranial hypotension in most patients (79%). Spinal imaging demonstrated a cerebrospinal fluid (CSF) leak with or without an associated meningeal diverticulum in 12 patients (50%) and with dural ectasia or meningeal diverticula in 10 patients (42%), and it was normal in 2 patients (8%). Twenty-three patients initially underwent epidural blood patching, but 8 patients also were treated with percutaneous injections of fibrin glue and 11 patients eventually required surgical correction of the underlying CSF leak. There was no morbidity or mortality associated with any of the treatments, but 5 patients required acetazolamide for rebound high intracranial pressure headache. Overall, outcome was good in 22 patients (92%) and poor in 2 patients (8%). CONCLUSIONS: Spontaneous intracranial hypotension in childhood is rare. Most patients can be treated effectively using a combination of epidural blood patching and percutaneous injections of fibrin glue or surgical CSF leak repair in refractory cases.

Adverse Effects Associated with Patient-Controlled Analgesia with Ketamine Combined with Opioids and Ketamine Infusion with PCA Bolus in Postoperative Spine Patients: A Retrospective Review.

Objective: There has been increasing use of ketamine at subanesthetic doses as an adjunct to opioids in perioperative pain management. There are several known adverse drug effects (ADEs) associated with ketamine. However, the incidence of ADEs with ketamine infusions with patient-controlled analgesia (PCA) boluses compared with combined opioid and ketamine PCAs is not well described. The objectives of this study were to compare the incidence and type of ADEs in postoperative spine surgery patients on ketamine infusions with as-needed PCA boluses to patients on combined opioid and ketamine PCAs. Methods: The medical records of patients who underwent spine surgery between March 2016 and March 2020 who were postoperatively treated with a ketamine infusion and as-needed PCA boluses and parenteral opioids or treated with a combined opioid and ketamine PCA were reviewed. Perioperative information including patient characteristics and preoperative morphine equivalent daily dose (MEDD) were collected. Patient charts were reviewed for ADEs including psychological and neurological side effects, nausea, and new-onset tachycardia. Results: A total of 315 patients met the inclusion criteria and were included in the final analysis. Of these patients, 121 experienced at least one ADE (38%). Sixteen of the 68 ketamine infusion with PCA bolus patients (24%), 77 of the 203 hydromorphone and ketamine patients (38%), and 28 of the 44 morphine and ketamine patients (64%) experienced an ADE [p<0.01]. In patients with preoperative MEDD ≤ 90, nausea was the only ADE that differed significantly among the three groups. Conclusion: This retrospective analysis suggests that postoperative spine patients treated with a ketamine infusion with as-needed PCA boluses and parenteral opioids were associated with fewer ADEs when compared to an intravenous combined opioid and ketamine PCA. In patients with preoperative MEDD ≤ 90, nausea with and without emesis was the only ADE that showed statistically significant difference amongst the three groups.

A two-level large-volume epidural blood patch protocol for spontaneous intracranial hypotension: retrospective analysis of risk and benefit.

BACKGROUND: We report a retrospective analysis of a two-level, variable-volume epidural blood patch (EBP) technique for the treatment of spontaneous intracranial hypotension (SIH). METHODS: Ninety-four patients with SIH underwent EBPs. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the EBP. Patients were a responder if no invasive treatment was necessary for SIH symptoms after the first EBP. Baseline patient characteristics, including presenting symptoms and imaging findings, were compared between responders and non-responders. Adverse events were recorded. RESULTS: The mean first EBP volume was 45.3±23.2 (range 4-124 mL). The responder rate was 28.7% after the first EBP, improving to 41.5% and 46.8% after a second and third EBP, respectively. Baseline characteristics were similar between groups, except for the greater prevalence of subdural fluid collections in the responder group (48% vs 18%, p=0.003). Two severe complications occurred: transient bilateral paraplegia and cauda equina syndrome from arachnoiditis. CONCLUSIONS: Our protocol can be used to treat SIH but carries risks that require meticulous attention. EBP volumes were variable across patients, demonstrating the variability in the elastance of the epidural space. Rigorous monitoring for neurological symptoms is necessary throughout the procedure to limit complications and determine the endpoint of the EBP. We advocate for rigorous confirmation of epidural placement of the EBP with contrast-imaging studies to limit intrathecal placement of blood, which can lead to arachnoiditis. Randomized controlled trials are needed to determine the safety and efficacy of large-volume EBPs.

Pain and Depression: A Systematic Review.

BACKGROUND: Pain comorbid with depression is frequently encountered in clinical settings and often leads to significant impaired functioning. Given the complexity of comorbidities, it is important to address both pain and depressive symptoms when evaluating treatment options. AIM: To review studies addressing pain comorbid with depression, and to report the impact of current treatments. METHOD: A systematic search of the literature databases was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 28 articles to be included in this review. RESULTS: Overall, studies suggested that pain and depression are highly intertwined and may co-exacerbate physical and psychological symptoms. These symptoms could lead to poor physical functional outcomes and longer duration of symptoms. An important biochemical basis for pain and depression focuses on serotonergic and norepinephrine systems, which is evident in the pain-ameliorating properties of serotonergic and norepinephrine antidepressants. Alternative pharmacotherapies such as ketamine and cannabinoids appear to be safe and effective options for improving depressive symptoms and ameliorating pain. In addition, cognitive-behavioral therapy may be a promising tool in the management of chronic pain and depression. CONCLUSION: The majority of the literature indicates that patients with pain and depression experience reduced physical, mental, and social functioning as opposed to patients with only depression or only pain. In addition, ketamine, psychotropic, and cognitive-behavioral therapies present promising options for treating both pain and depression.

Perioperative factors associated with Hospital Consumer Assessment of Healthcare Providers and Systems responses of total hip arthroplasty patients.

OBJECTIVE: To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) responses among patients who undergo total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). DESIGN: Retrospective analysis. SETTING: Single tertiary care, academic, urban, level 1 trauma center. PARTICIPANTS: Final cohort represents 301 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS survey. EXPOSURES: Responses to 4 HCAHPS questions were analyzed against perioperative treatments and events. MEASURES: Positive and negative responses to HCAHPS questions. RESULTS: THA patients responding affirmatively to both pain specific and general satisfaction were associated with preoperative use of chronic nonsteroidal anti-inflammatory drugs. In addition, THA patients responding affirmatively "how often was your pain well controlled" were also associated decreased postanesthesia care unit (PACU) opioid requirement. TKA patients responding affirmatively to "what number would you use to rate this hospital" were associated with shorter PACU stays and lower final pain scores. TKA patients responding affirmatively to "would you recommend this hospital to your family" were associated with shorter lengths of stay in the hospital and in the PACU. TKA patients responding affirmatively to "How often did the hospital staff do everything to help with your pain" were not associated with any measured perioperative event. TKA patients responding affirmatively to "how often was your pain well controlled" were associated with older age, decreased use of preoperative chronic benzodiazepines, and increased use of preoperative midazolam. CONCLUSIONS: These data suggest that chronic use of nonsteroidal anti-inflammatory drugs is associated with improved overall satisfaction and satisfaction with pain in THA patients. Furthermore, increased PACU opioid use was negatively associated satisfaction with pain management. Age, lengths of stay preadmission medications, anxiolytic medications, and PACU pain scores are associated with patient satisfaction with regards to both pain management and overall satisfaction in TKA patients.

A wearable epidural catheter infusion system for patients with intractable spontaneous intracranial hypotension.

BACKGROUND AND OBJECTIVES: Spontaneous intracranial hypotension is an important cause of secondary headaches, and most patients respond well to epidural blood patching or direct repair of the underlying spinal cerebrospinal fluid leak. However, options are limited for those patients who have exhausted these traditional treatments, especially when spinal imaging is normal. We describe a wearable epidural catheter infusion system for patients with intractable spontaneous intracranial hypotension. METHODS: Six patients with intractable spontaneous intracranial hypotension (4 women and 2 men; mean age, 53 years; mean duration of symptoms, 50 months) underwent placement of a permanent indwelling spinal epidural catheter attached to an external infusion pump. The Migraine Disability Assessment questionnaire was used to assess the severity of the symptoms, before and during treatment. RESULTS: The infusion resulted in complete or near-complete symptom relief in 5 of 6 patients (Migraine Disability Assessment score decreased from grade IV to grade I or II). However, the epidural catheter infusion system was removed in 2 patients because of infection, in 1 patient because of delayed failure to provide adequate symptom control, and in 1 patient because of minimal symptom relief. Two patients reported excellent and sustained symptom relief over 27 and 36 months of follow-up. CONCLUSIONS: This wearable epidural catheter infusion system showed promising efficacy results but the high rate of complications limits its use to a very select group of patients.

Initial Experience with IV Ketamine Infusion for Treatment of Post Sternotomy Pain in a Patient with a Total Artificial Heart.

The implantation of total artificial hearts (TAH) via midline sternotomy for the treatment of severe biventricular cardiac dysfunction is associated with complex postoperative pain management. Ketamaine increases blood pressure by raising sympathetic outflow and cardiac output; however, ketamine is a direct vasodilator on isolated arterial tissues. In the setting of a TAH with a mechanically fixed cardiac output, a ketamine infusion for postoperative pain control has the potential to decrease blood pressure due to direct arterial vasodilation. We present the initial experience with a ketamine infusion in a patient with a TAH with minimal observed decreases in blood pressure and significantly improved postoperative pain.

Epidural Analgesia after Rib Fractures.

Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderate-to-severe injuries from January 1, 2004 to December 31, 2013. During the 10-year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderate-to-severe injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.

Perioperative substance use disorder, opioid diversion, and opioid misuse by a medical professional undergoing orthopedic surgery.

Patients with substance use disorders can present challenges for effective perioperative pain management. Healthcare professionals with substance abuse disorders requiring medical treatment and pain management represent a unique subpopulation. The authors present a case of a nurse undergoing an orthopedic surgical procedure who was found with two large, organized tackle boxes of opioid medication in her hospital room. Although the incidence of substance use disorders in healthcare professionals is thought to be equivalent to the general population, the presentation, substances of choice, and inciting factors are unique. Further, treatment options available to such individuals have been established and proven successful.

Spontaneous spinal cerebrospinal fluid leaks as the cause of subdural hematomas in elderly patients on anticoagulation.

Subdural hematoma is a relatively common complication of long-term anticoagulation, particularly in the elderly. The combination of anticoagulation and cerebral cortical atrophy is believed to be sufficient to explain the subdural bleeding. The authors report a series of elderly patients who were on a regimen of anticoagulation and developed chronic subdural hematomas (SDHs) due to a spontaneous spinal CSF leak. They reviewed the medical records and imaging studies of a consecutive group of patients with spontaneous intracranial hypotension who were evaluated at Cedars-Sinai Medical Center. Among 141 patients with spontaneous spinal CSF leaks and spontaneous intracranial hypotension, 3 (2%) were taking anticoagulants at the time of onset of symptoms. The mean age of the 3 patients (1 woman and 2 men) was 74 years (range 68-86 years). All 3 patients had chronic SDHs measuring between 12 and 23 mm in maximal diameter. The SDHs resolved after treatment of the underlying spontaneous spinal CSF leak, and there was no need for hematoma evacuation. Epidural blood patches were used in 2 patients, and percutaneous placement of a fibrin sealant was used in 1 patient. The presence of an underlying spontaneous spinal CSF leak should be considered in patients with chronic SDHs, even among the elderly taking anticoagulants.

Reversible cerebral vasoconstriction in spontaneous intracranial hypotension.

Myelography showed an opening pressure of 0 cm H2O and multiple thoracic meningeal diverticula in a 52-year-old woman suffering from orthostatic headaches of instantaneous onset. MR-angiography showed severe segmental arterial stenosis of the anterior and posterior circulation, which resolved over a 4-day period following an epidural blood patch. Spontaneous intracranial hypotension should be considered in the differential diagnosis of reversible cerebral vasoconstriction.

Cranial MRI predicts outcome of spontaneous intracranial hypotension.

The outcome of spontaneous intracranial hypotension has been unpredictable. The results of initial MRI were correlated to outcome of treatment in 33 patients with spontaneous intracranial hypotension. A good outcome was obtained in 25 (97%) of 26 patients with an abnormal MRI vs only 1 (14%) of 7 patients with a normal MRI (p = 0.00004). These findings show that normal initial MRI is predictive of poor outcome in spontaneous intracranial hypotension.