Association Between Single-Injection Regional Analgesia and Postoperative Pain in Cardiac Surgery Patients: A Single-Center Retrospective Cohort Study.

OBJECTIVES: Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution. DESIGN: Retrospective cohort study. SETTING: Midwestern academic hospital. PARTICIPANTS: Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022. INTERVENTIONS: Ultrasound-guided single-injection chest wall block with liposomal bupivacaine. MEASUREMENTS AND MAIN RESULTS: Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195). CONCLUSIONS: In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.

Correlations of Opioid Intake During Different Predischarge Time Frames with Postdischarge Opioid Use Following Inpatient Surgery.

Previous work has shown that predischarge opioid use is the most reliable and practical predictor of postdischarge opioid intake after inpatient surgery. However, the most appropriate predischarge time frame for operationalizing this relationship into more individualized prescriptions is unknown. We compared the correlations between the quantity of opioids taken during 5 predischarge time frames and self-reported postdischarge opioid intake in 604 adult surgery patients. We found that the 24-hour predischarge time frame was most strongly correlated (ρ= 0.60, P < .001) with postdischarge opioid use and may provide actionable information for predicting opioid use after discharge.

Rethinking ketamine as a panacea: adverse effects on oxygenation and postoperative outcomes.

Ketamine is receiving renewed interest in perioperative medicine as an anaesthetic adjunct and a treatment for chronic conditions, including depression. Ketamine's complex pharmacologic profile results not only in several desirable effects, such as anaesthesia and analgesia, but also multiple adverse effects affecting the central nervous, cardiovascular, and respiratory systems. In addition to defining patient-centred outcomes in future clinical studies on the perioperative uses of ketamine, careful monitoring for its numerous adverse effects will be paramount.

Best Practice Alerts Informed by Inpatient Opioid Intake to Reduce Opioid Prescribing after Surgery (PRIOR): A Cluster Randomized Multiple Crossover Trial.

BACKGROUND: Overprescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. This study therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery. METHODS: This study included 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating 8-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on previous inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid and nonopioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial. RESULTS: The total postdischarge opioid prescription was a median [quartile 1, quartile 3] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI, 0.80 to 1.13; P = 0.586). The alert was displayed in 28% (3,074 of 11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid and nonopioid combination medications or additional opioid prescriptions written after discharge. CONCLUSIONS: A decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.(Anesthesiology 2023; 139:186-96).

Association between alcohol use disorder and hospital outcomes in colectomy patients - A retrospective cohort study.

STUDY OBJECTIVE: In the United States, alcohol use disorder adversely affects 5.6% of all adults. Excessive alcohol consumption adversely affects organ functions critical for adaptation to stress induced by surgery. Colorectal resection is one of the most common major surgeries in patients at risk for alcohol use disorder. The objective of this study was to assess the impact of alcohol use disorder on hospital outcomes after colectomy using a population-based discharge database. SETTING: Population-based discharge database. PATIENTS: The Premier Healthcare Database was queried for the 603,730 adult patients who underwent colectomy from 2016 to 2019. INTERVENTIONS: None. MEASUREMENTS: Multiple logistic regressions estimated the associations between in-hospital mortality, length of stay, and hospitalization cost with alcohol use disorder as the primary predictor, adjusting for other substance use disorders, psychotic disorders, depression, other Elixhauser comorbidities, age, payor, race, gender, non-elective surgery, and other unbalanced variables. MAIN RESULTS: A discharge code for alcohol use disorder was identified in 2.9% of colectomy patients and the overall in-hospital mortality rate in all sampled colectomy patients was 1.4%. Alcohol use disorder was associated with a significantly increased risk of in-hospital mortality after adjusting for other factors (AOR 1.36, 95% CI 1.24-1.48, p < 0.0001). Alcohol use disorder was also significantly associated with long length of stay (AOR 1.45, 95% CI 1.39-1.52, p < 0.0001) and high hospitalization costs (AOR 1.63, 95% CI 1.56-1.70, p < 0.0001). CONCLUSIONS: Alcohol use disorder is associated with an increased risk of in-hospital mortality in patients undergoing colectomy, one of the most common major surgeries. Future research should examine if enhanced efforts to identify patients with alcohol use disorder could enable anesthesiologists to provide worthwhile perioperative interventions for this high-risk population.