Fentanyl-Induced Serotonin Syndrome 5 Days After Cessation of Serotonergic Agents: A Case Report.

A 21-year-old patient with intellectual disability was admitted for gastroenteritis due to serotonergic medication overdose, and subsequently developed serotonin syndrome. Her symptoms initially improved after the cessation of serotonergic medications, but worsened 5 days later after fentanyl administration during general anesthesia. On emergence, she had convulsions and was nonresponsive. Subsequent imaging and electroencephalography did not demonstrate intracranial pathology or seizure activity. We suspect she had an exacerbation of her serotonin syndrome. She recovered successfully after supportive care. This case demonstrates that common medications used during anesthesia such as fentanyl can provoke serotonin syndrome, even several days after serotonergic drug discontinuation.

Intraoperative Nerve Stimulation as an Approach for the Surgical Treatment of Genitofemoral Neuralgia.

BACKGROUND Genitofemoral neuralgia is a pain syndrome that involves injury to the genitofemoral nerve and is frequently iatrogenic. We report intraoperative nerve localization using ultrasound, nerve stimulation, and the cremasteric reflex in the surgical treatment of genitofemoral neuralgia. CASE REPORT A 49-year-old man with a history of extracorporeal membrane oxygenation with cannulation sites in bilateral inguinal regions presented with right groin numbness and pain following decannulation. His symptoms corresponded to the distribution of the genitofemoral nerve. He had a Tinel's sign over the midpoint of his inguinal incision. A nerve block resulted in temporary resolution of his symptoms. Due to the presence of a pacemaker, peripheral nerve neuromodulation was contraindicated. He underwent external neurolysis and neurectomy of the right genitofemoral nerve. Following direct stimulation and ultrasound for localization, the nerve was further localized intraoperatively using nerve stimulation with monitoring for the presence of the cremasteric reflex. At his 1-month postoperative visit, his right medial thigh pain had resolved and his right testicular pain 50% improved; his residual pain continued to improve at last evaluation 3 months after surgery. CONCLUSIONS We report the successful use of nerve stimulation and the cremasteric reflex to aid in identification of the genitofemoral nerve intraoperatively for the treatment of genitofemoral neuralgia.

Risk Factors for Postoperative Unplanned Reintubation in a Cohort of Patients Undergoing General Anesthesia.

Background Unplanned post-operative reintubation (UPR) is a complication of general anesthesia (GA) that can be associated with worsened outcomes. Objective Evaluate characteristics associated with UPR in patients undergoing procedures under GA. Methods Patients over the age of 18 undergoing surgical procedures under GA were extracted from our institution's electronic medical record. Patient baseline, procedural, and anesthesia characteristics were evaluated for associations with UPR. Results In 29,284 surgical procedures undergoing GA, there were 29 (0.1%) patients that required UPR. The most common surgical service with UPR was otolaryngology; the most common surgical positioning was supine. When controlling for operative time and case complexity, UPR was predicted by high-dose opioids, defined as opioid administration greater than the 75th percentile of our institutional cohort. Prolonged operative time, estimated blood loss (EBL), body mass index (BMI), extubation time after reversal, or age were not independently associated with UPR. Conclusion Our analysis revealed that high-dose opioid administration is independently associated with intraoperative UPR. Awareness of patients at the highest risk for UPR along with provider education regarding techniques to avoid respiratory depression in this patient population is essential in reducing patient morbidity and mortality. This knowledge will help guide perioperative physicians in medical optimization, appropriate selection of intraoperative analgesics, and cautious extubation criteria to ensure patient safety.

A history of opioid abuse: Why buprenorphine is superior for the management of opioid use disorder and pain.

Opioid abuse represents a public health crisis that has significant associated morbidity and mortality. Since beginning in the early 1990's, the opioid abuse epidemic has been difficult to control due to regulatory, economic, and psychosocial factors that have perpetuated its existence. This era of opioid abuse has been punctuated by three distinct rises in mortality, precipitated by unique public health problems that needed to be addressed. Patients affected by opioid abuse have been historically treated with either methadone or naltrexone. While these agents have clinical utility supported by robust literature, we the authors posit that buprenorphine is a superior therapy for both opioid use disorder (OUD) as well as pain. This primacy is due to the pharmacological properties of buprenorphine which render it unique among other opioid medications. One such property is buprenorphine's ceiling effect of respiratory depression, a common side effect and complicating factor in the administration of many classical opioid medications. This profile renders buprenorphine safer, while simultaneously retaining therapeutic utility in the medical practitioner's pharmacopeia for the treatment of opioid use disorder and pain.

A meta-analysis of the potential antidepressant effects of buprenorphine versus placebo as an adjunctive pharmacotherapy for treatment-resistant depression.

BACKGROUND: Numerous reports have suggested that buprenorphine may have antidepressant effects. Many individuals with depressive disorders don't respond to first-line treatment and are classified with treatment-resistant depression (TRD). Novel therapies for depression are required to better treat this population. This meta-analysis of randomized placebo-controlled trials sought to evaluate the potential antidepressant effects of buprenorphine as an adjunctive pharmacological treatment for individuals with TRD. METHODS: PubMed, Embase, CINAHL, Web of Science, and ClinicalTrials.gov databases were searched until June 2019 for original peer-reviewed reports of buprenorphine used for the treatment of depression. Standardized mean differences (SMD) were generated from random effects models. Risk of publication bias was assessed using a funnel plot. Potential sources of heterogeneity were explored in subgroup analyses. RESULTS: In six studies that met inclusion criteria, depression symptom severity in individuals with TRD was not significantly decreased after an adjunctive intervention with buprenorphine when compared to placebo (SMD = -0.07, 95% CI: -0.21-0.06, p = 0.30). Five of the six studies utilized a combination of buprenorphine/samidorphan. In these studies, depression symptom severity was also not significantly reduced after intervention compared to placebo (SMD = -0.08, 95% CI: -0.21 - 0.05, p = 0.23). LIMITATIONS: Five included studies were performed by the same research group with significant conflicts of interest. CONCLUSIONS: This meta-analysis did not reveal a significant reduction in depression symptom severity in individuals with TRD after an adjunctive intervention with buprenorphine when compared to placebo. However, more optimal doses of buprenorphine (2 mg/day) and longer treatment lengths should be explored.

Attitudes toward and Barriers to Acetaminophen Use in the Chronic Pain Population: A Cross-Sectional Study.

The use of acetaminophen is recommended in pain management, particularly acute pain management, to reduce opioid utilization and opioid related adverse drug events. Acetaminophen's role in chronic pain conditions is understudied. This cross-sectional study was performed in a pain management office to explore how chronic pain patients use acetaminophen. The final study sample included 100 patients. Current users of acetaminophen were most likely to report that a doctor had recommended acetaminophen to them (86.4%) compared to ever (66.7%) and never (55.6%) users (p < .001). Patients who were recommended taking acetaminophen by a physician were 3.60 times as likely (95% CI 1.58, 8.25) to be a current or ever user of acetaminophen as compared to those who did not receive such a recommendation from their physician. There were no significant differences between current, ever, and never users on their knowledge of the maximum daily dose of acetaminophen of 4 g (p = .925). The study suggests that patients are often unaware of acetaminophen's role in the treatment of their chronic pain.

Comparison Of Digital Manometer And Water Column Manometer Pressures Measurements During Lumbar Puncture.

BACKGROUND: Cerebrospinal fluid (CSF) pressure measurement is routinely performed via a conventional water column manometer. There is increasing interest in using a digital manometer in measuring CSF pressures. The aim of this study is to compare column and digital manometers, in addition to measuring time to acquire the pressure readings. RESEARCH DESIGN AND METHODS: This prospective study included 27 patients who were referred for a fluoroscopically guided lumbar puncture. Opening pressure and closing pressure measurements were done with a digital manometer and then a traditional water column manometer. The time to obtain each pressure measurement was also recorded and compared. RESULTS: Mean time to obtain pressure reading was significantly lower in the digital manometer group when compared to the water column manometer group (8.1 seconds vs. 42.2 seconds, P<0.05 for opening pressure and 8.92 seconds vs. 45.15 seconds, P<0.05 for closing pressure). Correlation between the opening pressure measurements (Pearson coefficient r= 0.98) and closing pressure (Pearson coefficient r= 0.89) was strong. However, the digital manometer reading consistently read higher. CONCLUSION: Digital manometry during an LP yielded is faster however there might be a clinical difference between the devices. Clinicians must be careful in using the device across all cases.

Radiofrequency Ablation of the Stellate Ganglion for Management of Acute Digital Ischemia: A Case Report.

The authors present a report of a pulsed radiofrequency ablation of the stellate ganglion performed on a patient with microemboli to the hand from a thrombosed abandoned arteriovenous fistula. The patient was initially managed using vasodilators and anticoagulation. However, the patient's skin mottling, pain, and decreased strength persisted. Ablation of the stellate ganglia increased perfusion to his hand and likely prevented amputation that has lasted for approximately 1 year. While radiofrequency ablation is more commonly used for pain syndromes, this is an example of its use in the treatment and potential treatment of acute ischemia.