Continuation of Buprenorphine to Facilitate Postoperative Pain Management for Patients on Buprenorphine Opioid Agonist Therapy.

BACKGROUND: Acute pain management in patients on buprenorphine opioid agonist therapy (BOAT) can be challenging. It is unclear whether BOAT should be continued or interrupted for optimization of postoperative pain control. OBJECTIVES: To determine an evidence-based approach for pain management in patients on BOAT in the perioperative setting, particularly whether BOAT should be continued or interrupted with or without bridging to another mu opioid agonist and to identify benefits and harms of either perioperative strategy. STUDY DESIGN: Systematic literature review with qualitative data synthesis. SETTING: Hospital, perioperative. METHODS: The study protocol was registered on PROSPERO (Registration number 9030276355). Medline via OVID, EMBASE, CINAHL, and the Cochrane CENTRAL register of trials were searched for prospective or retrospective observational or controlled studies, case series, and case reports that described perioperative or acute pain care for patients on BOAT. References of narrative and systematic reviews addressing acute pain management in patients on BOAT and references of included articles were hand-searched to identify additional original articles for inclusion. The full text of publications were reviewed for final inclusion, and data were extracted using a standardized data extraction form. Results were summarized qualitatively. Primary outcomes were postoperative pain intensity and total opioid use and identification of benefits and harms of perioperative strategies. RESULTS: Eighteen publications presenting data on the perioperative management of patients on BOAT were identified: 10 case reports, 5 case series, and 3 retrospective cohort studies. Eleven articles reported continuation of BOAT, 2 concerned bridging BOAT, and 4 articles described stopping BOAT without planned bridging. In one retrospective cohort study, BOAT was continued in half and interrupted in half of patients. Patients on BOAT may have pain that is more difficult to treat than those who are not on OAT. There is no clear evidence that one particular strategy provides superior postoperative pain control, but interruption of BOAT may result in harm, including failure to return to baseline BOAT doses, continuing non-BOAT opioid use, or relapse of opioid use disorder. LIMITATIONS: There were a limited number of articles relevant to the study question consisting of case reports and retrospective observational studies. Some omitted relevant details. No prospective studies were found. CONCLUSIONS: There is no clear benefit to bridging or stopping BOAT but failure to restart it may pose concerns for relapse. We recommend continuing BOAT in the perioperative period when possible and incorporating an interdisciplinary approach with multimodal analgesia. KEY WORDS: Opioid use disorder, opiate substitution treatment, buprenorphine, buprenorphine-naloxone, buprenorphine opioid agonist therapy, postoperative pain, acute pain, multimodal analgesia.

Access to Palliative Care for Patients Undergoing Mechanical Ventilation With Idiopathic Pulmonary Fibrosis in the United States.

OBJECTIVE: The utilization of palliative care (PC) in patients with end-stage idiopathic pulmonary fibrosis (IPF) is not well understood. METHODS: The Nationwide Inpatient Sample (NIS) was utilized to examine the use of PC in mechanically ventilated (MV) patients with IPF. The NIS captures 20% of all US inpatient hospitalizations and is weighted to estimate 95% of all inpatient care. RESULTS: A total of 55 208 382 hospital admissions from the 2006 to 2012 NIS samples were examined. There were 21 808 patients identified with pulmonary fibrosis, of which 3166 underwent mechanical ventilation and were included in the analysis. Of the 3166 patients in the main cohort, 408 (12.9%) had an encounter with PC, whereas 2758 (87.1%) did not. After multivariate logistic regression modeling, variables associated with increased access to PC referral were age (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01-1.03, P < .01), treatment in an urban teaching hospital (OR: 1.49, 95% CI: 1.27-3.58, P < .01), and do-not-resuscitate status (OR: 9.86, 95% CI: 7.48-13.00, P < .01). Factors associated with less access to PC were Hispanic race (OR: 0.64, 95% CI: 0.41-0.99, P = .04) and missing race (OR: 0.52, 95% CI: 0.34-0.79, P < .01), with white race serving as the reference. The use of PC has increased almost 10-fold from 2.3% in 2006 to 21.6% in 2012 ( P < .01). CONCLUSION: The utilization of PC in patients with IPF who undergo MV has increased dramatically between 2006 and 2012.

Optic nerve sheath diameter on computed tomography not predictive of neurological status post-cardiac arrest.

OBJECTIVE: Optic nerve sheath diameter (ONSD) measured on a head computed tomography (CT) has been suggested as a potential prognostic factor for poor neurological outcome after cardiac arrest. We performed a single centre retrospective cohort analysis to further investigate this relationship. METHODS: All patients >18 years of age admitted to St. Paul's Hospital in Vancouver, Canada who survived a cardiac arrest and had a CT scan of the head within 48 hours were included in the analysis. RESULTS: A total of 72 patients met inclusion criteria for the study; 54 (75.0%) of the patients had a poor neurological outcome, whereas 18 (25.0%) patients were discharged from the hospital with a good outcome. A CT head was obtained for patients in the good outcome group in a mean time of 9.3 hours (SD 10.0) compared to 10.2 hours (SD 11.2) for the poor outcome group (p=0.75). There was no difference in average ONSD observed between the two outcome groups (6.66 mm SD 0.78 v. 6.60 mm SD 0.82, p=0.77). Multiple logistic regression failed to show any association between ONSD and neurological outcome when adjusted for all other covariates (OR 1.32 95% CI 0.40-4.34, p=0.65). Setting an ONSD threshold of >8 mm (OR 2.32, 95% CI 0.14-39.40, p=0.55) or >7 mm (OR 0.28, 95% CI 0.03-2.77, p=0.28) also failed to show any association on neurological outcome. CONCLUSION: There was no observed difference in ONSD between those with a good neurological outcome and those with a poor outcome. ONSD was not an independent predictor of poor neurological outcome.

Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States.

OBJECTIVES: Our aim was to describe patient characteristics and trends in the use of extracorporeal membrane oxygenation (ECMO) for the treatment of acute respiratory distress syndrome (ARDS) in the United States from 2006 to 2011. METHODS: We used the Nationwide Inpatient Sample to isolate all patients aged 18 years who had a discharge International Classification of Diseases, Ninth Revision diagnosis of ARDS, with and without procedure codes for ECMO, between 2006 and 2011. RESULTS: We examined a total of 47 911 414 hospital discharges, representing 235 911 271 hospitalizations using national weights. Of the 1 479 022 patients meeting the definition of ARDS (representing 7 281 206 discharges), 775 underwent ECMO. There was a 409% relative increase in the use of ECMO for ARDS in the United States between 2006 and 2011, from 0.0178% to 0.090% ( P = .0041). Patients treated with ECMO had higher in-hospital mortality (58.6% vs 25.1%, P < .0001) and longer hospital stays (15.8 days vs 6.9 days, P < .0001). They were also younger (47.9 vs 66.4 years, P < .0001) and more likely to be male (62.2% vs 49.6%, P < .0001). The median time to initiate ECMO from the time of admission was 0.5 days (interquartile range [IQR] 4.9 days). CONCLUSION: There has been a dramatic increase in ECMO use for the treatment of ARDS in the United States.

Mechanical Ventilation Outcomes in Patients With Pulmonary Hypertension in the United States: A National Retrospective Cohort Analysis.

OBJECTIVE: The outcome of patients with pulmonary arterial hypertension (PAH) who undergo mechanical ventilation is not well known. METHODS: The Nationwide Inpatient Sample for 2006 to 2012 was used to isolate patients with a diagnosis of PAH who also underwent invasive (MV) and noninvasive (NIMV) mechanical ventilation. The primary outcome was in-hospital mortality. RESULTS: The hospital records of 55 208 382 patients were studied, and there were 21 070 patients with PAH, of whom 1646 (7.8%) received MV and 834 (4.0%) received NIMV. Those receiving MV had higher mortality (39.1% vs 12.6%, P < .001) and longer hospital stays (11.9 days, interquartile range [IQR] 6.1-22.2 vs 6.7 days, IQR 3.4-11.9, P < .001) than those undergoing NIMV. Of the patients treated with MV, 4.4% also used home oxygen therapy and had similar overall mortality to those who did not use home oxygen (35.3% vs 39.1%, P = .46). Similarly, there was no relationship between home oxygen use and mortality in patients treated with NIMV (10.6% vs 12.6%, P = .48). Notably, more patients treated with NIMV used home oxygen than those treated with MV (14.4% vs 4.4%, P < .001). CONCLUSION: Patients with PAH who undergo invasive mechanical ventilation have an in-hospital mortality of 39.1%. Future work may help identify the types of patients who benefit most from advanced respiratory support in a critical care setting.

The Use of Thrombolysis for Acute Pulmonary Embolism in the United States: National Trends and Patient Characteristics from 2006 to 2011.

BACKGROUND: Thrombolysis for the treatment of pulmonary embolism (PE) has received significant attention in the literature over the past 10 years. OBJECTIVE: Our primary objective was to examine the trend in thrombolysis use in the United States from 2006 to 2011. Secondary objectives include examining patient and hospital characteristics associated with receiving thrombolysis and rates of complications associated with thrombolysis. METHODS: In this retrospective cohort study, we used the Nationwide Inpatient Sample from 2006 to 2011 to identify patients with a diagnosis of PE who received or did not receive thrombolytic agents. RESULTS: Examining the records of 47,911,414 hospital discharges identified a cohort of 1,317,329 patients with PE; of these patients, 10,617 received thrombolysis. During the study period, there was a 30% relative increase in the use of thrombolysis, from 0.68% (95% confidence interval [CI] 0.64-0.73%) to 0.89% (95% CI 0.83-0.95%; p < 0.01). After controlling for all factors in the model, factors associated with decreased access to thrombolysis were increasing age (odds ratio [OR] 0.981 [95% CI 0.980-0.982]; p < 0.01), female sex (OR 0.78 [95% CI 0.75-0.81]; p < 0.01), Black race (OR 0.86 [95% CI 0.81-0.91]; p < 0.01), Hispanic race (OR 0.78 [95% CI 0.71-0.86]; p < 0.01), other race (OR 0.72 [95% CI 0.59-0.88]; p = 0.02), and rural hospital location (OR 0.48 [95% CI 0.43-0.52]; p < 0.01). CONCLUSIONS: The use of thrombolysis increased between 2006 and 2011 in the United States. Patients who receive thrombolysis tend to be white men, live in higher-income ZIP codes, and receive the therapy at large academic teaching hospitals.

The use of mechanical ventilation in patients with idiopathic pulmonary fibrosis in the United States: A nationwide retrospective cohort analysis.

OBJECTIVE: To investigate the mortality of patients with Idiopathic Pulmonary Fibrosis (IPF) who undergo mechanical ventilation (MV) and non-invasive mechanical ventilation (NIMV) in the United States. METHODS: We performed a retrospective cohort study using data from the Nationwide Inpatient Sample, isolating patients with a diagnosis of IPF who underwent MV and NIMV between 2006 and 2012. RESULTS: We analyzed 55,208,382 hospitalizations and identified 17,770 patients with IPF, of whom 1703 received MV and 778 received NIMV. Those receiving MV had higher mortality (51.6 vs. 30.9%, p < 0.0001), were younger (66.3 years, SD 12.8 vs. 70.2 years, SD 12.9) and had longer hospital stays (13.3 days, IQR 16 vs. 6.5 days, IQR 7, p < 0.0001), compared to those receiving NIMV. The mortality of IPF patients treated with MV decreased from 58.4% in 2006 to 49.3% in 2012 (p = 0.03). There were 149 (8.7%) patients in the mechanical ventilation group who were also receiving home oxygen therapy. They experienced an overall mortality of 48.1%, which was not significantly different than patients who did not rely on home oxygen (p = 0.35). CONCLUSIONS: In a large national cohort, the in-hospital mortality of patients with IPF who are mechanically ventilated is approximately 50%.

Tacrolimus Therapy for Ulcerative Colitis-Associated Post-Colectomy Enteritis.

Ulcerative colitis (UC)-associated pan-enteritis is a newly identified clinical entity that occurs almost exclusively after colectomy. Characterized by diffuse small bowel mucosal inflammation not compatible with Crohn's disease, the optimal treatment modality for this condition is unknown. Tacrolimus is a potent calcineurin inhibitor that has been successfully used in the treatment of UC. We describe a case of severe refractory pan-enteritis after colectomy for UC that was successfully treated with oral tacrolimus after failing intravenous corticosteroid treatment. Tacrolimus may be a safe and effective treatment modality for diffuse enteritis after colectomy in UC patients.