Association between perioperative non-steroidal anti-inflammatory drug use and cardiovascular complications after non-cardiac surgery in older adult patients.

BACKGROUND: We investigated in older adult non-cardiac surgical patients whether receipt of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased incidence of postoperative cardiovascular complications. METHODS: We retrospectively extracted the information for patients with age ≥  65 years who had inpatient non-cardiac surgery with a duration of ≥  1 h from the American College of Surgeons-National Surgical Quality Improvement Program registry data acquired at the University of Washington Medical Center. We compared patients who received NSAIDs perioperatively to those who did not receive NSAIDs, on the two composite outcomes: (1) the incidence of postoperative cardiovascular complications within 30 days of the surgery, and (2) the incidence of combined postoperative gastrointestinal and renal complications, and length of postoperative hospital stay. We used separate multivariable logistic regression models to analyze the two composite outcomes and a Poisson regression model for the length of hospital stay. RESULTS: The receipt of perioperative NSAIDs was not associated with postoperative cardiovascular complications (estimated odds ratio (OR), 1.78; 95% confidence interval (CI), 0.97 to 3.25; P =  0.06), combined renal and gastrointestinal complications (estimated OR, 1.30; 95% CI, 0.53 to 3.20; P =  0.57), and length of postoperative hospital stay in days (incidence rate ratio, 1.06; 95% CI, 0.93 to 1.21; P =  0.39). CONCLUSIONS: In older adult non-cardiac surgical patients, receipt of perioperative NSAIDs was not associated with increased incidences of postoperative cardiovascular complications, and renal and gastrointestinal complications within 30 days after surgery, or length of postoperative hospital stay.

Association Between Postoperative Methocarbamol and Postoperative Pain Opioid Dose Requirements: A Retrospective Cohort Study.

OBJECTIVES: We tested the hypothesis that patients who received methocarbamol postoperatively experience less severe pain and require smaller doses of opioids than those who did not receive methocarbamol. MATERIALS AND METHODS: This is a retrospective cohort study of patients undergoing surgery involving the musculoskeletal system. Of 9089 patients, 704 received methocarbamol during 48 hours postoperatively, while 8385 did not receive methocarbamol. The patients who received methocarbamol postoperatively and the patients who did not receive methocarbamol were compared on the time-weighted average (TWA) pain score and opioid dose requirements in morphine milligram equivalents (MME) during the first 48 hours postoperatively, using propensity score-weighted regression models to adjusting for preoperative and intraoperative covariates. RESULTS: Postoperative 48-hour TWA pain scores were 5.5±1.7 (mean±SD), and 4.3±2.1 for methocarbamol and non-methocarbamol patients. Postoperative 48-hour opioid dose requirements in MME were 276 [170-347] (median [interquartile range (IQR)]) mg, and 190 [60-248] mg for methocarbamol and non-methocarbamol patients. In propensity score-weighted regression models, receiving methocarbamol postoperatively was associated with 0.97-point higher postoperative TWA pain score (95% CI, 0.83-1.11; P <0.001), and 93.6-MME higher postoperative opioid dose requirements (95% CI, 79.9 to 107.4; P <0.001), compared with not receiving methocarbamol postoperatively. DISCUSSION: Postoperative methocarbamol was associated with significantly higher acute postoperative pain burden and opioid dose requirements. Although the results of the study are influenced by residual confounding, they suggest a limited-if any-benefit of methocarbamol as an adjunct of postoperative pain management.

Prediction of postoperative respiratory depression and respiratory complications in patients on preoperative methadone.

PURPOSE: We developed prediction models for postoperative respiratory depression and respiratory complications for 958 patients who were on methadone preoperatively. METHODS: The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/min, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. Secondary outcome was the composite of postoperative respiratory complications. Prediction models for postoperative respiratory depression and respiratory complications were constructed using multivariate logistic regression with preoperative and intraoperative characteristics as the predictors. RESULTS: For the multivariate logistic regression model for postoperative respiratory depression, surgery duration (P = 0.005), body mass index (BMI) (P = 0.008), surgery involving digestive system (P = 0.031), and American Society of Anesthesiologists (ASA) physical status ≥ 4 (P = 0.038) were statistically significant predictors. The area under the receiver operating characteristic curve (AUROC) of the model was 0.581 (0.558-0.601) [median (95% confidence interval (CI))] with fivefold cross-validation. For the model for postoperative respiratory complications, surgery duration (P = 0.001), history of hypertension (P = 0.028), surgery involving musculoskeletal system (P < 0.001), surgery involving integumental system (P = 0.034), surgery categorized to miscellaneous therapeutic procedures (P = 0.028), combined general and regional anesthesia (P = 0.033), ASA physical status 3 (P < 0.001), and ASA physical status ≥ 4 (P < 0.001) were statistically significant predictors, and AUROC of the model was 0.726 (0.712-0.737). CONCLUSIONS: Multivariate logistic regression models including preoperative, and intraoperative characteristics as the predictors performed poorly to predict postoperative respiratory depression, and moderately for postoperative respiratory complications. Neither model is accurate enough to be subject to clinical use.

Postoperative respiratory depression in patients on sublingual buprenorphine: a retrospective cohort study for comparison between postoperative continuation and discontinuation of buprenorphine.

BACKGROUND: We tested the hypothesis that patients who continued buprenorphine postoperatively experience postoperative respiratory depression less frequently than those who discontinued buprenorphine. METHODS: This is a retrospective cohort study of patients who were on buprenorphine preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/minute, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. The secondary outcome was the composite of postoperative respiratory complications. The associations between postoperative buprenorphine continuation and respiratory depression and respiratory complications were estimated using separate multivariable logistic regression models, including demographic, intraoperative characteristics, and preoperative buprenorphine dose as covariates. RESULTS: Postoperative buprenorphine continuation was not associated with postoperative respiratory depression (adjusted odds ratio (OR), 1.11, 95% confidence interval (CI), 0.61 to 1.99, P=0.72). In subanalysis stratified by the preoperative buprenorphine dose, buprenorphine continuation was not associated with postoperative respiratory depression either when preoperative buprenorphine dose was high (≥16 mg daily) or low (<16 mg daily). Postoperative buprenorphine continuation was associated with lower incidence of postoperative respiratory complications (adjusted OR, 0.43, 95% CI, 0.21 to 0.86, P=0.02). CONCLUSIONS: Continuing buprenorphine was not associated with respiratory depression, but it was associated with a lower incidence of respiratory complications.

Postoperative Pain and Opioid Dose Requirements in Patients on Sublingual Buprenorphine: A Retrospective Cohort Study for Comparison Between Postoperative Continuation and Discontinuation of Buprenorphine.

OBJECTIVE: To test the hypothesis that patients who continued buprenorphine postoperatively experience less severe pain and require a smaller dose of opioids than those who discontinued buprenorphine. MATERIALS AND METHODS: This is a retrospective cohort study of surgical patients who were on buprenorphine preoperatively. Using our previous study's data as pilot data, we selected the covariates to be included in 2 regression models with postoperative time-weighted average pain score and opioid dose requirements in morphine milligram equivalents during 48 hours after surgery as the outcomes. Both contained preoperative daily buprenorphine dose, whether buprenorphine was continued postoperatively, and the preoperative daily dose-by-postoperative continuation interaction as predictors. Precision variables were identified by exhaustive search of perioperative parameters with the exposure variables (preoperative daily dose, postoperative continuation, and their interaction) included in the regression model. The model selected by using the pilot data was estimated again using the new data extracted for this study to make inference about the effect of the 2 exposures (postoperative buprenorphine continuation and preoperative daily buprenorphine dose) and their interaction on the outcomes. RESULTS: Continuing buprenorphine was associated with a 1.3-point lower time-weighted average pain score than discontinuing (95% confidence interval, 0.39-2.21; P=0.005) but was not associated with a difference in opioid dose requirements (P=0.48). DISCUSSION: Continuing buprenorphine was associated with lower postoperative pain levels than discontinuing. Our results were primarily driven by patients on lower buprenorphine dose as only 22% of patients were on daily doses of 24 mg or above.

Acute Pain Burden and Opioid Dose Requirements after Cesarean Delivery in Parturients with Preexisting Chronic Back Pain and Migraine.

INTRODUCTION: Preexisting chronic pain has been reported to be a consistent risk factor for severe acute postoperative pain. However, each specific chronic pain condition has unique pathophysiology, and it is possible that the effect of each condition on postoperative pain is different. METHODS: This is a retrospective cohort study of pregnant women with preexisting chronic pain conditions (i.e., migraine, chronic back pain, and the combination of migraine + chronic back pain), who underwent cesarean delivery. The effects of the three chronic pain conditions on time-weighted average (TWA) pain score (primary outcome) and opioid dose requirements in morphine milligram equivalents (MME) during postoperative 48 hours were compared. RESULTS: The TWA pain score was similar in preexisting migraine and chronic back pain. Chronic back pain was associated with significantly greater opioid dose requirements than migraine (12.92 MME, 95% CI: 0.41 to 25.43, P=0.041). Preoperative opioid use (P < 0.001) was associated with a greater TWA pain score. Preoperative opioid use (P < 0.001), smoking (P=0.004), and lower postoperative ibuprofen dose (P=0.002) were associated with greater opioid dose requirements. CONCLUSIONS: Findings suggest women with chronic back pain and migraine do not report different postpartum pain intensities; however, women with preexisting chronic back pain required 13 MME greater opioid dose than those with migraine during 48 hours after cesarean delivery.

An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost.

BACKGROUND: Enhanced recovery after surgery pathways provide a multidisciplinary, evidence-based approach to the care of surgical patients. They have been shown to decrease postoperative length of stay and cost in several surgical subspecialties, including gynecology, but have not been well-studied in obstetric patients who undergo cesarean delivery. OBJECTIVE: We sought to determine whether the implementation of an enhanced recovery after surgery pathway for cesarean delivery would decrease postoperative length of stay and postoperative direct cost compared with historic controls. STUDY DESIGN: We conducted a retrospective cohort study that compared postoperative length of stay and postoperative direct cost among women on the enhanced recovery after surgery cesarean delivery pathway in the first year of implementation (April 1, 2017, to March 31, 2018; n=531) compared with historic controls (March 1, 2016, to February 28, 2017; n=661). Literature review informed the development of a prototype enhanced recovery after surgery pathway for cesarean delivery based on best practices from previous enhanced recovery after surgery experience in obstetrics (if available) or from other surgical disciplines if there were no available data for obstetrics. When there was not relevant published evidence from obstetrics, the taskforce used clinical experience and expert opinion to develop the pathway. The enhanced recovery after surgery cesarean delivery pathway included preadmission patient education and preoperative, intrapartum, and postoperative elements. Some components reflected standard obstetric care, and others were specific to the enhanced recovery after surgery pathway. Women with pregestational diabetes mellitus who were receiving insulin therapy before pregnancy, women with preeclampsia with severe features, women with complex pain needs, and women with surgical complications were excluded from baseline and implementation groups. Enhanced recovery after surgery cesarean delivery pathway participation was determined by order set usage. Analysis was stratified for women who underwent planned (no labor; n=530) and unplanned (labor; n=662) cesarean delivery. Demographic and clinical characteristics, postoperative length of stay, postoperative direct cost, and readmission rates for the baseline and implementation groups were compared with the use of chi-square and t-tests. RESULTS: During the first year of implementation, 531 of 640 eligible women (83%) were included in the enhanced recovery after surgery cesarean delivery pathway. Body mass index was marginally higher in the baseline group for unplanned cesarean delivery (32.5±7.1 vs 31.4±6.7 kg/m2; P=.04). Otherwise there were no significant differences in demographic or maternal clinical characteristics between baseline or implementation groups overall or for planned or unplanned cesarean delivery. Compared with baseline, implementation of the enhanced recovery after surgery cesarean delivery pathway resulted in a significant decrease in postoperative length of stay by 7.8% or 4.86 hours overall (P<.001) and for both planned (P=.001) and unplanned (P=.002) cesarean delivery. Total postoperative direct costs decreased by 8.4% or $642.85 per patient overall (P<.001) and for both planned (P<.001) and unplanned (P<.001) cesarean delivery. There were no significant differences in readmission rates. CONCLUSION: Implementation of an enhanced recovery after surgery pathway for women who had planned or unplanned cesarean delivery was associated with significantly decreased postoperative length of stay and significant direct cost-savings per patient, without an increase in hospital readmissions. Given that cesarean delivery is 1 of the most common surgical procedures performed in the United States, positively impacting postoperative length of stay and direct cost for women who undergo cesarean delivery could have significant healthcare cost-savings.

Dual Epidural Catheter Therapy for Abdominal Surgery Pain: 2 Case Reports.

Dual epidural catheter (DEC) therapy improves postoperative pain control in scoliosis correction surgery, esophagectomies, and labor. Reports about the use of a second epidural catheter to improve pain control after abdominal surgeries are sparse. We describe the successful use of unplanned DEC therapy in 2 complex pain patients who underwent large exploratory laparotomies. In both patients, the addition of the second catheter led to improved pain control and mobility and reduced side effects from adjuvant intravenous analgesics. DEC therapy merits consideration as an additional tool for managing postoperative pain after large abdominal surgeries despite existing incomplete epidural analgesia.

Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control.

BACKGROUND: Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery. METHODS: In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System-mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives. RESULTS: Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73-4.49; P < .001). In the PRE and POST groups, cumulative postoperative intravenous opioid use (geometric mean) was 62 and 34 mg oral morphine equivalents, respectively. A segmented regression analysis did not demonstrate a statistically significant difference (P = .38) after adjustment for preintervention time trends. CONCLUSIONS: Process workflow optimization along with Anesthesia Information Management System-mediated digital quality improvement efforts increased compliance to intraoperative epidural infusion initiation. Adjusted for preintervention time trends, these findings coincided with a statistically insignificant decrease in postoperative opioid use in the postanesthesia care unit during the POST phase.

Case Report: Anesthetic management for Cesarean section in a parturient with unspecified inherited bleeding disorder.

Neuraxial anesthesia, as the standard of care for Cesarean deliveries, is associated with decreased blood loss. However, parturients with inherited bleeding disorders are at increased risk for epidural hematomas. A small retrospective study has shown that parturients with known factor deficiencies can safely undergo neuraxial anesthesia once the specific factors are replenished. We present a patient who had a considerably increased risk of peripartum bleeding from an unspecified inherited bleeding disorder and was provided a successful neuraxial anesthetic without complications. We discuss the multidisciplinary approach among the surgeons, anesthesiologists, hematologist, and nursing staff to maximize patient safety and comfort.

Neuraxial anesthesia for postpartum tubal ligation at an academic medical center.

Background: Use of an in situ epidural catheter has been suggested to be efficient to provide anesthesia for postpartum tubal ligation (PPTL). Reported epidural reactivation success rates vary from 74% to 92%. Predictors for reactivation failure include poor patient satisfaction with labor analgesia, increased delivery-to-reactivation time and the need for top-ups during labor. Some have suggested that this high failure rate precludes leaving the catheter in situ after delivery for subsequent reactivation attempts. In this study, we sought to evaluate the success rate of neuraxial techniques for PPTL and to determine if predictors of failure can be identified. Methods: After obtaining IRB approval, a retrospective chart review of patients undergoing PPTL after vaginal delivery from July 2010 to July 2016 was conducted using CPT codes, yielding 93 records for analysis. Demographic, obstetric and anesthetic data (labor analgesia administration, length of epidural catheter in epidural space, top-up requirements, time of catheter reactivation, final anesthetic technique and corresponding doses for spinal and epidural anesthesia) were obtained. Results: A total of 70 patients received labor neuraxial analgesia. Reactivation was attempted in 33 with a success rate of 66.7%. Patient height, epidural volume of local anesthetic and administered fentanyl dose were lower in the group that failed reactivation. Overall, spinal anesthesia was performed in 60 patients, with a success rate of 80%. Conclusions: Our observed rate of successful postpartum epidural reactivation for tubal ligation was lower than the range reported in the literature. Our success rates for both spinal anesthesia and epidural reactivation for PPTL were lower than the generally accepted rates of successful epidural and spinal anesthesia for cesarean delivery. This gap may reflect a lower level of motivation on behalf of both the patients and anesthesia providers to tolerate "imperfect" neuraxial anesthesia once fetal considerations are removed.

Continuous intraoperative epidural infusions affect recovery room length of stay and analgesic requirements: a single-center observational study.

PURPOSE: Continuous intraoperative epidural analgesia may improve post-operative pain control and decrease opioid requirements. We investigate the effect of epidural infusion initiation before or after arrival in the post-anesthesia care unit on recovery room duration and post-operative opioid use. METHODS: We performed a retrospective chart review of abdominal, thoracic and orthopedic surgeries where an epidural catheter was placed prior to surgery at the University of Washington Medical Center during a 24 month period. RESULTS: Patients whose epidural infusions were started prior to PACU arrival (Group 2: n = 540) exhibited a shorter PACU length of stay (p = .004) and were less likely to receive intravenous opioids in the recovery room (34 vs. 48%; p < .001) compared to patients whose infusions were started after surgery (Group 1: n = 374). Although the highest patient-reported pain scores were lower in Group 2 (5.3 vs. 6.0; p = .030), no differences in the pain scores prior to PACU discharge were observed. CONCLUSION: Intraoperative continuous epidural infusions decrease PACU LOS as discharge criteria for patient-reported NRS pain scores are met earlier.

Hypoglossal nerve palsy after airway management for general anesthesia: an analysis of 69 patients.

Isolated hypoglossal nerve palsy (HNP), or neurapraxia, a rare postoperative complication after airway management, causes ipsilateral tongue deviation, dysarthria, and dysphagia. We reviewed the pathophysiological causes of hypoglossal nerve injury and discuss the associated clinical and procedural characteristics of affected patients. Furthermore, we identified procedural factors potentially affecting HNP recovery duration and propose several measures that may reduce the risk of HNP. While HNP can occur after a variety of surgeries, most cases in the literature were reported after orthopedic and otolaryngology operations, typically in males. The diagnosis is frequently missed by the anesthesia care team in the recovery room due to the delayed symptomatic onset and often requires neurology and otolaryngology evaluations to exclude serious etiologies. Signs and symptoms are self-limited, with resolution occurring within 2 months in 50% of patients, and 80% resolving within 4 months. Currently, there are no specific preventive or therapeutic recommendations. We found 69 cases of HNP after procedural airway management reported in the literature from 1926 to 2013.