Impact of Liposomal Bupivacaine on Enhanced Recovery After Surgery Protocol for Lung Resection.

BACKGROUND: There is limited data showing the benefit of liposomal bupivacaine as part of an Enhanced Recovery After Surgery (ERAS) protocol in reducing opioid use in minimally invasive lobectomies. METHODS: A retrospective observational study compared three cohorts of patients undergoing lobectomies between January 2015 and December 2021. The control group neither received liposomal bupivacaine intraoperatively nor underwent an ERAS protocol. The liposomal bupivacaine cohort only received a nerve block, whereas the ERAS cohort received a nerve block intraoperatively and underwent an ERAS protocol. Primary outcome was post-operative opioid consumption. RESULTS: There were 433 patients in this study (n=87 for controls, n=138 for liposomal bupivacaine alone, and n=208 for ERAS/liposomal bupivacaine). There was a statistically significant difference in the amount of opioids used between the control (43 OME) and liposomal bupivacaine alone cohort (30.5 OME) (p<.001); between control vs. ERAS/liposomal bupivacaine cohort (17 OME) (p<.001); and between liposomal bupivacaine alone and ERAS/liposomal bupivacaine cohorts (p<.001). Hospital stay was not statistically different between the two groups of interest (3 days); however, hospital stay differed from the control (4 days). 30-day readmission was not significantly different between the 3 groups (p=.43). CONCLUSIONS: Liposomal bupivacaine alone as part of a larger ERAS protocol significantly reduced opioid use and hospitalization duration; however, the reduction in opioid use was much greater with incorporation of liposomal bupivacaine into an ERAS protocol rather than in isolation. Prospective studies are needed to determine reproducibility and applicability of liposomal bupivacaine for opioid use reduction in other US hospital systems.

Evaluation of biological and economic efficiency of the All Heifer, No Cow beef production system using a system dynamics model based on 6 yr of demonstration herd data.

Alternative management strategies with no cows and all heifers may improve biological and economic efficiency of beef production. The All Heifer, No Cow (AHNC) beef production system involves insemination of nulliparous heifers with female sex-selected semen (FSS) to produce primarily female calves that are early weaned at 3 mo of age. Dams are finished on a high concentrate diet and harvested before 30 mo of age. The objectives of this research were to: 1) build a dynamic model of an AHNC beef production system to quantify system biological and economic efficiency; 2) compare effects of utilizing FSS vs. conventional semen on biological and economic efficiency; 3) evaluate what-if scenarios to determine the effects on biological and economic efficiency of changing variables ±5%, 10%, 15%, and 20% from initial observed values; and 4) evaluate the effects on biological and economic efficiency of changing variables ±10% from initial observed values. A model was built over a 21-yr horizon using Stella Architect. Biological parameter values in the model were based on the 6 yr of data collected from the management of an AHNC demonstration herd. In the model animal, total digestible nutrients (TDN) intake, hot carcass weight (HCW), and age at harvest were randomized. Feed, animal, and carcass prices included in the model were based on 10 yr of historical U.S. price data. Key response variables were biological and economic efficiency (mean ± SD). Biological efficiency was defined as the ratio of output (kilograms of HCW produced) to input (lifetime kilograms of feed TDN consumed), and economic efficiency was measured using a benefit-cost ratio (BCR) and unit variable cost (UVC). Over 40 simulation runs, the predicted mean biological efficiency was 0.0714 ± 0.0008. Economic efficiency was 0.95 ± 0.02 and US $445.41 ± 0.06 for BCR and UVC, respectively. Biological and economic efficiency was improved in the conventional semen scenario; biological efficiency was 0.0738 ± 0.0008, and BCR and UVC were 0.99 ± 0.04 and US $407.24 ± 0.006, respectively. Under this parameterization and market conditions, the AHNC beef production system failed to achieve profitability under any scenario that was evaluated. However, this review did not account for the potential increased genetic benefit from a decreased generation interval and the reduction in feed energy in comparison to a conventional cow/calf system.

Shortness of Breath in a 38-Year-Old Woman With Pulmonary and Hepatic Nodules.

CASE PRESENTATION: A 38-year-old African American woman with a history of menometrorrhagia on previous estrogen therapy and a previously biopsied benign thyroid nodule with recent interval enlargement presented with symptoms of shortness of breath on exertion, an intermittent nonproductive cough, and right upper quadrant abdominal pain for 1 year. She denied wheezing, hemoptysis, fevers, night sweats, or unintentional weight loss. Socially, the patient was a lifelong nonsmoker and denied alcohol or drug use. Travel history was not significant, and she had no contributory occupational, environmental, or animal exposures. Recent cancer screening that included Papanicolaou smear and mammography were negative for neoplasia. Vital signs were normal, and ambulatory pulse oximetry did not demonstrate evidence of oxygen desaturation. Physical examination demonstrated normal respiratory effort, diffuse vesicular breath sounds, and a soft abdomen without hepatomegaly or right upper quadrant tenderness.

Evaluation of performance and carcass traits for a five-cohort All Heifer, No Cow beef production system demonstration herd.

The All Heifer, No Cow (AHNC) beef production system is an alternative to conventional cow/calf production that involves insemination of nulliparous heifers with sexed semen to produce female calves that are early weaned at 3 mo of age. Dams are finished on a high-concentrate diet and harvested before reaching 30 mo of age. Objectives of this research were to document reproductive, feedyard, calf, and carcass performance of an AHNC herd; evaluate effects of carcass maturity on carcass quality; and determine if performance of initial cohorts (i.e., cohorts 1 and 2) differed from sustaining cohorts (i.e., cohorts 3-5). A total of 272 heifers were enrolled in the AHNC system via five annual cohorts. The system was initiated with 51 yearling, Angus-based heifers, and a replicate set (n = 56) was started 12 mo after. Heifers in cohorts 3 (n = 53), 4 (n = 56), and 5 (n = 56) were primarily offspring of prior cohorts (i.e., cohort 3 heifers born to cohort 1 females), but some were purchased to maintain inventory. Angus replacement heifers were purchased in cohorts 3 (n = 26), 4 (n = 26), and 5 (n = 28). Mean (±standard deviation) pregnancy rate at 30 d after fixed-time artificial insemination (AI) with sexed semen was 50.8% ± 9.4%, and 140-d pregnancy rate was 93.0% ± 1.5%. With AHNC, 61.0% ± 6.5% of females replaced themselves with a heifer. During finishing, average daily gain (ADG) was 1.9 ± 0.4 kg • d-1 and dry matter intake (DMI) was 14.9 ± 1.9 kg • d-1. Hot carcass weight (HCW) was 367 ± 35 kg. The USDA grading system classified 20.5% of all carcasses (n = 220) as C maturity (A00 = 100, B00 = 200, etc.), 62.4% ± 29.1% of carcasses as USDA Choice. USDA yield grade (YG) was 2.6 ± 0.7. Based on cohorts 1 and 2, there were no differences (P = 0.96) in Warner-Bratzler shear force values between A and B maturity vs. C maturity carcasses. Across all cohorts, there were no differences in USDA YG, marbling score (MA), and lean maturity between A and B maturity vs. C maturity carcasses; there were differences in age (P < 0.001), bone maturity (P < 0.001), and overall maturity (P <0.001). A comparison of initial vs. sustaining cohorts showed that initial cohorts had lower (P < 0.001) DMI, heavier (P < 0.001) HCW, and more advanced (P < 0.05) bone maturity. However, there were no differences for 30- and 140-d pregnancy rates, ADG, USDA YG, and MA between initial and sustaining cohorts. The AHNC beef production system can effectively produce female calves and quality carcasses for harvest.

Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year.

BACKGROUND: To minimize the stress of operations, improve the patient experience, reduce variability, and optimize resource utilization, we implemented a thoracic enhanced recovery after surgery (ERAS) protocol and evaluated progress after 1 year. METHODS: Two protocols were developed: video-assisted thoracic surgery (ERAS-VATS) and thoracotomy (ERAS-T). Each incorporated preoperative patient education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, and early ambulation. Patient outcomes, length of stay, pain scores, opioid use, fluid administration, and cost for ERAS patients were compared with historic controls from the year before program initiation. RESULTS: Historic VATS (n = 162) were compared with 81 ERAS-VATS patients. Median postoperative morphine equivalents (86 versus 22 mg, p < 0.0001), total fluid balance (1279 versus 227 mL, p < 0.0001), and mean inflation adjusted hospital costs ($20,169 versus $14,870, p = 0.0003) all decreased significantly. Historic thoracotomy patients (n = 62) were compared with 58 ERAS-T patients. Median postoperative morphine equivalents (130 versus 54 mg, p < 0.0001), total fluid balance (788 versus -489 mL, p = 0.012), length of stay (6.0 versus 4.0 days, p = 0.009), and mean inflation adjusted hospital costs ($41,950 versus $26,089, p < 0.00001) all decreased significantly. CONCLUSIONS: Implementation of thoracic ERAS is a dynamic process with potential to improve outcomes in thoracic surgical procedures. In the first year we shortened length of stay, decreased opioid usage, minimized fluid overload, and decreased hospital costs.

Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation.

BACKGROUND:: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously. METHODS:: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (>300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade. RESULTS:: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO. CONCLUSIONS:: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery.

Racial disparity in in-hospital mortality after lobectomy for lung cancer.

BACKGROUND: Using data from the Nationwide Inpatient Sample, we investigated the impact of surgical approach and race on in-hospital mortality after lobectomy for lung cancer. METHODS: Logistic regression was used to model odds ratios for in-hospital mortality related to surgical technique (thoracotomy vs video assisted thoracoscopic surgery [VATS]) and race using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (2008 to 2011). RESULTS: VATS lobectomies increased each year (25.9% to 39.2%, P = .001) in the 19,353 patients identified. A racial disparity was noted, with black patients being 66% more likely to die in the hospital (odds ratio 1.66, 95% confidence interval 1.17 to 2.37, P = .005). Excluding 2010 data suggests that there is evidence of benefit associated with VATS; however, no evidence of an association between race and in-hospital mortality exists. CONCLUSIONS: This study elucidates race-related mortality in lobectomy patients. Although racial disparities are present throughout health care, this finding emphasizes one of the challenges in using large databases to assess such disparities.