Pain and Opioid Consumption and Mobilization after Surgery: Post Hoc Analysis of Two Randomized Trials.

BACKGROUND: Early mobilization is incorporated into many enhanced recovery pathways. Inadequate analgesia or excessive opioids may restrict postoperative mobilization. The authors tested the hypotheses that in adults recovering from abdominal surgery, postoperative pain and opioid consumption are inversely related to postoperative mobilization, and that postoperative mobilization is associated with fewer potentially related complications. METHODS: The authors conducted a subanalysis of two trials that enrolled adults recovering from abdominal surgery. Posture and movement were continuously monitored for 48 postoperative hours using noninvasive untethered monitors. Mobilization was defined as the fraction of monitored time spent sitting or standing. RESULTS: A total of 673 patients spent a median [interquartile range] of 7% [3 to 13%] of monitored time sitting or standing. Mobilization time was 1.9 [1.0 to 3.6] h/day for patients with average pain scores 3 or lower, but only 1.2 [0.5 to 2.6] h/day in those with average scores 6 or greater. Each unit increase in average pain score was associated with a decrease in mobilization time of 0.12 (97.5% CI, 0.02 to 0.24; P = 0.009) h/day. In contrast, there was no association between postoperative opioid consumption and mobilization time. The incidence of the composite of postoperative complications was 6.0% (10 of 168) in the lower mobilization quartile, 4.2% (7 of 168) in the second quartile, and 0% among 337 patients in the highest two quartiles (P = 0.009). CONCLUSIONS: Patients recovering from abdominal surgery spent only 7% of their time mobilized, which is considerably less than recommended. Lower pain scores are associated with increased mobility, independently of opioid consumption. Complications were more common in patients who mobilized poorly.

Cerebral Venous Thrombosis After a Possible Inadvertent Dural Puncture for Labor Epidural Analgesia.

Pregnancy is a hypercoagulable state that increases the risk of thrombotic complications. A 32-year-old gravida 4 para 3 (G4P3) had a dural puncture during epidural catheter placement for labor analgesia. A positional headache started after delivery and continued for several days. A week after the delivery, she developed non-positional headaches along with seizures. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) lead to the diagnosis of cerebral venous thrombosis (CVT). A factor V Leiden mutation was also found; that was suspected to contribute to the development of CVT along with dural puncture and pregnancy. CVT can present with non-positional headaches a week after the dural puncture.

Superior Vena Cava Syndrome and Otorrhagia During Cardiac Surgery.

Otorrhagia during cardiac surgery is rare. Otorrhagia combined with other signs of increased venous pressure in the upper body indicates the development of superior vena cava (SVC) syndrome. In this case, ear bleeding, facial engorgement, and conjunctival edema were noticed. The SVC cannula was displaced, leading to SVC syndrome. Repositioning of the cannula led to rapid recovery of the symptoms and an uneventful postoperative course. Providers should be vigilant about signs of SVC obstruction. Transparent coverings and surgical shelves should be used for constant examination of the head and neck to immediately detect changes.

A Case of Pseudo-pneumothorax with Complications.

Pseudo-pneumothorax occurs after inappropriately diagnosing a pneumothorax based on a chest X-ray. This can be attributed to skin folds, bed sheets, previous pneumothorax, heating blankets, clothes, and other circumstances that may mimic the radiographic findings of a pneumothorax. We present a case where a patient underwent a tube thoracostomy due to the diagnosis of a pneumothorax that was not, in fact, present. The unnecessary intervention was complicated by hemoptysis and cardiac arrest.

A Case of Takotsubo Cardiomyopathy After Local Anesthetic and Epinephrine Infiltration.

Takotsubo cardiomyopathy (TC) is a non-ischemic cardiomyopathy that is accompanied by sudden left ventricular myocardial stunning, dilation and dysfunction. It often results from severe emotional or physical stress. We present the case of a 41-year-old female patient who had general anesthesia induced uneventfully for an elective bladder sling procedure. After an intravaginal injection of local anesthesia (lidocaine 2%; epinephrine 1:100,000) just prior to the surgical incision, the patient had cardiovascular collapse for which cardiopulmonary resuscitation (CPR) was performed. The patient was eventually stabilized but transesophageal echocardiography showed impairment in cardiac motion and remarkably reduced ejection fraction. Troponin levels were elevated but coronary angiography was unremarkable. The ejection fraction returned to normal the next day. Local anesthetic with epinephrine administration can lead to TC, and with optimal management, long-term cardiac sequela can be avoided.