Surgical opioid-avoidance protocol: a postoperative pharmacological multimodal analgesic intervention in diverse patient populations.

INTRODUCTION: This study evaluated the effect of a surgical opioid-avoidance protocol (SOAP) on postoperative pain scores. The primary goal was to demonstrate that the SOAP was as effective as the pre-existing non-SOAP (without opioid restriction) protocol by measuring postoperative pain in a diverse, opioid-naive patient population undergoing inpatient surgery across multiple surgical services. METHODS: This prospective cohort study was divided into SOAP and non-SOAP groups based on surgery date. The non-SOAP group had no opioid restrictions (n=382), while the SOAP group (n=449) used a rigorous, opioid-avoidance order set with patient and staff education regarding multimodal analgesia. A non-inferiority analysis assessed the SOAP impact on postoperative pain scores. RESULTS: Postoperative pain scores in the SOAP group compared with the non-SOAP group were non-inferior (95% CI: -0.58, 0.10; non-inferiority margin=-1). The SOAP group consumed fewer postoperative opioids (median=0.67 (IQR=15) vs 8.17 morphine milliequivalents (MMEs) (IQR=40.33); p<0.01) and had fewer discharge prescription opioids (median=0 (IQR=60) vs 86.4 MMEs (IQR=140.4); p<0.01). DISCUSSION: The SOAP was as effective as the non-SOAP group in postoperative pain scores across a diverse patient population and associated with lower postoperative opioid consumption and discharge prescription opioids.

[Peri-interventional management of platelet aggregation inhibition and anticoagulation in urology]. / Periinterventionelles Management von Thrombozytenaggregationshemmung und Antikoagulation in der Urologie.

Perioperative management of anticoagulation in patients receiving long-term anticoagulation or platelet aggregation inhibitors requires an individual consideration of competing risks. If the risk for bleeding is low, anticoagulation can often be continued. If it is necessary to pause anticoagulation, the necessity and dosage of bridging must be determined based on the individual risk of thromboembolism. Only patients with a high risk of thromboembolism should receive bridging in the full therapeutic dosage. The timing of pausing anticoagulation depends on the risk of bleeding from the urological intervention and the renal function of the patient. Platelet aggregation inhibitors should not be discontinued in the first month after coronary stent implantation, especially after acute coronary syndrome.

Perioperative Retinal Artery Occlusion: Risk Factors in Cardiac Surgery from the United States National Inpatient Sample 1998-2013.

PURPOSE: To study the incidence and risk factors for retinal artery occlusion (RAO) in cardiac surgery. DESIGN: Retrospective study using the National Inpatient Sample (NIS). METHODS: The NIS was searched for cardiac surgery. Retinal artery occlusion was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Postulated risk factors based on literature review were included in multivariate logistic models. MAIN OUTCOME MEASURES: Diagnosis of RAO. RESULTS: A total of 5 872 833 cardiac operative procedures were estimated in the United States from 1998 to 2013, with 4564 RAO cases (95% confidence interval [95% CI], 4282-4869). Nationally estimated RAO incidence was 7.77/10 000 cardiac operative procedures from 1998 to 2013 (95% CI, 7.29-8.29). Associated with increased RAO were giant cell arteritis (odds ratio [OR], 7.73; CI, 2.78-21.52; P < 0.001), transient cerebral ischemia (OR, 7.67; CI, 5.31-11.07; P < 0.001), carotid artery stenosis (OR, 7.52; CI, 6.22-9.09; P < 0.001), embolic stroke (OR, 4.43; CI, 3.05-6.42; P < 0.001), hypercoagulability (OR, 2.90; CI, 1.56-5.39; P < 0.001), myxoma (OR, 2.43; CI, 1.39-4.26; P = 0.002), diabetes mellitus (DM) with ophthalmic complications (OR, 1.89; CI, 1.10-3.24; P = 0.02), and aortic insufficiency (OR, 1.85; CI, 1.26-2.71; P = 0.002). Perioperative bleeding, aortic and mitral valve surgery, and septal surgery increased the odds of RAO. Negatively associated with RAO were female gender (OR, 0.77; CI, 0.66-0.89; P < 0.001), thrombocytopenia (OR, 0.79; CI, 0.62-1.00; P = 0.049), acute coronary syndrome (OR, 0.72; CI, 0.58-0.89; P = 0.003), atrial fibrillation (OR, 0.82; CI, 0.70-0.95; P = 0.01), congestive heart failure (OR, 0.73; CI, 0.60-0.88; P < 0.001), DM 2 (OR, 0.74; CI, 0.61-0.89; P = 0.001), and smoking (OR, 0.82; CI, 0.70-0.97; P = 0.02). CONCLUSIONS: Risk factors for RAO in cardiac surgery include giant cell arteritis, carotid stenosis, stroke, hypercoagulable state, and DM with ophthalmic complications; associated with lower risk were female gender, thrombocytopenia, acute coronary syndrome, atrial fibrillation, congestive heart failure, DM 2, and smoking. Surgery in which the heart was opened (e.g., septal repair) versus surgery in which it was not (e.g., CABG) and perioperative bleeding increased the risk of RAO.

The effect of the arterial catheter insertion technique on the success of radial artery cannulation: a prospective and randomized study.

PURPOSE: The main objective of the current investigation was to compare a single wall puncture to vessel transfixing on the success of radial artery cannulation by resident physicians. MATERIAL AND METHODS: The study was a prospective and randomized investigation. Twelve anesthesiology residents performed radial arterial insertions in 126 patients using both the single wall and vessel transfixing technique in random order. The primary outcome was successful cannulation of the radial artery in 4 or less attempts. Other data collected included the total number of attempts and total time to catheter cannulation. RESULTS: Successful radial artery cannulation was achieved in 88% and 86% of patients using the transfixing technique and single wall group, respectively (difference 2%; 95% CI, 14-9, P=0.8, Fisher exact test). Cannulation was successfully on the first attempt in 38% of the transfixing compared to 54% using the single wall technique (difference--16%; 95% CI, 32-2, P=0.1, Fisher Exact test). The median (interquartile range) time to successful cannulation was longer in the transfixing group, 105 (69-176) seconds compared to 65 (25-114) seconds in the single puncture group (P=.009, log-rank test). CONCLUSIONS: Our findings suggest that there does not appear to be an advantage of the transfixing technique over the single wall puncture method for cannulating the radial artery by resident physicians. Cannulation was achieved in shorter time using the single wall puncture technique even after accounting for differences between residents and prior levels of experience.

Perioperative estimation of the intracranial pressure using the optic nerve sheath diameter during liver transplantation.

An elevation of the intracranial pressure (ICP) secondary to cerebral edema is a major contributor to morbidity and mortality in acute liver failure. In addition, invasive ICP monitoring in this setting is controversial because coagulopathy predisposes patients to hemorrhagic complications. In this case report, we describe the novel use of optic nerve sheath diameter monitoring as a noninvasive modality for checking for acute elevations in ICP in this setting. Because of the merits of rapidly evolving ultrasound technologies, this may serve as a safe method for improving patient care in this setting.