Optimizing opioid prescribing practices after minimally invasive lung resection through a quality-improvement intervention.

BACKGROUND: In their 2019 guideline on the prescribing and management of opioids after elective ambulatory thoracic surgery, the Canadian Association of Thoracic Surgeons (CATS) recommended 120 morphine milligram equivalents (MME) after minimally invasive (video-assisted thoracoscopic surgery [VATS]) lung resection. We conducted a quality-improvement project to optimize opioid prescribing after VATS lung resection. METHODS: We assessed baseline prescribing practices for opioid-naive patients. Using a mixed-methods approach, we selected 2 quality-improvement interventions: formal incorporation of the CATS guideline into our postoperative care pathway, and development of a patient information handout regarding opioids. The intervention was initiated on Oct. 1, 2020, and was formally implemented on Dec. 1, 2020. The outcome measure was average MME of discharge opioid prescriptions, the process measure was proportion of discharge prescriptions exceeding the recommended dosage, and the balancing measure was opioid prescription refills. We analyzed the data using control charts, and compared all measures between the pre-intervention (12 mo before) and postintervention (12 mo after) groups. RESULTS: A total of 348 patients who underwent VATS lung resection were identified, 173 before the intervention and 175 after the intervention. Significantly less MME was prescribed after the intervention (100 v. 158, p < 0.001), and a lower proportion of prescriptions were nonadherent to the guideline (18.9% v. 50.9%, p < 0.001). Control charts showed special cause variation corresponding with the intervention, and system stability existed after the intervention. There was no statistically significant difference in the proportion or dosage of opioid prescription refills after the intervention. CONCLUSION: After implementation of the CATS opioid guideline, there was a significant reduction in opioids prescribed at discharge and no increase in opioid prescription refills. Control charts are a valuable resource for monitoring outcomes on an ongoing basis and for assessing the effects of an intervention.

Lung hemorrhage in trauma: Technical tricks and tips.

At some point as the on-call trauma surgeon, you may need to operate on a bleeding lung. This concise review addresses preoperative and intraoperative considerations for traumatic lung injuries, including how to deal with specific findings at the time of surgery.

Recognition and Management of Acute and Late Complications of Pneumonectomy: Clinical Cases and Treatment.

Several important complications of pneumonectomy are discussed in a case-based format. Topics include chylothorax, cardiac herniation, postpneumonectomy syndrome, postpneumonectomy pulmonary edema, bronchopleural fistula, and empyema.

Permanent implantation of the Solitaire device as a bailout technique for large vessel intracranial occlusions.

The Solitaire (Medtronic Inc, Mansfield, Massachusetts, USA) is a stentriever device for endovascular treatment of acute ischemic stroke. Temporary endovascular bypass and mechanical thrombectomy are well-described applications of this device. However, few reports of permanent stent placement have been published. We present a series of five cases in which the Solitaire stent was implanted to restore distal flow after failure of conventional mechanical thrombectomy. All patients presented with large vessel occlusions with thrombi that were resistant to retrieval or suction-aspiration. Immediately after implantation the patients were given a loading dose of abciximab and then transitioned to dual antiplatelet therapy within 24 hours. Our series suggests that permanent deployment of the Solitaire may be considered as a bailout technique in the treatment of cerebral large vessel occlusion. Long-term antiplatelet therapy is required after deployment.

Painful erections secondary to rare epithelioid hemangioma of the penis.

Epithelioid hemangioma is a rare benign vascular tumour that atypically involves the penis and usually presents as a painful nodule. A 35-year-old man presented with a 5-month history of painful erections without a clinically apparent lesion or deformity. Magnetic resonance imaging (MRI) with pharmacologically induced erection demonstrated a 1.3-cm nodular lesion deep to the skin at the base of his penis. Following local excision of the lesion, which was diagnosed as an epithelioid hemangioma, the patient was symptom free. This case demonstrates a rare etiology of painful erections with a unique presentation. To the authors' knowledge, it is also the first report of MRI with intracavernosal injection of trimix to assess for a specific cause of painful erections.