National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA. METHODS: A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics. RESULTS: Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions. CONCLUSIONS: Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored.

Safe transition to opioid-free pathway after robotic-assisted laparoscopic prostatectomy.

To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control.

A Retrospective Pilot Study for Preoperative Screening to Prevent Iatrogenic Cervical Spinal Cord Injury.

PURPOSE: The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series. METHODS: Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure. RESULTS: There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman's and Spurling's sign, independently, were significantly associated with a positive neck extension exam (p<0.05). Fourteen patients were recommended for cervical decompression prior to planned procedure. CONCLUSIONS: Our preoperative cervical spine clearance protocol is safe and may aid in identifying patients susceptible to iatrogenic cervical spine injury.

Concomitant elective resection of pheochromocytoma and repair of aortic abdominal aneurysm.

Perioperative management of a patient with ischemic heart disease with coexisting abdominal aortic aneurysm and pheochromocytoma creates a difficult management dilemma, and surgical intervention in these patients carries a significant risk. The state of catecholamine excess and various other coexisting factors can lead to simultaneous occurrence of abdominal aortic aneurysm and pheocromocytoma. The purpose of this report is to present an integrated approach to the management of concomitant abdominal aortic aneurysm and pheochromocytoma, where a combined surgical approach in addressing these two lesions was preferable due to patient comorbidities and surgical implications without significant complication.

Intraabdominal compartment syndrome complicating transurethral resection of bladder tumor.

Abdominal compartment syndrome can result from many different causes. We present a case where this dangerous syndrome occurred in the operating room during a transurethral resection of a bladder tumor. It was initially recognized by an elevation in the peak inspiratory pressure. We report the typical physiologic changes that occur with this syndrome and its treatment options.

An unusual case of tracheoesophageal fistulae.

Acquired tracheoesophageal fistulae (TEF) are commonly due to malignancy (M. F. Reed and D. J. Mathisen, 2003). We present the case of a patient with a deceptive history for TEF and report an approach that provides adequate oxygenation, ventilation, surgical exposure, and postoperative analgesia with excellent outcome.

Managing acute postoperative pain: is 3 hours too long?

This case study discusses a 64-year-old opioid-tolerant patient who underwent amputation below the left knee and received pain management in the PACU. The patient's self-reported pain level remained 9 on a 0 to 10 scale despite having received a total of 62 mg of morphine sulfate (MSO 4 ) and 60 mg of ketorolac in just less than 3 hours. The patient's facial expression corresponded to a score of 4 to 5 based on the Wong-Baker Faces Pain Scale. This case study illustrates that it is crucial to promptly involve the pain management service when an opioid-tolerant patient requires aggressive pain treatment. The initial patient-controlled analgesia (PCA) order and MSO 4 -loading doses must take into account the patient history of opioid tolerance, increasing the frequency and dosage-loading doses of MSO 4 for treating severe pain until the patient's pain is reduced by at least 50% on a numeric scale, or until the patient states satisfactory relief. The most important rule of pain management is that pain is what the patient says it is.

Rapid sevoflurane induction compared with thiopental.

STUDY OBJECTIVES: To examine whether the speed of induction of anesthesia with sevoflurane/nitrous oxide (N2O) utilizing a 10-second vital capacity rapid inhalation induction (VCRII) followed by tidal breathing was similar or faster than cautious intravenous (i.v.V) thiopental induction with inhaled N2O. DESIGN: Prospective, randomized, double-blinded study. SETTING: Veterans Affairs Medical Center. PATIENTS: 50 male ASA physical status I, II, and III patients scheduled for general anesthesia. INTERVENTIONS: Patients were randomized to receive either 8% sevoflurane or i.v. thiopental. Patients were allocated to one of two groups of 25 patients each. In both groups, the breathing circuit was initially primed for 5 minutes with (4 L/min) and O2 (2 L/min), while the Y-piece was occluded. In the sevoflurane group, the circuit was additionally primed with 8% sevoflurane. Patients were trained to perform a vital capacity breath. After maximal exhalation, the occluding plug was rapidly removed from the Y-piece and connected to the facemask. The patient then inspired to vital capacity, held his breath for 10 seconds, and then was allowed to breathe normally. At the end of the 10-second breathhold, and as the patient started normal breathing, either thiopental (thiopental group) or normal saline (sevoflurane group) was injected at a rate of 4 mL every 10 seconds. MEASUREMENTS: A study-blinded observer recorded the time to induction, as defined by the time to loss of eyelash reflex, and noted the occurrence of side effects. MAIN RESULTS: The speed of induction was the same for both groups (p > 0.05). An average of eight breaths was required before loss of eyelash reflex. Side effects occurred in 36% of the patients in the thiopental group, and 32% in the sevoflurane group (p > 0.05); these were minor and did not affect induction. CONCLUSION: Sevoflurane/N2O VCRII as used in this investigation is an effective inhalation technique; it resulted in an induction time similar to that of slow i.v. thiopental with inhaled N2O.