Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study.

BACKGROUND: An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting. METHODS: This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications. RESULTS: We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups. CONCLUSION: Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA. TRIALS REGISTRATION: The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).

The transit of oral premedication beyond the stomach in patients undergoing laparoscopic sleeve gastrectomy: a retrospective observational multicentre study.

BACKGROUND: Antiemetic and analgesic oral premedications are frequently prescribed preoperatively to enhance recovery after laparoscopic sleeve gastrectomy. However, it is unknown whether these medications transit beyond the stomach or if they remain in the sleeve resection specimen, thereby negating their pharmacological effects. METHODS: A retrospective cohort study was performed on patients undergoing laparoscopic sleeve gastrectomy and receiving oral premedication (slow-release tapentadol and netupitant/palonosetron) as part of enhanced recovery after bariatric surgery program. Patients were stratified into the Transit group (premedication absent in the resection specimen) and Failure-to-Transit group (premedication present in the resection specimen). Age, sex, body mass index, and presence of diabetes were compared amongst the groups. The premedication lead time (time between premedications' administration and gastric specimen resection), and the premedication presence or absence in the specimen was evaluated. RESULTS: One hundred consecutive patients were included in the analysis. Ninety-nine patients (99%) were morbidly obese, and 17 patients (17%) had Type 2 diabetes mellitus. One hundred patients (100%) received tapentadol and 89 patients (89%) received netupitant/palonosetron. One or more tablets were discovered in the resected specimens of 38 patients (38%). No statistically significant differences were observed between the groups regarding age, sex, diabetes, or body mass index. The median (Q1‒Q3) premedication lead time was 80 min (57.8‒140.0) in the Failure-to-Transit group and 119.5 min (85.0‒171.3) in the Transit group; P = 0.006. The lead time required to expect complete absorption in 80% of patients was 232 min (95%CI:180‒310). CONCLUSIONS: Preoperative oral analgesia and antiemetics did not transit beyond the stomach in 38% of patients undergoing laparoscopic sleeve gastrectomy. When given orally in combination, tapentadol and netupitant/palonosetron should be administered at least 4 h before surgery to ensure transition beyond the stomach. Future enhanced recovery after bariatric surgery guidelines may benefit from the standardization of premedication lead times to facilitate increased absorption. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry; number ACTRN12623000187640; retrospective registered on 22/02/2023.

The Association of Postoperative Complications and Hospital Costs Following Distal Pancreatectomy.

Background: Understanding the financial implications associated with the complications post-distal pancreatectomy (DP) may be beneficial for the future optimisation of postoperative care pathways and improved cost-efficiency. The primary outcome of this retrospective study was the characterisation of the additional cost associated with postoperative complications following DP. The secondary outcome was the estimation of the prevalence, type and severity of complications post-DP and the determination of which complications were associated with higher costs. Methods: Postoperative complications were retrospectively examined for 62 adult patients undergoing distal pancreatectomy at an Australian university hospital between January 2012 and July 2021. Complications were defined and graded using the Clavien-Dindo (CVD) classification system. In-hospital cost of index admission was calculated using an activity-based costing methodology and was reported in US dollars at 2021 rates. Regression modelling was used to investigate the relationships among selected perioperative variables, complications and costs. Results: 45 patients (72.6%) experienced one or more postoperative complications. The median (IQR) hospital cost in US dollars was 31.6% greater in patients who experienced complications compared to those who experienced no complications ($40,717.8 [27,358.0-59,834.3] vs. $30,946.9 [23,910.8-46,828.1]). Costs for patients with four or more complications were 43.5% higher than for those with three or fewer complications (p = 0.015). Compared to patients with no complications, the median hospital costs increased by 17.1% in patients with minor complications (CVD grade I/II) and by 252% in patients who developed major complication (i.e., CVD grade III/IV) complications. Conclusion: Postoperative complications are a key target for cost-containment strategies. Our findings demonstrate a high prevalence of postoperative complications following distal pancreatectomy with number and severity of postoperative complications being associated with increased hospital costs. (Registered in the Australian New Zealand Clinical Trials Registry [No. ACTRN12622000202763]).

Evaluation of a calcium, magnesium and phosphate clinical ordering tool in the emergency department.

OBJECTIVE: We developed a clinical tool comprising patient risk factors for having an abnormal calcium (Ca), magnesium (Mg) or phosphate (PO4) level. We hypothesized that patients without a risk factor do not require testing. This study examined the tool's potential utility for rationalizing Ca, Mg and PO4 ordering in the emergency department (ED). METHODS: We undertook a retrospective observational study in a single metropolitan ED. Patients aged 18 years or more who presented between July and December 2019 were included if they had a Ca, Mg or PO4 test during their ED stay. Demographic and clinical data, including the presence of risk factors, were extracted from the medical record. The primary outcome was a clinically significant abnormal Ca, Mg or PO4 level (>0.2 mmol/l above or below the laboratory reference range). RESULTS: Calcium, Mg and PO4 levels were measured on 1426, 1296 and 1099 patients, respectively. The positive and negative predictive values and likelihood ratios of the tool identifying a patient with a Ca level > 0.2 mmol/l outside the range were 0.05, 0.99, 1.59 and 0.41, respectively. The values for Mg were 0.02, 1.00, 1.44 and 0.35 and those for PO4 were 0.15, 0.93, 1.38 and 0.57, respectively. The majority of patients not identified as having an abnormal level did not receive electrolyte correction treatment. Application of the tool would have resulted in a 35.8% cost reduction. CONCLUSION: The tool failed to predict a very small proportion of patients (approximately 1%) with an abnormal Ca or Mg level and for whom it would have been desirable to have these levels measured. It may help rationalize Ca and Mg ordering and reduce laboratory costs.

Nature and extent of selection bias resulting from convenience sampling in the emergency department.

BACKGROUND: To compare the clinical and demographic variables of patients who present to the ED at different times of the day in order to determine the nature and extent of potential selection bias inherent in convenience sampling METHODS: We undertook a retrospective, observational study of data routinely collected in five EDs in 2019. Adult patients (aged ≥18 years) who presented with abdominal or chest pain, headache or dyspnoea were enrolled. For each patient group, the discharge diagnoses (primary outcome) of patients who presented during the day (08:00-15:59), evening (16:00-23:59), and night (00:00-07:59) were compared. Demographics, triage category and pain score, and initial vital signs were also compared. RESULTS: 2500 patients were enrolled in each of the four patient groups. For patients with abdominal pain, the diagnoses differed significantly across the time periods (p<0.001) with greater proportions of unspecified/unknown cause diagnoses in the evening (47.4%) compared with the morning (41.7%). For patients with chest pain, heart rate differed (p<0.001) with a mean rate higher in the evening (80 beats/minute) than at night (76). For patients with headache, mean patient age differed (p=0.004) with a greater age in the daytime (46 years) than the evening (41). For patients with dyspnoea, discharge diagnoses differed (p<0.001). Asthma diagnoses were more common at night (12.6%) than during the daytime (7.5%). For patients with dyspnoea, there were also differences in gender distribution (p=0.003), age (p<0.001) and respiratory rates (p=0.003) across the time periods. For each patient group, the departure status differed across the time periods (p<0.001). CONCLUSION: Patients with abdominal or chest pain, headache or dyspnoea differ in a range of clinical and demographic variables depending upon their time of presentation. These differences may potentially introduce selection bias impacting upon the internal validity of a study if convenience sampling of patients is undertaken.

Author and journal self-citation in Emergency Medicine original research articles.

OBJECTIVE: To determine author and journal self-citation rates in a sample of original emergency medicine (EM) research articles. METHODS: We undertook a retrospective observational study of original research articles published in 2019 in the top six English language general EM journals. Data comprised the total numbers of articles, citations, authors and self-citations for each author (author self-citations) as well as the number of articles in the reference list that had been previously published in the same journal (journal self-citations). RESULTS: 3213 individual authors and 581 articles were examined. Most authors did not self-cite at all although 62 self-cited five or more times in a single article. The mean (SD) and median (IQR) numbers of individual author self-citations/article/year were 0.6 (1.3) and 0 (0-1), respectively. Overall, author self-citations accounted for 2.4% of all cited articles. There was a weak positive but significant correlation between the number of individual author self-citations/article/year and the number of articles published by the author (r = 0.38, p < 0.001). There was no correlation between the journal impact factor (IF) and the author self-citation rate (r = 0.14, p = 0.79). The journals differed significantly in their author self-citation rates (p < 0.001). Annals of Emergency Medicine had the highest journal self-citation rate at 8.1% (95%CI 7.0%-9.2%) self-citations/100 citations/year, almost twice that of some other journals. There was a large but non-significant positive correlation between the journal IF and journal self-citation rates (r = 0.78, p = 0.07). CONCLUSION: Both author and journal self-citation rates in the articles examined are relatively low compared to other medical and scientific disciplines.

Risk events during intrahospital transport of patients from the emergency department: a prospective observational study.

BACKGROUND: We aimed to determine the incidence, nature of and predisposing factors for risk events (REs) that occur during the intrahospital transport of patients from the ED. METHODS: We undertook a prospective, observational study of intrahospital patient transports from a single ED between 30 January and 20 March 2020. An investigator attended each transport and recorded any RE on a specifically designed data collection document. An RE was any mishap, even if not foreseen, that had the potential to cause the patient harm. A patient equipment number was assigned based on the number of pieces of equipment required during the transport. Poisson regression generated incidence rate ratios (IRRs) and determined risk factors for REs. RESULTS: Of 738 transports, 289 (39.1%, 95% CI 35.6% to 42.8%) had at least one RE. The total of 521 REs comprised 125 patient-related, 279 device-related and 117 line/catheter-related REs. The most common included trolley collisions (n=142), intravenous fluid line catching/tangling (n=93), agitation/aggression events (n=31) and cardiac monitoring issues (n=31). Thirty-four (6.5%) REs resulted in an undesirable patient outcome, most commonly distress and pain. Predisposing factors for REs included an equipment number ≥3 (IRR 5.68, 95% CI 3.95 to 8.17), transport to a general ward (IRR 2.68, 95% CI 2.12 to 3.39), hypertension (IRR 1.93, 95% CI 1.07 to 3.50), an abnormal temperature and a GCS<14. CONCLUSIONS: REs are common in transport of patients from the ED and can result in undesirable patient outcomes. Adequate pre-transfer preparation, especially securing equipment and lines, would result in a reduced risk.