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1.
Crit Care Med ; 2021 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-33938718

RESUMO

OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.

3.
Anesth Analg ; 132(5): 1206-1214, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33857962

RESUMO

BACKGROUND: The frequency and temporal distribution of postoperative respiratory depression (RD) events are not completely understood. This study determined the temporal distribution and frequency of RD episodes in postsurgical patients continuously monitored by bedside capnography and pulse oximetry. METHODS: This was a post hoc study of a subset of postsurgical patients enrolled in The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial from 2 sites in the United States. These patients had undergone continuous bedside monitoring on general care wards. These data were adjudicated for potential RD episodes. The number of RD episodes per patient and the time of each RD episode were determined. The first RD episode experienced by a patient was classified as an "initial" episode, and the initial and all subsequent RD episodes experienced by a patient were classified as "all" episodes. A PRODIGY risk score was calculated. RESULTS: Data analyzed from 250 patients contained 2539 RD episodes in 155 (62.0%, 95% confidence interval, 55.7-68.0) patients with median 2 [0-8], range of 0-545 RD episodes per patient, with a PRODIGY risk score distribution of 100 (40.0%) low, 79 (31.6%) intermediate, 70 (28.0%) high (missing data from 1 patient). Median time to the initial RD episode was 8.8 [5.1-18.0] hours postoperatively. There was a peak occurrence of initial RD events between 14:00 and 20:00 on the day of surgery, and these were associated with a large number of subsequent events in the same timeframe. The peak time of all RD episodes occurred from 02:00 to 06:00. Patients with high PRODIGY risk scores had higher incidence and greater number of RD episodes per patient (P < .001, overall comparisons between groups for both incidence [χ2] and number of episodes [Kruskal-Wallis test]). CONCLUSIONS: Continuous monitoring of surgical patients demonstrates that RD episodes are common, and risk increases with higher PRODIGY scores. In this patient cohort, the rate of initial RD episodes peaked in the afternoon to early evening, while peak rate of all RD episodes occurred in early morning. Further, among patients with RD episodes, the number of episodes increased with higher PRODIGY scores.

4.
Anesth Analg ; 2021 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-33886519

RESUMO

BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

5.
Urol Int ; : 1-5, 2021 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-33902060

RESUMO

INTRODUCTION: Injuries to surrounding structures during radical prostatectomy (RP) are rare but serious complications. However, it remains unknown if injuries to intestines, rectum, or vascular structures occur at different rates depending on the surgical approach. METHODS: We compared the frequency of these outcomes in open RP (ORP) and minimally invasive RP (MIS-RP) using the national American College of Surgeons National Surgical Quality Improvement Program database (2012-2017). Along with important metrics of clinical and surgical outcomes, patients were identified as undergoing surgical repair of small or large bowel, vascular structures, or hernias based on Current Procedural Terminology codes. RESULTS: In our propensity matched analysis, a total of 13,044 patients were captured. Bowel injury occurred more frequently in ORP than in MIS-RP (0.89 vs. 0.26%, p < 0.01). By intestinal segment, rectal and large bowel injuries were more common in ORP than MIS-RP (0.41 vs. 0.11% and 0.31 vs. 0.05%, both p < 0.01). However, there was no statistically significant difference between the groups for small bowel injury (0.17 vs. 0.11%, p = 0.39). Vascular injury was more common in MIS-RP (0.18 vs. 0.08%, p = 0.08). Hernias requiring repair were only identified in the MIS-RP group (0.12%). CONCLUSION: When considering surgical approach, rectal and large bowel injuries were more common in ORP, while vascular injuries and hernia repair were more common in MIS-RP. Our findings can be used in counseling patients and identifying risk factors and strategies to reduce these complications.

7.
Neuromodulation ; 24(3): 434-440, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33723896

RESUMO

INTRODUCTION: Spinal cord stimulation (SCS) is used in the treatment of many chronic pain conditions. This study investigates racial and socioeconomic disparities in SCS among Medicare patients with chronic pain. MATERIALS AND METHODS: Patients over the age of 18 with a primary diagnosis of postlaminectomy syndrome (ICD-10 M96.1) or chronic pain syndrome (ICD-10 G89.4) were identified in the Center for Medicare and Medicaid Services (CMS) Medicare Claims Limited Data Set. We defined our outcome as SCS therapy by race and socioeconomic status. Multivariable logistic regression was used to determine the variables associated with SCS. RESULTS: We identified 1,244,927 patients treated between 2016 and 2019 with a primary diagnosis of postlaminectomy syndrome (PLS) or chronic pain syndrome (CPS). Of these patients, 59,182 (4.8%) received SCS. Multivariable logistic regression analysis revealed that, compared with White patients, Black (OR [95%CI], 0.62 [0.6-0.65], p < 0.001), Asian (0.66 [0.56-0.76], p < 0.001), Hispanic (0.86 [0.8-0.93], p < 0.001), and North American Native (0.62 [0.56-0.69], p < 0.001) patients were significantly less likely to receive SCS. In addition, patients who were dual-eligible for Medicare and Medicaid were significantly less likely to receive SCS than those eligible for Medicare only (OR = 0.38 [95% CI: 0.37-0.39], p < 0.001). CONCLUSIONS: This study suggests that racial and socioeconomic disparities exist in SCS among Medicare and Medicaid patients with PLS and CPS. Further work is required to elucidate the complex etiology underlying these findings.

8.
Curr Pain Headache Rep ; 25(5): 28, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33761010

RESUMO

PURPOSE OF REVIEW: In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD). RECENT FINDINGS: Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.

9.
Pain Physician ; 24(2): 153-163, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33740349

RESUMO

BACKGROUND: Although conventional pain relief therapeutics have centered around mu-opioid agonists, these drugs are limited by adverse side effects, including respiratory depression and addiction potential. The ongoing opioid epidemic has galvanized research into novel analgesic therapies with more favorable profiles. New pharmacologic agents have been developed to target neuronal pathways involved in pain sensation. Certain receptors have been recognized to mediate nociceptive transmission, central sensitization, and the development of chronic pain states. OBJECTIVES: We conducted a literature review to identify potential targets for novel analgesic therapies. STUDY DESIGN: This study is a narrative review of potential analgesic targets. We characterize their antinociceptive mechanisms of action and evaluate their therapeutic potential. METHODS: A systemized search of available literature on novel analgesics was performed. A search was performed through the PubMed database to identify articles with key words of "novel analgesics," "novel non-opioid analgesics," "novel pain targets," and "non-opioid analgesics." Potential drug classes were identified and researched through corresponding keywords, with an emphasis on publications from 2018 to 2020. Older articles were included if frequently referenced by current literature. RESULTS: Potential novel analgesic targets include Nav1.7, Nav1.8, CaV2.2, and transient receptor potential vanilloid-1 (TRPV1) cation channel receptors in the peripheral nervous system. Other approaches disrupt the synthesis of pronociceptive signaling molecules such as nitric oxide, prostaglandin E2, and interleukin-6 (IL-6). Within central pain pathways, modification of kappa-opioid, delta-opioid, N-methyl-D-aspartate, and cannabinoid receptors have been investigated in chronic pain and hyperalgesia models. Recent advances in molecular technology have also presented opportunities to modify protein expression or the cellular genome altogether. LIMITATIONS: Several analgesic targets have only demonstrated efficacy in preclinical trials. There are limited data evaluating the long-term safety profiles of therapies further on in development. CONCLUSIONS: We provide an overview of potential analgesic therapies in various stages of development, which may become clinically relevant in the near future. Some drugs such as TRPV1 agonists, anti-IL-6, and anti-nerve growth factor antibodies have demonstrated analgesic effect in specific clinical pain states.

10.
Mayo Clin Proc ; 2021 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-33741131

RESUMO

The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.

13.
World J Surg ; 45(5): 1272-1290, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33677649

RESUMO

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS: Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

15.
Mayo Clin Proc ; 2021 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-33714600

RESUMO

Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources utilize the recommendations derived from individual studies and do not include a multidisciplinary focus or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.

17.
Adv Ther ; 38(3): 1447-1469, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33580485

RESUMO

INTRODUCTION: Preoperative anemia is associated with increased morbidity, mortality, and healthcare costs. As a result of the increased incidence of chronic blood loss and iron deficiency anemia in abdominal surgery patients and its impact on patient outcomes, we systematically evaluated the quality of evidence for preoperative intravenous (IV) administration of iron to patients with anemia undergoing major abdominal surgery with the focus on clinical outcomes. METHODS: In this systematic review, PubMed, Cochrane, The Cumulative Index to Nursing and Allied Health Literature, Web Of Science, and Excerpta Medica Database databases were searched up to 2019 using specific keywords. Inclusion criteria were patients that were over 18 years of age, underwent abdominal surgery, and received an IV iron treatment in the preoperative setting. RESULTS: The nine studies included in the final systematic review do not provide consistent evidence of a reduced incidence of allogeneic blood transfusions with preoperative IV iron administration. However, IV iron administration did consistently cause a significant increase in hemoglobin levels relative to oral iron therapy or no iron. CONCLUSION: Overall, these findings are consistent in that IV iron administration is highly effective at rapidly increasing hemoglobin levels in patients with iron deficiency anemia undergoing major abdominal surgery. Unfortunately, there is currently no evidence of reduced incidence of allogeneic blood transfusions or other enhanced outcomes.


Assuntos
Anemia Ferropriva , Anemia , Administração Intravenosa , Adolescente , Adulto , Anemia/tratamento farmacológico , Anemia Ferropriva/tratamento farmacológico , Transfusão de Sangue , Humanos , Ferro/uso terapêutico
19.
A A Pract ; 15(2): e01404, 2021 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-33577169

RESUMO

Inaccurate anesthesia start time (AST) documentation can result in lost revenue. Using a retrospective analysis, we estimated lost revenue from inaccurate documentation of the AST within a single health care system, including academic and community-based facilities. We used differences in nursing documentation of "in-room" time and AST to calculate lost billable revenue. Of the 282,432 cases included, 25.6% had a documented "in-room" time before the documented AST, resulting in an estimated loss of $703,522 within 30-month study period. Through educational interventions and feedback, anesthesia clinicians have the potential to significantly increase revenue through more accurate documentation of AST.

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