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1.
Medicine (Baltimore) ; 100(10): e24941, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725856

RESUMO

INTRODUCTION: Total knee replacement (TKR) is a surgical procedure that is being increasingly performed as a result of population aging and the increased average human life expectancy in South Korea. Consistent with the growing number of TKR procedures, the number of patients seeking acupuncture for relief from adverse effects, effective pain management, and the enhancement of rehabilitative therapy effects and bodily function after TKR has also been increasing. Thus, an objective examination of the evidence regarding the safety and efficacy of acupuncture treatments is essential. The aim of this study is to verify the hypothesis that the concurrent use of acupuncture treatment and usual care after TKR is more effective, safe, and cost-effective for the relief of TKR symptoms than usual care therapy alone. METHODS/DESIGN: This is an open-label, parallel, assessor-blinded randomized controlled trial that includes 50 patients with TKR. After screening the patients and receiving informed consent, the patients are divided into two groups (usual care + acupuncture group and usual care group); the patients will then undergo TKR surgery and will be hospitalized for 2 weeks. The patients will receive a total of 8 acupuncture treatments over 2 weeks after surgery and will be followed up at 3, 4, and 12 weeks after the end of the intervention. The primary outcome is assessed using the Korean version of the Western Ontario and McMaster Universities Arthritis Index (K-WOMAC), and the secondary outcome is measured using the Numerical Rating Scale (NRS), Risk of Fall, and Range of Motion (ROM). Moreover, the cost per quality-adjusted life years (QALYs) is adopted as a primary economic outcome for economic evaluation, and the cost per NRS is adopted as a secondary economic outcome. ETHICS AND DISSEMINATION: This trial has received complete ethical approval from the Ethics Committee of Catholic Kwandong University International St. Mary's Hospital (IS17ENSS0063). We intend to submit the results to a peer-reviewed journal and/or conferences. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03633097.


Assuntos
Terapia por Acupuntura/efeitos adversos , Artroplastia do Joelho/reabilitação , Osteoartrite do Joelho/cirurgia , Manejo da Dor/métodos , Dor Pós-Operatória/diagnóstico , Terapia por Acupuntura/economia , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Terapia Combinada/efeitos adversos , Terapia Combinada/economia , Terapia Combinada/métodos , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/economia , Manejo da Dor/efeitos adversos , Manejo da Dor/economia , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/reabilitação , Projetos Piloto , Anos de Vida Ajustados por Qualidade de Vida , República da Coreia , Resultado do Tratamento
2.
Trials ; 20(1): 732, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842977

RESUMO

BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.


Assuntos
Anestésicos Locais/administração & dosagem , Artroplastia do Joelho , Bupivacaína/administração & dosagem , Osteoartrite do Joelho/cirurgia , Dor Pós-Operatória/prevenção & controle , Anestésicos Locais/efeitos adversos , Anestésicos Locais/economia , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Bupivacaína/efeitos adversos , Bupivacaína/economia , Análise Custo-Benefício , Custos de Medicamentos , Estudos de Equivalência como Asunto , Humanos , Lipossomos , Estudos Multicêntricos como Assunto , Osteoartrite do Joelho/diagnóstico , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Reino Unido
3.
Gynecol Oncol ; 155(1): 93-97, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31492539

RESUMO

OBJECTIVE: To compare postoperative outcomes by primary payer status for patients with gynecologic malignancies. METHODS: We retrospectively reviewed patients who underwent elective surgery for gynecologic malignancies between 2015 and 2019. Patient outcomes were compared by payer status using logistic regression. Sociodemographic and clinical covariates were selected a priori and included age, American Society of Anesthesiologists physical status classification, body mass index, smoking status, malignancy site, surgery type, race, estimated income, marital status, and medical interpreter requirement. RESULTS: A total of 1894 patients comprised the study sample. In the multivariate model, compared to patients with private insurance, Medicaid and Medicare patients were more likely to mobilize >24 h after surgery (OR 1.9, p < 0.05 and OR 3.2, p < 0.001, respectively), to require ICU admission (OR 4.0, p < 0.05 and OR 5.0, p < 0.05, respectively), and to have longer lengths of stay (OR 1.8, p < 0.05 and OR 2.2, p < 0.001, respectively). Medicaid patients were also more likely to have higher total hospital costs (OR 1.7, p < 0.05). Payer status was not associated with postoperative pain, postoperative opiate use, or 30-day readmission rates. CONCLUSIONS: Medicaid and Medicare payer status are associated with worse postoperative outcomes in patients with gynecologic malignancies. The poor outcomes of Medicaid patients - a cohort defined by limited income - are noteworthy. The etiology is likely multifactorial, arising from a complex interplay of factors ranging from system issues such as access to care to the unique health status of a population bearing a high burden of disease and socioeconomic adversity.


Assuntos
Neoplasias dos Genitais Femininos/economia , Neoplasias dos Genitais Femininos/cirurgia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Custos Hospitalares , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , São Francisco , Resultado do Tratamento , Estados Unidos
4.
Neurosurg Focus ; 46(4): E10, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30933911

RESUMO

OBJECTIVEEnhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.METHODSThis study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods-during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II-V or if they were younger than 18 years or older than 65.Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.RESULTSThe ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.CONCLUSIONSERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.


Assuntos
Discotomia/economia , Discotomia/métodos , Recuperação Pós-Cirúrgica Melhorada , Vértebras Lombares/cirurgia , Adulto , Anestesia/economia , Análise Custo-Benefício , Feminino , Humanos , Incidência , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/economia , Náusea e Vômito Pós-Operatórios/economia , Náusea e Vômito Pós-Operatórios/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
5.
Turk Neurosurg ; 29(6): 843-850, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30984998

RESUMO

AIM: To compare the effects of spinal anesthesia (SA) and general anesthesia (GA) in lumbar microdiscectomy in terms of their costeffectiveness, and perioperative outcomes. MATERIAL AND METHODS: We randomly allocated 100 consecutive patients who were scheduled to undergo elective lumbar microdiscectomy, into either SA or GA groups. We recorded and evaluated various parameters, including demographic aspects, body mass index (BMI), perioperative hemodynamics, time elapsed from operating room (OR) entry until incision, operative time, time elapsed from application of the surgical dressing to exiting OR, blood loss, post anesthetic care unit (PACU) time, preoperative and postoperative pain scores, postoperative analgesic requirements, first mobilization time, first oral intake, the length of hospital stay, time to return to work, and perioperative anesthetic costs. The patients, anesthesiologists, and neurosurgeons were handed a questionnaire before discharge to determine their satisfaction with the procedure. RESULTS: Several variables were found to be better in the SA group: the mean arterial pressure and heart rate changes were significantly lower, and the time elapsed from OR entry until incision, operative time, time elapsed from application of the surgical dressing to exiting OR, PACU time, the length of hospital stay, and time to return to work were shorter; furthermore, the postoperative pain scores, the analgesic requirements, the intraoperative blood loss, and the cost of anesthesia were all lower. Moreover the first mobilization and oral intake occurred earlier; and most significantly, the satisfaction of the patients and surgeons was higher in the SA group. Furthermore, we encountered no complications. CONCLUSION: Based on our results, we conclude that SA is reliable and clinically successful procedure in lumbar microdiscectomy.


Assuntos
Anestesia Geral/economia , Raquianestesia/economia , Análise Custo-Benefício/métodos , Discotomia/economia , Microcirurgia/economia , Dor Pós-Operatória/economia , Adulto , Anestesia Geral/métodos , Raquianestesia/métodos , Discotomia/métodos , Feminino , Humanos , Tempo de Internação/tendências , Vértebras Lombares/cirurgia , Masculino , Microcirurgia/métodos , Pessoa de Meia-Idade , Dor Pós-Operatória/prevenção & controle , Resultado do Tratamento
6.
Afr Health Sci ; 19(4): 3127-3135, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32127889

RESUMO

Background: In developing countries, post-operative pain remains underestimated and undertreated due to economic constraints, lack of awareness and limited resources. In contrast, ketamine is an effective, readily available, easy to use and inexpensive drug frequently used in poor settings. Objectives: The aim of this study was to explore the overall reduction in the medication treatment cost of acute post-operative pain by adding intra-operative low-dose ketamine to traditional intravenous morphine for surgery in a low-income country. Methods: A double blind randomized controlled trial with placebo-controlled parallel group was performed in Mulago National Hospital (Uganda). Consenting adults scheduled for elective surgery were randomized into two study arms: Group K received ketamine 0.15mg/kg bolus at induction and a continuous infusion of 0.12 mg/kg/hour till start of skin closure; Group C (control) received normal saline. Both groups received Morphine 0.1 mg/kg IV at debulking. The total medication cost was registered. NRS pain scores and other measurements such vital signs and incidence of major and minor side effects were also recorded. Results: A total of 46 patients were included. Patients' baseline characteristics were comparable in both groups. No statistically significant difference was found between the groups concerning the overall medication cost of post-operative pain management. Pain scores, patients' satisfaction in the first 24 hours after surgery and hospital length of stay were similar in both groups. Conclusion: Our results do not support the utilization of intra-operative low dose ketamine as a cost-saving post-operative pain treatment strategy for all types of surgery in low-resource settings.


Assuntos
Ketamina/administração & dosagem , Ketamina/economia , Morfina/administração & dosagem , Morfina/economia , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/economia , Pobreza/estatística & dados numéricos , Adulto , Analgésicos/administração & dosagem , Analgésicos/economia , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/economia , Análise Custo-Benefício , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/economia , Manejo da Dor/métodos , Manejo da Dor/estatística & dados numéricos , Uganda
7.
J Surg Res ; 233: 88-95, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30502293

RESUMO

BACKGROUND: We aimed to assess whether the use of the harmonic scalpel (HS) in axillary dissection would reduce long-term shoulder-arm morbidity compared to traditional instruments (TIs). MATERIALS AND METHODS: A retrospective analysis on 180 patients who underwent standard axillary dissection for breast cancer between 2007 and 2015 was carried out. All patients were evaluated for postoperative pain, impairment of shoulder-arm mobility, seroma formation in axilla, frozen shoulder, and lymphedema. RESULTS: HS procedure on average was 50% shorter compared to the TI technique. HS reduced by 4.5 times the risk of axillary seroma. TIs were associated with 4 times higher risk of developing a painful frozen shoulder. CONCLUSIONS: Use of the HS was associated with reduced costs and a positive long-term effect on shoulder-arm morbidity. Axillary seromas are not the only reason of later postoperative shoulder-arm morbidity: other mechanisms are hypothesized in the onset of this very disabling disorder.


Assuntos
Linfedema Relacionado a Câncer de Mama/epidemiologia , Neoplasias da Mama/cirurgia , Bursite/epidemiologia , Dor Pós-Operatória/epidemiologia , Biópsia de Linfonodo Sentinela/efeitos adversos , Seroma/epidemiologia , Procedimentos Cirúrgicos Ultrassônicos/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Braço/fisiopatologia , Axila , Linfedema Relacionado a Câncer de Mama/economia , Linfedema Relacionado a Câncer de Mama/fisiopatologia , Neoplasias da Mama/patologia , Bursite/economia , Bursite/fisiopatologia , Redução de Custos , Feminino , Seguimentos , Humanos , Metástase Linfática/diagnóstico , Metástase Linfática/patologia , Mastectomia/efeitos adversos , Mastectomia/instrumentação , Pessoa de Meia-Idade , Dor Pós-Operatória/economia , Dor Pós-Operatória/fisiopatologia , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela/instrumentação , Seroma/economia , Seroma/fisiopatologia , Ombro/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Ultrassônicos/instrumentação
8.
Neuromodulation ; 22(8): 960-969, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30320933

RESUMO

OBJECTIVES: Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair. MATERIALS AND METHODS: A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow-up; or 5) had less than one-year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs. RESULTS: We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n = 14,919, No CP: n = 61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one-year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75-fold increase (p < 0.001) in total inpatient/outpatient costs and a 2.26-fold increase (p < 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14-fold increase (p < 0.001) in total inpatient/outpatient costs and 2.00-fold increase (p < 0.001) in pain prescription costs. CONCLUSIONS: Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair.


Assuntos
Dor Crônica/economia , Dor Crônica/epidemiologia , Terapia por Estimulação Elétrica/economia , Hérnia/economia , Herniorrafia/efeitos adversos , Herniorrafia/economia , Dor Pós-Operatória/economia , Dor Pós-Operatória/epidemiologia , Adulto , Idoso , Dor Crônica/etiologia , Estudos de Coortes , Custos e Análise de Custo , Custos de Medicamentos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Prevalência , Estudos Retrospectivos
9.
J Perianesth Nurs ; 34(1): 143-150, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29935798

RESUMO

PURPOSE: This quality improvement project aimed to change the practice of administration route of acetaminophen from intravenous (IV) to oral to patients having a hysterectomy at a community hospital, reduce costs, and maintain postanesthesia care unit pain scores for patients who receive oral acetaminophen comparable to those who receive IV acetaminophen. DESIGN: There were 46 participants: 23 in the preintervention group and 23 in the postintervention group. METHODS: Data retrieved from the electronic medical record included the route of acetaminophen administered, cost, and pain scores. FINDINGS: Implementation of this quality improvement project resulted in no difference in the pain scores between the preintervention and postintervention groups (P = .637). In addition, the hospital cost for acetaminophen decreased 95.25% and patients saved $6,683 during the 3-month implementation period. CONCLUSIONS: The administration of oral acetaminophen provided equivalent postoperative analgesia compared with IV acetaminophen and reduced costs for both the hospital and patients.


Assuntos
Acetaminofen/administração & dosagem , Analgésicos não Entorpecentes/administração & dosagem , Histerectomia/métodos , Dor Pós-Operatória/tratamento farmacológico , Acetaminofen/economia , Administração Intravenosa , Administração Oral , Adulto , Idoso , Analgésicos não Entorpecentes/economia , Feminino , Custos Hospitalares , Hospitais Comunitários , Humanos , Histerectomia/economia , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/economia , Estudos Prospectivos , Melhoria de Qualidade , Estudos Retrospectivos
10.
J Surg Res ; 230: 40-46, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30100038

RESUMO

BACKGROUND: The purpose of this study is to describe a cohort of pediatric patients undergoing cholecystectomy for biliary dyskinesia (BD) and characterize postoperative resource utilization. METHODS: Single-institution, retrospective chart review of pediatric patients after cholecystectomy for BD was done. Patient demographics and clinical characteristics as well as operative details and postoperative interventions were abstracted. Telephone follow-up was performed to identify persistent symptoms, characterize the patient experience, and quantify postoperative resource utilization. RESULTS: Forty-nine patients were included. Twenty-two patients (45%) were seen postoperatively by a gastroenterologist, of which, only 32% were known to the gastroenterologist before surgery. Postoperative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, five endoscopic retrograde cholangiopancreatographies (ERCPs), one endoscopic ultrasound, one magnetic resonance cholangiopancreaticogram, and five colonoscopies. Of the patients with additional diagnostic testing postoperatively, one had mild esophagitis, three had sphincter of Oddi dysfunction, and one was suspected to have inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea, or vomiting at an average of 26 mo after operation. Of note, all patients who underwent postoperative ERCP with sphincterotomy reported symptom relief following this procedure. CONCLUSIONS: Relief of symptoms postoperatively in pediatric patients with BD is inconsistent. Postoperative studies, though numerous, are of low diagnostic yield and generate high costs. These findings suggest that the initial diagnostic criteria and treatment algorithm may require revision to better predict symptom improvement after surgery. Improvement seen after ERCP/sphincterotomy is anecdotal but appears to merit further investigation.


Assuntos
Discinesia Biliar/cirurgia , Colecistectomia/efeitos adversos , Dor Pós-Operatória/diagnóstico por imagem , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Adolescente , Discinesia Biliar/diagnóstico por imagem , Discinesia Biliar/economia , Colangiopancreatografia Retrógrada Endoscópica/economia , Colangiopancreatografia Retrógrada Endoscópica/estatística & dados numéricos , Colecistectomia/economia , Colecistectomia/métodos , Colecistectomia/normas , Procedimentos Clínicos/normas , Endoscopia do Sistema Digestório/estatística & dados numéricos , Endossonografia/estatística & dados numéricos , Feminino , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/cirurgia , Humanos , Masculino , Dor Pós-Operatória/economia , Dor Pós-Operatória/cirurgia , Utilização de Procedimentos e Técnicas/economia , Estudos Retrospectivos , Esfincterotomia/estatística & dados numéricos , Resultado do Tratamento
11.
Plast Reconstr Surg ; 141(6): 1327-1330, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29750760

RESUMO

Effective postsurgical analgesia is a critical aspect of patient recovery. The goal of this prospective, randomized, controlled, blinded study was to examine the effect that liposomal bupivacaine delivered by means of a transversus abdominis plane block has on pain control in women undergoing unilateral deep inferior epigastric perforator flap reconstruction. Institutional review board approval was granted for this prospective study. Patients were eligible if they were undergoing unilateral, delayed deep inferior epigastric perforator flap reconstruction. Patients were randomized to one of three groups: liposomal bupivacaine transversus abdominis plane block, or bupivacaine pain pump. Charts were reviewed for demographics, length of stay, and postoperative narcotic use. There were eight patients in the liposomal bupivacaine and bupivacaine transversus abdominis plane block groups and five patients in the pain pump group. A retrospective cohort of six patients who did not receive any intervention was included. Patients who received a liposomal bupivacaine transversus abdominis plane block used statistically significantly less intravenous and total postoperative narcotics in milligrams and milligrams per kilogram per day compared with all other cohorts. They were able to get out of bed at an earlier time point. Overall hospital costs were similar among the groups. This is the first study to investigate liposomal bupivacaine delivered as a transversus abdominis plane block in a prospective, randomized, blinded study in women undergoing unilateral, delayed, abdominally based autologous breast reconstruction. The authors were able to demonstrate a significant reduction in intravenous and total narcotic use when a liposomal bupivacaine transversus abdominis plane block was used. Future studies are needed to prospectively investigate the effect that liposomal bupivacaine would have on immediate and bilateral reconstructions.


Assuntos
Anestésicos Locais/administração & dosagem , Neoplasias da Mama/cirurgia , Bupivacaína/administração & dosagem , Mamoplastia/métodos , Dor Pós-Operatória/prevenção & controle , Retalho Perfurante , Músculos Abdominais/inervação , Anestésicos Locais/economia , Bupivacaína/análogos & derivados , Bupivacaína/economia , Custos de Medicamentos , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Lipossomos , Pessoa de Meia-Idade , Entorpecentes/administração & dosagem , Bloqueio Nervoso/métodos , Medição da Dor , Dor Pós-Operatória/economia , Cuidados Pós-Operatórios/métodos , Náusea e Vômito Pós-Operatórios/induzido quimicamente , Estudos Prospectivos
12.
J Vasc Surg ; 68(2): 384-391, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29526378

RESUMO

OBJECTIVE: Because of its minimally invasive nature, percutaneous femoral access for endovascular aneurysm repair (pEVAR) is currently undergoing rapid popularization. Compared with surgical cutdown for femoral access (cEVAR), it offers the advantage of faster recovery after surgery as well as a reduction in wound complications. Despite proposed advantages, the method is largely considered uneconomical because of its reliance on costly closure devices. METHODS: There were 50 patients undergoing EVAR who were enrolled in this randomized prospective single-center trial. Each patient randomly received percutaneous access in one groin and surgical access in the other. The primary end points were access duration and cost. Secondary end points were wound complications and the postoperative pain levels. RESULTS: Surgery was performed per protocol in 44 patients. Mean access times for pEVAR and cEVAR were 11.5 ± 3.4 minutes and 24.8 ± 12.1 minutes (P < .001), respectively. Total access costs were €559.65 ± €112.69 for pEVAR and €674.85 ± €289.55 for cEVAR (P = .016). Eight complications in six patients were attributed to cutdown, none to pEVAR (P = .02). The percutaneously accessed groin was significantly less painful at day 1 and day 5 after surgery (P < .001). An intention-to-treat analysis (N = 50 patients) included six cases of pEVAR conversion due to technical failure in three patients (6%) and change of the operative strategy in another three patients (eg, aortouni-iliac stent graft followed by crossover bypass). The intention-to-treat analysis showed shorter mean overall access time for pEVAR (pEVAR, 14.65 ± 10.20 minutes; cEVAR, 25.12 ± 11.77 minutes; P < .001) and no cost difference between the two methods (pEVAR, €651.29 ± €313.49; cEVAR, €625.53 ± €238.29; P = .65). CONCLUSIONS: Our data confirm proposed potential benefits attributable to the minimally invasive nature of pEVAR while demonstrating cost-effectiveness despite the additional cost of closure devices. Taking into account pEVAR failures still does not increase pEVAR costs over cEVAR. Further considering reduced postoperative pain and wound complications, the technique deserves consideration in suitable patients.


Assuntos
Aneurisma/economia , Aneurisma/cirurgia , Implante de Prótese Vascular/economia , Cateterismo Periférico/economia , Procedimentos Endovasculares/economia , Artéria Femoral/cirurgia , Custos Hospitalares , Idoso , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico por imagem , Áustria , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Redução de Custos , Análise Custo-Benefício , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Artéria Femoral/diagnóstico por imagem , Hematoma/economia , Hematoma/etiologia , Hematoma/terapia , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Hemorragia Pós-Operatória/economia , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Estudos Prospectivos , Punções , Instrumentos Cirúrgicos/economia , Fatores de Tempo , Resultado do Tratamento , Cicatrização
14.
Anesth Analg ; 127(5): 1221-1228, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29596101

RESUMO

BACKGROUND: Having entered the US market relatively recently, the perioperative role of intravenous acetaminophen (ivAPAP) remains to be established for several surgeries. Using national data, we therefore assessed current utilization and whether it reduces inpatient opioid prescription and opioid-related side effects in a procedure with relatively high opioid utilization. METHODS: Patients undergoing a lumbar/lumbosacral spinal fusion (n = 117,269; 2011-2014) were retrospectively identified in a nationwide database and categorized by the amount and timing of ivAPAP administration (1 or >1 dose on postoperative day [POD] 0, 1, or 1+). Multivariable models measured associations between ivAPAP utilization categories and opioid prescription and perioperative complications; odds ratios (or % change) and 95% confidence intervals are reported. RESULTS: Overall, ivAPAP was used in 18.9% (n = 22,208) of cases of which 1 dose on POD 0 was the most common (73.6%; n = 16,335). After covariate adjustment, use of ivAPAP on POD 0 and 1 was associated with minimal changes in opioid prescription, length and cost of hospitalization particularly favoring >1 ivAPAP dose with a modestly (-5.2%, confidence interval, -7.2% to -3.1%; P < .0001) decreased length of stay. Use of ivAPAP did not coincide with a consistent pattern of significantly reduced odds for complications. In comparison, the most commonly used nonopioid analgesic, pregabalin/gabapentin, did demonstrate reduced opioid prescription combined with lower complication risk. CONCLUSIONS: We could not show that perioperative ivAPAP reduces inpatient opioid prescription with subsequent reduced odds for adverse outcomes. It remains to be determined if and under what circumstances ivAPAP has a meaningful clinical role in everyday practice.


Assuntos
Acetaminofen/administração & dosagem , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/efeitos adversos , Pacientes Internados , Vértebras Lombares/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Sacro/cirurgia , Fusão Vertebral/efeitos adversos , Acetaminofen/efeitos adversos , Acetaminofen/economia , Administração Intravenosa , Idoso , Analgésicos não Entorpecentes/efeitos adversos , Analgésicos não Entorpecentes/economia , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/economia , Análise Custo-Benefício , Bases de Dados Factuais , Custos de Medicamentos , Feminino , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Fusão Vertebral/economia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
Trials ; 19(1): 132, 2018 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-29467019

RESUMO

BACKGROUND: Approximately 20% of patients experience chronic pain after total knee replacement. There is little evidence for effective interventions for the management of this pain, and current healthcare provision is patchy and inconsistent. Given the complexity of this condition, multimodal and individualised interventions matched to pain characteristics are needed. We have undertaken a comprehensive programme of work to develop a care pathway for patients with chronic pain after total knee replacement. This protocol describes the design of a randomised controlled trial to evaluate the clinical- and cost-effectiveness of a complex intervention care pathway compared with usual care. METHODS: This is a pragmatic two-armed, open, multi-centred randomised controlled trial conducted within secondary care in the UK. Patients will be screened at 2 months after total knee replacement and 381 patients with chronic pain at 3 months postoperatively will be recruited. Recruitment processes will be optimised through qualitative research during a 6-month internal pilot phase. Patients are randomised using a 2:1 intervention:control allocation ratio. All participants receive usual care as provided by their hospital. The intervention comprises an assessment clinic appointment at 3 months postoperatively with an Extended Scope Practitioner and up to six telephone follow-up calls over 12 months. In the assessment clinic, a standardised protocol is followed to identify potential underlying causes for the chronic pain and enable appropriate onward referrals to existing services for targeted and individualised treatment. Outcomes are assessed by questionnaires at 6 and 12 months after randomisation. The co-primary outcomes are pain severity and pain interference assessed using the Brief Pain Inventory at 12 months after randomisation. Secondary outcomes relate to resource use, function, neuropathic pain, mental well-being, use of pain medications, satisfaction with pain relief, pain frequency, capability, health-related quality of life and bodily pain. After trial completion, up to 30 patients in the intervention group will be interviewed about their experiences of the care pathway. DISCUSSION: If shown to be clinically and cost-effective, this care pathway intervention could improve the management of chronic pain after total knee replacement. TRIAL REGISTRATION: ISRCTN registry ( ISRCTN92545361 ), prospectively registered on 30 August 2016.


Assuntos
Artroplastia do Joelho/efeitos adversos , Dor Crônica/terapia , Procedimentos Clínicos , Manejo da Dor , Dor Pós-Operatória/terapia , Artroplastia do Joelho/economia , Dor Crônica/diagnóstico , Dor Crônica/economia , Dor Crônica/etiologia , Análise Custo-Benefício , Procedimentos Clínicos/economia , Custos de Cuidados de Saúde , Humanos , Estudos Multicêntricos como Assunto , Manejo da Dor/economia , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Projetos Piloto , Ensaios Clínicos Pragmáticos como Assunto , Atenção Secundária à Saúde , Fatores de Tempo , Resultado do Tratamento , Reino Unido
16.
Bone Joint J ; 100-B(1 Supple A): 55-61, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29292341

RESUMO

AIMS: The aim of this study was to determine the optimal regimen for the management of pain following total knee arthroplasty (TKA) by comparing the outcomes and cost-effectiveness of different protocols implemented at a large, urban, academic medical centre. PATIENTS AND METHODS: Between September 2013 and September 2015, we used a series of modifications to our standard regimen for the management of pain after TKA. In May 2014, there was a department-wide transition from protocols focused on femoral nerve blocks (FNB) to periarticular injections of liposomal bupivacaine. In February 2015, patient-controlled analgesia (PCA) was removed from the protocol while continuing liposomal bupivacaine injections. Quality measures and hospital costs were compared between the three protocols. RESULTS: The cohort being treated with PCA-less liposomal bupivacaine injections had a significantly higher percentage of patients who were discharged to their home (p = 0.010) and a significantly shorter length of stay (p < 0.001). Patient-reported Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores relating to pain being "well-controlled" and "overall pain management" also favoured this cohort (p = 0.214 and p = 0.463, respectively), in which cost was significantly lower compared with the other two cohorts (p = 0.005). CONCLUSION: The replacement of FNBs injections and the removal of PCAs, both of which are known to be associated with high rates of adverse outcomes, and the addition of liposomal bupivacaine periarticular injections to a multimodal pain regimen, led to improvements in many quality measures, HCAHPS pain scores, and cost-effectiveness. Cite this article: Bone Joint J 2018;100-B(1 Supple A):55-61.


Assuntos
Artroplastia do Joelho , Análise Custo-Benefício , Custos Hospitalares/estatística & dados numéricos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/normas , Idoso , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Manejo da Dor/efeitos adversos , Manejo da Dor/economia , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Satisfação do Paciente/economia , Satisfação do Paciente/estatística & dados numéricos , Melhoria de Qualidade/economia , Melhoria de Qualidade/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/economia , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
17.
Trials ; 19(1): 65, 2018 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-29368636

RESUMO

BACKGROUND: Although pain after back surgery is known to be difficult to control, various treatment options are available to patients and physicians. A protocol for a confirmatory randomized controlled trial (RCT) on pain and function after back surgery was designed based on the results of a pilot trial. The aim of this study is to compare the effectiveness and safety of electroacupuncture (EA) with usual care (UC) versus UC alone on pain control and functional improvement after back surgery. METHODS/DESIGN: This study is a multi-center, randomized, assessor-blinded trial with an active control conducted in conjunction with a cost-effectiveness analysis and qualitative research. Participants with non-acute low back pain with or without leg pain after back surgery who have a Visual Analogue Scale (VAS) pain intensity score ≥ 50 mm will be randomly assigned to either the EA with UC group (n = 54) or the UC group (n = 54). Following randomization, participants in both groups will receive the same UC treatment twice a week for a four-week treatment period. Participants assigned to the EA with UC group will additionally receive EA twice a week for the same four-week period. The primary outcome measure will be assessed using a VAS pain intensity score for low back pain. The secondary outcomes will include the Oswestry Disability Index, EuroQol 5-Dimension score, and drug intake. The primary and secondary outcomes will be measured at one, four, and eight weeks post randomization. DISCUSSION: The results of this study will provide evidence of the effectiveness and cost-effectiveness of EA in managing postoperative pain following back surgery. In addition, the qualitative research results will help improve the quality of integrative medical interventions. TRIAL REGISTRATION: Clinical Research Information Service (CRIS), Republic of Korea, KCT0001939 . Registered on 8 June 2016.


Assuntos
Eletroacupuntura , Dor Lombar/terapia , Dor Pós-Operatória/terapia , Adulto , Idoso , Análise Custo-Benefício , Avaliação da Deficiência , Eletroacupuntura/efeitos adversos , Eletroacupuntura/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Dor Lombar/diagnóstico , Dor Lombar/economia , Dor Lombar/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Pesquisa Qualitativa , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , República da Coreia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
18.
World Neurosurg ; 110: e599-e604, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29175573

RESUMO

INTRODUCTION: In Chiari I patients, postoperative pain and discomfort frequently slow the transition back to the home setting. OBJECTIVE: We sought to determine the effect of standardized ketamine infusion protocols on hospital length of stay (LOS). METHODS: This retrospective cohort study reviewed 100 consecutive adult patients undergoing Chiari I decompression. Fifty-nine patients were placed on a 2-3 mg/hr ketamine drip until postoperative day 1. This group was compared with a group who received 2-3 mg/hr of ketamine until postoperative day 2 (19 patients) and patients who did not receive ketamine at all (22 patients). Clinical characteristics, opioid use, LOS, and relative hospitalization costs were assessed. All narcotic amounts were converted into milligram equivalents of morphine. RESULTS: LOS of the short-ketamine group was 46.5 hours when compared with the long-ketamine group (66.8 hours) and no-ketamine group (56.9 hours). There was a statistically significant difference when comparing the short-ketamine group with the long-ketamine group and no-ketamine group together (P < 0.001), as well as when compared individually (P = 0.001 and 0.004). The mean cost of hospitalization was 20% less when a short-ketamine protocol was used (P < 0.001). Mean morphine milligram equivalents used postoperatively were 148 mg in the short-ketamine group, 196 mg in the long-ketamine group, and 187 mg in the no-ketamine group (P = 0.65). No adverse events from ketamine were noted. CONCLUSIONS: Ketamine at subanesthetic levels may be an effective tool to facilitate early return home postoperatively and may significantly reduce medical costs.


Assuntos
Analgésicos/administração & dosagem , Malformação de Arnold-Chiari/cirurgia , Análise Custo-Benefício , Ketamina/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Adulto , Analgésicos/economia , Malformação de Arnold-Chiari/economia , Protocolos Clínicos , Feminino , Custos de Cuidados de Saúde , Humanos , Ketamina/economia , Tempo de Internação/economia , Masculino , Dor Pós-Operatória/economia , Melhoria de Qualidade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
19.
Surgery ; 163(4): 661-666, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29133112

RESUMO

BACKGROUND: Although, 33% to 40% of symptomatic gallstone patients reported persistent abdominal pain after laparoscopic cholecystectomy, there is no data on the burden of this pain to the healthcare system and society at large. This study determined healthcare consumption, sick leave, and costs in patients with persistent abdominal pain after laparoscopic cholecystectomy. Secondly, predictive factors for healthcare consumption were assessed. METHODS: This cross-sectional study included all 146 patients with persistent abdominal pain (patient-reported on Gastro-Intestinal Quality of Life Index (score 0-3) 24 weeks after laparoscopic cholecystectomy, derived from a previous prospective cohort. Healthcare consumption was assessed using Medical Consumption Questionnaire and medical records, and sick leave using Productivity Cost Questionnaire. Costs were calculated according "Guideline for performing economic evaluations in healthcare." Predictors of healthcare consumption were assessed using logistic regression analysis. RESULTS: In the study, 124/146 patients (85%) responded after mean follow-up of 31.0 months (standard deviation 6.5); 104 were female, mean age of responders was 52 years. Sixty-nine patients needed additional healthcare; 30.6% primary care; 37.1% secondary care; 16% emergency department admission; 8.9% hospital admission; 33.9% diagnostic procedures; 17.7% medication; 5.6% other interventions. Medical costs were $555 (BCa 95% confidence interval, $329-$852) and costs of sick leave were $361 (Bias-corrected and accelerated (BCa) 95% confidence interval, $189-$566) per year per patient. Younger age (odds ratio 0.95, 95% confidence interval, 0.92-0.98) and higher postoperative pain score (odds ratio 1.02, 95% confidence interval, 1.01-1.04) were associated with increased healthcare consumption. CONCLUSION: Persistent abdominal pain after laparoscopic cholecystectomy is associated with additional healthcare in 56% of patients. Yearly, medical costs and costs of sick leave are 20% of the initial costs of laparoscopic cholecystectomy.


Assuntos
Dor Abdominal/economia , Colecistectomia Laparoscópica/efeitos adversos , Assistência à Saúde/estatística & dados numéricos , Custos de Cuidados de Saúde , Dor Pós-Operatória/economia , Licença Médica , Dor Abdominal/etiologia , Adulto , Idoso , Estudos Transversais , Assistência à Saúde/economia , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia
20.
Plast Reconstr Surg ; 140(6S Prepectoral Breast Reconstruction): 49S-52S, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29166348

RESUMO

The world of breast reconstruction over the last several years has seen a dramatic shift in focus to discussion and the application of placing tissue expanders and implants back into the prepectoral space. Although this technique failed during the early advent of breast reconstruction, newer technologies such as advances in fat grafting, improved acellular dermal matrices, better methods of assessing breast flap viability, and enhanced implants appear to have set the stage for the resurgence and positive early results seen with this technique. The main benefits of a switch to prepectoral breast reconstruction clinically appears to be less associated pain, lower incidence of animation deformities, and its associated symptoms as well as presumably better aesthetics. Early data suggest that the results are extremely promising and early adopters have attempted to define the ideal patients for prepectoral breast reconstruction. As with any new operative procedure, an assessment of finances and costs are crucial to its successful implementation. Although current data are minimal, this article attempts to build the fundamentals of an economic model that exhibits and displays potential savings through the use of prepectoral breast reconstruction.


Assuntos
Neoplasias da Mama/economia , Mamoplastia/economia , Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Neoplasias da Mama/reabilitação , Neoplasias da Mama/cirurgia , Contratura/prevenção & controle , Estética , Feminino , Humanos , Tempo de Internação/economia , Mamoplastia/métodos , Mamoplastia/reabilitação , Duração da Cirurgia , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Satisfação do Paciente , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Amplitude de Movimento Articular/fisiologia , Reoperação , Retorno ao Trabalho , Expansão de Tecido/economia , Expansão de Tecido/estatística & dados numéricos
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