Catheter Tip-Associated Mass With Continuous Infusion of Sufentanil for Persistent Spinal Pain Syndrome Type 2: A Case Report Including Histopathologic Examination and Review of the Associated Basic and Clinical Research.

OBJECTIVES: Intrathecal opioids delivered by implanted pumps are used to treat malignant or nonmalignant chronic pain. In this study, we 1) review a case in which intrathecal infusions of sufentanil along with other adjuvants were used and after an extended period led to an intrathecal mass and 2) compared and contrasted the potential mechanisms for these phenomena. MATERIALS AND METHODS: A woman aged 66 years with a history of scoliosis and multiple spine surgeries was treated with an implantable drug delivery system for treating persistent pain after laminectomy. The patient received intrathecal medication comprising sufentanil, bupivacaine, and clonidine. RESULTS: Intrathecal therapy over approximately ten years served to reduce pain and improve function over the treatment period. After the extended treatment interval, the patient developed an intrathecal mass that was associated with impairment. The mass was surgically removed. Systematic histopathology revealed the space-occupying mass to largely comprise fibroblasts and some inflammatory cells embedded in a collagen mass located proximally to the catheter tip. CONCLUSIONS: To our knowledge, this is the first published case report of sufentanil causing this complication. The science and mechanism of intrathecal catheter tip-associated mass formation and associated clinical research correlates are reviewed in detail, and explanations for this phenomenon are proposed based on histochemical analysis of the patient's pathology findings.

Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and Persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States: A Large Retrospective Cohort Study of Administrative Claims Data.

OBJECTIVE: Between 17% and 40% of patients undergoing elective arthroplasty are preoperative opioid users. This US study analyzed patients in this population to illustrate the relationship between preoperative opioid use and adverse surgical outcomes. DESIGN: Retrospective study of administrative medical and pharmaceutical claims data. SUBJECTS: Adults (aged 18+) who received elective total knee, hip, or shoulder replacement in 2014-2015. METHODS: A patient was a preoperative opioid user if opioid prescription fills occurred in two periods: 1-30 and 31-90 days presurgery. Zero-truncated Poisson (incidence rate ratio [IRR]), logistic (odds ratio [OR]), Cox (hazard ratio [HR]), and quantile regressions modeled the effects of preoperative opioid use and opioid dose, adjusted for demographics, comorbidities, and utilization. RESULTS: Among 34,792 patients (38% hip, 58% knee, 4% shoulder), 6,043 (17.4%) were preoperative opioid users with a median morphine equivalent daily dose of 32 mg. Preoperative opioid users had increased length of stay (IRR = 1.03, 95% CI = 1.02 to 1.05), nonhome discharge (OR = 1.10, 95% CI = 1.00 to 1.21), and 30-day unplanned readmission (OR = 1.43, 95% CI = 1.17 to 1.74); experienced 35% higher surgical site infection (HR = 1.35, 95% CI = 1.14 to 1.59) and 44% higher surgical revision (HR = 1.44, 95% CI = 1.21 to 1.71); had a median $1,084 (95% CI = $833 to $1334) increase in medical spend during the 365 days after discharge; and had a 64% lower rate of opioid cessation (HR = 0.34, 95% CI = 0.33 to 0.35) compared with patients not filling two or more prescriptions across periods. CONCLUSIONS: Preoperative opioid users had longer length of stay, increased revision rates, higher spend, and persistent opioid use, which worsened with dose. Adverse outcomes after elective joint replacement may be reduced if preoperative opioid risk is managed through increased monitoring or opioid cessation.

Perioperative Outcomes after Regional Versus General Anesthesia for Above the Knee Amputations.

BACKGROUND: Nontraumatic lower extremity amputation (LEA) remains a common procedure among patients who frequently have significant comorbidities. Patients undergoing above knee amputation (AKA) have the highest rates of mortality in this cohort, yet there is little evidence to support selection between peripheral nerve block or neuraxial regional anesthesia (RA) versus general anesthesia (GA) techniques. The objective of this study was to determine whether RA (neuraxial or peripheral nerve block) techniques were associated with more favorable outcomes versus general anesthesia among patients undergoing AKA. METHODS: This is a retrospective cohort study using propensity-matched groups. Patients undergoing AKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data set and grouped according to anesthetic type as either RA or GA. Patients undergoing AKA with RA were propensity matched to similar patients who had GA. Primary outcome was 30-day mortality. Secondary outcomes were numerous and included cardiac, pulmonary, infectious, and bleeding complications, as well as length of stay. Among a subset of patients for whom readmission data were available, rate of readmission was compared as a secondary outcome. RESULTS: Nine thousand nine hundred ninety-nine patients were identified in the ACS-NSQIP database. One thousand three hundred twelve received a regional anesthetic, and the remainder had a general anesthetic. Factors significantly associated with GA included younger age (70 vs. 75 years; P < 0.001), higher body mass index (26.5 vs. 25.4; P < 0.001), and ethnically white (62.4% vs. 57%; P < 0.001). Before matching, patients receiving RA were less likely to be smokers (22% vs. 29%; P < 0.001), have a bleeding disorder (15% vs 30%; P < 0.001), or have a diagnosis of sepsis (26% vs 34%; P < 0.001). Propensity score matching produced a cohort composed of 1,916 patients equally divided between RA and GA. We found no difference with respect to the primary end point of 30-day mortality (11.7% vs 11.7%; odds ratio [OR] 1.01; P = 0.943) nor was there any difference with respect to secondary outcomes. Among patients for whom readmission data were available, there was no statistically significant difference between rates of readmission between the groups (15.6% for RA vs. 12.7% for GA; OR 1.26, confidence interval 0.87-1.828, P = 0.221). CONCLUSIONS: The present investigation did not detect any difference between regional and general anesthetic with respect to morbidity or mortality among patients undergoing AKA. This data set did not allow us to address other relevant markers including pain control or phantom limb syndrome.

Encounter Preparedness, Satisfaction, and Performance Effects of Influence in Assertive Community Treatment (ACT) Teams.

Assertive community treatment (ACT) teams are linked to high quality outcomes for individuals with severe mental illness. This paper tests arguments that influence shared between team members is associated with better encounter preparedness, higher work satisfaction, and improved performance in ACT teams. Influence is conceptualized in three ways: the average level according to team members, the team's evaluation of the dispersion of team member influence, and as the person-organization fit of individual perception of empowerment. The study design is a retrospective observational design using survey data from a longitudinal study of 26 ACT teams (approximately 275 team members total) over 18 months. This study finds that average team influence and person-organization fit are positively correlated with encounter preparedness and satisfaction. Dispersion of influence was not significantly correlated with study outcomes. Influence in ACT teams has multiple dimensions, each with differential effects on team outcomes. These findings provide guidance as to how one might encourage equal and substantive contribution from ACT team members.

Neurogenic Lower Urinary Tract Dysfunction in Adults with Cerebral Palsy: Outcomes following a Conservative Management Approach.

PURPOSE: Cerebral palsy is characterized by motor impairment following injury to the developing brain. Neurogenic lower urinary tract dysfunction is estimated to affect at least a third of children with cerebral palsy. However there are limited data as patients transition to adulthood. We sought to describe the symptoms, sequelae and management of neurogenic lower urinary tract dysfunction in adults with cerebral palsy. MATERIALS AND METHODS: We retrospectively reviewed the charts of adult patients with cerebral palsy between 2011 and 2014. Patients with prior bladder reconstruction or catheterization based bladder drainage were excluded from study. Cerebral palsy severity was determined using GMFCS (Gross Motor Function Classification System). A conservative evaluation and treatment paradigm was used. Noninvasive treatments were encouraged. Specifically clean intermittent catheterization, which is often not feasible, is avoided unless urinary retention, hydronephrosis or refractory lower urinary tract symptoms develop. RESULTS: There were 121 patients included in final analysis. Median age was 25 and 61 patients (50%) had GMFCS level V. Noninvasive management failed in 28 of 121 patients (23%) as defined by hydronephrosis in 9, persistent urinary retention in 10 and refractory lower urinary tract symptoms/incontinence in 9. Urethral clean intermittent catheterization was poorly tolerated. Of all patients 25% showed evidence of urolithiasis during the study period. Surgical intervention was rare and associated with significant morbidity. CONCLUSIONS: Adults with cerebral palsy may present with variable signs and symptoms of neurogenic lower urinary tract dysfunction. Conservative treatment was successful in more than 75% of patients. Clean intermittent catheterization was poorly tolerated in patients in whom conservative treatment failed. Surgical intervention was rarely indicated and it should be reserved for select individuals.

Education and training for nonanesthesia providers performing deep sedation.

PURPOSE OF REVIEW: There has been a significant increase in the number and types of procedures performed outside of the operating room with nonanesthesia providers administering sedation. This review describes current recommendations for training nonanesthesiologists involved in administering deep sedation, summarizes best practices and highlights select patient outcomes. RECENT FINDINGS: There are numerous guidelines and standards related to the administration of deep sedation. However, there are no universally accepted guidelines regarding the necessary educational and skill competencies needed for nonanesthesiologists to provide deep sedation. The American Society of Anesthesiologists has published a position statement and guidelines on these educational requirements, yet the extent to which these are adhered to remains unknown. As evidence-based guidelines continue to evolve, more research is needed to describe how current practices affect patient outcomes. SUMMARY: The American Society of Anesthesiologists publishes recommendations regarding the essential educational components for nonanesthesiologist providers who administer deep sedation. The available data support the need for formal educational programmes to prevent adverse events associated with deep sedation. Competencies should include preprocedural evaluation, understanding sedation levels, airway management, documentation, emergency life support skills, teamwork and quality improvement.

Anesthetic management of a patient with left ventricular assist device undergoing robotic laparoscopic prostatectomy: a case report.

BACKGROUND: Patients with left ventricular assist devices (LVAD) require specific anesthetic and hemodynamic considerations. We report the specific anesthetic preparation and management in this scenario. CASE PRESENTATION: We present the case of a 66-year-old male with a HeartMate II LVAD undergoing robotic prostatectomy for prostate cancer in the steep Trendelenburg position. We employed central venous and radial arterial access, LVAD pump parameters, near-infrared sensor of cerebral oximetry, and transesophageal echocardiography for monitoring. Hemodynamics were managed with nicardipine, dobutamine, epinephrine, and phenylephrine during abdominal insufflation, operative positioning, and desufflation. The patient had a successful procedure, was discharged on postoperative day 2, and achieved surgical cure of his prostate cancer. DISCUSSION: By presenting the first detailed account of anesthetic management in this scenario, we provide a clinical vignette for use by the clinical anesthesiologist in his or her preparation prior to caring for this type of patient.

Common elements in opioid use disorder guidelines for buprenorphine prescribing.

OBJECTIVES: This study sought to formulate a consolidation of guidelines representing best practices related to office-based opioid treatment (OBOT) of opioid use disorder (OUD) using buprenorphine. It also demonstrates how a set of evidence-based guidelines may be linked with claims data to leverage analytic techniques that drive cost-effective, positive health outcomes. STUDY DESIGN: Literature review of US and international guidelines for OBOT using buprenorphine for OUD. METHODS: The study conducted a review of currently available US and several international guidelines from 2009 to 2018 published on OUD and the use of buprenorphine in OBOT. Guidelines were consolidated based on common elements. The process of correlating common elements with available commercial and state Medicaid claims data is described, including which elements are amenable to analysis along with relative complexity. RESULTS: Seven guidelines met inclusion criteria and are presented as 3 tables, organized by clinical themes and phase of care related to OBOT use of buprenorphine for OUD. Themes included establishing care, monitoring treatment stability and engagement, and nonpharmacologic treatment to improve outcomes. Areas of agreement and divergence between guidelines are highlighted. Specific components are identified as they relate to metrics of interest to public and private payers. CONCLUSIONS: Among US and international guidelines for treatment of OUD, common themes are readily identified and may indicate agreement in regard to interventions. Linking pharmacy and medical billing claims data to evidence-supported best practices provides public and private payers the ability to track individual patients, facilitate high-quality care, and monitor outcomes.

Tobacco exposure and wound healing in head and neck surgical wounds.

OBJECTIVE: Smoking impairs wound healing, yet the underlying pathophysiological mechanisms are unclear. We evaluated tobacco-altered healing in head and neck surgery by studying the association between biomarkers and tobacco exposure, as well as cutaneous perfusion by smoking status. STUDY DESIGN: Prospective cohort study, tertiary/academic care center, 2011 to present. METHODS: Patients who required head and neck surgery were enrolled prospectively. Postsurgical drain fluid was collected 24 hours postoperatively. Biomarkers associated with postulated mechanisms of smoking-impaired healing were assayed. These included interleukin-1, -6, and -8; tumor necrosis factor- alpha; transforming growth factor-beta; epidermal growth factor (EGF); basic fibroblastic growth factor (bFGF); C-reactive protein; vascular endothelial growth factor; soluble FMS-like tyrosine kinase-1 (sFLT-1); and placental growth factor. Tobacco exposure and clinical outcomes were recorded. Two sample two-sided t tests evaluated the differences in cytokine levels by tobacco exposure. In a second cohort, cutaneous vascular assessment via indocyanine green angiography was compared by smoking status. RESULTS: Twenty-eight patients were enrolled with drain fluid collection. Twenty-one subjects were current/former smokers, whereas seven were never smokers. EGF was higher in never smokers than smokers in a statistically significant manner (P = 0.030). Likewise, sFLT-1 was significantly higher in never smokers (P = 0.011). Cutaneous angiography revealed nonsmokers to have significantly higher cutaneous perfusion than smokers. CONCLUSION: In this head and neck surgical cohort, significantly higher EGF and sFLT-1 levels in wound fluid were associated with never smoking, suggesting that smoking has adverse effects on the inflammatory phase of wound healing. Cutaneous angiography supports the detrimental effect of smoking on skin perfusion. These findings suggest the need for further study as well as therapeutic targets for smokers undergoing surgery. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:618-625, 2018.

Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture.

AIM: To determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures. METHODS: We conducted a propensity score matched retrospective analysis using de-identified data from the American College of Surgeons' National Surgical Quality Improvement Project (ACS NSQIP) for all patients undergoing hip fracture surgery over a 7 year period in hospitals across the United States enrolled in the ACS NSQIP with and without DNR status. We measured patient demographics including DNR status, co-morbidities, frailty and functional baseline, surgical and anaesthetic procedure data, post-operative morbidity/complications, length of stay, discharge destination and mortality. RESULTS: Of 9218 patients meeting the inclusion criteria, 13.6% had a DNR status, 86.4% did not. Mortality was higher in the DNR compared to the non-DNR group, at 15.3% vs 8.1% and propensity score matched multivariable analysis demonstrated that DNR status was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, analysis of the propensity score matched cohort demonstrated that DNR status was associated with a significant, but very small increased likelihood of post-operative complications (0.53 vs 0.43 complications per episode; OR = 1.21; 95%CI: 1.04-1.41, P = 0.004). Cardiopulmonary resuscitation and unplanned reintubation were significantly less likely in patients with DNR status. CONCLUSION: While DNR status patients had higher rates of post-operative complications and mortality, DNR status itself was not otherwise associated with increased morbidity. DNR status appears to increase 30-d mortality via ceilings of care in keeping with a DNR status, including withholding reintubation and cardiopulmonary resuscitation.

Evaluation of the outcomes after posterior urethroplasty.

Posterior urethral injury is a clinically significant complication of pelvic fractures. The management is complicated by the associated organ injuries, distortion of the pelvic anatomy and the ensuing fibrosis that occurs with urethral injury. We report a review of the outcomes after posterior urethroplasty in the context of pelvic fracture urethral injury.