Early In-Hospital Pain Control Is a Stronger Predictor for Patients Requiring a Refill of Narcotic Pain Medication Compared to the Amount of Narcotics Given at Discharge.

BACKGROUND: The United States is combating an opioid epidemic. Orthopedic surgeons are the third highest opioid prescribers and therefore have an opportunity and obligation to assist in the efforts to reduce opioid use and abuse. In this article, we evaluate risk factors for patients requiring an opioid refill after primary total knee arthroplasty, with the goal to reduce opioid prescriptions for those patients at low risk of requiring a refill in order to reduce the amount of unused medication. METHODS: We retrospectively reviewed narcotic-naïve patients who underwent total knee arthroplasty from December 2017 to May 2018. We performed multivariable analysis on demographics and preoperative, operative, and postoperative characteristics to determine risk factors for requiring a prescription refill following hospital discharge. RESULTS: One-hundred fifty-seven patients were included in the analysis. Sixty percent of patients required a prescription refill. Risk factors included younger age (P = .003) and increased pain on postoperative day one (P < .001). The amount of narcotic medication given at discharge did not independently affect the refill rate (P = .21). CONCLUSION: There is strong evidence that elderly patients and those with good pain control on postoperative day 1 are at a lower risk of requiring a narcotic refill postoperatively. With this information, physicians may begin to tailor narcotic prescriptions based on patient risk factors for requiring a prescription refill rather than provide patients with the same number of pills for a given surgery in an effort to reduce unused narcotic medication.

Outcomes of Endolymphatic Sac Surgery for Meniere's Disease with and without Comorbid Migraine.

PURPOSE: To explore outcomes of endolymphatic sac surgery for patients with Meniere's disease with and without the comorbid condition of migraine. MATERIALS AND METHODS: A retrospective chart review of adult patients undergoing endolymphatic sac surgery at a single tertiary care center from 1987 to 2019 was performed. All adult patients who failed medical therapy and underwent primary endolymphatic sac surgery were included. The main outcome measures were vertigo control and functional level scale (FLS) score. Patient characteristics, comorbidities, and audiometric outcomes were tracked as well. RESULTS: Patients with Meniere's disease and migraine had a stronger association with psychiatric comorbidities (64.29% vs. 25.80%, p=0.01), shorter duration of vertigo episodes (143 vs. 393 min, p=0.02), and younger age (36.6 vs. 50.8 yr, p=0.005) at the time of endolymphatic sac surgery. Postoperative pure tone averages and word recognition scores were nearly identical to preoperative baselines. Class A vertigo control (47.92%) was most common, followed by class B vertigo control (31.25%). The FLS score improved from 4.2 to 2.8 (p < 0.001). Both patients with and without migraine had classes A-B vertigo control (66.67% vs. 80.95%) without any statistically significant difference (p=0.59). Of the patients who required secondary treatment (10.42%), none had migraine. CONCLUSIONS: Endolymphatic sac surgery is an effective surgical intervention for Meniere's disease with and without migraine. Patients with comorbid migraine tend to be younger and present with psychiatric comorbidities.

Complex Pancreaticobiliary Maljunction with Pancreas Divisum and Obstructive Pseudocyst.

Pancreaticobiliary maljunction (PBM) is the congenital junction of the bile and pancreatic ducts into a common channel located anatomically outside of the duodenal wall. The complex type (Type D) is the rarest type and occurs in conjunction with other pancreaticobiliary anomalies. We present a case of complex PBM with pancreas divisum presenting as acute pancreatitis and obstructive symptoms secondary to a pancreatic pseudocyst. Surgical management is discussed, as complex type PBM is most predisposed to post-operative complications.

Lateral cervical abscesses: NSQIP-P perspective on length of stay, readmission, and reoperation.

OBJECTIVES: Identify risk factors and determine perioperative sequelae of children undergoing lateral cervical abscess incision and drainage. METHODS: Pediatric patients who underwent lateral cervical abscess incision and drainage aged 1-18 years were retrospectively queried via ACS-NSQIP-P (2012-2016) utilizing CPT code 21501. Analyzed outcomes include age, time to surgery, operative time, total length of stay, readmission, and reoperation. RESULTS: A total of 1917 children were identified, with a mean age at time of surgery of 4.05 years (95% CI 3.86-4.25). The mean number of days from hospital admission to operative intervention was 1.24 days (95% CI 1.16-1.31), with a mean total length of stay of 3.64 days (95% CI 3.46-3.82). The mean number of days from hospital admission to surgery was significantly lengthened in younger children (P = .0001) and pediatric patients of non-Caucasian origin (P < 0.001). Children with positive septic parameters not only had a prolonged time to surgery but also a significantly prolonged total length of stay (P < 0.001). Finally, a persistent requirement for postoperative mechanical ventilation and prolonged operative time (P = 0.003) was found to be related to reoperation. CONCLUSION: Younger children are more likely to have delays from hospital admission to definitive surgical intervention, but this does not appear to affect total length of stay. Recognition of pertinent clinical factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in the pediatric subpopulation.

Morbidity and mortality in children undergoing bronchoscopy for foreign body removal.

OBJECTIVES/HYPOTHESIS: Analyze morbidity and mortality among children undergoing bronchoscopy for foreign body removal. STUDY DESIGN: Multicenter retrospective review using the American College of Surgeons Pediatric National Surgical Quality Improvement Program from 2014 and 2015. METHODS: Patients were identified using Current Procedural Terminology code 31635. Demographics, time to surgery, operative times, hospitalization time, and complications were collected. Multivariate logistic regression was used to identify predictive factors for major adverse events. RESULTS: Three hundred thirty-four patients were included (mean age 3.7 years, 59.0% male). Preoperative sepsis syndrome was present in 5.7% of patients and 8.1% had asthma. Of the patients, 5.1% percent of patients had a tracheostomy. Bronchoscopy was performed by an otolaryngologist (65.4%) or a pediatric surgeon (33.1%). Mean operative time was 27.4 minutes, whereas mean total operating room time was 54.6 minutes. Airway foreign bodies were located in 269 patients (80.5%), with 62.5% being located in the mainstem bronchus. Operative time was longer when foreign bodies were in the mainstem bronchus or distal to it. Mean time to surgery from admission was 0 days, and mean duration of hospitalization was 1 day. One patient (0.3%) required reoperation for respiratory reasons, and three (0.9%) required readmission for related reasons. No patients remained hospitalized at 30 days. Two (0.6%) had a postoperative pneumonia, and two (0.6%) required reintubation. One patient death (0.3%) occurred within 2 weeks of bronchoscopy. No significant differences were identified in operative time, time to surgery, or hospitalization time based on age, gender, presence of a tracheostomy, or surgical specialty. CONCLUSIONS: Bronchoscopy for identification and removal of airway foreign bodies had minimal morbidity in this group. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:1226-1229, 2018.

Infants Are More Likely Than Older Children to Have Surgery for Cervical Infections.

OBJECTIVES: To identify differences in cervical infection management in infants versus older children. METHODS: Charts of patients 0-18 years, diagnosed with a cervical infection at our institution between 2004 and 2015, were included. Age, gender, presenting symptoms, comorbidities, CT scan findings and management including admission, procedures, antibiotics, cultures, length of stay, readmission rates, and complications were included. RESULTS: 239 patients were included: mean age was 4.6 years, with 55.6% boys and 44.4% girls. Mean length of stay was 3.2 days, with no significant difference between age categories. 12.55% were readmitted within 30 days with no significant difference when stratified for age (p = 0.268). The most common presenting symptoms were fever (74.3%), swelling (71.4%), and neck pain (48.2%). Infants had fewer symptoms documented than older children. 51% has lateral neck infections, and these were more common in younger children (p < 0.001). The most common antibiotic used was amoxicillin-clavulanic acid in 53.96% of inpatients and 48.05% of outpatients. Infants were most likely to have MRSA isolates (29.2% versus 11.7% of older children, p = 0.011). 70.0% went to the operating room for incision and drainage procedures. Younger children were more likely to undergo surgery, with an odds ratio of 2.38 for children under 1 year. (p = 0.029). 90.9% of infants underwent surgery with radiolucencies of at least 1 cm diameter in contrast to 50% of children over 8 years old. CONCLUSIONS: This study emphasizes the importance of considering early operative treatment of cervical abscesses in infants despite fewer symptoms and smaller radiolucencies on CT.

Randomized Prospective Evaluation of Intraoperative Intravenous Acetaminophen in Pediatric Adenotonsillectomy.

Objective To establish the safety and efficacy of single-dose intraoperative intravenous (IV) acetaminophen in postoperative pain management following adenotonsillectomy in addition to a standardized regimen of oral pain medication. Study Design Randomized, controlled prospective clinical trial. Setting Single academic medical center. Subjects and Methods Patients between the ages of 3 and 17 years scheduled for tonsillectomy or adenotonsillectomy by a single surgeon between December 2014 and November 2016 were recruited. Patients were randomly assigned to 1 of 2 groups; group 1 received a single intraoperative dose of IV acetaminophen, and group 2 did not. Induction and maintenance of anesthesia, as well as operative technique, were standardized. Nursing pain scores, pain medications administered, and recovery times were reviewed during the 24-hour postoperative period. Postoperative pain regimen included standing alternating oral acetaminophen and ibuprofen. Results In total, 260 patients were included in the study, and 131 (50.4%) received a single intraoperative dose of IV acetaminophen. Patients receiving IV acetaminophen were more likely to experience postoperative nausea and vomiting than patients who did not receive IV acetaminophen (1.53% vs 0.00%, P = .016). There were no significant differences noted for postoperative pain scores, requirements for breakthrough pain medications, time to discharge from the recovery room or hospital, or postoperative complications. Conclusion The use of a single intraoperative dose of IV acetaminophen was associated with minimal additional adverse effects. However, a single intraoperative IV dose of acetaminophen added to standard narcotic and nonnarcotic pain medication does not provide a statistically significant improvement in pain control.