Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery

2020 ◽  
Vol 45 (6) ◽  
pp. 474-478
Author(s):  
Sarah S Joo ◽  
Oluwatobi O Hunter ◽  
Mallika Tamboli ◽  
Jody C Leng ◽  
T Kyle Harrison ◽  
...  
Keyword(s):  
Spine Surgery ◽  
Joint Replacement ◽  
Oral Morphine ◽  
Hospital Length ◽  
Opioid Consumption ◽  
Hospital Length Of Stay ◽  
Patient Specific ◽  
Opioid Dose ◽  
Before And After ◽  
Primary Spine

Background and objectivesAt our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.MethodsIn this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1 year before and after introduction of the protocol. This protocol used the patient’s prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.ResultsEighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420–1440) preintervention compared with 300 (112–806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.ConclusionsThis patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.

Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction?

2021 ◽  
Author(s):  
Min-Jeong Cho ◽  
Ricardo Garza ◽  
Sumeet S. Teotia ◽  
Nicholas T. Haddock
Keyword(s):  
Length Of Stay ◽  
Breast Reconstruction ◽  
Statistical Difference ◽  
Enhanced Recovery ◽  
Oral Morphine ◽  
Hospital Length ◽  
Opioid Consumption ◽  
Hospital Length Of Stay ◽  
Procedure Time ◽  
Eras Protocol

Abstract Background Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. Methods Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. Results A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. Conclusion Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.

Efficacy of Methocarbamol for Acute Pain Management in Young Adults With Traumatic Rib Fractures

2020 ◽  
pp. 106002802096479
Author(s):  
Lindsay P. Deloney ◽  
Melanie Smith Condeni ◽  
Cassandra Carter ◽  
Alicia Privette ◽  
Stuart Leon ◽  
...  
Keyword(s):  
Young Adults ◽  
Pain Control ◽  
Oral Morphine ◽  
Hospital Length ◽  
Rib Fractures ◽  
Hospital Length Of Stay ◽  
Control Regimen ◽  
Before And After ◽  
The Impact ◽  
Level 1 Trauma Center

Background: Rib fractures account for more than one-third of blunt thoracic injuries and are associated with serious complications. Use of nonopioid adjunctive agents such as methocarbamol for pain control has increased considerably. Objective: This study aimed to assess the impact of methocarbamol addition to the pain control regimen on daily opioid requirements for young adults with rib fractures. Methods: This observational, retrospective study included patients aged 18 to 39 years with 3 or more rib fractures who were admitted to a level 1 trauma center between July 2014 and July 2018. Patients were dichotomized based on admission before and after methocarbamol addition to the institutional rib fracture protocol. The primary outcome was to determine the impact of methocarbamol on daily opioid requirements. Secondary outcomes included hospital length of stay (LOS) and diagnosis of pneumonia. Results: A total of 50 patients were included, with 22 and 28 patients in the preprotocol and postprotocol groups, respectively. All patients in the latter group received methocarbamol, whereas no patient in the preprotocol group received methocarbamol. Cumulative opioid exposure was significantly less for patients admitted after methocarbamol addition to the protocol (219 vs 337 mg oral morphine equivalents; P = 0.01), and hospital LOS was also decreased (4 vs 3 days; P = 0.03). No significant differences in the incidence of pneumonia or adverse effects were observed. Conclusion and Relevance: This is the first study to evaluate the impact of methocarbamol on reducing opioid requirements. Given the risks associated with opioids, use of methocarbamol as an analgesia-optimizing, opioid-sparing multimodal agent may be reasonable.

Incidence and predictors of epilepsy in children with congenital heart disease

2021 ◽  
pp. 1-7
Author(s):  
Carlos Castillo-Pinto ◽  
Jessica L. Carpenter ◽  
Mary T. Donofrio ◽  
Anqing Zhang ◽  
Gil Wernovsky ◽  
...  
Keyword(s):  
Hospital Length ◽  
Left Ventricular ◽  
Hospital Length Of Stay ◽  
Patient Specific ◽  
Ventricular Assist ◽  
Acute Seizures ◽  
Increased Risk ◽  
Long Term Follow Up ◽  
Arterial Ischaemic Stroke

Abstract Objective: Children with CHD may be at increased risk for epilepsy. While the incidence of perioperative seizures after surgical repair of CHD has been well-described, the incidence of epilepsy is less well-defined. We aim to determine the incidence and predictors of epilepsy in patients with CHD. Methods: Retrospective cohort study of patients with CHD who underwent cardiopulmonary bypass at <2 years of age between January, 2012 and December, 2013 and had at least 2 years of follow-up. Clinical variables were extracted from a cardiac surgery database and hospital records. Seizures were defined as acute if they occurred within 7 days after an inciting event. Epilepsy was defined based on the International League Against Epilepsy criteria. Results: Two-hundred and twenty-one patients were identified, 157 of whom were included in our analysis. Five patients (3.2%) developed epilepsy. Acute seizures occurred in 12 (7.7%) patients, only one of whom developed epilepsy. Predictors of epilepsy included an earlier gestational age, a lower birth weight, a greater number of cardiac surgeries, a need for extracorporeal membrane oxygenation or a left ventricular assist device, arterial ischaemic stroke, and a longer hospital length of stay. Conclusions: Epilepsy in children with CHD is rare. The mechanism of epileptogenesis in these patients may be the result of a complex interaction of patient-specific factors, some of which may be present even before surgery. Larger long-term follow-up studies are needed to identify risk factors associated with epilepsy in these patients.

scholarly journals A Multidisciplinary Patient-Specific Opioid Prescribing and Tapering Protocol Is Associated with a Decrease in Total Opioid Dose Prescribed for Six Weeks After Total Hip Arthroplasty

Pain Medicine ◽  
2019 ◽  
Vol 21 (7) ◽  
pp. 1474-1481 ◽  
Author(s):  
Mallika Tamboli ◽  
Edward R Mariano ◽  
Kerianne E Gustafson ◽  
Beverly L Briones ◽  
Oluwatobi O Hunter ◽  
...  
Keyword(s):  
Total Hip Arthroplasty ◽  
Hip Arthroplasty ◽  
Opioid Consumption ◽  
Mean Difference ◽  
Patient Specific ◽  
Prescription Data ◽  
Opioid Dose ◽  
Total Hip ◽  
Institutional Review ◽  
Discharge Protocol

Abstract Objective This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed. Methods With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients’ prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications. Results Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th–90th percentiles) MME for six weeks postoperatively was 900 (57–2082) MME PRE vs 295 (69–741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127–1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th–90th percentiles) initial discharge prescription in MME was 675 (57–1035) PRE vs 180 (18–534) POST (mean difference = 387, 95% CI = 156–618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes. Conclusions Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.

scholarly journals Matched pilot study examining cannabis-based dronabinol for acute pain following traumatic injury

2020 ◽  
Vol 5 (1) ◽  
pp. e000391 ◽  
Author(s):  
Elisabeth Schneider-Smith ◽  
Kristin Salottolo ◽  
Claire Swartwood ◽  
Casey Melvin ◽  
Robert M Madayag ◽  
...  
Keyword(s):  
Acute Pain ◽  
Primary Outcome ◽  
Traumatic Injury ◽  
Hospital Length ◽  
Opioid Consumption ◽  
Hospital Length Of Stay ◽  
Level Of Evidence ◽  
Off Label ◽  
Admission Data ◽  
Sparing Effect

BackgroundTo determine whether adjunctive dronabinol, a licensed form of delta-9-tetrahydrocannabinol, reduces opioid consumption when used off-label for managing acute pain following traumatic injury.MethodsThis matched cohort study included patients who were admitted with a traumatic injury between 1 March 2017 and 30 October 2017. The hospital pharmacy database was used to identify patients who received dronabinol (cases), and they were matched 1:1 to patients who did not receive dronabinol (controls) using age, cause of injury and hospital length of stay. The primary outcome, change in opioid consumption, was calculated using morphine milligram equivalents (MME). The change in MME was calculated for cases as total MME over 48 hours with adjunctive dronabinol minus 48 hours prior to dronabinol, and for controls as total MME 48–96 hours from admission minus 0–48 hours from admission. Data are presented as mean and SE or median and IQR. Statistical analysis was performed using paired t-tests and McNemar’s tests.ResultsThere were 66 patients included: 33 cases and 33 matched controls. Dronabinol was initiated 55 (28–107) hours from admission. Cases and controls were well matched. Cases had a significant reduction in opioid consumption with adjunctive dronabinol (−79 (20) MME, p<0.001), while opioid consumption was unchanged for controls (−9 (20) MME, p=0.63). This resulted in a ninefold greater reduction in opioid consumption for cases versus controls that was statistically different between pairs (p=0.02). Nineteen (58%) cases reported using marijuana; in this subset, opioid consumption was reduced with adjunctive dronabinol (−97 (24) MME, p<0.001) versus a non-significant increase in opioid consumption in matched controls (11 (29) MME, p=0.70); difference between groups, p=0.01.ConclusionsThe results of this study suggest adjunctive dronabinol reduces opioid consumption following traumatic injury. The opioid-sparing effect of dronabinol may be greater in patients who are marijuana users.Level of evidenceIII.

scholarly journals Continuous Intra-articular Analgesic Injection Versus Continuous Adductor Canal Block in Postoperative Total Knee Arthroplasty

2020 ◽  
Vol 8 (5_suppl5) ◽  
pp. 2325967120S0006
Author(s):  
Kadchan Limtharapond ◽  
AVM Chumroonkiat Leelasestaporn
Keyword(s):  
Pain Scale ◽  
Hospital Length ◽  
Opioid Consumption ◽  
Hospital Length Of Stay ◽  
Adductor Canal Block ◽  
Adductor Canal ◽  
Ambulatory Ability ◽  
Significant Difference ◽  
A New Technique ◽  
6 Minute Walk Test

Continuous adductor canal block (CACB) provides effective analgesia after TKA but this technique requires skill of anesthesiologists and equipment such as ultrasonography. A new technique, continuous intra-articular analgesia injection (CIA) is developed recently and found good results. However, effectiveness of these two techniques after TKA is not established. Purposes: We determined whether, after TKA, patients with CIA versus patients with CACB demonstrated (1) decreased pain scores (2) greater ambulatory ability postoperatively (3) decreased daily opioid consumption and hospital length of stay Methods: Between October 2016 and October 2018, 50 patients underwent unilateral TKA at our practice site, whom 50% (n = 25) had CACBs and the others had CIAs. The results were collected in postoperative day (POD) 1,2 and 3. Results: The results were analyzed by SPSS V18 and used student T-test for measurement of mean visual analog pain scale, time up-and-go test, 6-minute walk test and daily total opioid consumption and knee society score. All results show no statistical significant difference between two groups. Conclusion: This study shows continuous intra-articular injection in postoperative TKA is as effective as continuous adductor canal block. It can be used as alternative in postoperative TKA.

Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients

Neurosurgery ◽  
2020 ◽  
Author(s):  
Nitin Agarwal ◽  
Ezequiel Goldschmidt ◽  
Tavis Taylor ◽  
Souvik Roy ◽  
Stefanie C Altieri Dunn ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Spine Surgery ◽  
Cohort Analysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Quality Improvement Initiative ◽  
Exact Test ◽  
Frail Patients ◽  
Increased Risk ◽  
Venous Thromboembolic

Abstract BACKGROUND With an aging population, elderly patients with multiple comorbidities are more frequently undergoing spine surgery and may be at increased risk for complications. Objective measurement of frailty may predict the incidence of postoperative adverse events. OBJECTIVE To investigate the associations between preoperative frailty and postoperative spine surgery outcomes including mortality, length of stay, readmission, surgical site infection, and venous thromboembolic disease. METHODS As part of a system-wide quality improvement initiative, frailty assessment was added to the routine assessment of patients considering spine surgery beginning in July 2016. Frailty was assessed with the Risk Analysis Index (RAI), and patients were categorized as nonfrail (RAI 0-29) or prefrail/frail (RAI ≥ 30). Comparisons between nonfrail and prefrail/frail patients were analyzed using Fisher's exact test for categorical data or by Wilcoxon rank sum tests for continuous data. RESULTS From August 2016 through September 2018, 668 patients (age of 59.5 ± 13.3 yr) had a preoperative RAI score recorded and underwent scheduled spine surgery. Prefrail and frail patients suffered comparatively higher rates of mortality at 90 d (1.9% vs 0.2%, P &lt; .05) and 1 yr (5.1% vs 1.2%, P &lt; .01) from the procedure date. They also had longer in-hospital length of stay (LOS) (3.9 d ± 3.6 vs 3.1 d ± 2.8, P &lt; .001) and higher rates of 60 d (14.6% vs 8.2%, P &lt; .05) and 90 d (15.8% vs 9.8%, P &lt; .05) readmissions. CONCLUSION Preoperative frailty, as measured by the RAI, was associated with an increased risk of readmission and 90-d and 1-yr mortality following spine surgery. The RAI can be used to stratify spine patients and inform preoperative surgical decision making.

Outcome of Patients After Air Medical Transport for Management of Nontraumatic Acute Intracranial Bleeding

1994 ◽  
Vol 9 (4) ◽  
pp. 252-256 ◽  
Author(s):  
Robert Silbergleit ◽  
Richard E. Burney ◽  
Janine Draper ◽  
Kris Nelson
Keyword(s):  
Glasgow Coma Scale ◽  
Hospital Length ◽  
Intracranial Bleeding ◽  
Hospital Length Of Stay ◽  
Coma Scale ◽  
Management Measures ◽  
Before And After ◽  
Acute Subarachnoid Hemorrhage ◽  
Gcs Score ◽  
Hospital Days

AbstractIntroduction:Patients with acute, intracranial bleeding (ICB), particularly from intracranial aneurysms, are believed to be at high risk for rebleeding or neurologic deterioration if subjected to noise, motion, or stress, but are transported by helicopter with increasing frequency. This study was undertaken to examine the characteristics, safety, and outcomes of air transport for patients with acute subarachnoid hemorrhage (SAH) or other forms of acute ICB in an air medical system.Methods:Charts of all patients with spontaneous, acute ICB who were transported by air from 1986 through 1989 were reviewed. Age, gender, time of transport, transport management measures, pre- and post-transport Glasgow Coma Scale (GCS) score, intensive care unit (ICU) and hospital days, operations, and mortality were compiled for all patients and analyzed.Results:Eighty-seven patients ranging in age from 2 to 83 years (mean: 47.5 ±18.5 years) met entry criteria. The source of bleeding was cerebral aneurysm in 37 patients; intraparenchymal hemorrhage in 29; an unidentified vascular source in 11; and arteriovenous malformation (AVM) in 10. Mean GCS score measured in 69 patients before and after transport was 10.5 ±4.5 Glasgow Coma Scale score did not change during transport in 61 patients (88%), improved in three (4%), and deteriorated in five (7%). Fifty-nine patients (69%) underwent operations, 36 (41%) within 24 hours of arrival. Mean ICU stay was 14 days (95% CI: 12–15); mean hospital stay was 36 days (95% CI: 27–45 days). Overall mortality was 25% (95% CI: 16–34 days). A GCS score of 3 to 8 at time of transport was associated with both increased hospital length of stay and higher mortality. Patients transported within eight hours of symptom onset had lower GCS scores, but out-come measures were not significantly different from those transported later.Conclusion:Emergency air medical transfer of patients with acute ICB for definitive neurosurgical care appears to be both safe and effective, and facilitates early definitive diagnosis and operative intervention.

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