Narcotic Administration Research Articles

POST LAPAROSCOPIC PAIN CONTROL USING LOCAL ANESTHESIA THROUGH LAPAROSCOPIC PORT SITES

Background: Severe abdominal pain is not common after laparoscopic surgeries, but acute or chronic pain after operation is considerable in some patients. Post-operative Pain control after laparoscopic surgeries, is conventionally achieved using analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and narcotics, but their administration has a lot of side effects. This study compares the efficacy and side effects of local anesthetic drugs versus conventional analgesics in post-operative pain control. Materials and Methods: This prospective investigation was conducted into two groups of patients (n=93). Group 1, as control group, was given conventional analgesics such as narcotics and NSAIDs. In investigational group, at the end of laparoscopic surgery, prior to port withdrawal, a local anesthetic mixture, a short acting (Lidocaine 2%) plus a long acting (Bupivacaine 0.5%) is instilled through the port lumen between the abdominal wall layers. The efficacy of both types of medications was compared to their efficacy and side effects. Results: 85% of the control group, received 5 to 20 ml Morphine for pain control while the others were controlled with trans-rectal NSAIDs. In the treatment group, the pain of 65% of the patients was controlled only by local anesthetic drugs, 30% required NSAIDs and the other 5% required narcotics administration for pain control. Conclusion: The administration of local anesthetic drugs after laparoscopic surgery is an effective method for pain control with a low complications rate and side effects of narcotics.

Robot assisted laparoscopic pyeloplasty in obese and non-obese patients

ObjectiveWe assessed whether increased BMI has a negative impact in children undergoing robot assisted laparoscopic pyeloplasty (RALP). Patients and methodsRecords of patients who underwent RALP were retrospectively reviewed and separated into healthy weight, overweight, and obese cohorts based on age-adjusted BMI percentile, and surgical and postsurgical outcomes were evaluated. ResultsOf the 103 patients, there were 79 healthy weight and 24 overweight, with 10 of the 24 considered obese (BMI <85th, ≥85th, and ≥95th percentile for age, respectively). Cohorts were similar in respect to age, sex, laterality and symptoms. Operative time (234 min, 241 min, p = 0.642; 254 min, p = 0.324), EBL (7.1 ml, 10.5 ml, p = 0.293; 6.8 ml, p = 0.906), length of stay (1.2d, 1.2d p = 0.545; 1.1d p = 0.550), and narcotic administration (0.25 mg/kg, 0.25 mg/kg, p = 0.545; 0.13 mg/kg, p = 0.430) were similar between healthy weight, overweight, and obese cohorts, respectively. Complication rates were similar in regard to minor and major complications. There was no difference in decreased hydronephrosis (92.2%, 89.6%, p = 0.440; 88.9%, p = 0.730). Four patients (3.4%) required a reoperative procedure (three healthy weight, one overweight; p = NS). ConclusionsDespite the potential difficulties with surgery in overweight patients, our data indicate that robot-assisted laparoscopic pyeloplasty can be performed as safely and effectively in overweight or obese children as in healthy weight children.

Outcomes of Fast-Track Program after Colorectal Cancer Surgery - Comparison with Conventional Method

Purpose: To assess the effectiveness of a care map for a fast-track discharge program after colorectal cancer surgery. Methods: Ninetynine patients who underwent colorectal surgery were retrospectively analyzed: 45 patients who were placed in a conventional program (January 3 to March 13, 2013) and 44 patients who were placed in a fast-track program using the care map (July 26 to September 24, 2014). Patients in the fast-track program started eating on postoperative day 1, while those in the conventional program started eating on post-operative day 2. complications, and pain were compared between the two groups. Results: A slight decrease in the average duration of hospitalization was observed for the fast-track group (5.31 ± 0.98 days) compared to the conventional group (5.38 ± 2.80 days), although this difference was not statistically significant. All other outcomes for the fast-track group were scored as 0. Furthermore, there was no statistically significant differences between pain, narcotics administration, and non-narcotic analgesics (aside from patient-controlled analgesia). Conclusion: The care map for the colorectal surgery fast-track program was effective and program validation and supplementation of the active standardization early recovery program should be performed using multi-disciplinary research.

Acute Cholecystitis: A Dischargeable Diagnosis?

The standard management for patients diagnosed with acute cholecystitis (AC) is antibiotics, admission and cholecystectomy. If improperly treated, significant complications can occur leading to high morbidity and mortality. Our institution implemented a pathway to discharge clinically stable patients with mild disease. This pathway included patients who were afebrile, pain-controlled, tolerating fluids, with normal white blood cell (WBC) counts, liver function tests (LFT) and lipase, with no significant comorbidities and presumed to be reliable. At discharge, they are given prescriptions and a surgical follow-up appointment. Our hypothesis is that there is a subset of reliable patients presenting to the adult ED, without significant comorbidities with mild disease, for whom emergent admission and surgery is not needed and a conservative approach is feasible. Elmhurst Hospital is a city hospital located in Queens, NY and has >100 000 visits per year. We reviewed charts of patients discharged with AC from the adult ED from March 2007 to March 2010. We excluded only incarcerated patients from analysis. Charts of all patients were examined for abnormal vitals, past medical history, WBC count, LFTs, lipase, imaging modality, administration of antibiotics and narcotics in the ED, surgical consultation, PO trial, return visits to the ED for the same complaint, surgical clinic notes and operative reports. A query of our electronic medical record revealed 574 patient charts diagnosed with AC between 3/1/07-3/10/10. Of those, 71 patients (12%) were discharged from the ED. Ages ranged from 17-78 years and 62% were female. Of those discharged, 53/71 (75%) attended surgery clinic for follow up with 34 (64%) having cholecystectomy. There were only two return visits; neither of whom experienced any significant complications or were admitted for definitive care. 16/71 (23%) did not follow up or revisit the ED. In a busy city hospital, utilization of our mild AC algorithm reduced admission rates by 12% with 75% attending their recommended follow-up appointments. Despite the 23% lost to follow-up, this review suggests that a subset of these patients can be safely discharged from the ED. This translates to significant overall cost savings and warrants further prospective study.

Postoperative Analgesia in Russia: Clinical and Organizational Aspects

This review addresses the issue of postoperative pain relief in Russian medical institutions and provides the analysis of the causes of inadequate administration of the opioid analgesics that lead to inadequate pain relief in patients who undergo operations. In Russia opioid analgesics are hard-to-reach even for incurable patients with oncological diseases and chronic pain syndrome. In order to improve the situation with the postoperative pain relief in Russia wide discussion of this topic is necessary. Poor availability of effective analgetics for patients is caused by administrative barriers within the medical institutions. These barriers are the consequence of the present system of reporting and control of narcotic analgetics administration and usage in Russia. This system is based on the strict requirements of Federal Service of the narcotics control and related orders and directions of Ministry of Health that block the appropriate administration of opioid analgetics by physicians. All these prescriptions must be coordinated with authorities. This situation contradicts with international principles of supply of patients with acute and chronic pain with analgetics. These principles are secured by official documents and publications by UNO, WHO and International Narcotic control Board (INCB) which are available in Russian on the INCB website cited in the article.

Short-term and long-term outcomes of minimally invasive and open transforaminal lumbar interbody fusions: is there a difference?

Previous studies comparing minimally invasive transforaminal lumbar interbody fusion (MITLIF) with open TLIF have demonstrated that MITLIF reduces blood loss and decreases postoperative pain while preserving fusion rates and reducing complications. In this study, the authors wanted to compare outcomes of MITLIF with those of open TLIF to determine whether MITLIF also improves postoperative functional mobility and decreases the usage of pain medication. In total, 75 consecutive patients who underwent either single-level open TLIF or MITLIF at the University of California, San Francisco, between 2006 and 2011 were included, and patients were followed up for an average of 5.05 years. Fifty patients underwent MITLIF and 25 underwent open TLIF. Primary outcomes included administration of morphine-equivalent narcotics and functional status on postoperative Day 1. Secondary outcomes included operative characteristics, complications, long-term fusion rates, and visual analog scale (VAS) scores. No statistically significant differences in age, sex, body mass index (BMI), level of disease, or surgical indication were detected between the open TLIF and MITLIF groups. Similarly, preoperative medication usage did not significantly differ between these groups. Intraoperatively, compared with TLIF, MITLIF resulted in decreased lengths of operation, lower blood loss, and fewer complications (p < 0.05). Total administration of morphine-equivalent pain medication in the hospital also tended to be lower in the MITLIF than in the TLIF group. Functional assessment by physical therapy on postoperative Day 1 demonstrated higher function in the MITLIF patients for transfer-related tasks, ambulatory ability, and distance walked than in the TLIF patients (p < 0.05). This translated to shorter inpatient hospitalizations (6.05 vs 4.8 days for open TLIF vs MITLIF patients, respectively, p = 0.006) and an average cost reduction of $3885 per MITLIF patient. Long-term fusion rates were 92% in the MITLIF group and 100% in the open TLIF group (p = 0.09). Preoperative VAS pain scores were 7.1 for the MITLIF patients and 7.6 for the TLIF patients (p = 0.26). At the last follow-up, the reported VAS pain score was 2.9 in the MITLIF patients and 3.5 in the open TLIF patients, but this difference was not statistically significant (p = 0.25). There was also no statistically significant difference in the degree change in this score (p = 0.44). The MITLIF approach achieves improved functional mobility, decreases the usage of postoperative pain medication, and significantly reduces cost compared with open TLIF while preserving long-term fusion rates. To the authors' knowledge, this is the first study comparing the postoperative usage of pain medication between treatments in the postoperative period before discharge.

Implementing Capnography in the PACU and Beyond

The potential risk of adverse effects from hypoventilation due to intravenous and/or intrathecal narcotics administration was recognized. SPMHC understood the limitations with the use of pulse oximetry and respiratory assessment in detecting adequate ventilation. Evidence has shown that capnography is the best indicator of respiratory depression.

Sa1450 Safety and Risk Factors for Procedural Sedation in the 21st Century: a Review of Over 2 Million Patients From 2000-2011

Safety and Risk Factors for Procedural Sedation in the 21st Century: a Review of Over 2 Million Patients From 2000-2011 John J. Vargo*, Douglas O. Faigel, Paul Niklewski, James Martin, Jeffrey L. Williams, Jennifer L. Holub Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, AZ; Ethicon Endo-Surgery, Cincinnati, OH; Department of Gastroenterology, Oregon Health and Science University, Portland, OR; Neuroscience, University of Cincinnati, Cincinnati, OH Background: The advent of propofol-mediated sedation and the use of anesthesia professionals (APanesthesiologist or nurse anesthetist) have changed the procedural sedation landscape over the past ten years. The identification of risk factors for serious adverse events during EGD and colonoscopy in this new landscape has not been well studied. Aim: To assess the prevalence and risk factors for serious interventions as related to procedural sedation. Design: Retrospective cohort study. A procedure specific multivariate logistic regression analysis was performed, with covariates including age, gender, ASA classification, sedationist, and procedure indications. Setting: Clinical Outcomes Research Initiative National Endoscopy Database, 2000-2011. Patients: Adults undergoing colonoscopy or EGD procedures in 84 academic, VA and community sites throughout the US. Main Outcome Measurement: The risk of serious intervention based on the use of hemostasis, CPR, hospital/ER admittance, sedation reversal, emergency surgery, stopped procedure, and blood transfusion. Results: 1,372,524 colonoscopy and 805,006 EGD patients were included with 70% seen in the community setting. The presence of an AP increased from 4.3% to 23.5% for colonoscopy and from 4.1% to 23.4% for EGD procedures during this 11 year period. Propofol use increased from 2.3% to 24.5% for colonoscopy and 1.8% to 21.5% for EGD. Fentanyl use increased (colonoscopy 27.1 to 65.5%, EGD 25.1 to 67.2%) and meperidine use decreased (colonoscopy 68.2 to 5.4%, EGD 60.2 to 5.4%). CPR remained stable across the 11 years at 0.005% for colonoscopy and 0.05% for EGD. Use of a reversal agent for colonoscopy decreased from 0.17% to 0.01% and from 0.20% to 0.02% for EGD. 18 deaths were reported for EGD (4 possibly due to sedation, bradycardia/hypoxemia). 8 deaths were reported for colonoscopy (1 possibly due to sedation, hypoxemia). The table shows older age, higher ASA classifications, narcotic administration, trainee involvement, certain non-screening indications, and presence of AP for EGD procedures are associated with increased risk of serious events. Limitations: The main outcome measurement assesses procedural interventions and is not limited to only interventions directly related to sedation. Fields pertaining to sedationist and procedure medications are not required in the CORI software, leading to some missing data. Conclusion: We identified sedation practice changes over this time period and risk factors for adverse outcomes related to procedural sedation. In this analysis of over 2.1 million patients across 11 years, it is clear that sedation during routine colonoscopy and EGD has an excellent safety profile for healthy patients when administered by endoscopists. Utilization of an anesthesia provider did not improve patient safety; in fact the endoscopist was safer for EGD procedures.

Post-Operative Effects: Comparison of Total Intravenous and Inhalational Anesthesia

Background: Propofol is an intravenous anesthetic with known antiemetic properties. Less confirmed are its potential analgesic or antinociceptive postoperative effects when used as a maintenance anesthetic during surgery. We compared the postoperative effects of total intravenous anesthesia (TIVA) with propofol to those of inhalational anesthesia with sevoflurane and looked for differences in the quality of recovery of patients. Methods: We studied 23 patients scheduled to undergo endoscopic sinus surgery (ESS). Using a doubleblind experimental method, we randomly assigned patients to receive either TIVA with propofol/remifentanil (PR) or inhalational anesthesia with sevoflurane/remifentanil (SR). We measured degree of pain (per visual analog scale where 1=no pain and 10=worst pain imaginable), incidence of nausea and vomiting, and duration of recovery postoperatively. Results: Mean pain rating was 3.4±3.3 in the PR group and 5.3±2.8 in the SR group. Median pain rating was 3±3 in the PR group and 5.5±1.5 in the SR group. In the PR group, 3 out of 12 patients reported a pain score > 4; In the SR group, 6 out of 10 patients reported a pain score > 4. Only 1 incidence of nausea was reported per group. Narcotics administered were comparable between both groups. Mean recovery time was 67±30 minutes in the PR group and 69±27 minutes in the SR group. Conclusion: We found no statistically significant difference between TIVA with propofol and inhalational anesthesia with sevoflurane as they relate to postoperative pain, nausea and vomiting, narcotic administration, and recovery time.

Narcotic administration and fall-related injury in the hospital: Implications for patient safety programs and providers

Identify factors that predict fall-related injury in hospitalized adults. Retrospective records review. 435-bed university hospital. Inpatients with reported falls in 2010. Medical records were available for 286/293 (98%) of reported falls in 251 patients. 25% (63/286) of falls were associated with injury, 4% (11/286) with serious injury. Compared to all fallers, patients with injury did not differ by gender or age. In univariate analysis, patients who reported hitting their head, had pre-fall confusion, or who received narcotics within 24 hours before falling were more likely to suffer injury (estimated odds ratios 6.04, 2.00 and 5.1, respectfully). In multivariate analysis, receiving a narcotic prior to falling was the strongest predictor of injury (estimated odds ratio 5.38; 95% confidence intervals 2.07-13.98, p < 0.001). In this single-institution study, 25% of patients who fell suffered injury and 4% serious injury. Neither age nor gender predicted fall-related injury. Recent narcotic administration was the strongest predictor of injury. Strategies to prevent fall-related injury in the hospital should target patients receiving narcotics. When evaluating inpatients who have fallen, providers should be especially vigilant about injury in patients who have pre-fall confusion, hit their head, or have received recent narcotics.

New Management Strategy for Fluid Resuscitation

This study evaluated a 24-hour resuscitation protocol, established a formula to quantify resuscitation volume for the second 24 hours, described the relationship between the first and second 24 hours, and identified which patients required high volumes. A protocol for patients with burn >15% TBSA was implemented in 2009. Initial fluid was based on the Parkland calculation and adjusted to meet a goal urine output. Protocol compliance was defined as appropriate fluid titration to maintain urine output. Resuscitation ratio in the second 24 hours was tabulated as total fluid /(evaporative loss + maintenance fluid + estimated colloid). Data were collected prospectively from 2009 to 2011. A Wilcoxon rank test compared differences between groups. Regression analyses analyzed volume administered. P < .05 was statistically significant. Forty patients with burn >15% TBSA met criteria for inclusion. Mean age, burn size, and resuscitation volumes in the first and second 24 hours (mean + SD) were 47+ 20.7 years, 29.9 + 14.6% TBSA, 7.4 + 3.7 ml/kg/% TBSA, and a ratio of 1.9 times expected volume (SD, 1.3), respectively. Protocol compliance was 34%. Intubation, older age, and increased narcotic administration correlated with higher resuscitation volumes. A higher resuscitation volume in the first 24 hours significantly correlated with a higher resuscitation volume in the second 24 hours (P < .001). In conclusion, there is a significant relationship between fluid administration in the first and second 24 hours of resuscitation; intubation, older age, and narcotics correlate with higher volumes. A formula for observed/expected volumes in the second 24 hours is total fluid/(evaporative loss + maintenance fluid +estimated colloid).

Efficacy of Popliteal Block in Postoperative Pain Control After Ankle Fracture Fixation

To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. Institutional Review Board approved prospective randomized study. Metropolitan tertiary-care referral center. All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control.

Toxicity of autologous hematopoietic cell transplantation in patients with multiple myeloma – comparison between two different induction regimens

Induction therapy in patients with multiple myeloma has evolved from chemotherapy-based to novel agents-based regimens. We compared autologous hematopoietic cell transplantation (HCT)-associated toxicity in patients induced with VTD-PACE (bortezomib, thalidomide, dexamethasone, cisplatinum, adriamycin, cyclophosphamide, and etoposide) to that of patients induced with novel agents-only therapy. We reviewed medical charts of all patients with multiple myeloma who were given induction therapy and HCT. Between the years 2007 and 2011, 38 patients received VTD-PACE, and 31 patients received novel agents-only regimen. Mean time to neutrophil and platelets recovery was longer in patients given VTD-PACE compared with those given novel agents-only regimen (7 vs. 6 d, p = 0.0002 and 11 vs. 10 d, p = 0.04, respectively). We observed higher rates of grade 2-4 mucositis and parenteral narcotic analgesia administration in the patients given VTD-PACE (45% vs. 19%, p = 0.05 and 37% vs. 12%, p = 0.07, respectively). Progression free survival and overall survival were not statistically significantly different between the two groups. A more intensive induction regimen was associated with slightly delayed counts recovery and a higher rate of mucositis during HCT compared with novel agents-only regimens. A longer follow-up is needed to assess long-term disease control of the two different regimens.

Extremity Fracture Pain After Emergency Department Reduction and Casting: Predictors of Pain After Discharge

The aims of this study are to determine the prevalence of pediatric extremity fracture pain after emergency department (ED) discharge, compare pain severity between fractures requiring simple casting versus sedated reduction and casting, and explore predictors of postdischarge pain. This is a prospective observational study of children aged 4 to younger than 18 years and presenting to the ED with extremity fracture from May 2010 to February 2011. The Parents' Postoperative Pain Measure, which scores pain according to 15 behavior-related questions, was completed 48 to 72 hours after discharge. A score greater than or equal to 6 of 15 indicates clinically meaningful pain. Univariate tests and multivariable regression analyses were used to compare Parents' Postoperative Pain Measure scores between cohorts. Two hundred fifty-seven patients were enrolled; 202 (79%) had Parents' Postoperative Pain Measure scores for analysis. Pain scores greater than or equal to 6 were reported by 37 of 102 (36%) of the simple casted and 44 of 100 (44%) of the reduced casted children. There was no difference in scores between the simple (median 4.0) and reduced casted (median 5.0) cohorts (difference 16.7%; 95% confidence interval [CI] -3.0% to 40%). In the multivariate analysis, ED narcotic administration was associated with 24% higher Parents' Postoperative Pain Measure scores (95% CI 0.95% to 53.6%). Children receiving ED narcotics had more than 2 times increased odds of pain scores greater than or equal to 6 after discharge (95% CI 1.24 to 5.39). Children in both simple casted and reduced casted groups had clinically meaningful pain after ED discharge. Identifying these children is important to improving pain management and discharge care.

Comparison of ultrasound-guided anterior versus transgluteal sciatic nerve blockade for knee surgery.

Background:Ultrasound-guided sciatic nerve block, in combination with femoral nerve and lateral femoral cutaneous nerve blocks, is frequently used to induce anesthesia for lower limb surgery. The anterior approach to the sciatic nerve is performed in the supine position and repositioning of the patient between injections is avoidable. We compared the relative utility and efficiency of anterior versus transgluteal sciatic nerve blocks in conjunction with femoral nerve and lateral femoral cutaneous nerve blockade.Materials and Methods:Twenty-four patients were enrolled in this prospective double-blind randomized study and were randomly divided into two equal groups: Anterior (Group A) and transgluteal (Group T). We evaluated the following parameters: ultrasound view quality, procedural duration, onset time to block, quality of anesthesia during surgery and postoperative analgesia, required administration of supplemental sedation or narcotics during surgery, amount of pethidine administered within 24 hours post surgery, and overall patient satisfaction.Results:There were no significant differences between patient groups with regard to the demographic data, onset time to block, quality of ultrasound view, use of narcotics to augment the anesthesia during surgery, and patient satisfaction. Although procedural completion time for the sciatic injection alone was shorter in Group T, the total completion time of all blocks together was significantly less in Group A.Conclusion:Ultrasound-guided anterior blockade of the sciatic nerve has advantages over the transgluteal approach — it provides efficient anesthesia and results in excellent patient satisfaction.

Low Incidence of Severe Mucositis After Myeloablative, HLA-Matched Bone Marrow Transplantation and High Dose, Post-Transplantation Cyclophosphamide

Abstract 893▪▪This icon denotes a clinically relevant abstract Background:Oral mucositis is a debilitating and frequently encountered consequence of high-intensity chemotherapy used prior to and after bone marrow transplantation (BMT). It is associated with increased acute oral pain, use of total parenteral nutrition (TPN) and intravenous narcotic analgesics, length of hospital stay, incidence and severity of graft-versus-host disease (GVHD), risk of severe infections, and mortality. Important contributors to the duration and severity of mucositis include certain agents used in the conditioning regimen and as GVHD prophylaxis, especially methotrexate (MTX). High dose post-transplantation cyclophosphamide (PT/Cy) has been shown to be effective as a single-agent prophylaxis of GVHD after HLA-matched BMT. Due to the reduced toxicity profile of Cy compared to MTX, we sought to characterize mucositis among patients receiving PT/Cy, and to compare it to historical controls receiving cyclosporine A (CsA) and MTX as GVHD prophylaxis. Methods:We performed a retrospective record review of 142 consecutive patients treated at our institution between June 2004 and October 2009 who received a standard regimen of busulfan (Bu) 4 mg/kg/day orally or 3.2 mg/kg/day IV from days −6 to −3, Cy 50 mg/kg/day IV on days −2 and −1, and T cell-replete bone marrow from HLA-matched siblings (n = 79) or unrelated donors (n = 63) on day 0. GVHD prophylaxis consisted of PT/Cy 50 mg/kg/day IV on days +3 and +4. We also examined a historical control group of 15 patients treated between 2002 and 2005, who also received myeloablative conditioning with BuCy, but subsequently received CsA/MTX (15 mg/m2 IV on day 1, 10 mg/m2 IV on days 3, 6, and 11), instead of PT/Cy, for GVHD prophylaxis. Mucositis was graded on a scale from 0 to 4, where 0 connotes normal oral mucosa; 1 indicates the presence of erythema only; 2 and 3 reflect ulcerations and/or white patches covering <25% and >25% of the oral mucosa, respectively; and 4 represents hemorrhagic ulcerations. Mucositis assessments were documented daily for at least 28 days following the start of conditioning. Results:Recipients of PT/Cy experienced a significantly lower incidence of severe (grades 3–4) mucositis than did recipients of CsA/MTX (25.3% vs. 93.3%, Fisher’s exact test, p < 0.001). The peak mucositis severity among recipients of PT/Cy was 2.2, compared to 3.4 for patients receiving CsA/MTX (Mann-Whitney, p < 0.0001). The mean duration of severe mucositis among PT/Cy recipients was 4.2 days. Incidences of total parenteral nutrition (TPN) use and IV narcotics administration via patient-controlled analgesia (PCA) were 8.4% and 41.5%, respectively, among patients receiving PT/Cy. The total number of days of TPN and PCA use were 9.5 and 8.7, respectively. Among patients using PCA, the average cumulative dose of IV narcotics administered was 950.1 milligrams of morphine equivalents (MME). Patients receiving PT/Cy experienced a mean maximum oral pain rating of 4.5. The 100-day cumulative incidences of grades II–IV and grades III–IV GVHD in the PT/Cy cohort were 46% and 13%, respectively. Comparative data for duration of severe mucositis, use of PCA and TPN, severity of oral pain, and cumulative incidence of GVHD in the group of patients treated with CsA/MTX is currently being collected; however, all of the mucositis-associated clinical outcomes described above compare favorably with those reported in previously published studies. Conclusions:The incidence and severity of mucositis among patients receiving myeloablative, HLA-matched BMT with high dose PT/Cy are low compared to those of historical patients treated with CsA/MTX for GVHD prophylaxis. Measures of TPN use, PCA use, oral pain, and GVHD compare favorably with previous reports. Thus, GVHD prophylaxis with high dose cyclophopshamide can significantly reduce mucositis and may impact associated clinical sequelae after transplant. Disclosures:Off Label Use: Post-transplantation cyclophosphamide for graft-versus-host disease prophylaxis. Jones:Accentia Biopharmaceuticals: Patents & Royalties. Luznik:Otsuka Pharmaceuticals: Research Funding. Fuchs:Accentia Biopharmaceuticals: Patents & Royalties.

Application of Clinical Microsystems Improves the Speed of the Initial Pain Relief in Sickle Cell Disease (SCD) Patients Admitted with Acute Vaso-Occlusive Crisis (VOC)

Abstract 4740 Background-The management of acute vaso-occlusive crisis continues to be a challenge in patients with sickle cell anemia. Long Island Jewish Medical Center is a 500 adult bed, tertiary care facility, with more than 500 reported admissions for acute vaso-occlusive crisis in 2009. Suboptimal pain management in the Emergency Department (ED) frequently resulted in unrelieved pain, recurrent admissions, prolonged hospitalization, and increased patient dissatisfaction. Methods-An interdisciplinary team which included a patient with SCD was assembled to meet weekly to address the above issues. The team was educated in Clinical Microsystem methods as described by Nelson et.al (1) over 6 months. Preliminary data was collected to assess performance with respect to pain management in adult SCD patients presenting to the ED through pain diaries. The admission process was analyzed and significant delays were noted from time of presentation to the time that sufficient sustained analgesia was achieved. The PDSA (Plan Do Study Act) cycle method to test and study change was utilized. The specific aim was to achieve a sustained 2 point reduction in subjective pain score within 2 hours of inpatient admission. Four interventions were simultaneously tested. First, given the high frequency of admission from our ED for this patient population, we tested proactive bed designation initiated when the patient presented to the ED. Second, we educated the housestaff on providing appropriately dosed narcotic administration upon admission after pharmacy verification of previous patient specific dose requirements. Third, we arranged expedited transfer to the medical floors for these patients. Lastly, we arranged for storage of PCA pumps on the medical unit designated for SCD patients, facilitating immediate initiation of pain medication via this modality. Timing of analgesic response was assessed based on patient interviews and the above mentioned diaries. Results-During the pre-intervention stage it took an average of 55 hours and 20 minutes to achieve a sustained reduction in pain by two points. Post intervention, the team achieved a sustained 2 point reduction in subjective pain score by an average of 9 hours and 58 minutes (see figure). Conclusion-The Clinical Microsystems Methodology is an effective means of engaging an interdisciplinary team in improving the initial analgesic response to treatment in sickle cell patients admitted with acute vaso-occlusive crisis. Disclosures:No relevant conflicts of interest to declare.

Enhancing the clinical pathway for patients undergoing axillary lymph node dissection

BackgroundDay-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers. MethodsConsecutive patients (n=282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates. ResultsFrom July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education. ConclusionALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.

Seventy Per Cent Hydrofluoric Acid Burns: Delayed Decontamination With Hexafluorine® and Treatment With Calcium Gluconate

This is a case report of decontamination and treatment of a 70% hydrofluoric acid (HF) dermal splash injury. A worker was splashed with 70% HF, sustaining approximately 10% TBSA first- to third-degree chemical skin burns of the face, trunk, and left thigh and leg. Initial decontamination involved water rinsing, removal of contaminated clothing, more water rinsing, topical application of magnesium oxide, and administration of intravenous narcotics for management of severe pain. After a delay of approximately 3 hours, active skin washing with Hexafluorine®, 5 L, was performed, followed by intravenous, intradermal perilesional, and topical inunction administration of calcium gluconate. Pain relief and a cooling sensation were quite prompt after Hexafluorine® decontamination. Surgical debridement and skin grafting of the more severe burns were required. No significant systemic toxicity developed, although this has occurred in previously reported similar concentrated HF dermal splash exposure cases, some of which resulted in fatality. While burns did develop, the patient was released from the intensive care service after 2 days and, after skin grafting, had a good outcome at 90-day follow-up. Even after a long delay, decontamination with Hexafluorine® appeared to be beneficial in this case.

Opioid Sedation Comparison Study

Respiratory depression is a serious side effect from the use of opioids. Nurses are essential in recognizing respiratory depression. Patients become sedated prior to clinically significant opioid-induced respiratory depression (2009). The literature is stressing the need to monitor sedation for all narcotic administration to prevent untoward events.