Narcotic Medication Research Articles

Regional Anesthesia for Wrist Fractures and Dislocations: Are We Really Blocking Opioid Prescribing?

The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns. Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed. A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery. In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures. Level III, retrospective cohort study.

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA)

IntroductionIt has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established. MethodsThis study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival. Ethics and disseminationThe study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

Experience to date with elective transfemoral amputations incorporating agonist-antagonist myoneural interface (AMI) design

IntroductionThe agonist-antagonist myoneural interface (AMI) is a surgical construct that, when incorporated into limb amputation, offers to potential to preserve or restore proprioception, augment functionality, reduce neuropathic pain and enhance overall limb stability. We here present our experience to date with AMI construction in the context of transfemoral amputation (TFA). MethodsPatients were recruited for TFA with AMI construction at Brigham & Women’s and Brigham & Women’s Faulkner Hospital between June 2018 and June 2023. Data collection included demographic information, intraoperative parameters, clinical recovery metrics and complications. All data was then collated and analyzed. ResultsSeven TFA procedures were performed on seven patients during the study period. The operative technique employed evolved significantly over time, and included the development of both native and regenerative AMI models. Four patients were biological males (57%), and mean patient age was 42.0 ± 14.6 years. The etiology of conditions necessitating amputation included traumatic (43%), oncologic (29%), iatrogenic (14%) and congenital (14%). Mean operative time was 566 ± 97 min and average length of stay was 11.7 ± 8.4 days. Average postoperative follow-up was 2.19 ± 1.57 years (range 0.81–4.30 years). Postoperative imaging of AMI constructs demonstrated average muscle excursions of 6±3 mm, and total average limb volume preservation over time was 102 ± 14%. All patients demonstrated a complete wean from narcotic pain medications, with a mean time to wean of 86 ± 79 days. Minimal neuropathic pain was reported after the acute postoperative period. All seven (100%) of the subjects reported functional phantom limb sensation over the same time. Complications included significant soft tissue necrosis in two (29%) patients and minor wound healing issues in one (14%) patient. ConclusionsTFA incorporating AMI construction appears to offer promising benefits similar to those previously reported in patients undergoing similar interventions at the transtibial level.

Factors Associated with Inpatient Narcotic Medication Usage after Robotic-assisted Laparoscopy

Describe factors that contribute to an increased narcotic medication use after robotic-assisted laparoscopic (RAL) surgery. A retrospective cohort. A teaching hospital. All patients undergoing RAL surgery by gynecologist oncologists at St. Joseph's Hospital and Medical Center over a 3-year period. RAL by gynecologist oncologists. Using retrospective chart review, patients who underwent RAL surgery from 2012 to 2015 in the division of gynecologic oncology were identified; 757 patients were eligible for inclusion in the study. Total narcotic use during the postoperative hospital stay was converted to oral morphine milligram equivalents (OME). Bivariate correlations of total OME narcotics to multiple variables were evaluated using Spearman's rho. The average age, body mass index, and length of stay were 53.76 years (17-92), 31.75 kg/m2 (17-56), and 1.56 days (range, 0-19), respectively. Increased OME correlated positively with body mass index (Spearman's rho=.077, p=.036), any intraoperative complication (Spearman's rho=.05, p=.886), any postoperative complication (Spearman's rho=.16, p <.0001), length of stay in days (Spearman's rho=.282, p <.0001), procedure time (Spearman's rho .023, p=.52), and total anesthesia time (Spearman's rho, .032). Total OME narcotics were correlated negatively with age of 65 years or older (Spearman's rho, -.144, p <.0001) and use of patient-controlled analgesia (Spearman's rho, -.185, p <.0001). Age younger than 65 years seems to be a predictor for increased requirement of total morphine equivalent medication after RAL surgery, whereas patient-controlled analgesia use had a negative association.

Pain in Trauma Patients: Measurement and Predisposing Factors

IntroductionAcute pain is common after injury. This study intended to evaluate the feasibility of quantifying pain experience over an entire admission using “area under the pain curve” and to identify factors associated with increased pain. MethodsThis retrospective single-center study included all trauma patients admitted from 2013 to 2020. Maximum pain scores were extracted for each day. Pain was defined as area under the curve (AUC) of maximum pain scores/day plotted against time. Injury patterns were analyzed by dichotomizing Abbreviated Injury Scale (AIS) scores (AIS < 3 versus AIS ≥ 3) for each body region. Urinary drug screen results were collected from admission data. A general linear model was used to determine which injury patterns, mechanisms, and age groups were predictive of increased AUC in all patients together and separate by operative and nonoperative groups. ResultsWe identified 21,640 patients, of which 70% were male and 83% had suffered blunt injury. Overall injury severity was associated with increased pain experience. Serious head injury, younger age, and older age (compared to 45-49 y) were associated with decreased pain. Spinal injuries, thoraco-abdominal injuries, and combined thoracic and lower extremity injuries were predictive of increased pain. Compared to patients with no positive test for illicit substances or documentation of prehospital narcotic medications, the pain experience was greater for both, those who had been administered a narcotic in the prehospital setting and those who tested positive for illicit substances. ConclusionsThis study extends the concept of total pain experience using AUC methodology. Our results demonstrate associations between increased pain and certain patterns of injury, ages, and presence of drugs on admission. Measuring total pain experience could assist in comparing pain-management strategies. Future research should focus on validating pain experience against quality-of-life measurements.

(425) Counterincision for High Submuscular Penile Prosthesis Reservoir Placement

Abstract Introduction Inflatable penile prosthesis (IPP) reservoir placement into the high submuscular (HSM) space is safe and well tolerated. Recent studies have proposed that reservoirs placed via an abdominal counterincision (CI) may offer more precise positioning with herniation rates comparable to a transinguinal (TI) approach. Objective Our objective was to evaluate the CI-HSM technique with respect to operative time, pain control, and complications. Methods We retrospectively reviewed our patient database to identify all men who underwent IPP reservoir placement via the CI-HSM technique. From this database, a similarly sized and matched control group of TI-HSM patients was identified based on concomitant procedures, date of surgery, age, and medical history. Operative time, intraoperative and postoperative complications, morphine milligram equivalents (MME) prescribed, and postoperative patient phone calls were also compared between TI-HSM and CI-HSM patients. Statistical analysis was performed using Student’s T-test and Fisher’s Exact test for continuous and discrete variables, respectively. Results Among 580 IPP cases identified, CI-HSM technique was used in 44 (7.6%). Of these, thirty-five (80%) were primary implants, nine (20.4%) were remove/replace revisions, and seven (15.9%) were combined with other ancillary procedures (i.e. artificial urinary sphincter, urethral slings, or penile plications). The TI-HSM technique was used in 536 patients (92.4%); of these, 44 matched controls were identified for comparison to the CI-HSM cohort. Thirty-four (77%) of these patients underwent primary implants while ten (23%) were revision cases. Cases employing the CI-HSM technique had a longer mean operative time (90 minutes) compared to those using the TI-HSM technique (75 minutes) (Table). A similar number of CI-HSM patients (3/44, 6.8%) were treated for infection versus TI-HSM patients (1/44, 2.2%). Reservoir herniation was not observed in the CI-HSM cohort, however one (2.2%) patient in the TI-HSM matched control cohort required revision secondary to herniation. No differences were identified between TI-HSM and CI-HSM patients with regards to outpatient medications, narcotic medication refills, or postoperative phone calls. Conclusions IPP reservoir placement via CI-HSM technique is safe and well tolerated. Operative times were similar as compared to reservoirs placed via TI-HSM technique. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast.

The association between self-treatment and mental health among Swedish physicians.

Despite a high prevalence of mental health problems among physicians, the rate of help-seeking behaviour is low. Instead, physicians tend to self-treat. This can have a negative impact on individual physicians and society. The aim was to explore the relationship between self-rated depression, the use of psychotropic medication, and the extent of self-treatment across gender and hierarchical position among Swedish physicians. In addition, the aim was to investigate whether social support can buffer against self-treatment. This study draws on data from the Longitudinal Occupational Health for Health Care in Sweden 2021 study, comprising a representative sample of physicians. Descriptive statistics and logistic regressions were carried out. The present study showed that approximately 60% of the physicians using narcotic or non-narcotic psychotropic medication were self-prescribing. Male and more senior physicians self-treated to a greater extent. Physicians without depression were self-treating to a greater extent than those with depression. Those who used non-narcotic psychotropic medication intermittently were more likely to self-treat than those who used these medications regularly. The frequency of use was insignificant in relation to self-treatment with narcotic psychotropic medication. No buffering effect from social support at work was found. Self-treatment was common among physicians in Sweden, particularly among those who reported mild or no symptoms of depression. This may have negative long-term effects on an individual level and for Swedish health care at large.

Full-endoscopic technique mitigates obesity-related perioperative morbidity of minimally invasive lumbar decompression.

Obesity is associated with increased surgical complexity and postoperative complications in spine surgery. Minimally invasive procedures have been shown to lessen some of the increased risk in obese patients. This study investigated whether utilization of a working channel endoscope can further mitigate obesity-associated challenges in spinal surgery. A retrospective review of a single-surgeon database was conducted for all adult patients undergoing full-endoscopic unilateral laminotomies for bilateral decompression between November 2015 and March 2021. Data collected included body mass index, in operating room preparation time, procedure time, length of hospital stay, use of analgesics, complications, and quality of life measured by Oswestry Disability Index. Our cohort included 174 patients. Of these, 74 (42.5%) were obese. The average age was 63.6years. In-operating room preparation time was 70.0 ± 1.7min for obese patients and 64.4 ± 1.5min for non-obese patients (p = 0.02). There was no difference in operative time, durotomy rates or other perioperative complications between obese and non-obese patients. Hospital length of stay trended toward longer in the obese group, but did not reach significance. A greater percentage of obese patients were still using both narcotic and non-narcotic pain medications 2weeks after surgery. There was no significant difference in functional outcomes between groups. Full-endoscopic unilateral laminotomies for bilateral decompression are safe and effective in both non-obese and obese patients. The use of an endoscope can partially mitigate obesity-related morbidity in lumbar decompression. However, obesity is significantly related to increased postoperative analgesic use.

Opioid Use in Pediatric Patients After Common Orthopaedic Surgeries.

The use and misuse of opioid medications is an epidemic and public health emergency. There are currently no standard guidelines for treating perioperative pain in the pediatric population. The purpose of this study is to describe opioid use among pediatric patients after common orthopaedic surgeries. Patients between 5 and 20 years of age undergoing one of 7 common orthopaedic surgeries between the years 2018 to 2020 were prospectively studied. Patients and their families completed a medication logbook to track all doses of pain medication and associated pain scores. Three hundred forty-two patients completed the study, including 174 females and 168 males with a mean age of 14.0 years (range, 5 to 20y). A total of 4351 tablets or liquid doses of the narcotic medication, 44% of the total prescribed, were consumed. Of the prescribed medication,56% remained unused. Nonsteroidal anti-inflammatory drug use was identified to be the only independent predictor of less narcotic use, with a mean of 5.1 tablets ( P = 0.003) and 1.7 days ( P < 0.01) less opioid consumed among these patients. Thirty-two (9.4%) patients consumed 100% of their prescriptions. Nonmedicinal methods of pain control, most commonly ice, were used by 77% of patients, and this was highly variable between procedures. Physicians were cited as a source of medication information by only 50% of patients, with high variability between procedures. Opioid medication use in children and adolescents after orthopaedic surgery is significantly less than the number of tablets prescribed, with 56% of the medication prescribed remaining unused in the postoperative period. Duration of narcotic use was longer than anticipated with a wide SD (4.7d +/-3d).We recommend orthopaedic surgeons responsibly prescribe pain medications using evidence-based data or the results of their own experience monitoring medication consumption. In addition, and important in the setting of the "opioid epidemic," physicians must counsel patients and families on postoperative pain expectations and appropriate medication use. Level IV, prospective case series.

V07-05 EPIDURAL ANESTHESIA WITHOUT MECHANICAL VENTILATION IN SINGLE-PORT TRANSVESICAL RADICAL AND SIMPLE PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023V07-05 EPIDURAL ANESTHESIA WITHOUT MECHANICAL VENTILATION IN SINGLE-PORT TRANSVESICAL RADICAL AND SIMPLE PROSTATECTOMY Ethan Ferguson, Roxana Ramos, Albert Geskin, Jay Chavali, and Jihad Kaouk Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Jay ChavaliJay Chavali More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003288.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Due to pneumoperitoneum and Trendelenburg positioning, epidural-only anesthesia has a limited role in modern robotic or laparoscopic prostate surgery. Transvesical access in single-port (SP) robotic simple and radical prostatectomy allows for flat patient positioning and avoids the peritoneal cavity by limiting the surgical working space and insufflation to the bladder lumen. We sought to determine if epidural anesthesia without the need for paralysis or mechanical ventilation were feasible in patients undergoing transvesical SP simple and radical prostatectomy. METHODS: Patients previously scheduled for transvesical SP robotic radical or simple prostatectomy were selected and offered epidural or traditional general anesthesia. Exclusions included underlying obstructive sleep apnea, severe pulmonary disease, prior lumbar spinal surgery, or BMI >35. Low thoracic or high lumbar epidural catheters were placed in the preoperative unit prior to transport to the operating room. The transvesical access technique and basic operative steps of SP transvesical radical and simple prostatectomy are demonstrated. RESULTS: A total of 11 patients underwent epidural placement prior to transvesical SP radical (N=6) and simple (N=5) prostatectomy. All cases were completed by a single surgeon without extra ports, open conversion, or conversion to general anesthesia. No surgical interruptions were noted in 8 of 11 cases and all movement-related interruptions were brief and transient. No anesthetic complications were noted. Intraoperative narcotics were completely avoided in 3 patients. No patients required narcotic medications after discharge and there were no unplanned admissions. CONCLUSIONS: Epidural anesthesia without requiring mechanical ventilation is safe and feasible in selected patients undergoing transvesical SP robotic radical and simple prostatectomy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e597 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Albert Geskin More articles by this author Jay Chavali More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

Towards toxic and narcotic medication detection with rotated object detectors.

Recent years have witnessed the advancement of deep learning vision technologies and applications in the medical industry. Intelligent devices for specific medication management could alleviate workload of medical staff by providing assistance services to identify drug specifications and locations. In this work, object detectors based on the you only look once (YOLO) algorithm are tailored for toxic and narcotic medication detection tasks in which there are always numerous of arbitrarily oriented small bottles. Specifically, we propose a flexible annotation process that defines a rotated bounding box with a degree ranging from 0° to 90° without worry about the long-short edges. Moreover, a mask-mapping-based non-maximum suppression method has been leveraged to accelerate the post-processing speed and achieve a feasible and efficient medication detector that identifies arbitrarily oriented bounding boxes. Extensive experiments have demonstrated that rotated YOLO detectors are highly suitable for identifying densely arranged drugs. Six thousand synthetic data and 523 hospital collected images have been taken for training of the network. The mean average precision of the proposed network reaches 0.811 with an inference time of less than 300 ms. This study provides an accurate and fast drug detection solution for the management of special medications. The proposed rotated YOLO detector outperforms its YOLO counterpart in terms of precision.

Cannabinoid Hyperemesis Syndrome - A Case Report of an uncommon condition

IntroductionThe increasing prevalence of cannabis use in the world requires awareness of cannabis-related disorders such as cannabinoid hyperemesis syndrome (CHS). CHS is characterized by cyclic episodes of nausea, vomiting and abdominal pain, affecting chronic cannabis users, who usually recur to hot showers to relief the symptoms. The pathophysiology underlying this syndrome is still unclear. Despite the well-established anti-emetic properties of cannabis, there is increasing evidence of its paradoxical effects on the gastrointestinal tract and central nervous system.ObjectivesThe authors pretend to inform the readers about the rare Cannabinoid Hyperemesis Syndrome (CHS).MethodsThe authors describe a case of a 22 years old patient with chronic cannabis use, cyclic and intractable nausea and vomiting, to bring to the attention that this condition exists and is underdiagnosed.ResultsCHS should be strongly considered in the differential diagnosis of persistent vomiting in patients who reports relief with hot showers. In the acute setting, supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit. However, cannabis cessation appears to be the best treatment.ConclusionsCHS prevalence will continue to rise in parallel with increasing worldwide cannabis use and potency. So, health professionals must be aware of this syndrome, its diagnosis, and treatment, to provide better care and avoid overlooking CHS. Further research is required to elicit the exact mechanism and additional therapies for this condition.Disclosure of InterestNone Declared

Postoperative Opioid Prescribing Following Outpatient Male Urethral Surgery: Evidence for Change.

Surgeons play a central role in the opioid epidemic. We aim to evaluate the efficacy of a standardized perioperative pain management pathway and postoperative opioid requirements in men undergoing outpatient anterior urethroplasty at our institution. Patients undergoing outpatient anterior urethroplasty by a single surgeon from August 2017 to January 2021 were prospectively followed. Standardized nonopioid pathways were implemented based on location (penile vs bulbar) and need for buccal mucosa graft. A practice change in October 2018 transitioned (1) from oxycodone to tramadol, a weak mu opioid receptor agonist, postoperatively and (2) from 0.25% bupivacaine to liposomal bupivacaine intraoperatively. Postoperative validated questionnaires included 72-hour pain level (Likert 0-10), pain management satisfaction (Likert 1-6), and opioid consumption. A total of 116 eligible men underwent outpatient anterior urethroplasty during the study period. One-third of patients did not use opioids postoperatively, and nearly 78% of patients used ≤5 tablets. The median number of unused tablets was 8 (IQR 5-10). The only predictor for use of >5 tablets was preoperative opioid use (75% vs 25%, P < .01). Overall, patients using tramadol postoperatively reported higher satisfaction (6 vs 5, P < .01) and greater percentages of pain reduction (80% vs 50%, P < .01) compared to those using oxycodone. For opioid-naïve men, 5 tablets or less of opioid medication with a nonopioid care pathway provides satisfactory pain control following outpatient urethral surgery without excessive overprescribing of narcotic medication. Overall, multimodal pain pathways and perioperative patient counseling should be optimized to further limit postoperative opioid prescribing.

Transcranial Photobiomodulation Treatment: Significant Improvements in Four Ex-Football Players with Possible Chronic Traumatic Encephalopathy.

Chronic traumatic encephalopathy, diagnosed postmortem (hyperphosphorylated tau), is preceded by traumatic encephalopathy syndrome with worsening cognition and behavior/mood disturbances, over years. Transcranial photobiomodulation (tPBM) may promote improvements by increasing ATP in compromised/stressed cells and increasing local blood, lymphatic vessel vasodilation. Aim 1: Examine cognition, behavior/mood changes Post-tPBM. Aim 2: MRI changes - resting-state functional-connectivity MRI: salience, central executive, default mode networks (SN, CEN, DMN); magnetic resonance spectroscopy, cingulate cortex. Four ex-players with traumatic encephalopathy syndrome/possible chronic traumatic encephalopathy, playing 11- 16 years, received In-office, red/near-infrared tPBM to scalp, 3x/week for 6 weeks. Two had cavum septum pellucidum. The three younger cases (ages 55, 57, 65) improved 2 SD (p < 0.05) on three to six neuropsychological tests/subtests at 1 week or 1 month Post-tPBM, compared to Pre-Treatment, while the older case (age 74) improved by 1.5 SD on three tests. There was significant improvement at 1 month on post-traumatic stress disorder (PTSD), depression, pain, and sleep. One case discontinued narcotic pain medications and had reduced tinnitus. The possible placebo effect is unknown. At 2 months Post-tPBM, two cases regressed. Then, home tPBM was applied to only cortical nodes, DMN (12 weeks); again, significant improvements were seen. Significant correlations for increased SN functional connectivity (FC) over time, with executive function, attention, PTSD, pain, and sleep; and CEN FC, with verbal learning/memory, depression. Increased n-acetyl-aspartate (NAA) (oxygen consumption, mitochondria) was present in anterior cingulate cortex (ACC), parallel to less pain and PTSD. After tPBM, these ex-football players improved. Significant correlations of increased SN FC and CEN FC with specific cognitive tests and behavior/mood ratings, plus increased NAA in ACC support beneficial effects from tPBM.

Increasing role of counterincision for high submuscular penile prosthesis reservoir placement

AbstractBackgroundInflatable penile prosthesis (IPP) reservoir placement into the high submuscular (HSM) space is safe and well tolerated. Recent studies have proposed that reservoirs placed via an abdominal counterincision (CI) may offer more precise and durable positioning as compared with a transinguinal (TI) approach.AimHerein we compare the CI-HSM and TI-HSM techniques with respect to operative time, pain control, and postoperative complications.MethodsWe reviewed our penile prosthesis database at a large single-surgeon tertiary referral center from 2014 to 2021 to compare those who underwent virgin reservoir placement via the CI-HSM technique vs the TI-HSM technique. Statistical analysis was performed with the Mann-Whitney U test for continuous variables and the chi-square test and Fisher exact test for discrete variables.OutcomesOperative time, postoperative complications, morphine milligram equivalents prescribed, and postoperative correspondence were compared between patients undergoing the CI-HSM and TI-HSM techniques.ResultsAmong 456 virgin IPP implants, the CI-HSM technique was used in 34 cases (7.5%) and the TI-HSM technique in 422 cases (92.5%). Of these 456 cases, 92 (20.2%) were combined with ancillary procedures such as artificial urinary sphincter, urethral sling, or penile plication (6/34, CI; 86/422, TI). Cases employing the CI-HSM technique had a 19.9% greater median operative time: 81.5 minutes (IQR, 69.3-106.5) vs 68 minutes (IQR, 57.8-80.3; P &amp;lt; .01). A similar proportion of patients in the CI-HSM group (2/34, 5.9%) were treated for infection as in the TI-HSM group (17/422, 4.0%; P = .64). Reservoir herniation was seen in 12 patients in the TI-HSM group (2.8%) and in none of the CI-HSM group, but this did not reach significance (P &amp;gt; .99). No differences were identified between patients in the TI-HSM and CI-HSM groups with regard to postoperative morphine milligram equivalents prescribed, narcotic medication refills, or postoperative correspondence.Clinical ImplicationsCI-HSM reservoir placement was associated with similar surgical outcomes to TI-HSM without increased infection risk or need for narcotic pain management.Strengths and LimitationsAlthough this study is a large contemporary series addressing a clinically important subject, it is limited by its retrospective preliminary nature and nonrandomized unmatched design. Patient pain regimens were assessed via discharge prescriptions, although data regarding narcotic consumption were not available in the medical record.ConclusionsIPP reservoir placement via the CI-HSM technique is safe and well tolerated. Increased operative time of the CI-HSM technique as compared with the TI-HSM technique is clinically negligible given its potential safety benefits of direct visualization of reservoir placement.

Exploring the intravenous narcotics and controlled drugs wastage and their financial impact: A descriptive single-center study

ObjectiveThe objectives of this study were to explore the wastage of narcotics and controlled medications and, their financial impact in a tertiary care setting over a one-year period. MethodologyThe study period was of one year, i.e., October 2020 – September 2021. The venue of study was a tertiary care hospital. The narcotic medications included Fentanyl, Tramadol, Morphine, and Meperidine. The controlled medications included Midazolam, Phenobarbital, Diazepam, Ketamine and Lorazepam. The annual consumption and wastage of the narcotic and controlled medications were documented using data report generated by narcotics and controlled medication in-charge pharmacist through the hospital’s online system. Data was reported using average, minimum and maximum values. Quantities of wastage is expressed in terms of ampoules. Costs per ampoule were calculated and expressed in both Saudi Riyal (SAR) and United States Dollar (USD). The study was approved by an ethics committee. ResultsThe annual wastage of narcotics was 3.19 % while the same for controlled medications was 21.3 %. An annual wastage of 3.81 % was reported for narcotics and controlled medications combined. The total wastage cost of narcotics and controlled medications was 15,443.1 SAR that was equivalent to USD 4085.5. Fentanyl 500mcg formulations had the highest consumption, i.e., 28,580 ampoules followed by Morphine 10 mg formulations, i.e., 27,122 ampoules. The highest ampoule wastage was observed for Morphine 10 mg formulations, i.e., 1956 ampoules. The highest % wastage was observed for Midazolam formulations, i.e., 29.3 %. ConclusionThe overall wastage was less than 5% of the total consumption, however, midazolam was observed to have the highest wastage. Shifting to prefilled syringes supplied by pharmacies, making protocols, and safely pooling costly drugs could result in significant savings.

Surgical Management of Pain or Infection Secondary to Calciphylaxis: A Wound Center’s Experience and Algorithmic Multidisciplinary Approach

Background. The role of surgical management of calciphylaxis remains understudied. Objective. This article reports a case series and algorithmic approach to the multidisciplinary management of calciphylaxis. Methods. A single-center retrospective review of all adult patients with calciphylaxis treated surgically between January 2010 and November 2022 was performed. Results. Eleven patients met inclusion criteria. The average age was 50.9 years ± 15.8 SD, and most patients were female (n = 7 [63.6%]). Surgery was indicated for infection (n = 6 [54.5%]) and/or intractable pain (n = 11 [100%]). Patients underwent an average of 2.9 excisional debridements during their hospital course. Following the final excision, wounds were left open in 5 cases (29.4%), closed primarily in 4 (23.5%), and local flaps were used in 3 (27.3%). Postoperatively, the mean time to healing was 57.4 days ± 12.6. Complications included dehiscence (n = 1 [9.1%]), progression to cellulitis (n = 2 [18.2%]), osteomyelitis (n = 1 [9.1%]), and lower extremity amputation (n = 2 [18.2%]). Of the 6 patients alive at the time of healing, 5 (83.3%) were no longer taking narcotic medications. At an average follow-up of 26.4 months ± 34.1, 7 patients (63.6%) were deceased, with an average time to mortality of 4.8 months ± 6.7. Of the 4 remaining patients, 3 (75.0%) were ambulatory by their most recent follow-up visit. Conclusion. While the morbidity and mortality associated with calciphylaxis are substantial, surgical excision is effective in reducing pain and improving quality of life in patients with this end-stage disease. Wound care centers are uniquely equipped with a variety of medical and surgical specialists with experience in treating chronic wounds and thus facilitate an efficient multidisciplinary model.

Eras outcomes based on perioperative pain modalities: A single institution study

Background: Enhanced Recovery After Surgery (ERAS) pathways are evidence-based protocols to expedite postoperative recovery and provide cost-effective care. Outcome goals for ERAS pathway include minimization of narcotic pain medication and goal-directed intravenous (IV) fluid use. Surgically placed wound catheters, ON-Q pumps, deliver a constant anesthetic infusion in the preperitoneal or transverse abdominus plane (TAP), and are not associated with hemodynamic changes. The role of ON-Q pumps as a perioperative main modality used in an ERAS pathway remains unknown. The aim of this study was to evaluate outcomes in patients undergoing pancreatic or hepatic resection on an ERAS pathway with ON-Q pumps at our institution.

Multimodal Pain Control Reduces Narcotic Use after Outpatient Abdominoplasty: Retrospective Analysis in an Ambulatory Surgery Practice.

The authors retrospectively compared one surgeon's consecutive abdominoplasty patients over 24 months. The control group received primarily narcotic medications to manage pain, and the treatment cohort was given a multimodal protocol for perioperative analgesia. Demographic data, surgical time, and postanesthesia care unit time between the groups were similar. Although the mean intravenous narcotic decreased in the operating room and postanesthesia care unit for the treatment group, it failed to achieve statistical significance. The treatment cohort was prescribed two-thirds less oral narcotic than the control (251 versus 787 mean morphine milligram equivalents P < 0.001). Ten patients in the treatment cohort used no oral narcotics compared to one in the control (P = 0.002), and only four narcotic refills were given in the treatment group compared to 36 in the control (P < 0.001), suggesting that the treatment group had better pain control despite taking fewer narcotics. Optimally utilizing multimodal medications effectively reduces narcotic consumption while effectively managing postoperative pain from abdominoplasty in a private practice, ambulatory surgery setting. Surgeons must change their prescribing habits if we are going to make progress in the war against the opioid crisis.

Decreasing Opioids in Outpatient Breast Surgery with an Enhanced Recovery after Surgery Program and Preoperative Education.

Enhanced recovery after surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of this study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery. An ERAS protocol was formulated focusing on preoperative education, multimodal pain control, and an intraoperative block. The study was conducted as an institutional review board-approved retrospective review. Women undergoing breast reconstruction revision, breast reduction, delayed insertion of prosthesis, tissue expander to implant exchange, and matching procedures were included. The patients were separated into pre-ERAS and ERAS cohorts. Data on demographic characteristics, postanesthesia care unit (PACU) length of stay, PACU oral morphine equivalent (OME) consumption, outpatient OME prescriptions, major and minor complications, and need for additional opioid prescriptions were collected. Analysis was performed with the Fisher exact test or chi-square test as appropriate. Group 1 (pre-ERAS) and group 2 (ERAS) each included 68 patients. The cohorts had similar age, body mass index, diabetes status, and tobacco use. Group 1 was prescribed an average of 216 OMEs, compared with 126.4 OMEs for group 2, a 41.5% decrease ( P < 0.0001). The pre-ERAS group consumed an average of 23.3 OMEs in the PACU versus 16.6 OMEs in the ERAS group ( P = 0.005). Fewer patients in the ERAS group required additional prescriptions for narcotic pain medication at postoperative follow-up ( P = 0.116). No differences were seen in major or minor complications. An ERAS protocol that uses a multimodal approach to pain control and preoperative patient education is useful in the outpatient setting and can help decrease opioid consumption. Therapeutic, III.