Narcotic Use Research Articles

Evaluation of risk factors for chemotherapy-induced nausea and vomiting in cisplatin and gemcitabine treatment for biliary tract cancer: acid suppressants do not prevent nausea.

Chemotherapy-induced nausea and vomiting (CINV) is one of the most serious adverse effects of cancer therapy. Cancer patients frequently use acid suppressants (AS) for palliation of gastrointestinal symptoms associated with malignancy and/or anticancer therapy. AS are suggested as an additional option for CINV management in several antiemetic guidelines, although their efficacy remains unknown. The aim of this study was to determine whether AS administration affects CINV incidence in cisplatin and gemcitabine treatment for biliary tract cancer. The primary endpoint was to evaluate whether AS administration was associated with the incidence of all-grade nausea in the first administration by logistic analysis. The secondary endpoints were to assess factors associated with anorexia. Prophylactic antiemetics were based on current guidelines. Nausea occurred in 34.2% of patients (grade 1, 31.7%; grade 2, 2.5%). Patients exhibiting vomiting and anorexia represented 4.2% and 39.1%, respectively, without grade 3/4 symptoms. Multivariate analysis suggested that the independent risk factors for nausea as female sex, and no- or less-alcohol drinking habit and regular narcotics administration were associated with anorexia. In contrast, AS administration was not associated with nausea and anorexia incidence (odds ratio, 95% confidence interval: 1.43, 0.64-3.23; P =0.38 for nausea, 1.62, 0.71-3.68; P =0.25 for anorexia). In conclusion, we found that AS administration is not associated with CINV incidence, and female sex is a risk factor for nausea, and non-alcohol drinking habits and regular narcotic use are factors associated with anorexia in cisplatin and gemcitabine treatment for biliary tract cancer. We should correctly administer AS depending on the patient's situation. Successful CINV management needs effective monitoring and administration of prophylactic antiemetics and counter-measure medicines for patients at risk.

Regional block pilot for microvascular free-flap breast reconstruction.

e18646 Background: With increasing focus on improving patient outcomes and decreasing narcotic use, healthcare has prioritized the use of multidisciplinary, multimodal, and evidence-based approaches to perioperative management through enhanced recovery after surgery (ERAS) pathways. Currently, microsurgical breast reconstruction with or without concurrent mastectomy commonly may employ regional anesthesia in the preoperative and intraoperative techniques. To optimize perioperative analgesia, an ERAS protocol was piloted at a quaternary care academic center implementing a pre-operative anesthesia placed regional block with preference for anterior quadratum lumborum blocks. Methods: A total of 161 patients were enrolled in this single center Continuous Quality Improvement (CQI) project. The project consisted of 72 baseline, 20 pilot, and 69 after pilot patients who underwent unilateral (n = 65) or bilateral (n = 96) deep inferior epigastric perforator (DIEP) flap reconstruction either immediately (n = 87) or delayed (n = 74) after mastectomy. In the 20 CQI pilot group, anesthesiologists pre-operatively placed bilateral anterior quadratus lumborum blocks (aQLB) under direct ultrasound guidance. After positively observed metrics, the official ERAS pathway was implemented into clinical practice, allowing for subsequent accrual of 69 additional patients. We compared this after pilot group to 72 baseline patients who underwent a surgeon-placed intraoperative transversus abdominus plane (TAP) block using liposomal bupivacaine. Statistics data was tracked using a dedicated clinical EMR dashboard. Baseline patients were matched to the after pilot cohort based on laterality and timing of DIEP flap reconstruction. Results: The ERAS pathway with anesthesia-placed aQLB was associated with lower post-operative daily opioid consumption from 27.2 MME to 10.2 MME. Average pain scores, post-anesthesia care unit (PACU) length of stay, hospital length of stay, as well as re-admissions and complications were not statistically different before and after the implementation of the ERAS pathway. Conclusions: Anesthesia placed pre-operative aQLB is a safe and effective opioid-reducing pain control modality for DIEP flap reconstruction with or without mastectomy. Prospective and controlled studies will be important for the precise impacts of aQLB in DIEP procedures in an ERAS protocol.[Table: see text]

Opioid Prescribing for Kidney Stone Formers Undergoing Stone Removal

Background: Kidney stone formers may have episodes of severe pain and be at increased risk of narcotic use. Alabama has a high rate of opioid use. Within, we examine differences in opioid prescribing for kidney stone formers requiring stone removal procedures. Methods: A retrospective review was conducted from June 2013 to July 2019. Twenty-five patients with recurrent cystine stones were randomly matched by age, gender, and procedure to 25 recurrent non-cystine and 25 first-time non-cystine stone formers. Patients underwent ureteroscopic stone removal and percutaneous nephrolithotomy. Opioids prescribed were identified through medical record review and the prescription drug monitoring program (PDMP) database. Morphine milligram equivalents (MMEs) standardized opioid utilization. Results: Opioids prescribed at discharge significantly decreased (mean MME ± SD), 216.8 ± 125.9 for 2013 - 2016 and 124.2 ± 106.1 for 2017 - 2019 (P < 0.001) corresponding to implementation of an institutional opioid stewardship program. Opioids prescribed within 180 days of stone removal were similar amongst all three cohorts, mean 3,377.6 MME/patient. Over this 6-year time period, there was no difference in total amount of opioids prescribed for each cohort, mean 27,987.8 MME. The majority of prescriptions (56.4%) and MME prescribed (91.9 %) were from pain management and primary care providers. Conclusions: MME prescribed for stone removal in an environment of high utilization has not declined and is not influenced by stone disease complexity. An opioid stewardship program was associated with decreased opioids prescribed by the surgeons conducting stone removal but had a negligible overall influence. The latter is driven by other care providers. World J Nephrol Urol. 2022;11(1):10-17 doi: https://doi.org/10.14740/wjnu428

Management of post-operative pain in patients undergoing abdominal hysterectomy, is the transversus abdominis block a reliable option?

Objective: To determine the efficacy of transverse abdominal block for patients undergoing abdominal hysterectomy. Study Design: Randomized Controlled Study. Setting: Ghulam Muhammad Mahar Medical College Hospital, Sukkur. Period: September 2018 to September 2019. Material & Methods: Included all females above the age of 18 years who were scheduled for abdominal hysterectomy. We excluded all the patients who have had a abdominal hysterectomy before, had malignancy, and had a hospital stay of less than 24 hours. All the patients receiving transverse abdominal pain block, had received an ultrasound guided block after the hysterectomy procedure, and was given 20 cc to 60 cc of 0.25% Bupivacaine, while the non-TAP group received standard narcotics as required. Results: We included a total of n= 66 patients, the mean age of the patients was found to be 47 +/- 8 years. There were no statistically significant differences in the two groups based on the patients age, length of hospital stay, time spent in the recovery room, and time duration of the surgical procedure. The average consumption of narcotics was lower during the procedure, at 24 hours after the procedure, and the length of hospital say was also low for the TAP group, however these were not statistically significant findings, the p values were 0.419, 0.533 and 0.754 respectively. Overall narcotic use and patient controlled analgesia also showed no statistically significant differences in the two groups, the p values were 0.252 and 0.669. The numeric pain rating scale also did not show any significant differences between the two groups. Conclusion: Transverse abdominal pain block failed to lower the narcotics requirement and failed to be a superior analgesic in patients undergoing abdominal hysterectomy.

Postoperative Utilization of Opioids After Midurethral Sling Surgery: A Prospective Clinical Practice Study.

This study was performed to understand opioid consumption after midurethral sling (MUS) procedures to provide surgeons with guidelines on appropriate prescription regimens. This study aimed to evaluate postdischarge narcotic use (PDNU) after MUS surgery using a restrictive postdischarge opioid regimen. This prospective clinical practice study included women undergoing MUS surgery from December 2018 to October 2019. Patients were discharged with an electronic prescription for 5 tablets of an oral narcotic. Brief Pain Inventory (BPI) surveys were collected preoperatively. Patients answered questions regarding remaining number of opioid tablets, BPI scores, and patient satisfaction on day 1, week 1 (postoperative week [POW] 1), and 4-6 weeks (POW4-6) postoperatively. Electronic records were reviewed to determine narcotic refills. Primary outcome was PDNU measured in morphine milligram equivalents (MME). Secondary outcomes evaluated refill rate, BPI scores, and patient satisfaction. Standard statistical tests were applied. Fifty-six patients were included in the analysis. Total median (interquartile range) PDNU was 12.5 (0-37.5) MME at POW1 and 15.0 (0-37.5) MME at POW4-6, which is approximately equivalent to 2 oxycodone (5 mg) tablets. Eighteen patients (32.1%) took 0 narcotics postdischarge. Brief Pain Inventory scores showed that "worst pain" was highest on postoperative day 1 with a median (interquartile range) score of 6 (4-8). At the POW1 and POW4-6 mark, 94.3% and 92% of patients, respectively, were satisfied or extremely satisfied with their pain control. Seven patients (11.8%) required a refill. Most patients undergoing MUS surgery used no more than 2 oxycodone (5 mg) tablets during their 6-week postoperative course, with almost a third not requiring any narcotics. Low pain scores and high patient satisfaction rates were noted.

Association Between Patient Reported Outcomes Measurement Information System Physical Function With Postoperative Pain, Narcotics Consumption, and Patient-Reported Outcome Measures Following Lumbar Microdiscectomy.

Retrospective cohort study. To determine association between preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores with postoperative pain, narcotics consumption, and patient-reported outcome measures (PROMs) following single-level lumbar microdiscectomy. Consecutive patients who underwent single-level lumbar microdiscectomy were identified from May 2017-May 2020. Patients were grouped by their preoperative PROMIS-PF scores: mild disability (score≥40), moderate disability (score 30-39.9), and severe disability (score<30). Preoperative PROMIS-PF subgroups were tested for association with inpatient postoperative pain, total inpatient narcotics consumption, time to narcotic use cessation as well as improvements in postoperative PROMIS-PF, ODI, VAS-Leg Pain, VAS-Back Pain, SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS) at 2-, 6-, 12-weeks, 6-month, 1-year, 2-year follow-up. A total of 127 patients were included. Patients with greater disability reported higher inpatient maximum Visual Analog Scale (VAS) pain scores (P = .023) and total inpatient narcotics consumption (P = .008) but no difference in time to narcotic cessation after surgery (P = .373). However, patients with greater preoperative disability also demonstrated greater improvement from baseline in PROMIS-PF, ODI, SF-12 PCS, and SF-12 MCS at 2-week follow-up (P < .05). These higher improvements from baseline for patients with greater preoperative disability were sustained for PROMIS-PF, ODI, and VAS-Leg Pain at 2-year follow-up (P < .05). Patients with greater preoperative disability, as measured by PROMIS-PF, had increased inpatient postoperative pain and narcotics consumption, but also higher improvement from baseline in long-term PROMs. This data can be utilized for patient counseling and setting expectations.

0676 Increased Depression Symptoms are Associated with Higher Nightmare Frequency within the Wisconsin Sleep Cohort

Abstract Introduction Nightmare frequency has been suggested as a strong clinical indicator of psychiatric disorders. Additionally, frequent nightmares are a possible underrepresented outcome of depression. As nightmares may increase the risk of negative health outcomes, such as suicide attempts, understanding possible sources of nightmare frequency is imperative. This study sought to examine the association between depression and anxiety on the incidence of high frequency of nightmares. Methods Using cross-sectional and longitudinal data from the Wisconsin Sleep Cohort, accessed through the National Sleep Research Resource, we conducted an analysis of demographics, co-occurring sleep disturbances, and mental health measures of participants experiencing ordinal frequencies of nightmares. The study sample included 758 Wisconsin state employees with a baseline and follow-up assessment (mean 4.46 years between visits; standard deviation 1.7). All participants were screened for depression and anxiety symptoms using the Zung Depression Scale (SDS), and the State-Trait Anxiety Inventory. Sleep disturbances, medication use, nightmares and insomnia were based on self-report. Nightmare frequency was categorized as high (≥2 per month) and low (&amp;lt;2 per month). Logistic regression was used to determine the association of baseline anxiety and depression scales (in the same model) with incidence of high nightmare frequency at follow-up, adjusted by age, sex, body mass index, hypertension medications, use of narcotics and caffeine. Results After adjusting for covariates, SDS scores at baseline were associated with an increased incidence of higher frequency of nightmares at follow-up (OR=1.05; 95%CI=1.01-1.10, p = 0.026), while anxiety at baseline was not (OR=1.03; 95%CI=0.99-1.07; p = 0.165). An increase in one unit of the SDS was associated with a 5% increase in the odds of presenting higher frequency nightmares at follow-up. Conclusion Participants with higher SDS scores had higher incidence of high frequency of nightmares upon follow up, however, those with anxiety did not. Further research should be targeted at gaining better understanding of the role of psychiatric conditions on the onset of nightmares. Support (If Any) NIH NHLBI (R01HL62252), NIA (R01AG036838, R01AG058680), and National Center for Research Resources (1UL1RR025011). The National Sleep Research Resource was supported by NIH-NHLBI (R24 HL114473, 75N92019R002).

0602 Rapid Eye Movement (REM) Sleep Duration Is Inversely Related To Daytime Pruritus Severity: Preliminary Findings in Posttraumatic Stress Disorder (PTSD) Patients

Abstract Introduction Pruritus (itching) is one of the most distressing symptoms of dermatologic disease. There can be a bidirectional relationship between pruritus severity and sleep. Pruritus during sleep is most frequently encountered during stages N1 and N2 and sleep fragmentation can exacerbate pruritus. Often there are limited effective treatments available for pruritus. In this study we examined REM sleep data obtained from PTSD patients who reported somatic complaints including daytime pruritus. To our knowledge there are no studies of REM sleep and pruritus during wakefulness. Methods Seventy-five consenting patients with mild-to-moderate PTSD (all female; mean ±SD age 48.89 ±13.50 years) completed a battery of psychiatric and sleep ratings and underwent ≥ 1 home sleep apnea test (Watch PAT200; Itamar) which provided measures of %REM and REM duration. Exclusion criteria were use of benzodiazepines or narcotics. Pruritus was measured using Item 2 of the Pennebaker Inventory of Limbic Languidness (PILL), which assesses the frequency of common physical symptoms. For PILL Item 2 patients self-rated the frequency with which they experienced “Itchy eyes or skin” with a rating of “1” = “”never or almost never”, “2”=”less than 3 or 4 times per year”, “3”=”every month or so”, “4”=”every week or so’, and”5”=”more than once every week”. Results The mean±SD % REM was 21.78 ±7.64 (range 1.76% to 40.69%); and overall duration of REM sleep (mean ±SD) was 91.37±38.20 minutes (range 5.01 to 194.47 minutes). The frequency of pruritus ratings were as follows:: 39.5% endorsed a rating of “5” . The remainder self-endorsed the following frequencies: “4” (15.8%), “3” (21.1%), “2” (15.8%), and “1” (7.9%).. Pearson product moment correlation between the pruritus rating (item 2 of PILL) and REM sleep parameters were as follows: % REM (Pearson r= -0.172; p=0.144) and REM duration (Pearson r= -0.247; p=0.035). Conclusion Daytime pruritus was inversely related to the duration of REM sleep in a sample of PTSD patients. Pruritus can be a difficult condition to manage. Optimization of REM sleep may have a role in the management of pruritus. Support (If Any) None

Surgeon's Impact on Opioid Epidemic Following Uncomplicated Laparoscopic Appendectomy and Cholecystectomy.

The opioid crisis in the United States remains a major issue that is directly linked to the prescribing practices of physicians. There is a lack of consistency in post-operative prescribing of narcotic medications. We have designed a retrospective study to evaluate factors that contribute to the prescription of opioids following common laparoscopic procedures. In this study, we analyzed peri-operative medications and pain requirements and how they relate to the frequency in which narcotics are prescribed at Saint Joseph’s University Medical Center (SJUMC), a level two trauma center and teaching hospital. We also studied how the frequency of narcotic prescriptions is related to patient demographics and surgeon practices. We propose that standardizing pain medication protocols will be an effective way to decrease overall narcotic use as well as prescriptions for common laparoscopic procedures.

Use of Cannabis Does Not Decrease Opioid Consumption in Patients Who Underwent Total Joint Arthroplasty.

BackgroundThe primary purpose of this study was to determine if cannabis use decreases narcotic consumption in patients undergoing total joint arthroplasty (TJA).Material and methodsForty-six patients undergoing a primary unilateral TJA, who self-reported the use of cannabis, were prospectively enrolled and completed this study between July 2015 and November 2019. This cohort was prospectively matched to patients who did not report cannabis use. Morphine equivalents (MEs) were averaged and recorded at 1 and 2 weeks postoperatively. Secondary outcomes and complications were recorded and reported.ResultsThere were no differences noted in ME during the hospitalization between the user (78.7 ± 58.5) and nonusers (70.4 ± 46.3), P = .455. ME daily average did not differ between the cohorts (user [36.8 ± 30.7] and nonuser [31.7 ± 25.6] at 1 week (P = .389) or user [22.5 ± 26.3] and nonusers [15.9 ± 18.3] at 2 weeks, P = .164, postoperatively). The total ME at 2 weeks did not differ between the user and nonuser groups (415 ± 375 vs 333 ± 275, P = .235). Pain scores at 1 week were significantly higher in patients who used cannabis (4.1 ± 1.9 vs 3.4 ± 1.6, P = .05). No differences in pain were noted during the patient’s hospitalization or at 2- (P = .071) or 6-week (P = .111) follow-up. No differences in secondary outcomes or complications were noted.ConclusionWe were unable to show a decrease in narcotic consumption in patients who use cannabis undergoing primary unilateral joint replacement. These findings do not support the routine use of cannabis to decrease or supplement narcotic use after primary TJA.Level of evidenceLevel II therapeutic.

Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience.

This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization. A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol. Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001). ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay. Therapeutic, III.

Pediatric Pain and Pain Management After Ambulatory Plastic Surgery: Trends in the Age of Opioid Awareness.

Overprescribing by physicians has been shown to be a major contributor to the opioid epidemic. Although pediatric ambulatory plastic surgery patients are commonly prescribed opioids for postoperative pain control, there is a lack of evidence for their necessity. This study aimed to investigate the role of prescribed narcotics in the ambulatory pediatric plastic surgery setting. All assenting patients/guardians, ages 0 to 17 years, who underwent an ambulatory plastic surgery procedure by 1 attending surgeon from March 2018 to March 2019, were asked to participate in the study. A questionnaire was distributed at the first postoperative visit to interrogate postoperative pain, management, and narcotic use. A total of 95 patients/guardians completed the questionnaire. Seventy-eight percent (74) of patients picked up the narcotic medication, with 33% (31) taking at least 1 dose of narcotics, and only 9% (9) taking 4 or more doses. Patients overall found no difference in efficacy of the narcotics versus nonprescription analgesics (3.93/5 and 4.31/5, P = 0.11). Age was a significant predictor, with older patients requiring more narcotics (odds ratio, 1.12; 95% confidence interval, 1.02-1.24; P = 0.019). The type of surgery a patient underwent was not a significant predictor of the amount of narcotic used. Few patients knew how to properly dispose of the excess narcotics, with almost 50% still having it stored in their homes. This study demonstrates that the majority of pediatric ambulatory plastic surgery patients do not require narcotic pain medications and experience adequate pain relief with over-the-counter analgesics. Importantly, education on proper disposal of narcotic medications may be a simple, yet effective target to decrease opioid availability for abuse.

PD44-07 EVALUATING THE LONG-TERM IMPACT OF IMPLEMENTING STANDARDIZED POSTOPERATIVE OPIOID PRESCRIBING GUIDELINES FOLLOWING PELVIC ORGAN PROLAPSE SURGERY

You have accessJournal of UrologyCME1 May 2022PD44-07 EVALUATING THE LONG-TERM IMPACT OF IMPLEMENTING STANDARDIZED POSTOPERATIVE OPIOID PRESCRIBING GUIDELINES FOLLOWING PELVIC ORGAN PROLAPSE SURGERY Elizabeth J. Olive, Amy E. Glasgow, Elizabeth B. Habermann, John B. Gebhart, John A. Occhino, Emanuel C. Trabuco, and Brian J. Linder Elizabeth J. OliveElizabeth J. Olive More articles by this author , Amy E. GlasgowAmy E. Glasgow More articles by this author , Elizabeth B. HabermannElizabeth B. Habermann More articles by this author , John B. GebhartJohn B. Gebhart More articles by this author , John A. OcchinoJohn A. Occhino More articles by this author , Emanuel C. TrabucoEmanuel C. Trabuco More articles by this author , and Brian J. LinderBrian J. Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002605.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess longitudinal prescribing patterns for patients undergoing surgery for pelvic organ prolapse in the 2-year timeframe before and after implementing an evidence based opioid prescribing recommendation and evaluate the impact of these recommendations on institutional practices. METHODS: Prospective data was previously used to create a 3-tiered recommendation for opioid prescribing following pelvic organ prolapse surgery at our institution based on narcotic use postoperatively. The guideline was implemented December 2017. Prescribing patterns including the quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid naïve patients undergoing prolapse surgery before (November 2015 through November 2017; N=238) and after (December 2017-December 2019; N=361) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and chi-squared tests. Cochran- Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation. RESULTS: The quantity of opioids prescribed at hospital discharge decreased from a median 225 OMEs (Interquartile range [IQR] 225, 300) before the guideline to 0 OMEs (IQR 0,75) after guideline implementation overall (p=xx) and also within each individual subgroup of prolapse surgery: native tissue vaginal (p<0.0001), robotic sacrocolpopexy (p<0.0001), open sacrocolpopexy (p<0.0001), and colpocleisis (p<0.003). The overall proportion of patients discharged following prolapse surgery without opioids significantly increased after guideline implementation (49.9% after vs 4.2% before; p<0.0001). Despite the significant decrease in opioid prescribing, rate of opioid refills was similar before (2.9%) versus after (6.5%) guideline implementation (p=0.06). CONCLUSIONS: With two years of postimplementation follow up, the use of procedure-specific, tiered opioid prescribing guidelines at our institution was associated with a significant reduction in opioids prescribed without adversely impacting refill rates. This study further supports the use of evidence-based guidelines for opioid prescribing. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e710 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth J. Olive More articles by this author Amy E. Glasgow More articles by this author Elizabeth B. Habermann More articles by this author John B. Gebhart More articles by this author John A. Occhino More articles by this author Emanuel C. Trabuco More articles by this author Brian J. Linder More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP28-06 NATIONAL TRENDS IN THE PRESCRIPTION OF NARCOTICS IN THE EMERGENCY DEPARTMENT IN PATIENTS WITH NEPHROLITHIASIS

You have accessJournal of UrologyCME1 May 2022MP28-06 NATIONAL TRENDS IN THE PRESCRIPTION OF NARCOTICS IN THE EMERGENCY DEPARTMENT IN PATIENTS WITH NEPHROLITHIASIS Spencer Liem, Timothy Demus, Alexandra Perez, Crystal Lee, Kevin George, Alejandra Perez, Luigi Cubeddu, and Jorge Pereira Spencer LiemSpencer Liem More articles by this author , Timothy DemusTimothy Demus More articles by this author , Alexandra PerezAlexandra Perez More articles by this author , Crystal LeeCrystal Lee More articles by this author , Kevin GeorgeKevin George More articles by this author , Alejandra PerezAlejandra Perez More articles by this author , Luigi CubedduLuigi Cubeddu More articles by this author , and Jorge PereiraJorge Pereira More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002571.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In 2017, the Department of Health and Human Services (HHS) declared the opioid crisis a public health emergency. This study aims to describe the national changes in narcotic prescription and administration in the emergency department (ED) for patients with nephrolithiasis over a five-year period. METHODS: This is a retrospective cohort study using data collected from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from ED visits from 2014 through 2018. Patients with nephrolithiasis were identified by using the respective ICD 9/10 codes. The primary study endpoint was the use of any opioid medication. Pre-declaration period was defined as 2014-2016 and post-declaration from 2017-2018. Chi-square test was used to examine the association of narcotic use pre/post declaration period, over the 5-year period. Estimates were adjusted to complex survey design using appropriate weight variables. RESULTS: 63,546 weighted (608,220,000 unweighted) individuals visited the ED from 2014-2018. 1.9% (1,207/63,546) had nephrolithiasis as a discharge diagnosis. Opioid narcotics were prescribed in 81.2% (679/904) of weighted patients with nephrolithiasis compared to 40.1% (19,178/62,642) in patients non-nephrolithiasis (P<0.0005) (Table 1). In the post-declaration era (2017-2018), 75.7% (211/311) of patients with nephrolithiasis were prescribed opioids, compared to 84.6% (468/592) of patients in the pre-declaration era (2014-2016), (p=0.048). In the post-declaration era, 36.8% (5,777/22,658) of patients with non-nephrolithiasis diagnosis were prescribed opioids while 42.4% (13,401/39,948) of patients in the pre-declaration era were prescribed opioids, (p<0.001). In 904 unweighted visits with nephrolithiasis, opioids were prescribed in combination with NSAIDs in 58.9% (430/904) of visits. Opioids were the sole analgesic in 22.3% (249/904) of visits, while NSAIDs were the sole analgesic in 13.0%, (136/904). CONCLUSIONS: Since the opioid crisis was declared a public health emergency, overall narcotic prescriptions have decreased, but prescription of narcotics in patients with nephrolithiasis in the emergency department have remained relatively unchanged. Increased efforts into narcotic prescribing stewardship may be beneficial in this higher risk patient population. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e462 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Spencer Liem More articles by this author Timothy Demus More articles by this author Alexandra Perez More articles by this author Crystal Lee More articles by this author Kevin George More articles by this author Alejandra Perez More articles by this author Luigi Cubeddu More articles by this author Jorge Pereira More articles by this author Expand All Advertisement PDF DownloadLoading ...

V09-11 NOVEL USE OF THE DAVINCI SINGLE PORT ROBOT IN NEPHROURETERECTOMY OF A HORSESHOE KIDNEY

You have accessJournal of UrologyCME1 May 2022V09-11 NOVEL USE OF THE DAVINCI SINGLE PORT ROBOT IN NEPHROURETERECTOMY OF A HORSESHOE KIDNEY John Sheng, Chrystal Chang, Michael Stifelman, and Mutahar Ahmed John ShengJohn Sheng More articles by this author , Chrystal ChangChrystal Chang More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002617.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Performing a robotic-assisted laparoscopic nephroureterectomy can be challenging, especially during the distal ureterectomy and bladder cuff portion. We demonstrate how the Da Vinci Single Port Robot facilitates certain portions of the case. We show how the procedure can be performed with one incision compared to a multiport robotic or open technique. METHODS: A 73 year old male was diagnosed with a high grade urothelial cancer of the right renal pelvis on ureteroscopic biopsy. He then underwent neoadjuvant chemotherapy. He also has a horseshoe kidney, making the case more complex than a regular nephroureterectomy. Patient underwent single port robotic assisted laparoscopic right nephroureterectomy with bladder cuff. RESULTS: A single 25mm incision was made supraumbilically for the robotic instruments. No assistant port was used, making this a true single port procedure. The remotely operated suction irrigation system (ROSI) was used not only for suction but dissection as well. The operative time for the case was 187 minutes. Estimated blood loss was 150cc. The patient was discharged within 18 hours of surgery with a foley catheter and no need for post op narcotic use. Even though there is limited space underneath the liver, we were able to work underneath the liver without the use of a liver retractor by using the elbow of our 4th arm to hold it up. We use the “Relocate” function of the SP Robot to perform our distal ureterectomy and bladder cuff portion, preventing the need to re-dock the robot. We performed multiple procedures with one incision: partial nephrectomy, distal ureterectomy with bladder cuff and lymphadenectomy. At our institution, we have performed seven robotic single port nephroureterectomies. Average operating time is 126 minutes, estimated blood loss 92cc and average length of stay is 1.8 days. CONCLUSIONS: The use of the Da Vinci Single Port robot can make increasingly complex cases even more minimally invasive. This can reduce post-operative pain, improve cosmesis and shorten hospital stay. However there is a learning curve in the use of the Da Vinci SP robot. We hope to improve our techniques and surgical approaches further to keep our procedures as minimally invasive as possible. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e808 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Sheng More articles by this author Chrystal Chang More articles by this author Michael Stifelman More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF DownloadLoading ...

Crime of Encouraging the Use of Narcotics on Social Networks

Crime of Encouraging the Use of Narcotics on Social Networks

Intrathecal Fentanyl With a Myofascial Plane Block in Open Lumbar Surgeries: A Case Series.

Acute postoperative pain control after lumbar surgery is imperative to minimizing long-term narcotic use and associated adverse sequela. The safety of intrathecal morphine for postoperative pain management in spine surgery has been investigated; however, to date, no studies have investigated the safety of intrathecal fentanyl with a myofascial plane (MP) block in lumbar procedures. To assess the safety profile of intrathecal fentanyl with a MP block administered during lumbar surgery and the subsequent utilization of postoperative intravenous opioids. An intraoperative intrathecal injection of fentanyl and a MP block was administered in 40 patients undergoing open lumbar reconstructive surgery. The procedure performed was an open decompression with lumbar total joint reconstruction at 1 to 3 lumbar levels. Postoperative complications including urinary retention, respiratory depression, and need for IV opioid use were recorded. Postoperatively, none of the study patients required IV opioid medication for supplemental pain control. Thirty-six patients (85%) were discharged same day or before 23 hours postoperatively. No intrathecal fentanyl-related perioperative complications were noted. None of the 40 listed patients experienced urinary retention or delayed respiratory depression. One patient (2%) experienced orthostatic hypotension at postoperative day 1, which resolved on discontinuation of oral oxycodone. Intrathecal fentanyl and MP block may be a safe option for perioperative pain control and may reduce the need for supplemental intravenous opioids without increased risk of respiratory depression, urinary retention, or other side effects. Further studies are necessary to compare the efficacy of intrathecal fentanyl with other analgesia techniques.

A Practical Guide to Lower Extremity Nerve Blocks for the Sports Medicine Surgeon

Background: Peripheral nerve blocks (PNBs) are vital in the administration of surgical analgesia and have grown in popularity for use in lower extremity arthroscopic procedures because of their capacity to safely and effectively control pain. The number and specificity of PNBs, however, have made choosing the best option for a procedure nebulous for orthopaedic surgeons. Purpose: To present a narrative literature review of the PNBs available for arthroscopic hip and knee procedures that is adapted to an audience of orthopaedic surgeons. Study Design: Narrative literature review. Methods: A combination of the names of various lower extremity PNBs AND “hip arthroscopy” OR “knee arthroscopy” was used to search the English medical literature including PubMed, Cochrane Library, ScienceDirect, Embase, and Scopus. Placement technique, specificity of blockade, efficacy, and complications were assessed. Searches were performed through May 2, 2021. Results: A total of 157 studies were included in this review of lower extremity PNBs. Femoral nerve, lumbar plexus, sciatic nerve, and fascia iliaca compartment blocks were most commonly used in arthroscopic hip surgery, while femoral nerve, 3-in-1, and adductor canal blocks were preferred for arthroscopic knee surgery. Each block demonstrated a significant benefit (P > .05) in ≥1 of the following outcomes: intraoperative morphine, pain scores, nausea, and/or opioid consumption. Combination blocks including the lateral femoral cutaneous nerve block, obturator nerve block, quadratus lumborum block, and L1 and L2 paravertebral block have also been described. Complication rates ranged from 0% to 4.8% in those administered with ultrasound guidance. The most commonly reported complications included muscular weakness, postoperative falls, neuropathy, intravascular and intraneural injections, and hematomas. Conclusion: When administered properly, PNBs were a safe and effective adjuvant method of pain control with a significant potential to limit postoperative narcotic use. While blockade choice varies by surgeon preference and procedure, all PNBs should be administered with ultrasound guidance, and vigilant protocols for the risk of postoperative falls should be exercised in patients who receive them.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.

Prospective randomized trial of metal versus resorbable plates in surgical stabilization of rib fractures.

Surgical stabilization of rib fractures has gained popularity as both metal and resorbable plates have been approved for fracture repair. Is there a difference between metal and resorbable plate rib fixation regarding rib fracture alignment, control of pain, and quality-of-life (QOL) scores (Rand SF-36 survey)? Eligible patients (pts) included 18 years or older with one or more of the following: flail chest, one or more bicortical displaced fractures (3-10), nondisplaced fractures with failure of medical management. Patients were randomized to either metal or resorbable plate fixation. Primary outcome was fracture alignment. Secondary outcomes were pain scores, opioid use, and QOL scores. Thirty pts were randomized (15 metal/15 resorbable). Total ribs plated 167 (88 metal/79 resorbable). Patients with rib displacement at day of discharge (DOD) metal 0/14 (one pt died, not from plating) versus resorbable 9/15 or 60% ( p = 0.001). Ribs displaced at DOD metal 0/88 versus resorbable 22/79 or 28% ( p < 0.001), 48% in posterior location. Patients with increased rib displacement 3 months to 6 months: metal, 0/11 versus resorbable, 3/9 or 33% ( p = 0.043). Ribs with increased displacement 3 months to 6 months metal 0 of 67 versus resorbable 6 of 49 or 12.2% ( p < 0.004). Pain scores and narcotic use at postoperative Days 1, 2, 3, DOD, 2 weeks, 3 months and 6 months showed no statistically significant difference between groups. QOL scores were also similar at 3 months and 6 months. Trauma recidivism in outpatient period resulted in fracture of resorbable plates in two pts requiring a second surgery. Metal plates provided better initial alignment with no displacement over time. Clinical outcomes were similar regarding pain, narcotic use, and QOL scores. Routine use of resorbable plates for posterior rib fractures is not warranted. Lateral repairs were technically most feasible for using resorbable plates but still resulted in significant displacement. Resorbable plates may not maintain rib alignment when exposed to subsequent injury. Therapeutic/Care Management; Level II.