Readmissions For Pain Control Research Articles

Exceptional Cases of Spinal Cord Stimulation for the Treatment of Refractory Cancer-Related Pain

ObjectivesCancer pain has traditionally been managed with opioids, adjuvant medications, and interventions including injections, neural blockade, and intrathecal pump (ITP). Spinal cord stimulation (SCS), although increasingly used for conditions such as failed back surgery syndrome and complex regional pain syndrome, is not currently recommended for cancer pain. However, patients with cancer-related pain have demonstrated benefit with SCS. We sought to better characterize these patients and the benefit of SCS in exceptional cases of refractory pain secondary to progression of disease or evolving treatment-related complications. Materials and MethodsThis was a single-center, retrospective case series at a tertiary cancer center. Adults ≥18 years old with active cancer and evolving pain secondary to disease progression or treatment, whose symptoms were refractory to systemic opioids, and who underwent SCS trial followed by percutaneous implantation between 2016 and 2021 were included. Descriptive statistics included mean, SD, median, and interquartile range (IQR). ResultsEight patients met the inclusion criteria. The average age at SCS trial was 60.0 (SD: ±11.6) years, and 50% were men. Compared with baseline, the median (IQR) change in pain score by numeric rating scale (NRS) after trial was −3 (2). At an average of 14 days after implant, the median (IQR) change in NRS and daily oral morphine equivalents were −2 (3.5) and −126 mg (1095 mg), respectively. At a median of 63 days after implant, the corresponding values were −3 (0.75) and −96 mg (711 mg). There was no significant change in adjuvant therapies after SCS implantation at follow-up. Six patients were discharged within two days after implantation. Two patients were readmitted for pain control within the follow-up period. ConclusionsIn patients with cancer-related pain, SCS may significantly relieve pain, reduce systemic daily opioid consumption, and potentially decrease hospital length of stay and readmission for pain control. It may be appropriate to consider an SCS trial before ITP in select cases of cancer-related pain.

Total Ankle Arthoplasty as a Day Case Surgery: How Safe and Effective it is?

Category:Ankle ArthritisIntroduction/Purpose:Outpatient total joint arthroplasty (OTJA) allows for a safe, cost effective pathway for appropriately selected patients. Total ankle arthroplasty (TAA) is a surgical procedure commonly used for patients with painful arthritis. As the number of TAA procedures increase, so does the associated economic burden. The purpose of this study was to evaluate patients undergoing total ankle arthroplasty, who were discharged on the same day as undergoing surgery. These patients have stayed in the hospital for <12 hours, and are referred to as ‘‘outpatients.’’ Outpatients were evaluated with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission). We also assessed patients’ satisfaction regarding discharge on the same day as surgery.Methods:The medical records of 46 consecutive TAA outpatients from July 2018 to June 2019 with a minimum 1 month post- operative follow-up, were reviewed. All patients received an Integra Cadence TAA. Prior to surgery, all patients received popliteal blocks. Patients were discharged home with a popliteal catheter, which they were to remove themselves after 48 hours. After removal of the catheter, patients were prescribed oral pain medication to help with any pain or discomfort. The following data was collected: demographics, comorbidities, (ASA) class, and perioperative complications, including wound breakdown, infection, revision and non-revision surgeries. At their 1-month post-operative visit, patients completed a questionnaire regarding their satisfaction post-surgery, which consisted of six questions.Results:There were no readmissions for pain control, no signs of wound infection among the 46 outpatients. All patients were ‘very satisfied’ with the surgical procedure and with recommend methods of pain control. The majority of patients were also very satisfied with discharge on the same day as surgery with the exception of patients who would have liked to stay overnight. When asked if they would recommend the care they experienced to a friend with the same condition, 46 patients said that they would definitely recommend this process to a friend. In terms of rating their pain on a scale of 0-10 (0 being no pain, 10 being worst pain imaginable), the average score for the 46 patients was 2.03.Conclusion:Our study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory outpatient experience and no readmissions for pain control.

Combined Popliteal Catheter with Single Injection Versus Continuous Infusion Saphenous Nerve Block

Category: Ankle, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: Surgical and analgesic advancements have increasingly allowed more foot and ankle procedures to be performed on an outpatient basis. Dual nerve blockade of saphenous and popliteal nerves minimizes post-operative pain, and continuous infusion via catheter can provide extended pain relief. In our experience, the combination of popliteal nerve catheters and single-shot saphenous nerve block effectively eliminates post-operative pain after most foot and ankle surgery. However, the early return of pain in the saphenous nerve distribution can cause early discomfort and even readmission for pain control. We hypothesized that patients receiving continuous popliteal nerve infusion with single-injection saphenous nerve block (single) will have greater post-operative pain than those patients receiving continuous popliteal and saphenous nerve infusion (dual). Methods: A cohort of 62 patients undergoing outpatient foot and ankle surgery by a single fellowship trained orthopaedic surgeon were prospectively, sequentially enrolled. The surgeon rated each procedure for degree of saphenous involvement as limited, moderate, or extensive. Demographics, American Society of Anesthesiologists physical status classification system (ASA), anesthesia time and post-anesthesia care unit (PACU) time were documented. Total analgesia requirement and reported numeric pain score (NPS) at rest and with activity were recorded. Student’s t-test and chi-square test were utilized for single and dual block comparisons, and one-way ANOVA tested for differences in saphenous involvement. Results: The dual catheter group took significantly less opioid medication on post-operative day (POD) 1 compared to the single catheter group (Table 1; p=0.02). The dual catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 (p=0.03) and a significantly lower NPS at POD 1 and POD 2 (p=0.005). This trend is observed in all 3 subgroups of medial involvement. Patients in the single catheter group report about twice as much pain as patients in the dual catheter group when medial involvement was limited (7.4 v 3.8; p=0.033) or moderate (5.9 v 3.4; p=0.025). For patients with extensive medial involvement, pain was reduced when dual blocks were employed (5.4 v 6.7), but this difference was not significant (p=0.288). Conclusion: Patients in the single catheter group reported more pain and less satisfaction with pain control on POD 1, suggesting dual catheter use is superior to managing early post-operative pain in outpatient foot and ankle surgery. Interestingly, degree of medial involvement did not seem to correlate with better pain control within the dual group; in contrast, patients with less medial involvement reported better pain relief with dual than with a single catheter. From a pain management perspective, discharging patients on the day of routine outpatient foot and ankle surgery is appropriate with the judicious use of perioperative continuous infusion nerve catheters.

Outpatient-Focused Joint Arthroplasty Is the Future: The Midwest Center for Joint Replacement Experience

BackgroundPerhaps, the most significant developments in joint arthroplasty in the past decade have been in the area of multimodal perioperative management reducing pain, nausea, and length of stay leading to outpatient arthroplasty. MethodsOver a 2-year period, we performed 1230 arthroplasty cases including partial knee, total hip, total knee, and selected revision cases. ResultsPatient satisfaction ranged from 98% to 100% great/good. Ninety-eight percent of patients were discharged the same day. There were no readmissions for pain control and an overall readmission rate of 2%. ConclusionThe outpatient program centers on the patient needs, family engagement, essentials of home recovery, preoperative education, efficient surgery, and a surgeon-controlled environment with a highly standardized care. This is a distinct shift in today's health-care environment, which has seen the expansion of regulatory demands; focus on Electronic Health Record, and distractions from real discussions of demonstrated value creation. The future is bright for both ambulatory surgery center and hospital development of successful outpatient joint arthroplasty program for patients and surgeons alike.

A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates. The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months). There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis. This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management. Level IV, retrospective case series.

Oxford Partial Knee Replacement as a Gateway to Outpatient Arthroplasty “Lessons Learned along the Journey”

The Oxford Partial Knee Replacement was approved for implantation in the US in 2004 after the surgeon completed an educational training requirement. Since then my knee practiced has expanded to over 50% partial knee. This experience coupled with refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated the transformation to same day discharge for partial knee cases and has quickly transitioned to total hip, total knee, and selected revision surgeries. Patient selection has also expanded for outpatient joints and is now based on medical screening criteria and insurance access. Over a two-year period we have performed over 1,000 outpatient arthroplasty procedures with no readmissions for pain control. Overall readmission rate for all reasons was 2%. Patient satisfaction scores were 98% Great-Good for 2014-15. The combination of a partial knee replacement practice and an outpatient joint program brings the best VALUE to the patients, surgeons, and the arthroplasty system and represents the future of arthroplasty care.

Abstract P2-12-18: Outpatient mastectomy with reconstruction in a freestanding surgery center using multimodality opiod-sparing perioperative analgesia including liposomal bupivacaine

Abstract HYPOTHESIS: The introduction of effective non-narcotic analgesics and the long-acting local anesthetic bupivacaine liposome (Exparel) has resulted in improved postoperative pain control and decreased reliance on opioid analgesics that often have the undesirable adverse effects of sedation, nausea, respiratory depression, and dysphoria or confusion. This has resulted in shorter postoperative care unit stays, earlier return to normal activity, and improved patient satisfaction without sacrificing appropriate pain control. Based on a positive experience with these agents in the inpatient setting, we hypothesized that mastectomy with immediate implant-based reconstruction could be performed safely in a freestanding outpatient surgery center using a multimodality opioid-sparing analgesic regimen. METHOD: Over a 6 month period we performed unilateral or bilateral mastectomy with concurrent implant-based reconstruction on 20 patients. One patient had a unilateral mastectomy and 19 patients had bilateral mastectomy performed. Sixteen of the patients had nipple sparing mastectomy procedures. Reconstruction was performed with tissue expanders in 6 patients and as a single stage procedure with silicone gel implants in 14 patients. Acellular dermal matrix was used to support the implant in all but 1 patient. All patients were given gabapentin 600mg on the evening prior to and morning of surgery. Acetaminophen 1gm IV was given prior to induction of anesthesia in the preoperative area and again 6 hours later in the post anesthesia care unit. Ketorolac 30mg IV was given during the last half of the surgical procedure. All patients had general anesthesia with standard inhalational agents and IV fentanyl as needed. The retropectoral and serratus fascia were infiltrated with liposomal bupivacaine after surgical removal of the breast tissue, before reconstruction was started. The drain sites were also infiltrated with liposomal bupivacaine. Patients were discharged with prescriptions for gabapentin 300mg twice daily for 7 days followed by 300mg nightly for 7 days, carisoprodol 350mg every 6 hours as needed for muscle spasms, ibuprofen 800 mg every 8 hours for 5 days, hydrocodone/acetaminophen every 4 hours as needed for pain, and oral antibiotics of the surgeon's choice. RESULTS: All 20 patients completed their surgery and were discharged home after a brief stay in the postoperative care unit. No patient required readmission for pain control or any other complication in the perioperative period. No patient reported inadequate pain control. All patients were highly satisfied with their perioperative care as reported during postoperative follow-up phone calls the day after surgery and during their post-operative follow up visit. CONCLUSION: In our experience, outpatient mastectomy with reconstruction in a freestanding surgery center is safe and has a high degree of patient satisfaction when using a multimodality opioid-sparing analgesia regimen including liposomal bupivacaine. By avoiding opioid-related adverse effects, patients have a more rapid recovery, earlier return to activities of daily living, and therefore improved quality of life. Proper patient selection requires a multidisciplinary team approach for success. Citation Format: Rock DT, Jandik AL, Wittenborn WS, Fairfax K, Sandadi S. Outpatient mastectomy with reconstruction in a freestanding surgery center using multimodality opiod-sparing perioperative analgesia including liposomal bupivacaine. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-18.

Provision of a Mobile Uterine Artery Embolization Service to Medically Underserved Areas in Brazil

Purpose To determine the feasibility, efficacy, and safety of a mobile uterine artery embolization (UAE) program for patients in medically underserved, socioeconomically deprived areas. Materials and Methods One hundred women with symptomatic uterine leiomyomas were treated with UAE. A small truck containing a mobile c-arm and all needed supplies visited one hospital per week during a 6-month period. Four public hospitals were visited in rotation. Pre- and postprocedural magnetic resonance (MR) imaging and validated quality of life (QOL) questionnaires were obtained, and procedural details and complications were recorded. Results Technical success was achieved in 97 of 100 women. Mean procedure time was 41 minutes (range, 15–140 min) and mean fluoroscopy time was 17 minutes (range, 6–45 min). Mean hospital stay was 1.03 days (range, 1–3 d) and mean time to resumption of normal activities was 8.2 days (range, 2–20 d). At 12 weeks, 88% of patients noted symptomatic improvement and 98% stated they would recommend the procedure to other women. Complete tumor ischemia was seen on postprocedural MR imaging in 92% of women, with a mean uterine volume reduction of 36.3% (range, −4.3% to 65%) and a mean tumor volume reduction of 57.1% (range, −23.4% to 95.8%). Health-related QOL scores increased from 41.4 points before UAE to 81.2 points at 12 weeks and 85.3 points at 1 year after UAE. Complications were recorded in seven women (7%): three puncture site hematomas, three readmissions for pain control, and one case of leiomyoma passage. Conclusions A mobile interventional radiology unit is a feasible, efficient, and safe method to provide UAE to an underserved patient community. Outcomes and complications are similar to published results from centers with conventional angiographic facilities.

Adult tonsillectomy: Current indications and outcomes

Limited data exist with respect to the current prevalence of indications for tonsillectomy in adults. We sought to determine the indications for adult tonsillectomy and to identify factors associated with postoperative complications. The medical records of 361 adult patients who underwent tonsillectomy from 2001 to 2007 were reviewed. Indications for surgery were chronic infection in 207 (57%) patients, upper airway obstruction secondary to tonsillar hypertrophy in 98 (27%) patients, and suspected neoplasm in 56 (16%) patients. Postoperative complications occurred in 54 (15%) cases with hemorrhage in 19 (5%) patients, followed by dehydration in 16 (4%) patients, and admission for postoperative oxygen desaturations in 9 (3%) patients. Hospitalization beyond 24 hours occurred in 18 (5%) cases, with emergency room visits for pain and dehydration in 16 (4%) patients, and readmission for pain control in 17 (5%) cases. Patients who underwent tonsillectomy for upper airway obstruction had an increased incidence of prolonged hospitalization or readmission (19% vs 6%; P = 0.01), whereas patients who underwent tonsillectomy for infection had an increased incidence of postoperative bleeding (6% vs 4%; P = 0.02). Chronic infection remains the most common indication for adult tonsillectomy in contrast to the pediatric population. Complication rates vary according to the indication for surgery.

Adult Tonsillectomy: Current Indications and Outcomes

Objective With increased antibiotic usage, the indications for pediatric tonsillectomy have shifted from infection to treatment of airway obstruction. Limited data exists regarding the current prevalence of indications for tonsillectomy in adults. We sought to determine the indications for tonsillectomy in an adult population and identify factors associated with postoperative complications. Methods The medical records of all adult patients (18 or more years of age) who underwent tonsillectomy from 2001–2007 were reviewed. Patients who underwent concurrent procedures were excluded. Results A total of 361 patients met study criteria. Indications for surgery were chronic infection in 207 patients (57%), upper airway obstruction secondary to tonsillar hypertrophy in 98 patients (27%), and suspected neoplasm in 56 patients (16%). Postoperative complications occurred in 54 cases (15%) with hemorrhage in 19 patients (5%), followed by pain and dehydration in 16 patients (4%) and admission for postoperative oxygen desaturations in 11 patients (3%). Hospitalization beyond 24 hours occurred in 18 cases (5%), with emergency room visits for pain and dehydration in 16 patients (4%), and readmission for pain control in 17 cases (5%). Patients who underwent tonsillectomy for upper airway obstruction had an increased incidence of prolonged hospitalization or readmission (19% vs. 6%; P=0.01), while patients who underwent tonsillectomy for infection had an increased incidence of post-operative bleeding (6% vs. 4%; p=0.02). Conclusions Chronic infection remains the most common indication for adult tonsillectomy, in contrast to the pediatric population. Complication rates vary according to the indication for surgery. These data may provide useful information for preoperative counseling.

Hemorrhoidopexy Staple Line Height Predicts Return to Work

Previous studies identified reduction in pain and complications with stapled hemorrhoidopexy relative to conventional hemorrhoidectomy. Previously, the presence of resected squamous epithelium and a staple line height <20 mm above the dentate line were predictive of postoperative pain. The purpose of this study was to further investigate and refine the role of staple height in the prediction of postoperative outcomes. From July 2002 to October 2004, 75 patients with symptomatic Grade 3 and 4 mixed hemorrhoids underwent stapled hemorrhoidopexy in two teaching institutions with prospective data collection. All procedures were performed under the direct supervision of two colorectal teaching staff. The majority were performed under monitored anesthesia care as outpatient procedures. Preoperative, intraoperative, and postoperative patient characteristics were evaluated. This included demographics, staple line height, specimen histology, complications, days to return to work, duration of narcotic pain medicine, and preoperative/postoperative tone and seepage. The results were subjected to statistical analysis using t-test and ANOVA. Seventy-five patients with a median age of 49 (range, 25-87) years were identified. Histology identified 62 specimens with columnar and/or transitional cells, 10 with squamous epithelium, and 3 with muscle present. Overall complication rate was 14 percent. Complications included three readmissions for pain control, three acute postoperative anal fissures, two postoperative bleeds (with one requiring examination under anesthesia without intervention), one patient with subcutaneous emphysema, and one admission for fecal impaction. Staple line height was not a statistically significant predictor of postoperative complication. Median return to work was 14 (range, 1-31) days. Median duration of narcotic use was six (range, 0-40) days. Patients with a staple line height>22 mm required a significantly shorter duration of narcotic pain management (P=0.024). Median follow-up was 24 (range, 9-253) days. Staple line heights below 20 mm had a mean return to work of 15 days. A staple line height>20 mm had a mean return to work of nine days. Staple line height was inversely related to return to work (P=0.01). A hemorrhoidopexy staple line>or=22 mm above the dentate line correlates with a significantly shorter need for postoperative narcotics (P=0.024) and an earlier return to work (P=0.017). Staple line distance above the dentate line meaningfully impacts comfort-based outcomes.