|By Kelly Young
People whose family members have opioid prescriptions face increased risk for opioid overdose themselves, according to a case-control study in JAMA Internal Medicine.
Using claims data from 2004 to 2015, researchers matched roughly 2300 people with opioid overdose to 9200 controls without overdose. Having a family member with a prior opioid prescription was associated with nearly triple the odds of overdose. Additionally, the overdose odds increased when more opioids were prescribed. Children aged 0 to 12 years had a fourfold increase in overdose risk when a family member had a prescription, but risk was increased across most age groups.
The authors conclude: “Interventions may focus on opioid dispensing limits, encouraging patients to properly dispose of prescription opioids after use, enhancing patient and public education, and using secure medication storage boxes to limit the risk of opioid overdose among other household family members. Treating and preventing opioid overdose events at the family level, as well as expanding access to opioid antagonists, should also be considered.”
AUTHORS: Brovman, Ethan Y. MD et al
METHODS: We conducted a propensity-matched, retrospective cohort study of hospitalized patients. We used the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) dataset to identify patients undergoing surgical correction of low velocity orthopedic lower extremity traumas between 2011 and 2016. Patients were separated into 2 groups based on anesthesia type (RA/NA versus GA). The primary outcome was 30-day mortality. Secondary outcomes included return to the operating room, failure to wean from the ventilator, intubation, pneumonia, acute kidney injury, myocardial infarction, transfusion, venous thromboembolism (VTE), urinary tract infection, sepsis, length of stay, days from operation to discharge, number of complications, and unplanned readmission.
RESULTS: We identified 18,467 patients undergoing surgical repair of lower extremity fractures. Approximately 9.58% had RA/NA and 89.9% had GA as their primary anesthetic. After 1:1 propensity matching, the final cohort had 3254 patients. Our analysis did not find a difference in 30-day mortality between the 2 groups. There were also no significant differences in secondary outcomes.
CONCLUSIONS: Despite the potential advantages of RA/NA, utilization for lower extremity trauma was low in our analysis; only 9.58% of patients were in the RA/NA group, with the majority receiving spinal anesthesia. This may be due to surgeon preference to allow for postoperative monitoring for neurologic injury and compartment syndrome or logistical factors given the urgent nature of these trauma cases. No significant differences in 30-day mortality and postoperative complications were found between RA/NA and GA for patients with lower extremity orthopedic fractures. The choice of anesthesia is multifactorial and may be driven by patient and provider preferences in these operations.
AUTHORS: Subedi, Asish MD et al
METHODS: This prospective, double-blind, randomized controlled study enrolled 180 patients requiring general anesthesia with endotracheal intubation for >90 minutes. They received 1 of the 4 intravenous agents just before induction of anesthesia: lidocaine (1.5 mg/kg–) in group L, dexamethasone (8 mg) in group D, lidocaine (1.5 mg/kg) with dexamethasone (8 mg) in group DL, and placebo as normal saline in group NS. Standard anesthesia protocol was followed. Incidence and severity of a sore throat, cough, and hoarseness of voice were assessed up to 24 hours postoperatively. The primary outcome was the incidence of POST, and the main effects of dexamethasone and lidocaine were the primary interest.
RESULTS: Data of 45 patients in D, 44 in L, 44 in DL, and 43 in NS groups were analyzed. The incidence of a sore throat was 36%, 43%, 25%, and 56% in group D, L, DL, and NS, respectively (P = .02). Dexamethasone with or without lidocaine reduced the incidence of the POST (odds ratio, 0.44; 95% confidence interval, 0.24–0.82; P < .01). However, lidocaine was not effective in reducing POST (odds ratio, 0.62; 95% confidence interval, 0.33–1.14; P = .12). No difference was observed in the severity of a sore throat, incidence and severity of a cough, and hoarseness among the groups.
CONCLUSIONS: Dexamethasone, with or without lidocaine, was effective in reducing the incidence of POST in patients requiring prolonged tracheal intubation.
AUTHORS: Burjek, Nicholas E. MD et al
BACKGROUND: Preoperative pulmonary function tests are routinely obtained in children with scoliosis undergoing posterior spinal fusion despite unclear benefits as a perioperative risk assessment tool and frequent inability of patients to provide acceptable results. The goal of this study was to determine whether preoperative pulmonary function test results are associated with the need for postoperative intubation or intensive care unit admission after posterior spinal fusion.
METHODS: The electronic medical records of patients who underwent posterior spinal fusion at a pediatric tertiary hospital between June 2012 and August 2017 were reviewed. Pulmonary function tests were consistently ordered for all patients, unless the patient was deemed unable to perform the test due to cognitive disability. Cases were categorized as primary or secondary scoliosis.
Demographic data, preoperative bilevel positive airway pressure use, Cobb angle, intraoperative allogeneic blood transfusion, and ability to produce acceptable pulmonary function test results were collected for each patient. In patients with satisfactory pulmonary function test results, forced vital capacity and maximum inspiratory pressure were collected. Primary outcomes for analysis were postoperative intubation and intensive care unit admission. Univariable logistic regression models were used to assess the association between each variable of interest and the primary outcomes.
RESULTS: The study sample included 433 patients, 288 with primary scoliosis and 145 with secondary scoliosis. Among patients with primary scoliosis, 90% were able to produce acceptable pulmonary function test results, zero remained intubated postoperatively, and 6 were admitted to the intensive care unit. Among patients with secondary scoliosis, 44% could not attempt pulmonary function tests. Among those who did attempt the test, 30% were unable to produce meaningful results. Forced vital capacity and maximum inspiratory pressure were not found to be associated with postoperative intubation or intensive care unit admission. Weight, Cobb angle, intraoperative blood transfusion, American Society of Anesthesiologists physical status classification, and preoperative bilevel positive airway pressure use were associated with patient outcomes. Among 357 total patients who attempted pulmonary function tests, 37 had high-risk results. Only 1 of these 37 patients remained intubated postoperatively.
CONCLUSIONS: Patients undergoing posterior spinal fusion, especially those with secondary scoliosis, are frequently unable to adequately perform pulmonary function tests. Among patients with interpretable pulmonary function tests, there was no association between results and postoperative intubation or intensive care unit admission. Routine pulmonary function testing for all patients with scoliosis may not be indicated for purposes of risk assessment before posterior spinal fusion. Clinicians should consider a targeted approach and limit pulmonary function tests to patients for whom results may guide preoperative optimization as this may improve outcomes and reduce inefficiencies and costs.
AUTHORS: Liu, Lifei MD et al
METHODS: Sixty term neonates undergoing major abdominal surgery were randomized into the ultrasound or palpation group via the sealed-envelope method. The ultrasound group underwent radial artery cannulation using an ultrasonic apparatus, while traditional palpation of arterial pulsation was used in the palpation group. The arterial diameter and depth were measured on ultrasound before the puncture. We recorded age, weight, sex, and other background characteristics. The primary outcomes included the first-attempt, total success rates, and the total puncture procedure duration. Secondary outcomes included the incidence of complications (hematoma and thrombosis). Data were compared between the 2 groups.
RESULTS: Sixty term neonates were enrolled in the study. The success rates of the first attempt in the ultrasound and palpation groups were 40% (n = 30) and 10% (n = 30), respectively (P = .007; relative risk, 4.0; 95% confidence interval, 1.3–12.8). The total success rate was 96.7% in the ultrasound group and 60.0% in the palpation group (P = .001; relative risk, 1.61; 95% confidence interval, 1.19–2.17). The average time to accomplish radial artery cannulation in the ultrasound and palpation groups was 91.4 ± 55.4 and 284.7 ± 153.6 seconds, respectively (P < .001; estimated difference, −193; 95% confidence interval, −256 to −130). In addition, 3.3% of the patients in the ultrasound group and 26.7% in the palpation group suffered puncture hematoma (P = .026; relative risk, 0.13; 95% confidence interval, 0.02–0.94).
CONCLUSIONS: Modified dynamic needle tip positioning short-axis, out-of-plane, ultrasound-guided radial artery cannulation in neonates improves the first-attempt and total success rates and decreases the total procedural time and incidence of cannulation-related complications.
By Amy Orciari Herman
Roughly 1 in 14 older adults undergoing noncardiac surgery experiences a perioperative covert stroke, and these patients face increased risk for cognitive decline, according to an international study in The Lancet.
Over 1000 adults aged 65 and older undergoing elective, noncardiac surgery had cognitive assessments before their surgery, brain MRI 2 to 9 days after surgery, and then repeat cognitive assessments at 1 year. MRI identified covert stroke in 7% of participants.
Cognitive decline at 1 year — defined as a 2-point drop on the 30-point Montreal Cognitive Assessment — occurred in 42% of patients who had a covert stroke and 29% who did not. After multivariable adjustment, covert stroke was associated with a twofold increase in risk for cognitive decline. Risk for perioperative delirium was also doubled in those with covert stroke.
Author: Amy Orciari Herman
The rate of hepatitis C virus (HCV) infection among pregnant women at delivery increased from 0.8 to 4.1 per 1000 deliveries from 2000 to 2015, according to an analysis of national healthcare data in MMWR.
HCV rates were highest among women with opioid use disorder, increasing from 87 to 217 per 1000 deliveries. Still, among those without opioid use disorder, the rate increased significantly from 0.7 to 2.6 per 1000.
Women aged 25 to 34 (vs. older women), those on Medicaid or Medicare (vs. private insurance), and those living in the Northeast (vs. West) were more likely to have diagnoses of both opioid use disorder and HCV infection.
The authors write, “Treatment of opioid use disorder should include screening and referral for related conditions such as HCV infection.”
AUTHORS: Singh, Shubhangi MD et al
METHODS: Demographic data, details of anesthetic management, blood pressure measurements, and vasopressor requirement preceding delivery were compared between transient tachypnea newborns (n = 30) and healthy neonates (n = 151) with normal respiratory function born via elective cesarean delivery between July 2015 and February 2016. The degree and duration of hypotension were assessed using area under the curve for systolic blood pressure (SBP) ≤90 mm Hg and area under the curve for mean arterial pressure ≤65 mm Hg. After adjusting for confounders, multivariable logistic regression was used to evaluate the association between area under the curve for SBP and transient tachypnea of newborns.
RESULTS: The median area under the curve for SBP was higher in cases of transient tachypnea of newborns (0.94; interquartile range, 0–28.7 mm Hg*min) compared to healthy controls (0; interquartile range, 0–3.30 mm Hg*min; P = .001). Similarly, median area under the curve for mean arterial pressure was also higher in cases of transient tachypnea of newborns (0; interquartile range, 0–18.6 mm Hg*min) compared to controls (0; interquartile range, 0–1.1 mm Hg*min; P = .01). Mothers of transient tachypnea newborns received significantly higher amounts of phenylephrine and ephedrine compared to controls (P = .001 and 0.01, respectively). Hence, the total vasopressor dose given to mothers in the transient tachypnea of newborn group was much higher than for the control group (P = .001). In the multivariable logistic regression, area under the curve for SBP was significantly associated with transient tachypnea of newborns (odds ratio, 1.02; 95% CI, 1.01–1.04, P = .005) after adjusting for gravidity and the type of anesthetic (spinal versus combined spinal epidural).
CONCLUSIONS: Our results suggest that the degree and duration of maternal SBP <90 mm Hg after neuraxial anesthesia during elective cesarean delivery are associated with transient tachypnea of newborns. Future prospective studies should further explore the effects of maternal hypotension, its prevention, and treatment for transient tachypnea of newborns.
AUTHORS: Tadokoro, Takahiro MD et al
METHODS: In this study, 58 women who were scheduled for cesarean delivery under spinal and epidural anesthesia were recruited. Patients were randomly assigned to a control or treatment group. In the control group, the catheter was fixed solely by film dressing. In the treatment group, a small amount of Aron Alpha A was applied at 2 sites along the catheter. The fixation area was then covered by film dressing. The catheter insertion length was recorded after fixation (T0), immediately postoperatively (T1), on postoperative day 1 (T2), and when the catheter was removed (T3). The change in insertion length from T0 to T3 between the 2 groups was the primary outcome measure. The incidence of catheter failure was also recorded. For all comparisons, P < .05 was considered statistically significant.
RESULTS: Initially, 58 women were enrolled; however, 3 patients were excluded. From the remaining 55 patients, 27 and 28 were assigned to the control and treatment groups, respectively, and were evaluated. The change in insertion length from T0 to T3 was significantly more in the control group compared with the treatment group (−1.9 ± 2.2 vs 0 ± 0 cm, respectively; P < .001). In the control group, 11 catheters (41%) failed; in the treatment group, all catheters provided effective analgesia throughout the study (P < .001).
CONCLUSIONS: Epidural catheter fixation using film dressing combined with 2-ethyl cyanoacrylate adhesive application at 2 sites along the catheter resulted in secure fixation in patients receiving postoperative epidural analgesia for cesarean delivery.
AUTHORS: Li, Mengzhu MD et al
METHODS: Parturients with a body mass index (BMI) ≥30 kg/m2 scheduled for elective cesarean delivery were randomized to undergo spinal anesthesia using the conventional landmark location technique (landmark group, n = 40) or prepuncture ultrasound examination (ultrasound group, n = 40). All participants underwent spinal anesthesia in the lateral position. The primary outcome was the first-attempt success rate. Secondary outcomes were the number of skin punctures and needle passes, procedure times, patient satisfaction, changes in the intended interspace, and incidence of complications.
RESULTS: The ultrasound group had a significantly higher first-attempt success rate (87.5% vs 52.5%; P = .001), fewer cases requiring >10 needle passes (1 vs 17; P < .001), and fewer skin punctures and needle passes (P < .001 for both). There was no statistically significant difference in the time taken to identify the needle insertion site between the 2 groups (202.5 vs 272.0 seconds; P = .580). Both the spinal injection time and total procedure time were significantly longer in the landmark group (P < .001). Patient satisfaction scores were significantly higher in the ultrasound group (P = .001). Among patients with BMI between 30 and 34.9 kg/m2, there was no statistically significant difference in the first-attempt success rate (P = .407), number of cases with >10 needle passes (P = .231), spinal injection time (P = .081), or total procedure time (P = .729); however, more time was required to identify the needle insertion site in the ultrasound group (P < .001). For patients with BMI between 35 and 43 kg/m2, the ultrasound group had a significantly higher first-attempt success rate (P ≤ .041), fewer cases with >10 needle passes (P ≤ .01), and shorter procedure times, including the time required to identify the needle insertion site (P < .001).
CONCLUSIONS: Prepuncture ultrasound examination can facilitate spinal anesthesia in the lateral position in obese parturients (35 kg/m2 ≤ BMI ≤ 43 kg/m2) by improving the first-attempt success rate, reducing the number of needle passes and puncture attempts, shortening the total procedure time, and improving patient satisfaction.