Perioperative Medication Management Publications (1039)


Perioperative Medication Management Publications

Spine (Phila Pa 1976) 2017 Jan 16. Epub 2017 Jan 16.
*Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi, Nagoya 466-8550; Japan †Department of Quality and Patient Safety, Nagoya University Hospital, 65 Tsurumai Showa-ward, Aichi, Nagoya 466-8550; Japan.

A review of accident and incident reports.
To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery.
In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. Read More

All reports are analyzed by a medical safety management group. These reports contain valuable data for management of medical safety, but there have been no studies evaluating these kind of data for spine surgery.
A total of 320 incidents and accidents that occurred perioperatively in 172 of 415 spine surgeries were included in the study. Incidents were defined as events that were "problematic, but with no damage to the patient", and accidents as events "with damage to the patient". The details of these events were analyzed.
There were 278 incidents in 137 surgeries and 42 accidents in 35 surgeries, giving prevalences of 33% (137/415) and 8% (35/415), respectively. The proportion of accidents among all events was significantly higher for doctors than non-doctors (68.0% (17/25) vs. 8.5% (25/295), p < 0.01) and in the operating room compared to outside the operating room (40.5% (15/37) vs. 9.5% (27/283), p < 0.01). There was no significant difference in years of experience among personnel involved in all events. The major types of events were medication-related, line and tube problems, and falls and slips. Accidents also occurred due to a long-term prone position, with complications such as laryngeal edema, ulnar nerve palsy, and tooth damage.
Surgery and procedures in the operating room always have a risk of complications. Therefore, a particular effort is needed to establish safe management of this environment and to provide advice on risk to the doctor and medical care team.

Curr Pain Headache Rep
Curr Pain Headache Rep 2017 Jan;21(1)
Comprehensive Pain Center, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.

Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management?
Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. Read More

The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies. This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.

Med Klin Intensivmed Notfmed
Med Klin Intensivmed Notfmed 2017 Jan 10. Epub 2017 Jan 10.
Klinik für Anästhesie, Operative Intensiv- u. Palliativmedizin, Städtisches Klinikum Solingen gGmbH, Gotenstraße 1, 42653, Solingen, Deutschland.
Can J Neurol Sci
Can J Neurol Sci 2017 Jan 9:1-6. Epub 2017 Jan 9.
1Department of Clinical Neurological Sciences,Western University,London,Canada.

Painful diabetic neuropathy (PDN) is a frequent complication of diabetes mellitus. Current treatment recommendations are based on short-term trials, generally of ≤3 months' duration. Limited data are available on the long-term outcomes of this chronic disease. Read More

The objective of this study was to determine the long-term clinical effectiveness of the management of chronic PDN at tertiary pain centres.
From a prospective observational cohort study of patients with chronic neuropathic non-cancer pain recruited from seven Canadian tertiary pain centres, 60 patients diagnosed with PDN were identified for analysis. Data were collected according to Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials guidelines including the Brief Pain Inventory.
At 12-month follow-up, 37.2% (95% confidence interval [CI], 23.0-53.3) of 43 patients with complete data achieved pain reduction of ≥30%, 51.2% (95% CI, 35.5-66.7) achieved functional improvement with a reduction of ≥1 on the Pain Interference Scale (0-10, Brief Pain Inventory) and 30.2% (95% CI, 17.2-46.1) had achieved both these measures. Symptom management included at least two medication classes in 55.3% and three medication classes in 25.5% (opioids, antidepressants, anticonvulsants).
Almost one-third of patients being managed for PDN in a tertiary care setting achieve meaningful improvements in pain and function in the long term. Polypharmacy including analgesic antidepressants and anticonvulsants were the mainstays of effective symptom management.

World J Transplant
World J Transplant 2016 Dec;6(4):620-631
Aparna Dalal, Department of Anesthesiology, Icahn School of Medicine, New York, NY 10029, United States.

Patients listed for organ transplant frequently have severe coronary artery disease (CAD), which may be treated with drug eluting stents (DES). Everolimus and zotarolimus eluting stents are commonly used. Newer generation biolimus and novolimus eluting biodegradable stents are becoming increasingly popular. Read More

Patients undergoing transplant surgery soon after the placement of DES are at increased risk of stent thrombosis (ST) in the perioperative period. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel and ticagrelor is instated post stenting to decrease the incident of ST. Cangrelor has recently been approved by Food and Drug Administration and can be used as a bridging antiplatelet drug. The risk of ischemia vs bleeding must be considered when discontinuing or continuing DAPT for surgery. Though living donor transplant surgery is an elective procedure and can be optimally timed, cadaveric organ availability is unpredictable, therefore, discontinuation of antiplatelet medication cannot be optimally timed. The type of stent and timing of transplant surgery can be of utmost importance. Many platelet function point of care tests such as Light Transmittance Aggregrometry, Thromboelastography Platelet Mapping, VerifyNow, Multiple Electrode Aggregrometry are used to assess bleeding risk and guide perioperative platelet transfusion. Response to allogenic platelet transfusion to control severe intraoperative bleeding may differ with the antiplatelet drug. In stent thrombosis is an emergency where management with either a drug eluting balloon or a DES has shown superior outcomes. Post-transplant complications often involved stenosis of an important vessel that may need revascularization. DES are now used for endovascular interventions for transplant orthotropic heart CAD, hepatic artery stenosis post liver transplantation, transplant renal artery stenosis following kidney transplantation, etc. Several antiproliferative drugs used in the DES are inhibitors of mammalian target of rapamycin. Thus they are used for post-transplant immunosuppression to prevent acute rejection in recipients with heart, liver, lung and kidney transplantation. This article describes in detail the various perioperative challenges encountered in organ transplantation surgery and patients with drug eluting stents.

Am. J. Obstet. Gynecol.
Am J Obstet Gynecol 2016 Dec 30. Epub 2016 Dec 30.
Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Drive, L4000 Women's Hospital, Ann Arbor, MI 48109.

Less postoperative pain is typically associated with a minimally invasive hysterectomy compared to a laparotomy approach but poor pain control can still be an issues. Multiple guidelines exist for managing postoperative pain yet most are not specialty-specific and are based on procedures bearing little relevance to a minimally invasive hysterectomy.
To determine if there is enough quality evidence within the benign gynecology literature to make non-opioid pain control recommendations for women undergoing a benign minimally invasive hysterectomy. Read More

We queried PubMed, and Cochrane databases using MeSH terms: "postoperative pain," "perioperative pain," "postoperative analgesia," "pain management," "pain control," "minimally invasive gynecologic surgery" and "hysterectomy". A manual examination of references from identified studies was also performed. All PubMed published studies involving minimally invasive hysterectomies through November 9, 2016 were included. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were restricted to benign minimally invasive hysterectomies evaluating non-opioid pharmacologic therapies. Primary outcomes included amount of postoperative analgesics consumed and postoperative pain scores. Two reviewers independently completed an in-depth evaluation of each study for characteristics and results using an Excel database according to inclusion/exclusion criteria. A risk assessment was performed and a quality rating assigned using the Cochrane Collaboration's Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.
Initially 1,155 studies were identified, 24 met all inclusion criteria. Based on limited data of varying quality, intravenous (IV) acetaminophen, anticonvulsants and dexamethasone demonstrate opioid-sparing benefits while ketorolac shows mixed results in laparoscopic hysterectomies. Paracervical blocks provide pain-reducing benefits in vaginal hysterectomies.
Convincing conclusions are difficult to draw because of the heterogeneous and contradictory nature of the literature. There is a clear need for more high-quality research evaluating each medication type for post-hysterectomy pain control.

Br J Anaesth
Br J Anaesth 2017 Jan 30;118(1):32-43. Epub 2016 Dec 30.
Department of Anesthesiology, University of Tennessee College of Medicine, Memphis, TN, USA.

Human error poses significant risk for hospitalized patients causing an estimated 100,000 to 400,000 deaths in the USA annually. Medication errors contribute, with error occurring in 5.3% of medication administrations during surgery. Read More

In this study 70.3% of medication errors were deemed preventable. Given the paucity of randomized controlled studies, we undertook a rigorous review of the literature to identify recommendations supported by expert opinions. An extensive literature search pertaining to medication error, medication safety, operating room, and anaesthesia was performed. The National Guidelines Clearinghouse was searched for any anaesthesia or operating room medication safety guidelines.A total of 74 articles were included. Recommendations were tabulated and assigned points based on a scale revised from a prior study. A total of 138 unique recommendations were identified, with point tallies ranging from 4 to 190. An in-person focus meeting occurred, where the 138 recommendations were reviewed, combined and condensed. A modified Delphi process was used to eliminate items found to be unimportant or those unable to be quantified (e.g. "minimize fatigue"). A total of 35 specific recommendations remained. Adverse events as a result of medication errors occur frequently in the operative setting. There are few rigorous studies to direct medication safety strategies, but this should not lead us to do nothing. The overwhelming consensus regarding best practices should be accepted, and the recommendations implemented. Our list of recommended strategies can hopefully be used to assess local vulnerabilities and institute system solutions.

J. Pediatr. Surg.
J Pediatr Surg 2017 Feb 14;52(2):239-246. Epub 2016 Nov 14.
Department of Paediatric Surgery/Gastro-intestinal Surgery, Princess Elisabeth Children's Hospital, Ghent University Hospital, Ghent, Belgium.

The surgical management of oesophageal atresia (OA) differs between pediatric surgical teams without consensus. We aimed to describe the current practice of OA treatment in Belgium and Luxembourg and compare this to the literature.
A questionnaire was created and sent to all 18 hospitals (14 pediatric surgical units) performing OA surgery in Belgium and Luxembourg. Read More

The results were compared to the literature.
Most units treat an average of 2-5 OA+TOF (71%) and ≤1 pure OA (pOA) per year (86%). The preferred surgical approach for OA+TOF is thoracotomy (86%), mostly extra-pleural (75%). Thoracoscopic OA repair is performed in 21%. All centers perform an end-to-end anastomosis (interrupted sutures), and all leave a transanastomotic tube. A chest drain is routinely used in 8units (57%). In pOA the preferred surgical approach is gastrostomy formation with delayed primary anastomosis (77%). The timing for delayed anastomosis is 2 to 24months. Intra-operative lengthening is mostly attempted with Foker technique (46%). If oesophageal replacement is needed, gastric interposition is mostly used (75%). A postoperative contrast study is routinely performed in 86% for OA+TOF and in 100% for pOA. Anti-reflux medication is routinely prescribed by all units but one.
There are still many differences and controversies in the perioperative management of OA. Part of this is based on habits and is difficult to change without scientific evidence. There is a need for prospective (inter)national registries to further identify the existing differences, leading to a more widely accepted consensus.
Level III.

Neurology 2016 Dec 23. Epub 2016 Dec 23.
From the Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (I.S.F., M.C.J., M.G.L., K.K., T.L.), and Division of Critical Care, Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine (R.C.T.), Boston Children's Hospital, Harvard Medical School, MA; Department of Child Neurology (I.S.F.), Hospital Sant Joan de Déu, Universidad de Barcelona, Spain; Division of Neurology (N.S.A., A.A.T.), The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania; Cincinnati Children's Hospital Medical Center (R.A., T.A.G., K.P.), University of Cincinnati, OH; Department of Neurology and Pediatrics (J.N.B., H.P.G.), The University of Virginia Health System, Charlottesville; Department of Epilepsy, Neurophysiology, and Critical Care Neurology (J.L.C., W.D.G.), Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC; Departments of Pediatrics and Neurology (K.E.C.), Children's Hospital Colorado, University of Colorado School of Medicine, Aurora; Universidad Austral de Chile (M.G.L.), Valdivia, Chile; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program (J.L.G., M.S.W.), Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric Neurology (A.H., M.A.M.), Duke University Medical Center, Duke University, Durham, NC; Division of Child Neurology (T.L.M., J.R.), Department of Neurology, Columbia University Medical Center, Columbia University, New York, NY; Section of Neurology and Developmental Neuroscience (A.W.), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Barrows Neurological Institute (K.W.), Phoenix Children's Hospital; Department of Pediatrics (K.W.), University of Arizona School of Medicine, Tucson; and Department of Neurology (K.W.), Mayo Clinic, Scottsdale, AZ.

To compare refractory convulsive status epilepticus (rSE) management and outcome in children with and without a prior diagnosis of epilepsy and with and without a history of status epilepticus (SE).
This was a prospective observational descriptive study performed from June 2011 to May 2016 on pediatric patients (1 month-21 years of age) with rSE.
We enrolled 189 participants (53% male) with a median (25th-75th percentile) age of 4. Read More

2 (1.3-9.6) years. Eighty-nine (47%) patients had a prior diagnosis of epilepsy. Thirty-four (18%) patients had a history of SE. The time to the first benzodiazepine was similar in participants with and without a diagnosis of epilepsy (15 [5-60] vs 16.5 [5-42.75] minutes, p = 0.858). Patients with a diagnosis of epilepsy received their first non-benzodiazepine (BZD) antiepileptic drug (AED) later (93 [46-190] vs 50.5 [28-116] minutes, p = 0.002) and were less likely to receive at least one continuous infusion (35/89 [39.3%] vs 57/100 [57%], p = 0.03). Compared to patients with no history of SE, patients with a history of SE received their first BZD earlier (8 [3.5-22.3] vs 20 [5-60] minutes, p = 0.0073), although they had a similar time to first non-BZD AED (76.5 [45.3-124] vs 65 [32.5-156] minutes, p = 0.749). Differences were mostly driven by the patients with an out-of-hospital rSE onset.
Our study establishes that children with rSE do not receive more timely treatment if they have a prior diagnosis of epilepsy; however, a history of SE is associated with more timely administration of abortive medication.

Zhonghua Wei Chang Wai Ke Za Zhi
Zhonghua Wei Chang Wai Ke Za Zhi 2016 Dec;19(12):1329-1334
Research Institute of General Surgery, Jinling Hospital, Nangjing 210002, China.

For chronic transit constipation (STC), surgery should be considered when all pharmacological interventions, biofeedback, and sacral nerve stimulation failed to relieve severe symptoms. Chronic functional constipation can be subdivided into three subtypes: colonic slow-transit constipation, outlet obstruction and mixed refractory constipation. The pathological changes of colonic slow transit and outlet obstruction constipation can influence each other. Read More

Mixed refractory constipation accounts for 90.2% of chronic constipation. Therefore the surgery procedure should solve two types of pathological changes at the same time. The Jinling procedure combines subtotal colectomy and side-to-side cecorectal anastomosis, aiming to solve the coexistence of obstructive defecation and slow-transit constipation in one operation. A total of 1 768 patients with mixed refractory constipation received Jinling procedure from January 2001 to June 2016. Our clinical practice indicates that the Jinling procedure is safe and effective for refractory slow-transit constipation associated with obstructive defecation, with minimal major complications, significant improvement of quality of life, and a high satisfaction rate after long-term follow up. The safety and efficacy of Jinling procedure are improved continually with the progress of minimally invasive surgery, surgical instruments, recovery after surgery and perioperative management. Through long-term clinical and basic research, our institute has formed the comprehensive treatment strategy, such as Jinling procedure, intestinal microecological treatment, medication, biological feedback and sacral nerve stimulation in the treatment of functional constipation.