Tag: 11/10/21

Categories : Pain ManagementTags :

Fifth of Opioid-Naïve Patients Continue Use Post-surgery

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More than a fifth of ‘opioid-naïve’ patients continue to use opioids three months after having a procedure, underscoring the often-overlooked role surgery plays in the opioid epidemic.

In research presented at the ANESTHESIOLOGY® 2021 annual meeting, smokers and people with bipolar disorder, depression or pulmonary hypertension were found to be at highest risk.

Persistent opioid use was much higher than expected among opioid-naïve patients (those who did not have an opioid prescription filled in the previous year). Surgery is the first time many patients have used opioids, often prescribed for post-surgical pain management.

The study examined data on 13 970 opioid-naïve adults from 2013-2019. In the study, opioid-naïve patients were those who had not filled an opioid prescription 31 days to one year before surgery (patients often are prescribed opioids in advance so they are available immediately after the surgery). Researchers found that 21.2% of patients refilled their opioid prescription three months to one year after the procedure. Unless they have cancer or had chronic pain before surgery, very few patients should still need opioids three months after surgery, the researchers note.

Analysing 46 potential risk factors, researchers found many patients were still using opioids after three months. The top four risk-factors identified, which were modifiable, were: smoking, bipolar disorder, depression and pulmonary hypertension. They also found that procedures with cardiac and podiatry surgical providers and patients who had cataract surgery were at an increased risk of persistent opioid use.

“To reduce the likelihood of ongoing opioid use, physician anesthesiologists should use the preoperative assessment to identify patients at highest risk for persistent use,” said lead author Gia Pittet, AuD, PhD, visiting graduate researcher for anesthesiology and perioperative medicine at the University of California, Los Angeles. “Before they have surgery, patients who smoke should be encouraged to quit, those with pulmonary hypertension should see a doctor to help them get the condition under control and patients with bipolar disorder or depression may require a preoperative adjustment of their medications.”

Patients should also receive counseling about the safe use of opioids and be offered alternative pain management, such as limited or non-opioid multimodal treatment and be monitored frequently and closely while they are taking opioids.

Source: American Society of Anesthesiologists

Categories : PaediatricsTags :

Gymnast Simone Biles Urges Paediatricians to Report Abuse

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Photo by National Cancer Institute on Unsplash

Renowned American gymnast Simone Biles has a combined total of more than 30 Olympic and world championship medals, not to mention several world records. But there’s more to her than that, she said during a plenary session at the American Academy of Pediatrics (AAP) virtual meeting.

“I’m a person at the end of the day and people respect that and understand that,” she said, noting that the positive support she received during the Japan summer games when she cited mental health concerns, and withdrew from several events, “made me feel whole as a person and an athlete.”

In her AAP keynote talk with AAP president Lee Savio Beers, MD, 24 year-old Biles explained that “Growing up, we’re told ‘Push through, Push through,’ but I knew at that point [during the 2020 Tokyo games, held in 2021], I really couldn’t…my safety and my health were on the line.”

She also acknowledged that “I honestly expected a lot more backlash than what I got [for withdrawing]. What I got was an overwhelming outpouring of support and love and understanding. That’s something I never expected…so that was quite a twist for me.”

Injury, overtraining, and pressure in competitive athletes can take a toll on athletes’ mental health, research has shown. Biles is among a number of high-profile athletes who have been outspoken about supporting the mental health of athletes. She has adopted a platform “to help advocate for mental health and support initiatives that provide education and assistance for children and young adults associated with adoption and foster care,” according to AAP News. Biles and her siblings were in and out of foster care before being adopted by their grandparents.

Biles also talked about Larry Nassar, DO, the former team doctor of the US women’s national gymnastics team who was jailed for sexual abuse and child pornography, and tampering with evidence.

In testimony before Congress in September, Biles said, “I blame Larry Nassar, and I also blame an entire system that enabled and perpetrated his abuse.” The gymnast singled out the FBI which she said “turned a blind eye” as Nassar molested young female patients, according to the Washington Post.

Biles offered this advice on how paediatricians can help abuse cases: “If you see something, speak up no matter what the consequences are because not only could you be helping that individual, but you could be helping multiple individuals too.”

Biles hopes more youth athletic programs will educate young children on spotting and reporting abuses. “From a very young age, a lot of us are thrown into these sports and we don’t know what’s right or wrong, unless somebody sits down and tells us, or we have adults looking after us, so I think handbooks can be a really good thing.”

Biles told the AAP audience that, before she became a gymnast, she wanted to be a paediatric nurse like her mother. “After making five World and two Olympic teams, the nursing career didn’t work out for me,” she said, “but…I’ve always wanted to help kids and I love kids…and I come from a family of [nurses].”

Source: MedPage Today

Categories : HospitalsTags :

Equivalent Hip Surgery Outcomes for Spinal vs General Anaesthesia

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Research comparing general versus spinal anaesthesia for hip fracture surgery shows similar outcomes for patients, challenging the common thinking that patients receiving spinal anaesthesia fare better. 

Led by researchers from the Perelman School of Medicine at the University of Pennsylvania, the study was published in the New England Journal of Medicine and presented at Anesthesiology 2021, the annual meeting of the American Society of Anesthesiologists (ASA).

“Available evidence has not definitively addressed the question of whether spinal anaesthesia is safer than general anaesthesia for hip fracture surgery, an important question to clinicians, patients, and families. Our study argues that, in many cases, either form of anaesthesia appears to be safe,” said lead investigator Mark D. Neuman, MD, MSc, an associate professor of Anesthesiology and Critical Care. “This is important because it suggests that choices can be guided by patient preference rather than anticipated differences in outcomes in many cases.”

While most of the 250 000 annual hip fracture patients in the US undergo general anaesthesia, spinal anaesthesia increased by 50% between 2007 and 2017, while in the United Kingdom and other countries, spinal anaesthesia is used in over 50% of hip fracture cases. [PDF]

Most recent comparisons of general anaesthesia versus spinal anaesthesia come from non-randomised studies, some indicating fewer cognitive and medical complications with spinal. Some patients may choose spinal anaesthesia for lower complications, while those choosing general may have a fear of spinal injection or insufficient anaesthesia. 

The study enrolled 1600 patients, all at least 50 years old, who had broken a hip. Among older populations, hip fractures are particularly worrisome as they can lead to a loss of mobility, linked to a doubling or even tripling the risk of near-term death. The patients were randomised into two groups, a major advantage for the study.

The researchers combined subsequent patient death rates and whether they regained the ability to walk, even with a walker. By 60 days post-surgery, 18.5% of patients assigned to spinal anaesthesia had either died or become newly unable to walk versus 18% of patients who received general anaesthesia. Mortality at this point was 3.9% of patients who received spinal anaesthesia died versus 4.1% who got general anaesthesia.

Additionally, to examine how the different forms of anaesthesia factored into potential cognitive complications, the researchers also examined post-operative delirium. Delirium was experienced in 21% of spinal anaesthesia patients versus 20% for general anaesthesia.

“What our study offers is reassurance that general anaesthesia can represent a safe option for hip fracture surgery for many patients,” said Prof Neuman. “This is information that patients, families, and clinicians can use together to make the right choice for each patient’s personalised care.”

Source: Perelman School of Medicine at the University of Pennsylvania 

Categories : CancerTags :

Dexamethasone in Cancer Surgery Boosts Survival Rates

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The survival of patients with breast, pancreatic and certain other cancers could be extended if given the anti-nausea drug dexamethasone during surgery. 

This finding comes from a large study being presented at the ANESTHESIOLOGY® 2021 annual meeting.

A drug with an already great range of uses including COVID treatment, dexamethasone is given to patients to prevent nausea and vomiting after surgery and during chemotherapy. Researchers found dexamethasone can improve mid- to long-term outcomes in patients with non-immunogenic cancers (those that don’t provoke a strong immune response) such as sarcoma and cancers of the breast, uterus, ovary, esophagus, pancreas, thyroid, bones and joints.

“Dexamethasone has positive and negative effects – it inhibits cancer growth, but also suppresses the immune system,” said senior author Maximilian Schaefer, MD, PhD. “Previous research has reported that in cancers in which the immune system controls cancer growth, the positive and negative effects of dexamethasone balance each other, so there is no benefit. Ours is the first large study to show that for a wide variety of cancers where the immune system does not play a major role, the positive effects seem to predominate.”

Researchers analysed the records of over 74 000 patients who had surgeries to remove non-immunogenic cancerous tumours, about a third of whom received dexamethasone during surgery. After 90 days, 209 (0.83%) of the patients who had received dexamethasone died vs 1543 (3.2%) of patients without the drug.

After accounting for confounding factors, including that dexamethasone is often administered to younger patients, there was still a 21% reduced risk of dying within one year after surgery for those who received the drug. It was also shown to be particularly beneficial for patients with cancers of the ovary, uterus or cervix.

“Based on our data, physician anesthesiologists should feel more confident in administering dexamethasone to patients undergoing surgery for non-immunogenic cancers,” said Dr Schaefer. “It not only helps with nausea, but it also may result in improved survival.”

Source: American Society of Anesthesiologists

Categories : HospitalsTags :

Physician Anaesthesiologist-led Teams Reduce Cardiac Arrests and Deaths

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Rapid response teams led by physician anaesthesiologists resulted in a significant decrease in cardiac arrest and death, after a transition from nurse-only rapid response teams, according to a study presented at the ANESTHESIOLOGY® 2021 annual meeting.

“As anaesthesiologists, we care for the entire spectrum of a patient’s life from in utero to end of life,” said lead author Faith Factora, MD, medical director, Surgical Intensive Care Unit, Cleveland Clinic. “Our training gives us experience performing practical skills like resuscitation and CPR, in addition to more subtle skills like implementing quality improvement projects and developing safety processes for patient care. Our specialty affects entire patient populations of hospital care and this study represents an example of the care we provide across the spectrum of our patients’ lives and our health care institutions.”

Analysing 458 233 patient hospitalisations, the study found 103 103 patients who were cared for by the original nurse-led rapid response team and 355 130 patients were cared for by the physician anaesthesiologist-led rapid response team. Patients of the physician-led team had a 50% less chance of experiencing cardiac arrest and a 27% less chance of death, compared to the original nurse-led rapid response team.

Rapid response teams address early clinical deterioration, initiating critical care interventions before an emergency or intubation occurs outside of the intensive care unit. By implementing a hospital-wide system led by anaesthesiologists, using principles of monitoring and patient safety that guide the specialty, the physician-led team showed a decrease in cardiac arrests and deaths. The system included early warning systems, including regular monitoring of patients’ conditions and vital sign checks on a regular basis that triggered alerts if critical criteria were met. Examples of conditions that triggered alerts were low blood pressure or high heart rates.

Physician anaesthesiologists are champions of patient safety, uniquely educated and trained for critical moments in health care, with an ability to navigate life-and-death moments in patient care unmatched by other professions. Their education and training is extensive, with up to 14 years of education, including medical school, and 12 000 to 16 000 hours of clinical training.

Source: American Society of Anesthesiologists

Categories : Mental HealthTags :

Sleep Deprivation Affects Emotional Control but not Processing

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Phot by Mulyadi on Unsplash

While sleep deprivation really messes with mood, a new study in PlosOne shows it does not interfere with their ability to evaluate emotional situations.

Researchers found that, contrary to the assumption that feeling more negative affects people’s experiences of their environment, 24 hours without sleep did not affect participants’ ability to process emotional words and images.

“People do become less happy through sleep deprivation, but it’s not affecting how they are processing emotional stimuli in their environment,” said lead author Anthony Stenson, WSU psychology doctoral student.

The researchers found that sleep deprivation does not numb people to emotional situations, but it reduces their ability to control their own emotional responses, with implications for healthcare workers and other professions who must deal with sleep loss.

For the study, about 60 adult participants spent four consecutive days in a sleep centre at the WSU Elson S. Floyd College of Medicine. They were allowed to sleep normally the first night and then given a set of baseline tests to judge their mood as well as their emotional regulation and processing ability. Then, they were divided into one group of 40 people staying awake the second night, and a control group of 20 allowed a normal sleep period. The tests were then re-administered at different intervals.

The emotional regulation and processing tests both involved viewing a series of images with positive and negative emotional connotations. In the emotional regulation tests, participants were given a prompt to help them recontextualise negative images before seeing them and asked to control their feelings. The sleep-deprived group had greater difficulty reducing the emotion they felt when instructed to do so.

The processing tests involved responding to words and images with emotional content, for example rating the emotions conveyed by a smiling family, a growling dog or a crying child. All participants performed similarly on these tests whether they were sleep deprived or not.

The ability to process emotional content and the ability to control one’s emotions are distinct and important, especially for some professions, said co-author Paul Whitney, a WSU professor of psychology.
“I don’t think we want our first responders being numb to the emotional nature of the situations they encounter, and it looks like they are not,” he said. “On the other hand, reacting normally to emotional situations, but not being able to control your own emotions, could be one reason sleep loss sometimes produces catastrophic errors in stressful situations.”

Previous studies have largely focused on the impacts of sleep deprivation on ‘cold’ cognitive tasks, which are supposedly emotionally neutral tasks like recalling facts. These studies have also found that regulation, considered a ‘top-down’ cognitive process, is a major problem with cold cognitive tasks. Mental flexibility, for example, is compromised by sleep deprivation, an ability emergency room doctors use in dealing with unexpected situations.

The current study shows that top-down regulation is a problem as well with ‘hot’ or emotional cognitive processes. Future research is needed to understand whether the effects of sleep loss on the two top-down processes are linked.

Source: Washington State University