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Bajracharya GR, Esa WAS, Mao G, Leung S, Cohen B, Maheshwari K, Kessler HP, Gorgun E, Sessler DI, Turan A. Regional analgesia and surgical site infections after colorectal surgery: a retrospective cohort analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 73:10-15. [PMID: 35803369 PMCID: PMC9801205 DOI: 10.1016/j.bjane.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The effect of regional analgesia on perioperative infectious complications remains unknown. We therefore tested the hypothesis that a composite of serious infections after colorectal surgery is less common in patients with regional analgesia than in those given Intravenous Patient-Controlled Analgesia (IV-PCA) with opiates. METHODS Patients undergoing elective colorectal surgery lasting one hour or more under general anesthesia at the Cleveland Clinic Main Campus between 2009 and 2015 were included in this retrospective analysis. Exposures were defined as regional postoperative analgesia with epidurals or Transversus Abdominis Plane blocks (TAP); or IV-PCA with opiates only. The outcome was defined as a composite of in-hospital serious infections, including intraabdominal abscess, pelvic abscess, deep or organ-space Surgical Site Infection (SSI), clostridium difficile, pneumonia, or sepsis. Logistic regression model adjusted for the imbalanced potential confounding factors among the subset of matched surgeries was used to report the odds ratios along with 95% confidence limits. The significance criterion was p < 0.05. RESULTS A total of 7811 patients met inclusion and exclusion criteria of which we successfully matched 681 regional anesthesia patients to 2862 IV-PCA only patients based on propensity scores derived from potential confounding factors. There were 82 (12%) in-hospital postoperative serious infections in the regional analgesia group vs. 285 (10%) in IV-PCA patients. Regional analgesia was not significantly associated with serious infection (odds ratio: 1.14; 95% Confidence Interval 0.87‒1.49; p-value = 0.339) after adjusting for surgical duration and volume of intraoperative crystalloids. CONCLUSION Regional analgesia should not be selected as postoperative analgesic technique to reduce infections.
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Affiliation(s)
- Gausan Ratna Bajracharya
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA
| | - Wael Ali Sakr Esa
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA
| | - Guangmei Mao
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Departments of Quantitative Health Science, Cleveland, USA
| | - Steve Leung
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Metro Health, Department of Radiology, Cleveland, USA
| | - Barak Cohen
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv Medical Center, Division of Anesthesia, Critical Care, and Pain Management, Tel-Aviv, Israel
| | - Kamal Maheshwari
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA
| | | | - Emre Gorgun
- Cleveland Clinic, Department of Colorectal Surgery, Cleveland, USA
| | - Daniel I. Sessler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA.
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Teames R, Joyce A, Scranton R, Vick C, Nagaraj N. Characterization of Device-Related Malfunction, Injury, and Death Associated with Using Elastomeric Pumps for Delivery of Local Anesthetics in the US Food and Drug Administration MAUDE Database. Drug Healthc Patient Saf 2021; 12:293-299. [PMID: 33380842 PMCID: PMC7767709 DOI: 10.2147/dhps.s280006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose To characterize medical device reports about elastomeric pumps delivering local anesthesia made to the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. Patients and Methods We conducted a retrospective review of medical device reports submitted to MAUDE from January 2010 to July 2018. A systematic, computerized algorithm was used to identify records pertaining to elastomeric pumps using local anesthesia. Included records indicated the use of local anesthesia or were determined to involve the use of local anesthetics (if they did not contain specific information on drug use). Reports were analyzed within the MAUDE event type categories of malfunction, injury, death, other, and missing. Possible cases of liver injury or surgical site infection were also identified. Manual review of narratives provided in MAUDE was performed by 2 reviewers to identify possible or probable cases of local anesthetic system toxicity (LAST). Results From a pool of 384,285 reports about elastomeric pumps from the MAUDE database, 4093 met inclusion criteria for involving elastomeric pumps to deliver local anesthetics, with the peak number of reports occurring in 2014. Of these identified reports, 3624 (88.5%) were categorized as malfunctions, 292 (7.1%) as injuries, and 8 (0.2%) as involving death. We identified 13 cases (0.3%) of possible liver injury and 51 cases (1.2%) of possible surgical site infection; 139 reports (3.4%) were determined to be probably (n=53) or possibly (n=86) associated with LAST. Conclusion Malfunction of elastomeric pumps delivering local anesthetics leaves patients vulnerable to injury or death. Our study indicates that reports of malfunction, injury, and death have been reported to the MAUDE database. These reports likely reflect an underrepresentation of cases in the real-world population, emphasizing the need for more comprehensive medical device reporting.
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Affiliation(s)
- Richard Teames
- Department of Anesthesiology, JPS Health Network, Fort Worth, TX, USA
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3
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Impact of Preadmission Opioid Treatment on 1-Year Mortality Following Nonsurgical Intensive Care*. Crit Care Med 2018. [DOI: 10.1097/ccm.0000000000003080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Goodwin AJ. Critical Care Outcomes Among Opioid Users: Hidden Sequelae of a Growing Crisis? Crit Care Med 2018; 46:1005-1006. [PMID: 29762398 PMCID: PMC5957290 DOI: 10.1097/ccm.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC
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Hutchison RW, Anastassopoulos K, Vallow S, Mordin M, Olson W, Hewitt D, Sikirica V. Intravenous Patient-Controlled Analgesia Pump and Reservoir Logistics: Results from a Multicenter Questionnaire. Hosp Pharm 2017. [DOI: 10.1310/hpj4211-1036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rob W. Hutchison
- Texas Tech University School of Pharmacy in Dallas Texas and Clinical Specialist in Pain Management at Presbyterian Hospital of Dallas
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Abstract
Gut homeostasis plays an important role in maintaining animal and human health. The disruption of gut homeostasis has been shown to be associated with multiple diseases. The mutually beneficial relationship between the gut microbiota and the host has been demonstrated to maintain homeostasis of the mucosal immunity and preserve the integrity of the gut epithelial barrier. Currently, rapid progress in the understanding of the host-microbial interaction has redefined toxicological pathology of opioids and their pharmacokinetics. However, it is unclear how opioids modulate the gut microbiome and metabolome. Our study, showing opioid modulation of gut homeostasis in mice, suggests that medical interventions to ameliorate the consequences of drug use/abuse will provide potential therapeutic and diagnostic strategies for opioid-modulated intestinal infections. The study of morphine's modulation of the gut microbiome and metabolome will shed light on the toxicological pathology of opioids and its role in the susceptibility to infectious diseases.
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Affiliation(s)
- Fuyuan Wang
- 1 Department of Veterinary Population Medicine, College of Veterinary Medicine, University of Minnesota, Saint Paul, Minnesota, USA
| | - Sabita Roy
- 1 Department of Veterinary Population Medicine, College of Veterinary Medicine, University of Minnesota, Saint Paul, Minnesota, USA.,2 Department of Surgery, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
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Cochran A, Thuet W, Holt B, Faraklas I, Smout RJ, Horn SD. The impact of oxandrolone on length of stay following major burn injury: A clinical practice evaluation. Burns 2013; 39:1374-9. [DOI: 10.1016/j.burns.2013.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 02/06/2013] [Accepted: 04/01/2013] [Indexed: 10/26/2022]
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Carvalho B, Lemmens HJ, Ting V, Angst MS. Postoperative Subcutaneous Instillation of Low-Dose Ketorolac But Not Hydromorphone Reduces Wound Exudate Concentrations of Interleukin-6 and Interleukin-10 and Improves Analgesia Following Cesarean Delivery. THE JOURNAL OF PAIN 2013; 14:48-56. [DOI: 10.1016/j.jpain.2012.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/16/2012] [Accepted: 10/02/2012] [Indexed: 01/18/2023]
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Lee JS, Hayanga AJ, Kubus JJ, Makepeace H, Hutton M, Campbell DA, Englesbe MJ. Local Anesthesia: A Strategy for Reducing Surgical Site Infections? World J Surg 2011; 35:2596-602. [DOI: 10.1007/s00268-011-1298-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Chapman CR, Lipschitz DL, Angst MS, Chou R, Denisco RC, Donaldson GW, Fine PG, Foley KM, Gallagher RM, Gilson AM, Haddox JD, Horn SD, Inturrisi CE, Jick SS, Lipman AG, Loeser JD, Noble M, Porter L, Rowbotham MC, Schoelles KM, Turk DC, Volinn E, Von Korff MR, Webster LR, Weisner CM. Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base. THE JOURNAL OF PAIN 2010; 11:807-29. [PMID: 20430701 DOI: 10.1016/j.jpain.2010.02.019] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 02/04/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence. PERSPECTIVE Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.
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Affiliation(s)
- C Richard Chapman
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Out with the Old, In with the New: A Novel Approach to Treating Pain Associated with Rib Fractures. World J Surg 2010; 34:2359-62. [DOI: 10.1007/s00268-010-0651-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Opioids and Infections in the Intensive Care Unit Should Clinicians and Patients be Concerned? J Neuroimmune Pharmacol 2008; 3:218-29. [DOI: 10.1007/s11481-008-9124-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 08/18/2008] [Indexed: 12/17/2022]
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Abstract
OBJECTIVES To describe a new, rigorous, comprehensive practice-based evidence for clinical practice improvement (PBE-CPI) study methodology, and compare its features, advantages, and disadvantages to those of randomized controlled trials and sophisticated statistical methods for comparative effectiveness research. RESEARCH DESIGN PBE-CPI incorporates natural variation within data from routine clinical practice to determine what works, for whom, when, and at what cost. It uses the knowledge of front-line caregivers, who develop study questions and define variables as part of a transdisciplinary team. Its comprehensive measurement framework provides a basis for analyses of significant bivariate and multivariate associations between treatments and outcomes, controlling for patient differences, such as severity of illness. RESULTS PBE-CPI studies can uncover better practices more quickly than randomized controlled trials or sophisticated statistical methods, while achieving many of the same advantages. We present examples of actionable findings from PBE-CPI studies in postacute care settings related to comparative effectiveness of medications, nutritional support approaches, incontinence products, physical therapy activities, and other services. CONCLUSIONS Outcomes improved when practices associated with better outcomes in PBE-CPI analyses were adopted in practice.
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Affiliation(s)
- Susan D Horn
- International Severity Information Systems, Inc.; and Institute for Clinical Outcomes Research, Salt Lake City, Utah, USA.
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Schwacha MG, McGwin G, Hutchinson CB, Cross JM, Maclennan PA, Rue LW. The contribution of opiate analgesics to the development of infectious complications in burn patients. Am J Surg 2006; 192:82-6. [PMID: 16769281 DOI: 10.1016/j.amjsurg.2006.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2005] [Revised: 01/01/2006] [Accepted: 01/01/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Immune and infectious complications are associated with burn injury. Opiate analgesics also can induce similar complications, however, their impact on postburn infectious complications is unknown. METHODS A retrospective survey of records from 1997 to 2002 from an academic burn center was conducted. Information on all opiate analgesic use was obtained and expressed as opiate equivalents (OEs). Total OEs were summed for each patient and then compared between cases and controls. RESULTS Patients who developed infections were more likely to be in the high OE group. This association was modified by burn severity. Patients with small burns and infection were more likely to be in the high OE group, whereas patients with moderate to large burns and infections were not associated significantly with opiate use. CONCLUSIONS The results of this preliminary study suggest that opiate analgesics can contribute to the development of postburn infectious complications when the burn injury is of a less severe nature.
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Affiliation(s)
- Martin G Schwacha
- Center for Surgical Research and Departments of Surgery, Microbiology, and Pathology, University of Alabama at Birmingham, G094 Volker Hall, 1670 University Blvd., Birmingham, AL 35294-0019, USA.
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Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another Look at Observational Studies in Rehabilitation Research: Going Beyond the Holy Grail of the Randomized Controlled Trial. Arch Phys Med Rehabil 2005; 86:S8-S15. [PMID: 16373136 DOI: 10.1016/j.apmr.2005.08.116] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 07/31/2005] [Accepted: 08/02/2005] [Indexed: 01/21/2023]
Abstract
Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the "black box" of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.
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Affiliation(s)
- Susan D Horn
- International Severity Information Systems Inc and Institute for Clinical Outcomes Research, Salt Lake City, UT 84102-1282, USA.
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Fry DE. Patient-controlled analgesia pumps and surgical site infections. Surg Infect (Larchmt) 2003; 3:107-8. [PMID: 12519476 DOI: 10.1089/109629602760105763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Horn SD, Torres A, Willson D, Dean JM, Gassaway J, Smout R. Development of a pediatric age- and disease-specific severity measure. J Pediatr 2002; 141:496-503. [PMID: 12378188 DOI: 10.1067/mpd.2002.126925] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To adapt the adult Comprehensive Severity Index (CSI) for hospitalized pediatric patients and evaluate the ability of the CSI to predict common outcomes. STUDY DESIGN Adult CSI was modified by a panel of pediatric subspecialists from 10 children's hospitals. Predictive power was evaluated by using retrospective data collected from 16,495 randomly selected children admitted to these hospitals from April 1995 through September 1996. Outcomes were mortality, length of stay (LOS), and cost. RESULTS Admission CSI score predicted mortality well (Hosmer-Lemeshow tests: P =.41-.98) and discriminated well (area under receiver operating characteristic [ROC] curve range = 0.80-0.99) within 9 case-mix groups with > or =10 deaths (P <.0001). Maximum CSI score explained the variation in LOS (r2 = 0.13-0.67) and cost (r2 = 0.08-0.73) within 32 case-mix groups (P <.005). Significant differences existed in admission and maximum average CSI scores across sites in 26 and 29 of 32 case-mix groups, respectively (P <.05). CSI had better predictability than Pediatric Risk of Mortality. CONCLUSIONS The age- and disease-specific pediatric CSI score correlates highly with LOS, cost, and mortality in hospitalized children and can help determine the best clinical practices for specific diseases and adjust for differences in severity of illness across providers.
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Affiliation(s)
- Susan D Horn
- ISIS, Inc, the Institute for Clinical Outcomes Research, and the Department of Pediatrics, Primary Children's Medical Center, Salt Lake City, Utah 84109-1630, USA
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