Postoperative Respiratory Impairment Is a Real Risk for Our Patients: The Intensivist's Perspective

Locoregional Anaesthesia for Laparotomy: A Literature Review and Subsequent Case Series Highlighting the Potential of an Alternative Anaesthetic Technique

Laparotomy is a surgical incision utilised in both emergency and elective scenarios to gain access to abdominal surgery. General anaesthesia is usually necessitated due to the substantial insult of the approach and to facilitate organ relaxation and paralysis. However, this brings with it the need for an assessment of the suitability of the anaesthetic technique, with a large number of patients having comorbidities significant enough to exclude them from surgery. Locoregional anaesthesia, provided via spinal, epidural, or a combined approach offers a means of providing anaesthesia that places a reduced level of strain on patients' cardiorespiratory function. We review the existing literature on the topic of so-called "awake laparotomy" performed with locoregional anaesthesia and present a case series including both elective and emergency procedures.

Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

Budget impact and pharmacy costs with targeted use of oliceridine for postsurgical pain in patients at high risk of opioid-related adverse events

BACKGROUND

Oliceridine, a new class of μ-opioid receptor agonist, may be associated with fewer opioid-related adverse events (ORAEs) due to its unique mechanism of action. Thus, it may provide a cost-effective alternative to conventional opioids such as morphine.

PATIENTS AND METHODS

Using a decision tree with a 24-hour time horizon, we calculated costs for medication and management of the three most common AEs (oxygen saturation <90%, vomiting, somnolence) following postoperative oliceridine or morphine in high-risk patients. Costs were enumerated as differences in cost of analgesics and resource utilization in the first 24 hours post-surgery. An economic model compared expected AEs and costs in a blended cohort where elderly/obese patients at higher risk for ORAEs received oliceridine while those presumed to be at lower risk received morphine with a cohort that received morphine alone.

RESULTS

In high-risk patients, use of oliceridine resulted in overall savings of $363,944 (in 1,000 patients). Implementing a targeted approach of oliceridine utilization in patients with high risk for ORAEs can save a typical hospital system $122,296 in total cost of care.

CONCLUSION

Use of oliceridine in postoperative care among patients at high risk provides a favorable health economic benefit compared to the use of morphine.

Postoperative respiratory depression caused by iatrogenic hypermagnesaemia

Hypermagnesaemia is an uncommon electrolyte disorder which can be fatal if not recognised and treated promptly. The signs and symptoms of hypermagnesaemia are non-specific, making it an under-diagnosed cause of cardiovascular dysfunction, hypocalcaemia, and neurological and respiratory depression. Since magnesium homeostasis is handled almost exclusively by the kidneys, symptomatic hypermagnesaemia seldom occurs in the context of normal renal function; when it does, it is usually iatrogenic. Here, we report a case of iatrogenic hypermagnesaemia which presented as respiratory depression, preventing weaning from mechanical ventilation following cardiac surgery in a patient in the early stages of chronic kidney disease. On investigation he was found to have isolated severe hypermagnesaemia, following an intravenous bolus of magnesium sulphate administered intra-operatively to treat tachyarrhythmia. Before administering intravenous magnesium therapeutically, it is important for clinicians to assess renal function and baseline serum magnesium along with other possible risk factors for hypermagnesaemia, and to actively look for signs and symptoms of magnesium toxicity when the patient is receiving therapeutic magnesium.

Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners' Cases Exploring Similarities and Lessons Learnt

Although opioids are the cornerstone of moderate-to-severe acute pain management they are appropriately recognised as high-risk medicines. Patient and health service delivery factors can contribute to an increased risk of death associated with excessive sedation and respiratory impairment. Despite increasing awareness of opioid-induced ventilation impairment (OIVI), no reliable method consistently identifies individual characteristics and factors that increase mortality risk due to respiratory depression events. This study assessed similarities in available coronial inquest cases reviewing opioid-related deaths in Australian hospitals from 2010 to 2020. Cases included for review were in-hospital deaths that identified patient factors, clinical errors and service delivery factors that resulted in opioid therapy contributing to the death. Of the 2879 coroner’s inquest reports reviewed across six Australian states, 15 met the criteria for inclusion. Coroner’s inquest reports were analysed qualitatively to identify common themes, contributing patient and service delivery factors and recommendations. Descriptive statistics were used to summarise shared features between cases. All cases included had at least one, but often more, service delivery factors contributing to the death, including insufficient observations, prescribing/administration error, poor escalation and reduced communication. Wider awareness of the individual characteristics that pose increased risk of OIVI, greater uptake of formal, evidence-based pain management guidelines and improved documentation and observations may reduce OIVI mortality rates.