Multimodal Pain Control Utilizing Buprenorphine for Robotic-assisted Laparoscopic Prostatectomy: A Quality Improvement Comparison to Conventional Opioid Management

INTRODUCTION

This study investigated the effectiveness of buprenorphine as an alternative to the use of conventional opioids perioperatively in an effort to help mitigate the impact of the use of perioperative conventional opioids for patients undergoing robotic-assisted laparoscopic prostatectomy.

METHODS

Outcomes of patients with localized prostate cancer undergoing robotic-assisted laparoscopic prostatectomy were examined before and after implementation of novel quality improvement study that included receiving buprenorphine compared to conventional opioids for pain control intraoperatively and postoperatively. The primary end point was adequate pain control with secondary end points being analgesic consumption at home, opioid-related side effects, and patient satisfaction.

RESULTS

When analyzing the secondary end point of oral morphine milligram equivalents, the buprenorphine group received significantly less morphine milligram equivalent compared to the conventional opioid group (15.19 vs 47.91, P = .006). The buprenorphine group also had lower reported pain scores at discharge (4.3; scale 1-10) compared to the conventional opioid group (5.4), though this did not reach significance (P = .069). In the buprenorphine group, 76.9% strongly agreed that their pain was adequately controlled in the hospital compared to 57.5% of the conventional opioid group (P = .223). There was no difference in overall satisfaction at postoperative day 5 (P = .358).

CONCLUSIONS

Our study demonstrates buprenorphine's analgesic capabilities to maintain adequate pain control and patient satisfaction compared to conventional opioids during robotic-assisted laparoscopic prostatectomy, while decreasing perioperative opioid use.

The Elusive Sarcoidosis, an Eight-Year Journey to the Diagnosis of Sarcoidosis: A Case Report

We present a unique case of a patient coming to our internal medicine clinic with intermittent diffuse lymphadenopathy and non-specific symptoms for the past eight years. Initially, the patient was thought to have carcinoma of unknown primary origin, given the abnormalities seen in her imaging. The diagnosis of sarcoidosis was also dismissed, given that the patient had not responded to steroids with negative laboratory support. The patient was referred to several specialists, and only after a pulmonary biopsy was a non-caseating granuloma revealed after multiple prior failed biopsies. The patient was placed on infusion therapy and responded positively. This case demonstrates a challenging diagnosis and treatment which emphasizes the importance of considering alternative treatments if the initial therapy fails.

Automating Anesthesiology Resident Case Logs Reduces Reporting Variability

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) case log system for anesthesiology resident training relies on subjective categorization of surgical procedures and lacks clear guidelines for assigning credit roles. Therefore, resident reporting practices likely vary within and between institutions. Our primary aim was to develop a systematic process for generating automated case logs using data elements extracted from the electronic health care record. We hypothesized that automated case log reporting would improve accuracy and reduce reporting variability.

METHODS

We developed a systematic approach for automating anesthesiology resident case logs from the electronic health care record using a discrete classification system for assigning credit roles and Anesthesia Current Procedure Terminology codes to categorize cases. The median number of cases performed was compared between the automated case log and resident-reported ACGME case log.

RESULTS

Case log elements were identified in the electronic health care record and automatically extracted. A total of 42 individual case logs were generated from the extracted data and visualized in an external dashboard. Automated reporting captured a median of 1226.5 (interquartile range: 1097-1366) total anesthetic cases in contrast to 1134.5 (interquartile range: 899-1208) reported to ACGME by residents (P = .0014). Automation also decreased the case count interquartile range and the distribution approached normality, suggesting that automation reduces reporting variability.

CONCLUSIONS

Automated case log reporting uniformly captures the resident training experience and reduces reporting variability. We hope this work provides a foundation for aggregating graduate medical education data from the electronic health care record and advances adoption of case log automation.

The Anesthetic Management of a Parturient With Osteogenesis Imperfecta Type I Undergoing Cesarean Delivery

Osteogenesis imperfecta (OI) is a rare disorder of bone fragility caused by mutations in the COL1A1/2 genes, which encode type I procollagen. It commonly manifests with bone fractures, joint dislocations, and easy bruising. OI patients presenting for surgery may pose multiple challenges to the anesthesiologist such as management of a potentially difficult airway and heightened positional fracture risks. We present a case detailing the spinal anesthetic management of a 28-year-old woman with type I OI requiring cesarean delivery for a 32-week intrauterine pregnancy with fetal cardiac anomalies.

Outcomes of Lung Transplantation in Recipients With Hepatitis C Virus Infection

Hepatitis C virus (HCV) infection negatively impacts patient and graft survival following nonhepatic solid organ transplantation. Most data, however, are in kidney transplant, where despite modest impact on outcomes, transplantation is recommended for those with mild to moderate hepatic fibrosis given overall benefit compared to remaining on dialysis. In lung transplantation (LuTx), there is little data on outcomes and international guidelines are vague on the criteria under which transplant should be considered. The University of Alberta Lung Transplant Program routinely considers patients with HCV for lung transplant based on criteria extrapolated from the kidney transplant literature. Here we describe the outcomes of 27 HCV-positive, compared to 443 HCV-negative LuTx recipients. Prior to transplant, five patients were treated for HCV and cured. At the time of transplant, 14 patients remained HCV RNA positive. The 1-, 3-, and 5-year survival were similar in HCV RNA-positive versus -negative recipients at 93%, 77%, and 77% versus 86%, 75%, and 66% (p = 0.93), respectively. Long-term follow-up in eight patients demonstrated no significant progression of fibrosis. In our cohort, HCV did not impact LuTx outcomes and in the era of interferon-free HCV therapies this should not be a barrier to LuTx.

Successful Semi-Ambulatory Veno-Arterial Extracorporeal Membrane Oxygenation Bridge to Heart-Lung Transplantation in a Very Small Child

Lung transplantation (LTx) may be denied for children on extracorporeal membrane oxygenation (ECMO) due to high risk of cerebral hemorrhage. Rarely has successful LTx been reported in children over 10 years of age receiving awake or ambulatory veno-venous ECMO. LTx following support with ambulatory veno-arterial ECMO (VA ECMO) in children has never been reported to our knowledge. We present the case of a 4-year-old, 12-kg child with heritable pulmonary artery hypertension and refractory right ventricular failure. She was successfully bridged to heart-lung transplantation (HLTx) using ambulatory VA ECMO. Initial resuscitation with standard VA ECMO was converted to an ambulatory circuit using Berlin heart cannulae. She was extubated and ambulating around her bed while on VA ECMO for 40 days. She received an HLTx from an oversized marginal lung donor. Despite a cardiac arrest and Grade 3 primary graft dysfunction, she made a full recovery without neurological deficits. She achieved 104% force expiratory volume in 1 s 33 months post-HLTx. Ambulatory VA ECMO may be a useful strategy to bridge very young children to LTx or HLTx. Patient tailored ECMO cannulation, minimization of hemorrhage, and thrombosis risks while on ECMO contributed to a successful HLTx in our patient.

Strategies for safe living among lung transplant recipients: a single-center survey

BACKGROUND

Lung transplant (LT) recipients are at high risk for infection owing to lifelong immunosuppression and direct communication of the graft with the environment. Guidelines have been established for safe-living strategies after transplantation. We conducted a survey of LT patients to determine compliance with these strategies.

METHODS

Adult LT outpatients completed a survey consisting of questions on a 5-point Likert scale with the following categories: hand washing, gardening, respiratory infections, food and water safety, animal contact, travel, and occupation.

RESULTS

A total of 194 LT recipients completed the survey (age 54.4 ± 13.3 years; time post transplant 4.76 ± 3.5 years). Regular hand washing was practiced usually or always by 87.6%. Of those who worked with soil/gardened, 70/99 (70.7%) never wore a mask and 15.7% never wore gloves. Pet ownership was common (52%), but most patients used specific precautions during handling. Over one-third of patients continued employment after transplant but, of these, 56% had modified their occupation often because of perceived infectious risks. Most patients were fully compliant with influenza vaccination (92.3%). Patients <40 years of age were less likely to wear long-sleeved clothing in mosquito season (P = 0.002), more likely to handle pet feces (P = 0.005), and less likely to wear a mask with sick contacts (P = 0.021).

CONCLUSIONS

We provide important insight into safe-living practices following lung transplantation and identify specific areas and subgroups of patients that could be targeted for enhanced education, with potential significant clinical benefit.

Successful lung transplant in a child with cystic fibrosis and persistent Blastobotrys rhaffinosifermentans infection

Fungal respiratory infections in patients with CF are a significant concern both pre- and post-lung transplantation (LTx). Fungal infection is associated with increased mortality post-LTx, and in the past decade, the prevalence of fungal colonization in Canadian pediatric patients with CF has increased. The emergence of novel fungal pathogens is particularly challenging to the transplant community, as little is known regarding their virulence and optimal management. We present a case of a successful double-lung transplant in a pediatric patient with CF who was infected pretransplantation with a novel yeast, Blastobotrys rhaffinosifermentans. This patient was treated successfully with aggressive antifungal therapy post-transplantation, followed by extended fungal prophylaxis. The significance of fungal colonization and infection in children with CF pre- and post-LTx is reviewed.

Cervical spine clearance in Australian intensive care units

OBJECTIVE

Rigid or semi-rigid collar and spine board related complications may be causes of significant morbidity in intubated polytraumatised patients. As the process quantifying cervical spine injuries is controversial, exclusion of cervical spinal injuries (cervical spine clearance) can be delayed, thereby increasing complications associated with spinal cord immobilisation. We examined current practices in Australian ICUs by survey.

METHODS

The intensive care unit or trauma services director and the senior nursing unit manager from 17 units within designated Australian trauma centres were surveyed separately by telephone. The presence of a written protocol for cervical spine clearance including radiological and clinical criteria, time goals for clearance, immobilisation methods and formal surveillance of collar related complications were assessed using a standardised questionnaire.

RESULTS

All states and territories were represented. Of those services surveyed, only 50% had a written protocol, 50% had no specific time goal for cervical spinal clearance and the method of clearance ranged from plain cervical spine X-rays only to routine use of MRI. Immobilisation methods also varied, including use of rigid (hard) or soft collars with 71% having no formal surveillance of collar-related complications. Despite these results, 65% were satisfied with their approach to cervical spine clearance.

CONCLUSIONS

There is no standardised approach to the clearance of the cervical spine in intubated trauma patients in Australian intensive care units. In addition, morbidity from current practices and the true incidence of cervical spine injuries remains unknown. We recommend use of a written protocol and formal documentation of collar related complications. A standardised approach to radiological and clinical clearance of cervical spine injuries, which is practical, yet safe, remains a subject for future risk-benefit analysis.

Survival from profound alcohol-related lactic acidosis

We present the case of a patient with profound alcohol-related lactic acidosis (lactate = 16.1 mmol/L; pH = 6.67) associated with a multitude of metabolic derangements who made a remarkable recovery following aggressive management. The patient was in extremis upon arrival in the emergency department (ED), and resuscitation was begun immediately. While in the ED, the problem list generated included: acute alcohol intoxication, severe lactic acidosis, dehydration, hypothermia, hypoglycemia, acute renal insufficiency, and hepatic failure. Resuscitation continued in the intensive care unit with remarkable improvement and satisfactory outcome. In this patient, the severe lactic acidosis and associated abnormalities were all attributed to acute and chronic effects of ethanol. A brief summary of the proposed mechanism by which these metabolic derangements developed and an outline of her management follows.

Recommendations for patients with chronic respiratory disease considering air travel: a statement from the Canadian Thoracic Society

Patients with respiratory disease regularly seek the convenience of commercial airline travel. In addition to the stresses that all patients with chronic disease encounter, these patients are exposed to the affects of acute altitudinal hypoxemia. This in turn has the potential to produce significant symptoms and complications in-flight for patients with chronic respiratory disease. This article reviews the current literature, and seeks to help the practicing physician by providing recommendations on which patients should be assessed preflight, the type of assessment that should be carried out and recommendations for providing advice to these travelling patients.

Sources of the attentional blink during rapid serial visual presentation: perceptual interference and retrieval competition

Observers watched for 1 or 2 colored words as targets presented in lists of distractor strings (10 items/s). Identification of 1 target (T1) temporarily reduced the accuracy of reporting a 2nd target (T2). This attentional blink (AB) effect was most pronounced when T1 and T2 occurred close together in time. Use of recognition tests (instead of recall) improved performance but did not eliminate the AB effect. The AB effect was found with both word and nonword distractors, a smaller AB effect was found with consonant string distractors, and the AB effect was substantially attenuated with strings of unfamiliar characters (a false font). Analyses of errors indicated that the 2nd target is frequently replaced or corrupted by the following distractor during the blink. The AB effect appears to result from both attentional and mnemonic processes.

Sources of the attentional blink during rapid serial visual presentation: perceptual interference and retrieval competition

Observers watched for 1 or 2 colored words as targets presented in lists of distractor strings (10 items/s). Identification of 1 target (T1) temporarily reduced the accuracy of reporting a 2nd target (T2). This attentional blink (AB) effect was most pronounced when T1 and T2 occurred close together in time. Use of recognition tests (instead of recall) improved performance but did not eliminate the AB effect. The AB effect was found with both word and nonword distractors, a smaller AB effect was found with consonant string distractors, and the AB effect was substantially attenuated with strings of unfamiliar characters (a false font). Analyses of errors indicated that the 2nd target is frequently replaced or corrupted by the following distractor during the blink. The AB effect appears to result from both attentional and mnemonic processes.