IMPORTANCEThe opioid epidemic has reignited interest in opioid-sparing strategies in managing pain. However, few studies have focused on opioid use during perioperative care in patients undergoing head and neck surgery with free flap reconstruction.OBJECTIVES To examine the association between multimodal analgesia (MMA) administration and perioperative opioid requirements in patients undergoing head and neck surgery with free flap reconstruction and to investigate whether MMA alters the duration of stay in the postanesthesia care unit (PACU). DESIGN, SETTING, AND PARTICIPANTSIn this retrospective case-control study, data were collected between April 1, 2016, and December 31, 2017. The study was conducted at a single cancer center in the United States. Participants were 357 patients 18 years or older scheduled for head and neck surgery with free flap reconstruction.EXPOSURES Patients in the treatment group received oral celecoxib, gabapentin, and/or tramadol hydrochloride before surgery. Control group patients did not receive any of these medications. MAIN OUTCOMES AND MEASURESThe amount of opioid administered in the operating room and in the PACU was converted to morphine equivalent daily dose (MEDD) for comparison between the 2 groups. The duration of stay in the PACU was based on the start time and end time of PACU care recorded by nurses in the PACU. RESULTS Intotal, 149 patients (mean [SD] age, 60.3 [13.7] years; 104 [69.8%] men) were included in the treatment group, and 208 patients (mean [SD] age, 64.2 [13.6] years; 146 [70.2%] men) were included in the control group. The mean (SD) MEDD of opioid given during surgery was 51.7 (19.8) in the treatment group and 67.9 (24.7) in the control group, for a difference in the means (treatment vs control) of −16.17 (95% CI, −20.81 to −11.52). In the PACU, the mean (SD) MEDD of opioid given was 11.7 (13.3) in the treatment group and 14.9 (15.7) in the control group, for a difference in the means (treatment vs control) of −3.22 (95% CI, −6.40 to −0.03). The MMA treatment remained largely associated with reduced amount of opioid given during surgery, in the PACU, and both combined after controlling for other important factors.CONCLUSIONS AND RELEVANCE This case-control study found that the patients who received MMA before head and neck surgery with free flap reconstruction required less opioid medication. The treatment group also had shorter duration of stay in the PACU compared with the control group.
Introduction Plasma triglycerides (TG) and HDL-C are inversely related in Metabolic Syndrome (MetS), due to exchange of VLDL-TG for HDL-cholesteryl esters catalyzed by cholesteryl ester transfer protein (CETP). We investigated the relationship of TG to HDL-C in highly-active antiretroviral drug (HAART)-treated HIV patients. Methods Fasting plasma TG and HDL-C levels were compared in 179 hypertriglyceridemic HIV/HAART patients and 71 HIV-negative persons (31 normotriglyceridemic (NL) and 40 hypertriglyceridemic due to type IV hyperlipidemia (HTG)). CETP mass and activity were compared in 19 NL and 87 HIV/HAART subjects. Results Among the three groups, a plot of HDL-C vs. TG gave similar slopes but significantly different y-intercepts (9.24 ± 0.45, 8.16 ± 0.54, 6.70 ± 0.65, sqrt(HDL-C) for NL, HIV and HTG respectively; P<0.001); this difference persisted after adjusting HDL-C for TG, age, BMI, gender, glucose, CD4 count, viral load and HAART strata (7.18 ± 0.20, 6.20 ± 0.05 and 4.55 ± 0.15 sqrt(HDL-C) for NL, HIV and HTG, respectively, P <0.001). CETP activity was not different between NL and HIV, but CETP mass was significantly higher in HIV (1.47 ± 0.53 compared to 0.93 ± 0.27 μg/mL, P<0.0001), hence CETP specific activity was lower in HIV (22.67 ± 13.46 compared to 28.46 ± 8.24 nmol/μg/h, P=0.001). Conclusions Dyslipidemic HIV/HAART patients have a distinctive HDL-C plasma concentration adjusted for TG. The weak inverse relationship between HDL-C and TG is not explained by altered total CETP activity; it could result from a non-CETP-dependent mechanism or a decrease in CETP function due to inhibitors of CETP activity in HIV patients’ plasma.
As of mid-October 2014, the ongoing Ebola epidemic in Western Africa has affected approximately 10,000 patients, approached a 50% mortality rate, and crossed political and geographic borders without precedent. The disease has spread throughout Liberia, Guinea, and Sierra Leone. Isolated cases have arrived in urban centers in Europe and North America. The exponential growth, currently unabated, highlights the urgent need for effective and immediate management protocols for the various health care subspecialties that may care for Ebola virus disease patients. We conducted a comprehensive review of the literature to identify key areas of anesthetic care affected by this disease. The serious potential for "high-risk exposure" and "direct contact" (as defined by the Centers for Disease Control and Prevention) of anesthesiologists caring for Ebola patients prompted this urgent investigation. A search was conducted using MEDLINE/PubMed, MeSH, Cochrane Review, and Google Scholar. Key words included "anesthesia" and/or "ebola" combined with "surgery," "intubation," "laryngoscopy," "bronchoscopy," "stethoscope," "ventilation," "ventilator," "phlebotomy," "venous cannulation," "operating room," "personal protection," "equipment," "aerosol," "respiratory failure," or "needle stick." No language or date limits were applied. We also included secondary-source data from government organizations and scientific societies such as the Centers for Disease Control and Prevention, World Health Organization, American Society of Anesthesiologists, and American College of Surgeons. Articles were reviewed for primary-source data related to inpatient management of Ebola cases as well as evidence-based management guidelines and protocols for the care of Ebola patients in the operative room, infection control, and health care worker personal protection. Two hundred thirty-six articles were identified using the aforementioned terminology in the scientific database search engines. Twenty articles met search criteria for information related to inpatient Ebola virus disease management or animal virology studies as primary or secondary sources. In addition, 9 articles met search criteria as tertiary sources, representing published guidelines. The recommendations developed in this article are based on these 29 source documents. Anesthesia-specific literature regarding the care of Ebola patients is very limited. Secondary-source guidelines and policies represent the majority of available information. Data from controlled animal experiments and tuberculosis patient research provide some evidence for the existing recommendations and identify future guideline considerations.
Perioperative difficult airway management is one of the most challenging tasks encountered by anesthesiologists. Awake intubation is considered the gold standard in securing the anticipated difficult airway. Effective communication between the anesthesiologist and patient is vital during awake intubation. A language barrier can significantly hinder success and jeopardize patient safety. We report a case of a monolingual Arabic-speaking patient with a difficult airway who required awake intubation to undergo surgery. Google Translate, a free and accessible translation software application, was used during his awake intubation—we recommend such an approach to be considered to reduce anxiety and facilitate success by providing concise, real-time instruction in the patient’s preferred language.
worsening oxygenation owing to pleural effusion and development of acute respiratory distress syndrome and may receive a new course of antibiotics for suspected intra-abdominal infection. Such a patient who does not suffer from VAP fulfills all of the criteria for VAC and even for IVAC. In summary, the main conclusions arising from this study are (1) that preventing VAP is possible, although it will not improve overall outcomes and (2) that VAC cannot be used as a surrogate for VAP.A pandemic in 2014 brought the Ebola virus screaming back into the spotlight of the world stage. This article details the history, etiology, epidemiology, and pathophysiology of this dangerous disease, as well as limited known coverage of Ebola patient management.During the course of the past 38 years, the Ebola virus has sparked a number of epidemics. Characteristics of this type of disease include fever and bleeding diathesis. The first documented case believed to be tied to the Ebola virus is believed to have occurred in 1967. The disease is transmitted when secretions from an infected patient come in contact with mucosa, conjunctiva, or percutaneous injury.As emphasized in the piece, the Ebola virus spreads easily and is highly lethal. The emphasis is on symptom management, not treatment. Rehydration with an electrolyte solution is the most common form of management. Studies of nonhuman primates with the Ebola virus indicate that the greater the viral exposure, the shorter the incubation period and therefore the greater likelihood of death. Survival is possible, however. As the article points out, several promising therapies for Ebola are being developed and on the horizon.
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