IntroductionOpioid-based analgesic therapy represents a cornerstone of pain management after surgery. The recent rise in opioid sales and opioid overdoses suggests it is important to maximize the safety of opioid prescribing after surgery. Given that patients may live with other family members in the home, safe storage and appropriate disposal of excess opioids after hospital discharge are necessary to prevent unintended secondary exposures. Identifying characteristics of patients who are likely to be prescribed excess opioids after surgery may enable more targeted prescription practices and safety interventions. Our study aimed to elucidate patient-reported opioid use patterns and modes of home storage of opioids among patients discharged home after Cesarean section (C-section) and thoracic surgery. Specifically, we sought to identify characteristics of patients who reported using about half or more versus less of the opioids prescribed to them for use after hospital discharge.MethodsFor this cohort study, we developed a survey on quality of analgesia following hospital discharge, amounts of opioids taken relative to the amount prescribed, reasons for not taking all prescribed medications, and storage and disposal methods for leftover opioids. Adult patients, who had C-section or thoracic surgery at a tertiary academic medical center, were given a web-based self-administered survey after discharge. Descriptive statistics (means and standard deviations, proportions) were used to describe the study sample and survey results. Comparisons between patients who reported taking about half or more versus less of the opioids prescribed to them for use after hospital discharge were made using unpaired t-tests, Mann-Whitney tests, and Chi-square tests as appropriate.ResultsThe majority (53%) of respondents after C-section (N = 30) reported taking either no or very few (less than 5) prescribed opioid pills; 83% reported taking half or less; and 17% of women, reported taking all or nearly all (5 or fewer pills left over) of their opioid prescription. In a cohort of patients after thoracic surgery (n = 31) 45% reported taking either no or very few (5 or less) prescribed opioid pills; 71% reported taking half or less; and 29% of patients reported taking all or nearly all (5 or fewer pills left over) of their opioid prescription. In both cohorts, use of opioids while hospitalized was higher in the group reporting using about half or more of prescribed opioids after discharge. Leftover opioids were stored in an unlocked location in 77% and 73% of cases following C-section and thoracic surgery, respectively.ConclusionOur findings from surveys in two distinct patient populations at a single academic medical center suggest that current opioid prescribing practices for pain management at hospital discharge following Cesarean section and thoracic surgery may not account for individual patients’ analgesic requirements. Excess opioid pills are commonly stored in unsecured locations and represent a potential source for non-medical opioi...

Propofol abuse in academic anesthesiology likely has increased over the last 10 yr. Much of the mortality is in residents. Most programs have no pharmacy accounting or control of propofol stocks. This may be of concern, given that all programs reporting deaths from propofol abuse were centers in which there was no pharmacy accounting for the drug.

Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.

WHAT IS ALREADY KNOWN ABOUT THE SUBJECT • Ciclosporin's nephrotoxicity initially targets the proximal tubule and is, at least in part, driven by increased formation of oxygen radicals. • 1H‐nuclear magnetic resonance spectroscopy (NMR)‐ and mass spectrometry (MS)‐based biochemical profiling (metabolomics) allows for the sensitive detection of metabolite pattern changes in urine. • In systematic studies in rats we showed that ciclosporin caused urine metabolite pattern changes typical for proximal tubule damage and that these pattern changes seemed to be more sensitive than established clinical kidney function markers such as serum creatinine concentrations. WHAT THIS PAPER ADDS • This study showed that urine metabolite pattern changes as assessed by 1H‐NMR and HPLC‐MS are sensitive enough to detect the effect of ciclosporin as early as 4 h after a single oral dose. • In our previous rat studies, changes in urine metabolite pattern in response to ciclosporin translated into healthy humans, indicating the involvement of the same toxicodynamic mechanisms. • The results provide proof of concept for further development of this combination molecular marker strategy into diagnostic tools for the detection and monitoring of drug nephrotoxicity. AIMS The immunosuppressant ciclosporin is an efficient prophylaxis against transplant organ rejection but its clinical use is limited by its nephrotoxicity. Our previous systematic studies in the rat indicated urine metabolite pattern changes to be sensitive indicators of the negative effects of ciclosporin on the kidney. To translate these results, we conducted an open label, placebo‐controlled, crossover study assessing the time‐dependent toxicodynamic effects of a single oral ciclosporin dose (5 mg kg−1) on the kidney in 13 healthy individuals. METHODS In plasma and urine samples, ciclosporin and 15‐F2t‐isoprostane concentrations were assessed using HPLC‐MS and metabolite profiles using 1H‐NMR spectroscopy. RESULTS The maximum ciclosporin concentrations were 1489 ± 425 ng ml−1 (blood) and 2629 ± 1308 ng ml−1 (urine). The increase in urinary 15‐F2t‐isoprostane observed 4 h after administration of ciclosporin indicated an increase in oxidative stress. 15‐F2t‐isoprostane concentrations were on average 2.9‐fold higher after ciclosporin than after placebo (59.8 ± 31.2 vs. 20.9 ± 19.9 pg mg−1 creatinine, P < 0.02). While there were no conclusive changes in plasma 15‐F2t‐isoprostane concentrations or metabolite patterns, non‐targeted metabolome analysis using principal components analysis and partial least square fit analysis revealed significant changes in urine metabolites typically associated with negative effects on proximal tubule cells. The major metabolites that differed between the 4 h urine samples after ciclosporin and placebo were citrate, hippurate, lactate, TMAO, creatinine and phenylalanine. CONCLUSION Changes in urine metabolite patterns as a molecular marker are sufficiently sensitive for the detection of the negative effects of ciclosporin on the kidney after a si...

BACKGROUND: Postoperative hypoxemia (POH) is common and primarily treated with temporary oxygen supplementation. Because the clinical impact of POH is sometimes presumed as minor, efforts to better understand and minimize it have been limited. Here, we hypothesized that, after adjusting for opioids received perioperatively and other confounders, the frequency of POH events (POH%) reported within the first 3 postoperative days (PODs) is associated with increased postoperative 1-year mortality. METHODS: With prior institutional review board (IRB) approval, the Epic Clarity database was queried for all adult inpatient anesthesia encounters performed at our health system (1 academic and 2 community hospitals) from January 1, 2012 to March 31, 2016. Patients with multiple hospitalizations or subsequent surgeries within the same hospitalization were excluded. We classified patients based on the presence (POH) or not (No-POH) of ≥1 documented peripheral saturation of oxyhemoglobin (Spo 2) ≤85% event of any duration occurring between the discharge from the postanesthesia care unit (PACU) until POD 3. Demographics, comorbidities, surgery duration, morphine milligram equivalents (OMME) administered perioperatively, respiratory therapies, intensive care unit (ICU) admission, and hospital length of stay (LOS) were also collected. Logistic regression was used to characterize the association between POH and 1-year postoperative mortality after adjusting for perioperatively administered opioids and other confounding factors. RESULTS: A total of 43,011 patients met study criteria. At least 1 POH event was reported in 10,727 (24.9%) patients. Of these, 7179 (66.9%) had ≥1 hypoxemic event on POD 1, 5340 (49.8%) on POD 2, and 3455 (32.3%) on POD 3. Patients with ≥1 POH event, compared to No-POH patients, were older, had more respiratory and other comorbidities, underwent longer surgeries, received greater opioid doses on the day of surgery and POD 1, and received more continuous pulse oximetry monitoring. POH patients required more frequent postoperative oxygen therapy, noninvasive ventilation (NIV), intubation, and ICU admission. One-year postoperative mortality occurred in 4.4% of patients with ≥1 POH and 3.0% of No-POH patients (P < .001). After adjusting for confounding factors, for every 10% increase in the frequency of Spo 2 ≤85% readings, the odds of postoperative 1-year mortality were 1.20 (95% confidence interval [CI], 1.11–1.29; P < .001). Perioperative opioids were not independently associated with increased 1-year mortality. CONCLUSIONS: After adjusting for perioperative opioids and other confounders, moderate/severe POH within the first 3 PODs was independently associated with increased 1-year postoperative mortality. Increased efforts should be directed to understand if efforts to detect and reduce POH lead to improved patient outcomes.