Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.
Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.
Objectives Opioids are commonly used for pain control after lower extremity amputations (LEA)—below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge. Methods Patients undergoing LEA (2008–2016) with identified peripheral vascular disease were selected from Cerner’s Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate. Results 2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6. Conclusions This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325 mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.
We report a rare case of a right orbital roof blow-in fracture in a 40-year-old male with concomitant basal skull fracture and intracranial hemorrhage after a fall backward. Trauma, neurosurgery, ophthalmology, and maxillofacial surgery consultations were obtained. Conservative, non-surgical management was recommended for all injuries, and outpatient follow up for orbital fracture with no surgery offered.
Objectives Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). Methods We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. Results TCAR was undertaken for a 58 year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10 months of follow-up. Conclusion This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.
Objective: Opioids are commonly used for pain control after lower extremity amputations, including below-the-knee amputations (BKAs) and above-the-knee amputations (AKAs). Well-defined benchmarks for discharge prescription requirements after amputation are deficient. We evaluated opioid usage after amputation to identify high-risk patients and provide recommendations for posthospitalization opioid prescriptions at discharge.Methods: Patients who had undergone lower extremity amputations from 2008 to 2016 were selected from the Cerner's HealthFacts database using the International Classification of Diseases, 9th and 10th revisions, diagnosis and procedure codes. The patient demographics, disease severity, and other comorbidities were evaluated. The opioid medications used during the hospital stay were identified from the data and converted to the opioid oral morphine milligram equivalent per day (MME/d) for evaluation and comparison. We used t tests for statistical analysis.Results: A total of 2400 patients who had undergone AKA or BKA were evaluated (63.4% male, 67.3% white, 41.7% married, and 58.0% with a Charlson comorbidity index >3). The average length of stay was 5.72 6 3.56 days. The patients who had had a significantly greater MME/d in the early postoperative period included those undergoing a BKA (61.5 vs 55.4; P ¼ .007), men (62.6 vs 54.0; P < .0001), white patients (64.3 vs 44.67; P < .0001), younger patients (age <60 years, 69.6 vs 54.0; P < .0001), and patients treated at nontraining institutions (66.7 vs 56.7; P < .0001). Patients staying >6 days had increased opioid usage, likely secondary to complications (Fig) . The mean MME/d used on postoperative day 1 was 59.5 6 52.2 and had decreased to a mean MME/d before discharge of 17.6 6 17.9.Conclusions: The present analysis has demonstrated that younger patients, white men, those undergoing BKAs, and those treated at nontraining institutions had greater opioid usage during the hospital stay. At discharge, the patients had used an average of 17.6 MME/d, which equates to only three hydrocodone/acetaminophen 5/325 mg Tablets daily. These findings have shown that vascular surgeons are likely overprescribing opioids at discharge and must be cognizant of the appropriate dosing quantities. Prescriptions at discharge should reflect this daily usage and be tapered to avoid chronic usage, overdose, and possible death.
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