Karishma Kodia*, Dao M. Nguyen

Section of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida, USA

Enhanced recovery after surgery protocols (ERAS®) have become increasingly popular in the past few decades. Initially instituted by csolorectal and gynecologic surgery, these optimized "fast track" pathways have expanded across surgical sub-specialties. We discuss critical components of such pathways, the implementation process, and particular facets of perioperative care that apply to various surgical subspecialties including cardiac, colorectal, gynecologic, and thoracic surgery. The spirit of ERAS® emphasizes a continuous internal auditing process. ERAS® protocols are known for faster recovery, shorter length of stay, improved pain control, and optimization of a patient’s perioperative course by way of a standardized protocol. The unique aspects of enhanced recovery after thoracic surgery (ERATS) protocols are discussed. We focus on intercostal nerve blocks as an important component of ERATS pathways and optimized postoperative pain control. Intercostal nerve blocks in thoracic surgery allow for excellent postoperative pain control, which is critical for early ambulation, improved chest physiotherapy and easier progression through the post-operative course. This mini-review serves to highlight key features of ERAS®, salient aspects of niche surgical specialties, and focuses on thoracic surgery enhanced recovery protocols and intercostal nerve blocks in the context of ERATS for optimized postoperative pain control.

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Bernice Ofosu1, Dan Ofori2, Michael Ntumy1,3, Kwaku Asah-Opoku1,3, Theodore Boafor1,3*

1Department of Obstetrics & Gynaecology, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana

2University of Ghana Business School, Legon, Ghana

3University of Ghana Medical School, Korle-Bu, Accra, Ghana

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Heather R. Walker1*, Heather Mueller1, Tyson Christensen1, Heidi Cozart1, Scott R. Junkins2

1University of Utah Health, Medical Group, Utah, USA

2University of Utah Health, Department of Anesthesiology, Utah, USA

Background: Following the publication of the Center for Diseases Control and Prevention Guidelines for Prescribing Opioids in Primary Care, providers and institutions alike have been modifying practices and policies for prescribing controlled substances (2016).

Study Setting:The University of Utah Health implemented a series of data-driven adaptive and innovative programs and initiatives to improve opioid prescribing across its connected hospital and ambulatory health centers.

Data Collection: Using data mined from the electronic heath record system, researchers have been developing a data-driven approach with a collaborative team spanning clinical and data analytics backgrounds.

Objective: This article discusses those collaborative initiatives and presents a discussion of mindfulness in prescribing practices.

Conclusion: The multi-tiered data-driven approach taken by the University of Utah collaborative team demonstrates a model of change that other health care systems can emulate.

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Stacia B. Shipman*, Kelly A. Painter

Department of Emergency Medicine, INTEGRIS Southwest Medical Center, Oklahoma City, OK, USA

Corneal abrasions are known to be extremely painful and are a commonly seen eye condition. Topical anesthetic drops used for diagnosis of corneal abrasions provide immediate pain relief for most patients, but their use for outpatient use has been controversial. There is lack of consensus regarding ideal management of pain associated with corneal abrasions, with some physicians prescribing nonsteroidal anti-inflammatory drugs or opioids which both can have serious side-effects and/or abuse potential. In recent years, several studies have been conducted to assess the efficacy and safety of short term topical anesthetic use for the treatment of acute corneal abrasions. For this review, four published randomized controlled trials were identified that focused on the effectiveness and safety of various topical analgesics used in treating corneal abrasions. These showed varying degrees of efficacy depending on the outcomes measured without any significant difference in complication rates. Additionally, we reviewed an observational study that investigated whether routinely sending corneal abrasion patients home with a 24-hour supply of topical tetracaine is safe. They found no increased risk of ED revisits, fluorescein uptake at follow up, or ophthalmology clinic referrals. Larger prospective studies are still required to establish definitive safety, but the current available evidence suggests use of topical anesthetics for simple corneal abrasions is efficacious and safe.

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Joanna R. O'Sullivan*, Nicola Crowley

Guys and St Thomas's NHS Foundation Trust, UK

The recent publication of a new framework for practice from the British Association of Perinatal Medicine has altered the management of babies born in the UK at the threshold of viability. A risk stratification is used to determine which infants will receive active management, and which receive palliative management. This is achieved through a combination of assessment of risk factors and discussion with parents. The most notable feature of the new framework is the recommendation to consider babies of 22 weeks gestation for active care. This has been the subject of much discussion amongst neonatal and obstetric teams. The framework also emphasises the importance of early transfer to a maternity unit with a co-located neonatal intensive care unit if active management is pursued. This new guidance has led to a change in the way the management of extreme prematurity is approached, and will continue to impact on neonatal, obstetric, and anaesthetic care.

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Fariba Farrokhi1, Sneha Priyadarshini Honnabovi1, Marisa Pavone1, Kamal AL-Eryani2, Oussama Abousamra3, Reyes Enciso4*

1Advanced graduate, Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

2Assistant Professor of Clinical Dentistry, Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

3Assistant Professor of Clinical Orthopaedic Surgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA

4Associate Professor – Instructional, Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

The authors conducted a systematic review and meta-analysis to determine if Core Decompression (CD) with Bone Marrow Stem Cells (BMSC) is more effective in treating Osteonecrosis of the Femoral Head (ONFH) compared to CD. Authors used Cochrane Library, EMBASE, PubMed, Web of Science, and hand-searched references through January 2020, identifying relevant randomized controlled trials (RCTs). Risk of bias was assessed with Cochrane's handbook. Fifty-four abstracts were screened, and eight RCTs (five at high and three at unclear risk of bias) with 432 patients were included. Meta-analyses found statistically significant improvement in Harris Hip Score (HHS) at 12 months (Difference in Means [DM]=10.065;95% Confidence Interval [CI]=4.509 to 15.622; p<0.001) and pain intensity at 24 months (DM=-7.364;95% CI=-12.113 to -2.615;p=0.002) in CD+BMSC group compared to CD alone although these results may not be clinically significant. Risk of Total Hip Replacement (THR) in patients receiving CD+BMSC was 33.4% lower than in CD group though not significant (RR=0.666; 95% CI=0.355 to 1.250;p=0.206). Though meta-analyses found the addition of BMSC to CD significantly improves clinical outcomes (HHS and pain intensity) compared to CD only, evidence was of moderate/low quality due to high risk of bias, imprecision, and small sample sizes. Further research is needed to confirm the results.

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Kimberly Ting1, Albert Huh1, Carlos J. Roldan1,2*

1Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

2McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA

Scope of the investigation: No standard protocol has been established for the treatment of myofascial pain syndrome (MPS). Invasive therapies such as dry needling and trigger point injection (TPI) with active pharmacological agents are commonly used. Growing evidence suggests the efficacy of TPI is independent of the injectate selected. Normal saline (NS) solution has been described as an efficient injectate used in TPI for the treatment of MPS.

Methods: A broad literature search was performed to compare the use of NS and other pharmacological agents as the injectate in TPI for the treatment of MPS.

Results: We identified 13 reports comparing the safety and efficacy of NS with that of botulinum toxin A or local anesthetic with or without steroid in TPI.

Conclusion: Pain of myofascial origin can be adequately treated with TPI independent of the injectate used. The use of NS in TPI offers lower cost, safety, and a more favorable side effect profile than other TPI injectates.

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Naveen Manchal

The Prince Charles Hospital, Brisbane, James Cook University, Australia

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Erick Gomez-Marroquin1, Yuka Abe1,2, Mariela Padilla1*, Reyes Enciso3, Glenn T. Clark1

1Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA

2Department of Prosthodontics, Showa University School of Dentistry, Tokyo, Japan. Visitor Scholar Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA

3Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA

Aim: To assess treatment efficacy in the management of orofacial myogenous conditions by a retrospective study of patients seen at an orofacial pain clinic.

Methods: A single researcher conducted a retrospective review of charts of patients assigned to the same provider, to identify those with myogenous disorders. The reviewed charts belonged to patients of the Orofacial Pain and Oral Medicine Center of the University of Southern California, seeing from June 2018 to October 2019.

Results: A total of 129 charts included a myogenous disorder; the most common primary myogenous disorder was localized myalgia (58 cases, 45.0%). Arthralgia was the most common TMD concomitant condition (82.9%), followed by internal derangement (41.9%). Forty-six patients were given a home-based conservative physical care protocol; ten additional cases also received trigger point injections (lidocaine or mepivacaine) with pain assessed by verbal numerical rating scale (NRS), pre- and post-treatment follow-up within 24 weeks. There was a significant overall pain improvement in NRS pain from pre- to post-treatment (p<0.001), though no difference was found between conservative treatment and trigger points in NRS pain (p=0.130). However, the rate of NRS unit improvement per week in the conservative treatment group was significantly greater than the trigger point group (p=0.036). These apparently contradictory results might be due to the small sample size of the trigger point injections group (n=10).

Conclusion: In this small sample size study, the addition of trigger point injections to conservative treatment provided inconclusive results, further studies are needed.

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Jessi Humphreys*, Laura Schoenherr

Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, USA

As the COVID-19 pandemic proceeds, systems continue to struggle with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high quality patient care. The reduced visitation capacity in hospitals has resulted in high levels of patient and family suffering, and patients both with and without COVID-19 require expert symptom management and goals of care conversations. A manuscript was published describing the rapid implementation of telepalliative medicine consultation by the Inpatient Palliative Care team at UCSF in attempts to meet these critical patient and family needs. This piece details additional lessons learned that were inadequately addressed in the original manuscript and/or that have been revealed in the months since the program’s inception. Key learning points include the need for: committed investment in effective hardware and software; communication skills adapted to effectively utilize technology to benefit patients and families; creative workforce models to render technology effective; interdisciplinary input in care models to reduce provider as well as patient and family suffering; and attention to burdens placed on already overstretched nurses and intensivists during respiratory pandemics.

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Joanne Szewczyk, Benjamin H Nguyen, Nestor Villamizar, Dao M. Nguyen*

Section of Thoracic Surgery, Department of Surgery, University of Miami, Miami, Florida, USA

In the last decade, the implementation of enhanced recovery protocol for patients undergoing thoracic surgical procedures, either by thoracotomy or thoracoscopy, has gained significant recognition. Such protocols have been developed following the enhanced recovery after surgery (ERAS) guiding principles, yet have been tailored with attention to the unique nuances of thoracic surgical patients. Over the last 5 years, a body of literature has been published attesting to the success of the enhanced recovery after thoracic surgery (ERATS) protocol, with reported improvements of measurable outcome metrics. This mini-review focuses on postoperative pain control using the innovative strategy of opioid-sparing multimodal analgesics of the ERATS care pathway.

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Alex K. Saltzman1, Thuyvan H. Luu1, Nicole Brunetti1, James D. Beckman1,2, Mary J. Hargett1, Stephen C. Haskins1,2*

1Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, USA

2Department of Anesthesiology, Weill Cornell Medicine, New York, USA

Background and Objectives: Point-of-care ultrasound (POCUS) in the form of focused cardiac ultrasound (FOCUS) is a powerful clinical tool for anesthesiologists to supplement bedside evaluation and optimize cardiopulmonary resuscitation in the perioperative setting. However, few courses are available to train physicians. At Hospital for Special Surgery (HSS), from March of 2013 to May of 2016, nine basic Focused Assessed Transthoracic Echocardiography (FATE) training courses were held. A large percentage of the participants were practicing regional anesthesiologists or trainees in fellowship for regional anesthesia and acute pain. In this study, a survey was used to assess clinical utilization as well as potential barriers to use for regional anesthesiologists.

Methods: Following IRB approval, 183 past participants of the basic FATE training course were contacted weekly from November 22nd, 2016, through January 3rd, 2017, via email and sent a maximum 40-item electronic survey hosted on REDCap. Responses were analyzed by a blinded statistician.

Results: 92 participants responded (50%), and 65 of the 92 (70.7%) indicated they had regional anesthesiology training or practice regional anesthesia regularly. Of the total number of respondents, 50% (95% CI: 40.3%, 59.8%; P-value = 0.001) have used FOCUS to guide clinical decision making. Of the regional anesthesiologists, 27 (45.8%) have used FOCUS to guide clinical decision making with left ventricular function assessment (40.7%) and hypovolemia (39.0%) being the most common reasons. Regional anesthesiologists utilized FOCUS in the following settings: preoperatively (44.6%), intraoperatively (41.5%), postoperatively (41.5%), and in the Intensive Care Unit (40.0%). Limitations were due to lack of opportunities (52.3%), resources (36.9%), and comfort with performance (30.8%). 84.4% agreed that basic FOCUS training should be a required part of anesthesia residents or fellows’ curriculum.

Conclusions: This study is the first formal evaluation of the impact of the implementation of a FOCUS training course on regional anesthesiologists’ current practice. Nearly 50% of regional anesthesiologists used FOCUS to guide clinical decision-making following formal training. The limitations to the use of FOCUS were a lack of relevant opportunities and resources. This evaluation of clinical use following training provides insight into how FOCUS is used by regional anesthesiologists and the limitations to implementation in the perioperative setting.

DOI: 10.29245/2768-5365/2020/2.1104 View / Download Pdf

Gerald E. Davis II1,2, George Sarandev1, Alexander T. Vaughan1, Kamal Al-Eryani3, Reyes Enciso4*

1Advanced graduate, Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of USC, Los Angeles, California, USA

2Assistant Dean of Academic Affairs, Assistant Professor, Restorative Dentistry, Meharry Medical College, School of Dentistry, Nashville, Tennessee, USA

3Assistant Professor of Clinical Dentistry, Division of Periodontology, Dental Hygiene & Diagnostic Sciences, Herman Ostrow School of Dentistry of USC, Los Angeles, California, USA

4Associate Professor (Instructional), Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles, California, USA

Background: Current treatments for pemphigus and Behcet's disease, such as corticosteroids, have long-term serious adverse effects.

Objective: The objective of this systematic review was to evaluate the efficacy of biologic agents (biopharmaceuticals manufactured via a biological source) on the treatment of intraoral lesions associated with pemphigus and Behcet's disease compared to glucocorticoids or placebo.

Methods: PubMed, Web of Science, Cochrane Library, and EMBASE were searched for randomized controlled studies up to January 2019. Bias was assessed with the risk of bias tool.

Results: Out of 740 references retrieved, only four randomized controlled trials (RCTs) were included, comprised of a total of 158 subjects (138 pemphigus and 20 Behcet's disease). All studies were assessed at high risk of bias. Heterogeneity of data prevented the authors from performing a meta-analysis. Infliximab or rituximab with short-term prednisone showed higher safety and lowered cumulative prednisone dose than prednisone alone in the treatment of pemphigus. Subcutaneous injection of etanercept provided 45% of patients free of ulcers compared to 5% in the placebo group in one study with Behcet's disease; however, no difference was found in pemphigus patients.

Conclusion: Though biological agents alone or in combination with prednisone showed favorable results in three RCTs compared to prednisone alone or placebo, a meta-analysis could not be undertaken due to high heterogeneity. Results are inconclusive, and larger, well-designed RCTs are needed.

DOI: 10.29245/2768-5365/2020/1.1105 View / Download Pdf

Ly Zhang*, Philip G. Boysen

Department of Anesthesiology, University of Mississippi Medical Center, The Mississippi Critical Care Organization, USA

DOI: 10.29245/2768-5365/2020/1.1101 View / Download Pdf

Sedat Özbay1, Abuzer Coskun1*, Sevki Hakan Eren2

1Department of Emergency, Sivas Numune Hospital, Sivas, Turkey

2Department of Emergency Medicine, Gaziantep University, Gaziantep, Turkey

Objective: This study aimed to evaluate acute coronary syndrome (ACS), serum procalcitonin levels, Platelet/Mean Platelet Volume ratio (PMR) and Neutrophil/lymphocyte ratio (NLR) concerning post-myocardial infarction (MI) complications, mortality, and morbidity.

Material and Method: The study included a total of 913 patients with ACS who presented to the emergency department with chest pain between January 2013 and December 2017. The patients were categorized as ST-elevated MI (STEMI), non-ST elevated MI (NSTEMI) and unstable angina (UA) according to the diagnosis. The demographic and laboratory characteristics of the patients were compared for three-vessel disease (TVD) and mortality rates.

Result: Post MI complications, TVD, and mortality were significant among acute coronary syndrome groups. The three-vessel disease was mostly observed in anterior MI with a maximum rate of 58 (39.7%). Mortality was found as 23 (16.3%) in anterior MI and 18 (12.2%) in NSTEMI. Serum procalcitonin levels were highest in anterior MI. Platelet to Mean Platelet Volume ratio was higher in UA, whereas it was lower in STEMI and NSTEMI. Neutrophil to lymphocyte ratio was the lowest in UA. The cTn I values of STEMIs at 0, 6, 12 hours were higher than UA, and the 12th-hour cTnI values in anterior MI were higher than NSTEMIs. It was found that procalcitonin and NLR had a positive correlation with post-MI complications, mortality, and TVD, whereas PMR exhibited a negative correlation.

Conclusion: The levels of procalcitonin, PMR, and NLR may be significant in respect of post-complications, mortality, and morbidity in acute coronary syndrome.

DOI: 10.29245/2768-5365/2020/1.1103 View / Download Pdf

Abuzer Coskun1*, Sevki Hakan Eren2

1Department of Emergency, Sivas Numune Hospital, Sivas, Turkey

2Department of Emergency Medicine, Gaziantep University, Gaziantep, Turkey

Pulmonary thromboembolism in which hemostatic balance is disrupted is a disease with high morbidity and mortality rates with challenging diagnosis. A 73-year-old female patient presented to the emergency department with respiratory distress. She had undergone surgery for femoral neck fracture three months ago. She had gradually aggravating respiratory distress for the last 3-4 days. The patient was admitted to the hospital with the diagnosis of massive pulmonary embolism. She had a cardiac arrest after completion of thoracic computed tomography (thoracic CT). Cardiopulmonary resuscitation (CPR) was initiated. Alteplase (rt-PA) was infused at 100 mg/2 hours starting at the 37th minute of CPR in the late phase. As there was no room on the wards, she was admitted to the emergency room observation unit and extubated on the 9th day. Coumadin (warfarin) dose was adjusted and the patient was discharged on day 17 with an INR (International Normalized Ratio) of 2.3.

DOI: 10.29245/2768-5365/2020/1.1102 View / Download Pdf