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.

DOI: 10.29245/2768-5365/2020/3.1110 View / Download Pdf

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