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Understanding and Mitigating Rebound Pain After Peripheral Nerve Blocks 

Peripheral nerve blocks are a widely used technique for providing effective pain relief during and after surgical procedures. While they offer significant benefits, one common and challenging issue is rebound pain. This phenomenon occurs when the nerve block wears off, leading to a sudden and often intense resurgence of pain. Understanding rebound pain and implementing strategies to mitigate it is crucial for improving patient outcomes and satisfaction. 

What is Rebound Pain? 

Rebound pain is characterized by a sharp increase in pain intensity following the resolution of a peripheral nerve block. It typically occurs within 12 to 24 hours after the block wears off and can be more severe than the initial postoperative pain. This sudden pain surge can be distressing for patients and challenging for healthcare providers to manage. 

Causes of Rebound Pain 

Rebound pain is believed to result from several factors. The primary cause is the sudden withdrawal of the nerve block’s analgesic effect, which can lead to heightened sensitivity and a strong pain response. Additionally, the body’s natural inflammatory response to surgery continues unabated once the block wears off, contributing to the pain intensity. 

Preoperative Strategies 

Effective management of rebound pain begins with preoperative planning. Educating patients about the possibility of rebound pain and setting realistic expectations can help them prepare mentally and emotionally. Preoperative discussions should include pain management plans that extend beyond the duration of the nerve block. 

Preemptive analgesia, involving the administration of pain medications before the onset of surgical pain, can also be beneficial. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and gabapentinoids can be given preoperatively to reduce the severity of rebound pain. 

Intraoperative Approaches 

During surgery, multimodal analgesia should be employed to manage pain from different pathways. Combining regional anesthesia with systemic analgesics, such as opioids and non-opioid medications, can provide a more balanced and prolonged pain relief. 

The choice of local anesthetic and its duration of action are critical factors. Longer-acting local anesthetics, such as bupivacaine or ropivacaine, can delay the onset of rebound pain, giving more time for other analgesic measures to take effect. 

Postoperative Pain Management 

A comprehensive postoperative pain management plan is essential to mitigate rebound pain. This plan should include: 

  • Scheduled Analgesics: Regularly scheduled pain medications, including NSAIDs and acetaminophen, can provide consistent pain control and reduce the intensity of rebound pain. 
  • Opioids: Short-term use of opioids may be necessary for managing severe rebound pain. However, their use should be carefully monitored to avoid dependency and side effects. 
  • Adjuvant Therapies: Medications such as gabapentinoids, muscle relaxants, and corticosteroids can be used as adjuncts to enhance pain relief. 
  • Rescue Analgesia: A plan for rescue analgesia should be in place for patients experiencing breakthrough pain. Rapid-acting opioids or additional doses of existing medications can help manage these pain episodes. 

Non-Pharmacological Interventions 

Non-pharmacological interventions can complement medical pain management strategies. Techniques such as ice packs, elevation, and physical therapy can help reduce pain and inflammation postoperatively. Additionally, mindfulness practices and relaxation techniques can aid in managing pain perception and reducing anxiety. 

Patient Education and Follow-Up 

Educating patients about the potential for rebound pain and the importance of adhering to the pain management plan is crucial. Providing clear instructions on medication schedules and non-pharmacological techniques empowers patients to manage their pain effectively. 

Regular follow-up appointments allow healthcare providers to monitor pain levels and adjust the pain management plan as needed. Early intervention in cases of severe rebound pain can prevent complications and improve overall patient comfort. 

Conclusion 

Rebound pain after peripheral nerve blocks is a significant concern that requires a proactive and multifaceted approach. By understanding its causes and implementing comprehensive pain management strategies, healthcare providers can significantly reduce the impact of rebound pain on patients. Preoperative planning, intraoperative techniques, and postoperative care all play vital roles in mitigating this challenging condition. 

Through patient education, careful monitoring, and the use of multimodal analgesia, the medical community can enhance the effectiveness of peripheral nerve blocks and improve postoperative recovery experiences. As research continues and new strategies are developed, the goal remains to provide optimal pain relief and enhance the quality of care for surgical patients. 

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OR Temperature

The temperature of an operating room (OR) affects both patient outcomes and the efficiency of surgical procedures. Maintaining an optimal OR temperature is essential for ensuring patient safety, preventing complications, and providing a comfortable environment for the surgical team.

Operating room temperature is crucial for several reasons. First, it affects patient outcomes. Hypothermia is a significant risk during surgery, particularly for patients undergoing lengthy procedures or those with compromised health. Even mild hypothermia can lead to complications such as increased blood loss, infection rates, and extended hospital stays. Maintaining an appropriate OR temperature helps prevent these risks. Second, OR temperature impacts surgical efficiency. A comfortable OR temperature ensures that the perioperative team can perform at their best. Anesthesiologists, surgeons, and supporting providers must remain focused and dexterous, and an overly cold environment can impair fine motor skills and concentration. Finally, OR temperature impacts infection control. Temperature and humidity levels in the OR play a role in controlling the spread of airborne contaminants. Maintaining a balanced temperature helps ensure that the environment remains sterile and reduces the risk of postoperative infections 1,2.

Several factors must be considered when setting and maintaining OR temperatures. Members of the perioperative team may wear multiple layers of sterile clothing, which can make a warmer OR uncomfortable and impair their performance. Additionally, different procedures may have varying requirements for temperature control. The health and age of the patient also influence temperature management, with infants, the elderly, and patients with compromised health requiring more careful temperature regulation to prevent hypothermia.

Typically, the ideal temperature range for an OR falls between 18 and 25°C, with some variation based on the type of surgery and the patient’s condition. The relative humidity, meanwhile, should be about 50%. For surgeries involving significant blood loss or prolonged duration, like cardiovascular and trauma surgery, a slightly higher temperature may be beneficial to help maintain patient body temperature. Since children are more susceptible to hypothermia, OR temperatures for pediatric surgical cases may be set slightly higher 3,4.

Warming blankets or fluid warmers are often used to maintain patient temperature during lengthy or complex surgeries. In addition, modern ORs are equipped with sophisticated HVAC systems that allow precise control of temperature and humidity levels. The use of temperature monitoring devices on patients provides important information to the perioperative team 5.

Maintaining an optimal OR temperature is a delicate balance that requires consideration of patient safety, surgical efficiency, and infection control. By adhering to recommended temperature ranges and adjusting based on the specific needs of the surgery and the patient, healthcare providers can enhance surgical outcomes and ensure a safe, comfortable environment for both patients and providers.

References

1.           Hakim, M. et al. The Effect of Operating Room Temperature on the Performance of Clinical and Cognitive Tasks. Pediatr. Qual. Saf. (2018). doi:10.1097/pq9.0000000000000069

2.           Why Operating Rooms Are So Cold. Available at: https://www.verywellhealth.com/are-operating-rooms-cold-to-prevent-infection-2549274. (Accessed: 21st May 2024)

3.           Operating Theatre Temperature & Humidity Guidelines – Cairn Technology. Available at: https://cairntechnology.com/operating-theatre-temperature-humidity-guidelines/. (Accessed: 21st May 2024)

4.           ELLIS, F. P. THE CONTROL OF OPERATING-SUITE TEMPERATURES. Br. J. Ind. Med. (1963). doi:10.1136/oem.20.4.284

5.           Broad to Precise Temperature Control for Industry – Air Innovations. Available at: https://airinnovations.com/environmental-control/broad-to-precise-temperature-control-for-industry/. (Accessed: 21st May 2024)

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Comparing Spinal vs. Epidural Anesthesia

Neuraxial anesthesia refers to the administration of local anesthesia around the central nervous system, specifically the spinal cord. Types of neuraxial anesthesia include spinal, epidural, and combined spinal-epidural techniques. The primary difference among these different anesthetic techniques is the anatomic location of injection. Epidural anesthesia is performed by introducing a needle between the lumbar, thoracic, or cervical vertebrae and injecting anesthetic medication into the epidural space, while spinal anesthesia involves administration of medications into the subarachnoid space. However, spinal and epidural anesthesia are applicable to many of the same surgical procedures.

Typically, neuraxial anesthesia is utilized for surgeries involving the lower abdomen and lower extremities. Spinal anesthesia is generally administered as a single injection, while epidural anesthesia is commonly delivered via a catheter for continuous infusion. The insertion of the spinal anesthesia needle is typically targeted at a mid- to low-lumbar intervertebral space, below the termination of the conus medullaris. In contrast, needle placement for an epidural injection can be performed at various locations along the distal end of the neuraxial canal. Catheter-based neuraxial anesthesia allows for prolonged anesthesia and the ability to adjust the onset of the anesthetic. Conversely, single-shot spinal or epidural anesthesia is limited to the duration of action of the administered drug.

Spinal and epidural techniques each have their own set of advantages and disadvantages. Common advantages of spinal anesthesia include: 1) rapid onset of block, 2) a technically easy procedure, 3) low required doses of local anesthetic and opioids, and 4) a reliably symmetric block. Disadvantages of spinal anesthesia include: 1) limited duration of action with single-shot injections, 2) limited ability to extend block, and 3) the requirement of dural puncture.

Advantages of epidural anesthesia include: 1) ability to easily prolong the duration and extent of the block, and 2) may be used for postoperative analgesia. Disadvantages of epidural anesthesia include: 1) relatively slow onset of anesthesia, 2) higher required doses of local anesthetic and opioids than spinal techniques, 3) risk of post-dural puncture headache with unintentional dural puncture, 4) possibility of patchy or asymmetric block, and 5) an unreliable sacral block.

A recent meta-analysis by Cochrane examined the efficacy and side-effects of spinal versus epidural anesthesia in women undergoing caesarean section. The analysis included ten randomized controlled trials. It found no significant differences between spinal and epidural techniques in terms of failure rate, need for additional intraoperative analgesia, conversion to general anesthesia, maternal satisfaction, need for postoperative pain relief, or neonatal intervention. However, although women who received spinal anesthesia had a shorter time from the start of the anesthetic to the start of the operation, they also had a higher likelihood of requiring treatment for hypotension. The authors concluded that both spinal and epidural techniques are effective for providing anesthesia during caesarean section. Still, due to the low incidence and/or lack of reporting, no definitive conclusions could be drawn regarding intraoperative side effects and postoperative complications.

Spinal and epidural anesthesia are two types of neuraxial anesthesia that primarily differ in terms of the anatomic location of local anesthetic administration. While each technique has its own advantages and disadvantages, they are both effective and relatively safe.

References

Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques: An Updated Report by the American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2017 Apr;126(4):585-601. doi: 10.1097/ALN.0000000000001521. PMID: 28114178.

Hebl JR, Horlocker TT, Kopp SL, Schroeder DR. Neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spine surgery: efficacy and neurologic complications. Anesth Analg. 2010 Dec;111(6):1511-9. doi: 10.1213/ANE.0b013e3181f71234. Epub 2010 Sep 22. PMID: 20861423.

Hebl JR, Horlocker TT, Schroeder DR. Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders. Anesth Analg. 2006 Jul;103(1):223-8, table of contents. doi: 10.1213/01.ane.0000220896.56427.53. PMID: 16790657.

Hartmann B, Junger A, Klasen J, Benson M, Jost A, Banzhaf A, Hempelmann G. The incidence and risk factors for hypotension after spinal anesthesia induction: an analysis with automated data collection. Anesth Analg. 2002 Jun;94(6):1521-9, table of contents. doi: 10.1097/00000539-200206000-00027. PMID: 12032019.

Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R. Incidence and risk factors for side effects of spinal anesthesia. Anesthesiology. 1992 Jun;76(6):906-16. doi: 10.1097/00000542-199206000-00006. PMID: 1599111.

Bonica JJ, Kennedy WF Jr, Ward RJ, Tolas AG. A comparison of the effects of high subarachnoid and epidural anesthesia. Acta Anaesthesiol Scand Suppl. 1966;23:429-37. doi: 10.1111/j.1399-6576.1966.tb01043.x. PMID: 6003651.

Ng K, Parsons J, Cyna AM, Middleton P. Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev. 2004;2004(2):CD003765. doi: 10.1002/14651858.CD003765.pub2. PMID: 15106218; PMCID: PMC8728877.

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CME for Anesthesiologist

Every five years, anesthesiologists need to earn 125 Continuing Medical Education (CME) credits, and every 10 years, they need to have earned a total of 250 CME credits. These CME credits are critical to maintaining a certification in anesthesiology and being able to practice in the United States. [1,2].

Many institutions, including the Mayo Clinic for example, offer a variety of CME opportunities that includes live courses and conferences, podcasts, and online courses. Anesthesiologists and other physicians can take advantage of what CME options best suit them (within certain limitations).

CME courses aim to keep clinicians up to date on healthcare delivery, clinical practice, quality improvements, medical research and more in order to guide physicians, advanced practice providers, anesthesiologists, nurses, and certified nurse anesthetists best serve a patient. Anesthesiologists can shop around for their own CME credit courses via the American Society of Anesthesiologists’ online portal [3]. You can now specifically search for courses by the type of credit they offer and visit the Education Center dashboard for the latest free courses at any time. The American Society of Anesthesiologists also publishes a CME journal which is free for all American Society of Anesthesiologists members [4]. Other opportunities and databases for CME also exist.

CME credits are integral to board certification by the American Board of Anesthesiologists. This is important because since 1938, American Board of Anesthesiologists certification has been the process for certifying anesthesiologists in the United States. Patients trust board certification to ensure that a physician has acquired the knowledge, skills, and judgement required to provide safe and high-quality specialty care [5].

Though CME requirements do add to an anesthesiologist’s responsibilities, there are significant benefits to acquiring and maintaining certification [5]. Thorough training ensures that an anesthesiologist has the clinical judgment, technical expertise, and scientific knowledge required to provide excellent patient care. In addition, through the continuing education (CME) requirements, an anesthesiologist can stay up to date with the most recent medical advances. Finally, board-certified professionals are required to demonstrate their proficiency through an ongoing rigorous board certification process. Specific requirements for leadership and educational activities ensure physicians consistently meet the highest standards of professionalism.

CME credits continue to be key to maintaining an anesthesiologist’s board certification and ensuring the safest health care delivery possible across the United States.

References

1. CME – The American Board of Anesthesiology. Available at: https://www.theaba.org/maintain-certification/cme/. (Accessed: 9th December 2023)

2. Journal CME – 2023 Full Subscription | American Society of Anesthesiologists (ASA).

Available at: https://www.asahq.org/shop-asa/e023j00w00. (Accessed: 9th December 2023)

3. ShopASA for CME. Available at: https://www.asahq.org/shop-asa#sort=%40searchdate descending. (Accessed: 9th December 2023)

4. CME | Anesthesiology | American Society of Anesthesiologists. Available at: https://pubs.asahq.org/anesthesiology/pages/cme. (Accessed: 9th December 2023)

5. Value of Board Certification – The American Board of Anesthesiology. Available at: https://www.theaba.org/get-certified/value-of-board-certification/. (Accessed: 9th December 2023)

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Applications of Robotic Surgery

Robotic surgery is a developing field that utilizes the precision of machines to assist surgeons. Several studies demonstrate that robotic surgery is superior to human executed surgery for certain procedures, and there are currently a number of different applications of robotic surgery in medicine. Overall, robotic surgery is typically used to increase control over surgical tools, reduce the invasiveness of a procedure, and incorporate helpful visualizations.

 

Groysman et al. studied a cohort of patients who underwent surgery for oropharyngeal squamous cell carcinoma to compare patient outcomes from non-robotic surgery with those from transoral robotic surgery (TORS). The results showed that non-robotic surgery was more likely to leave residual tumor when compared to TORS. The success rate of TORS is driven by its use of articulating arms which enhances tumor extraction and a high-definition endoscope which enhances visibility.  Because of residual tumor, patients who underwent non-robotic surgery were more likely to receive chemotherapy to treat residual tumor.1 These possibilities make tumor removal one of the applications of robotic surgery.

 

There are many benefits of robotic surgery, which Gauci et al. categorize in their assessment of implementing robotic techniques to treat advanced colorectal cancer. The minimally invasive approach features smaller incisions, reduced postoperative pain, reduced blood loss and thus faster recovery times. Enhanced visualization reduces complications because it enhances identification and thus dissection. Supportive technologies like indocyanine green integrates with robotic systems for superior anatomical assessments. Surgeons who use robotic technologies report improved comfort and reduced physical demand since these procedures can last up to 8 hours. Dual console surgery allows two surgeons to work on tumor removal simultaneously. The wristed components of robotic systems increase precision which is critical to preserve adjacent organs and blood vessels. Overall clinical outcomes are better; shorter hospital stays, reduced ICU visits and faster recovery have been reported.2

 

Other applications of robotic surgery can improve results in complicated procedures. Gul’s study does an in-depth comparison of complex gynecological procedures that benefit from robotic techniques. Patients with obesity and endometrial cancer, high BMI and fibroid masses, rectovaginal disease, frozen pelvis, or retroperitoneal masses, and those needing neuropelveology procedures (surgeries targeting sacral pudendal nerves), posterior myomectomies, , abdominal mesh vault suspensions and mesh removals are complex pelvic cases that have better suited for robotic surgeries. Like Gauci et al., Gul explains that the enhanced precision and visualization of robotic surgery improve surgical outcomes. In addition to the benefits listed by Gauci et al., robotic systems in gynecology have a 57 Newton grip force, 7 degrees of freedom during wrist like motions, virtual reality, a computer interface, and no hand tremors due to scaling and filtration. Patient benefits can include complete disease removal, early recovery and return to normal activities as well as reduced pain.

 

Ballet et al.’s study reports positive findings for treating pelvic cancers with robotic surgical techniques. The Da Vinci Xi robotic system was selected to replace the typical laparoscopic method which has ergonomic limitations. Purported benefits of this system include that fewer incisions are needed to achieve triangulation of surgical zone, switching to laparotomy is not required when laparoscopy cannot perform complex surgical techniques, and visualization is fully optimized. While patients are usually left with four scars from the standard laparoscopic method, one scar is the outcome when the Da Vinci Xi robotic system is applied.

 

IIn many cases, applications of robotic surgery are improving surgical results across various parameters. These parameters include patient recovery, disease complexity, workplace stress for physicians, scarring and most importantly, disease treatment.4 However, it is important to note that robotic surgery is not currently appropriate or applicable to all cases.

 

References

 

1. Groysman M, Gleadhill C, Baker A, Wang SJ, Bearelly S. Comparison of margins and survival between transoral robotic surgery (TORS) and non-robotic endoscopic surgery for oropharyngeal cancer. Am J Otolaryngol. 2023 Nov-Dec;44(6):103982. doi: 10.1016/j.amjoto.2023.103982. Epub 2023 Jul 6. PMID: 37531886.

2. Chahaya Gauci, Praveen Ravindran, Stephen Pillinger, Andrew Craig Lynch, Robotic surgery for multi-visceral resection in locally advanced colorectal cancer: Techniques, benefits and future directions, Laparoscopic, Endoscopic and Robotic Surgery, 2023,ISSN 2468-9009,

3. Nahid Gul. Robotic surgery in gynaecology. Obstetrics, Gynaecology & Reproductive Medicine, Volume 32, Issue 12, 2022, Pages 267-271, ISSN 1751-7214.

4. Elodie Ballet, Clement Rousseau, Tiphaine Raia Barjat, Céline Chauleur, Robotic retroperitoneal para-aortic lymphadenectomy via single-site port, Journal of Gynecology Obstetrics and Human Reproduction, Volume 52, Issue 10, 2023, 102675, ISSN 2468-7847.

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Hospital Competition in the US

The healthcare landscape in the United States is extremely complex, marked by exchanges and relationships between providers, insurance companies, patients, and hospitals. The competition among hospitals has significant potential to affect both healthcare providers and patients. The dynamics of hospital market competition in the US have changed greatly in the past few decades. The Affordable Care Act, passed in 2010, launched Medicare Value-Based Purchasing, informing the discourse surrounding hospital competition in the United States (Haley et al., 2016). The debate over hospital competition in the US remains an important and continuously evolving issue, especially given the substantial amount of healthcare spending in the United States (National CMS, 2017).

In recent years, hospital markets have become increasingly monopolized, with prominent health systems dominating heavily in many areas. In the United States, each region generally has 3 to 5 consolidated healthcare systems (Cutler and Morton, 2013). For example, between 2007 to 2017, the number of hospitals in the US grew from 2741 to 4597. In this same period, the percentage of hospitals in the U.S. affiliated with a health system increased from 53.4% to 64.3%. Remarkably, the number of health systems underwent little change. While the overall hospital market expanded in terms of beds, admissions, and inpatient days from 2007 to 2017, and the size of the overall hospital market has decreased (Johnson and Frakt, 2020).

Of note, hospitals located in more competitive markets have been associated with lower mortality rates for patients dealing with conditions such as myocardial infarction, heart failure, and pneumonia. This may point to potential benefits of hospital market competition. However, policymakers must strive to develop policies that promote a competitive, yet equitable and transparent healthcare marketplace to enhance patient outcomes (Haley et al., 2016).  Some advantages of consolidated health systems are the ability to coordinate complex care across a variety of providers and sites (Cutler and Morton, 2013).

As hospital competition decreases and markets become more concentrated, healthcare costs tend to increase, according to US data (Cutler and Morton, 2013). Concentrated healthcare networks have the leverage to demand higher insurance premiums and out-of-pocket expenses from patients. Policy interventions must therefore target the pricing strategies that these systems enforce on patients (Johnson and Frakt, 2020). At a local level, governments must propose policies that ensure customer protection in the face of market consolidation and a subsequent increase in healthcare costs (Cutler and Morton, 2013)

In conclusion, the landscape of hospital competition in the US is intricate, multifaceted, and in a constant state of flux. While discussing hospital competition, it is crucial to consider various factors, including the quality of care, patient satisfaction, cost innovation, regulation, as well as partnerships and collaboration. By addressing these dynamics, policymakers and relevant stakeholders can ensure a competitive yet fair and transparent healthcare marketplace that benefits patients.

References

Cutler, David M, and Fiona Scott Morton. “Hospitals, market share, and consolidation.” JAMA vol. 310,18 (2013): 1964-70. doi:10.1001/jama.2013.281675

Haley, Donald Robert et al. “The Influence of Hospital Market Competition on Patient Mortality and Total Performance Score.” The health care manager vol. 35,3 (2016): 266-76. doi:10.1097/HCM.0000000000000117

Johnson, Garret, and Austin Frakt. “Hospital markets in the United States, 2007-2017.” Healthcare (Amsterdam, Netherlands) vol. 8,3 (2020): 100445. doi:10.1016/j.hjdsi.2020.100445

National CMS. “Health Expenditures Fact Sheet, 2017.” CMS.Gov, Centers for Medicare & Medicaid Services, 2017, www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet.

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Portable Ultrasound for OR Use 

Ultrasound technology harnesses high-frequency sound waves beyond the hearing abilities of humans. Ultrasonography operates with probes which generate sound waves and capture what is reflected, which is then transformed into an image on a screen (Li et al., 2020). Portable ultrasound devices have been increasingly integrated into the operating room (OR) and have become a vital tool in modern medicine. Often referred to as point-of-care ultrasound (POCUS), this technology offers real-time imaging capabilities. In the operating room, this allows surgeons to make decisions during procedures quickly and with more information.  

Portable ultrasound can decrease the use of invasive procedures, including exploratory surgery, when it is unnecessary. With ultrasound, surgeons can assess the need for invasive measures more accurately (Bollard, et al., 2021). Portable ultrasound devices also provide real-time feedback in the OR. This enables surgeons to monitor changes and adapt their approach during complex surgery.  

Various surgical disciplines benefit from the incorporation of portable ultrasound in the OR. Some surgeries that utilize portable ultrasound include abdominal surgeries. For example, with portable ultrasound in liver or kidney surgeries, surgeons assess blood flow, identify anatomical variations, and detect abnormalities. The POCUS is especially important in detecting free fluid around the abdominal structures, which poses a surgical emergency (Abu-Zidan & Cevik, 2018). Even in plastic surgery, the portable ultrasound has had unique uses (Safran et al., 2018). Ultrasound can be used to visualize anatomy and offer an energy source for procedures. For example, in hand surgeries, POCUS allows surgeons to localize foreign bodies and guide procedures (Bollard, et al., 2021).  

Portable ultrasound is not only used on the surgeon’s side in the OR. Anesthesiologists use various forms of ultrasound during surgical procedures to monitor patients. For example, they may use transesophageal echocardiography to manage and watch cardiac and non-cardiac patients in the surgical setting. Cardiac ultrasound can detect pulmonary embolism and cardiac tamponade and guide immediate treatment (Kalagara, et al., 2022). Anesthesiologists may also complete ultrasounds of the lung to diagnose hypoxia, confirm proper placement of an endotracheal tube, or locate the cricothyroid membrane when securing an airway. Anesthesia may also do a gastric ultrasound to help understand the gastric contents of a patient. However, this type of ultrasound is more controversial (De Marchi & Massimiliano, 2017). For patients who have challenging airways, need emergency surgery, or have certain comorbidities, gastric ultrasound may help assess aspiration risk (Li et al., 2020).  

Ultrasound is becoming increasingly integrated in medical education. It is critical that medical students, residents, fellows, and physicians receive proper training on POCUS. An ultrasound’s effectiveness is very dependent on the operator’s skill and their ability to read the image produced by the ultrasound (Li et al., 2020). In anesthesia, where POCUS is of great use in the operating room, there is no standardized education. However, more groups have started organizing education series on this topic and creating frameworks for POCUS education (Li et al., 2020).  

In conclusion, the incorporation of portable ultrasound into the operating room is revolutionizing surgery by enhancing precision, reducing invasiveness, and enabling real-time assessment of anatomical structures and surgical procedures. These devices have become indispensable for surgeons across various medical specialties and for anesthesiologists. As ultrasound technology advances, their prevalence in the operating room is bound to grow. It is vital that research continues to assess best practices for utilizing this transformative technology.   

References 

1) Abu-Zidan, Fikri M, and Arif Alper Cevik. “Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced.” World journal of emergency surgery : WJES vol. 13 47. 15 Oct. 2018, doi:10.1186/s13017-018-0209-y 

2) Bollard, Stephanie Marie et al. “The Use of Point of Care Ultrasound in Hand Surgery.” The Journal of hand surgery vol. 46,7 (2021): 602-607. doi:10.1016/j.jhsa.2021.02.004 

3) De Marchi, Lorenzo, and Massimiliano Meineri. “POCUS in perioperative medicine: a North American perspective.” Critical ultrasound journal vol. 9,1 19. 9 Oct. 2017, doi:10.1186/s13089-017-0075-y 

4) Kalagara, Hari et al. “Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist.” Journal of cardiothoracic and vascular anesthesia vol. 36,4 (2022): 1132-1147. doi:10.1053/j.jvca.2021.01.018 

5) Li, Linda et al. “Perioperative Point of Care Ultrasound (POCUS) for Anesthesiologists: an Overview.” Current pain and headache reports vol. 24,5 20. 21 Mar. 2020, doi:10.1007/s11916-020-0847-0 

6) Safran, Tyler et al. “The role of ultrasound technology in plastic surgery.” Journal of plastic, reconstructive & aesthetic surgery : JPRAS vol. 71,3 (2018): 416-424. doi:10.1016/j.bjps.2017.08.031 

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Medications that Slow Gastric Emptying 

Medications that Slow Gastric Emptying

Gastric emptying is a complex physiological process that involves the coordinated movement of ingested food from the stomach to the small intestine, facilitating efficient digestion and nutrient absorption. Numerous factors, such as volume, pH, temperature, and medications, influence the rate of gastric emptying. Medications that slow gastric emptying can alter the rate of orally absorbed drugs and may increase the volume of gastric contents which can lead to significant nausea and vomiting [1,2]. This in turn can increase the risk of pulmonary aspiration, a serious complication in vulnerable patient populations [1,4]. Notably, opioid analgesics have long been recognized as the most common cause of delayed gastric emptying in the realm of anesthesia. However, it is important to note there are other medications with the potential to slow gastric emptying as well.  

Opioid medications, including morphine and codeine, slow gastric emptying by binding to opioid receptors located in the gastrointestinal tract. These medications can impede gastric transit via peripheral or central mechanisms [3]. Following an intramuscular dose of morphine, gastric emptying can be completely inhibited for up to two hours [4]. It is worth noting that drugs necessitating rapid absorption, such as analgesics, antiarrhythmics, and antibiotics, may encounter therapeutic failure when co-administered with opioids. Conversely, drugs with slower absorption profiles tend to be less affected by delayed gastric emptying caused by opioids [4]. 

 Additionally, other medications, such as proton pump inhibitors, anti-Parkinson’s drugs, and GLP-1 receptor agonists commonly used for diabetic patients, have been associated with slow gastric emptying [5]. Furthermore, anticholinergic agents such as atropine and scopolamine can affect gastric motility. These agents’ function by blocking the actions of acetylcholine, a neurotransmitter involved in stimulating gastric motility. Thus, by inhibiting cholinergic receptors in the stomach, they reduce antral contractility and slow gastric emptying [7]. Recent case reports have highlighted diverse causative agents of delayed gastric emptying in patients, emphasizing the importance of identifying the specific drug responsible [6]. In the case of diabetic patients, both diabetes itself and diabetic drugs, particularly GLP-1 agonists, can contribute to gastroparesis through distinct mechanisms [5]. This makes it particularly difficult to distinguish the underlying cause of gastroparesis in these patients.  

In conclusion, understanding the multifaceted factors that influence gastric emptying is important, particularly in the perioperative setting where a variety of pharmaceutical agents are administered. Medications that slow gastric emptying, including opioid analgesics and certain other drugs, can have significant implications for drug absorption and patient outcomes. Knowing which drugs slow gastric emptying and implementing appropriate modifications enables healthcare professionals to make informed decisions regarding drug administration and the management of patients who may be at elevated risk for delayed gastric emptying. 

References 

  1. D. B. Murphy, J. A. Sutton, L. F. Prescott, M. B. Murphy; Opioid-induced Delay in Gastric Emptying: A Peripheral Mechanism in Humans. Anesthesiology 1997; 87:765–770.  
  1. Nimmo WS: Effect of anaesthesia on gastric motility and emptying. Br J Anaesth 1984; 56:29-36. 
  1. Manara L, Bianchetti A: The central and peripheral influences of opioids on gastrointestinal propulsion. Ann Rev Pharmacol Toxicol 1985; 25:249-73. 
  1. Nimmo, W.S. Gastric emptying and anaesthesia. Can J Anaesth 36 (Suppl 1), S45–S47 (1989). 
  1. Little TJ, Pilichiewicz AN, Russo A, et al. Effects of intravenous glucagon-like peptide-1 on gastric emptying and intragastric distribution in healthy subjects: relationships with postprandial glycemic and insulinemic responses. J Clin Endocrinol Metab. 2006;91(5):1916-1923. 
  1. Kalas MA, Galura GM, McCallum RW. Medication-Induced Gastroparesis: A Case Report. Journal of Investigative Medicine High Impact Case Reports. 2021;9. 
  1. Parkman HP, Trate DM, Knight LC, et al. Cholinergic effects on human gastric motility. Gut 1999;45:346-354. 
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Subscription-Based Healthcare 

In recent years, subscription-based healthcare has emerged as a revolutionary alternative to the traditional healthcare system. This model, often labeled as “direct primary care” (DPC), involves patients paying a recurring subscription fee to a healthcare provider in exchange for a comprehensive package of medical services (1). Although this model remains relatively new, a 2023 survey showed that 37% of providers offered this form of care, while 80% offered the traditional fee-for-service model (2). Unlike traditional models wherein patients are billed for each individual visit or service, subscription-based healthcare focuses on providing holistic care through a membership-based system (1). With a subscription — typically less than $100 per month (3) — patients can enjoy a range of benefits, including enhanced access to providers and preventative care, while providers can benefit from a reduced clientele and stronger relationships with patients. However, as the system remains in its infancy, several components may render the model impractical for some patients and providers.  

Subscription-based healthcare presents several advantages for subscribers. Primarily, this model offers improved access to providers. Traditional primary care providers see their patients an average of 1.6 times per year with an average of 15 minutes per visit; in contrast, subscription-based providers see their patients an average of 4 times per year with an average of 35 minutes per visit (4). Additionally, subscribers benefit from treatment plans tailored to their specific needs (3). This personalized approach fosters a strong provider-patient relationship, which strengthens understanding, trust, and efficacy (3, 5). Subscriptions include comprehensive care, ranging from prophylactic services, wellness programs, and other crucial measures that can prevent health issues in the future, thereby lowering overall healthcare costs (4). Thus, for many patients, the regular monitoring, routine checkups, and holistic care involved in subscription-based healthcare ensure high-quality, cost-effective health maintenance.  

For specific patient populations, however, this model does not present a viable alternative to traditional healthcare. Subscription-based healthcare does not replace insurance, nor do most participating providers accept insurance, rendering it impractical for chronically ill patients and inaccessible for lower-income patients (4). First, as subscriptions typically exclude visits to the emergency room or urgent care, referrals to other providers, procedures, and specialty care, this method is unlikely to be cost-effective for patients with chronic ailments, who must continue to pay the subscription in addition to insurance costs for specialty or emergency care (3, 6). Second, the recurring cost of subscriptions presents a barrier to lower-income patients, who may be unable to afford the recurring payment, especially when combined with health insurance premiums (6).  

From the providers’ perspective, subscription-based healthcare exhibits the advantages of improved patient-provider relationships and reduced administrative burden. According to a 2018 survey, traditional providers retain an average of 2000 to 2500 patients, while subscription-based providers handle only 300 to 600 (7). With fewer patients, subscription-based providers can devote more time to direct patient care, spend less time completing administrative work, and maintain a smaller staff (2, 3). Moreover, as most subscription-based providers do not accept insurance, the difficulties associated with insurance compliance and management can be avoided altogether, alleviating a significant strain for providers (3, 4). However, with their smaller clientele and absence of fee-for-service payments, subscription-based providers normally generate less income than their traditional peers (3). Additionally, departing from the traditional model and creating a subscription-based practice results in start-up costs and the loss of established patients (8). To deliver quality care, retain subscribers, and still make a profit, providers must find a balance between the costs of care and the subscription fee.  

 

Subscription-based healthcare has surfaced as an alternative to the traditional fee-for-service model, offering benefits to both patients and providers. However, challenges related to insurance coverage, emergency and specialty care, and affordability may obstruct specific patient populations from subscribing, while difficulties related to income may prevent providers from adopting this model. Patients considering enrolling in subscription-based healthcare — as well as providers considering offering this model — must assess their own needs before shifting from traditional care to this approach.  

 

References 

1: Wolfson, B. 2021. Can a subscription model fix primary care in the U.S.? The Washington Post. URL: https://www.washingtonpost.com/business/2021/06/03/primary-care-one-medical/.  

2: Couey, C. 2023. What you need to know about the different types of medical practice payment models. Software Advice. URL: https://www.softwareadvice.com/resources/healthcare-payment-models/#survey-methodology.  

3: Lamberts, R. 2017. Pros and cons of switching to a subscription practice. Physicians Practice. URL: https://www.physicianspractice.com/view/pros-and-cons-switching-subscription-practice.  

4: Anderman, T. 2018. Pros and cons of concierge medical care. Consumer Reports. URL: https://www.consumerreports.org/healthcare-costs/concierge-medical-care-pros-and-cons/.  

5: Goforth, A. 2022. Could subscription model be the answer to US health care cost woes? Benefits Pro. URL: https://www.benefitspro.com/2022/06/27/could-subscription-model-be-the-answer-to-us-health-care-cost-woes/?slreturn=20230516160403.  

6: Salter, S. Is subscription model healthcare a real alternative? Daily Leader. URL: https://www.dailyleader.com/2023/03/01/is-subscription-model-healthcare-a-real-alternative/.  

7: Rajaee, L. 2019.  What is the patient load sweet spot for direct primary care physicians? Elation Health. URL: https://www.elationhealth.com/resources/blogs/what-is-the-patient-load-sweet-spot-for-direct-primary-care-physicians.  

8: Haefner, M. 2020. Physician viewpoint: a subscription model beats fee-for-service. Becker’s Hospital Review. URL: https://www.beckershospitalreview.com/finance/physician-viewpoint-a-subscription-model-beats-fee-for-service.html.  

 

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Effect of Stress on Surgery Outcomes 

Undergoing surgery places physiological stress on the body, but stress can also have an impact on surgery outcomes. Though there has been increased discussion about this phenomenon and system-based quality improvement efforts, more work is needed to minimize the negative effects of stress on surgery outcomes. Stress in both patients and clinicians must be examined and addressed. 

Research has shown that high psychological and physiological stress responses in patients prior to surgery result in poorer outcomes in otherwise healthy men undergoing simple elective surgical procedures 1. Such psychological stress has been associated with a chronic inflammatory response which tends to hamper postsurgical healing. 

Patient anxiety and depression in patients can also negatively impact surgical outcomes. A recent study which sought to assess this in a large cohort of patients found that preoperative depression and anxiety negatively affect surgical outcomes in female patients undergoing major surgery 2. 

Another recent study sought to further elucidate the link between preoperative psychological variables and interventions and early surgical outcomes. Overall, trait and state anxiety, state anger, active coping, intramarital hostility, and subclinical depression, were found to complicate recovery. In contrast, dispositional optimism, religiousness, anger control, an external locus of control, and low pain expectations were identified as promoting healing. Psychological interventions in the form of guided relaxation, couple support visits, and psychiatric interviews have further been found to promote patient recovery following surgery 3.  

Stress in patients is not the only factor impacting surgery outcomes. Research has demonstrated that acute mental stress in clinicians negatively impacts their surgical performance. In particular, stress-induced negative intraoperative interpersonal dynamics may lead to performance errors and undesirable patient outcomes. A recent research report further confirmed a clear negative relationship between negative responses, both emotional and behavioral, to acute intraoperative stressors and provider performance on surgical outcomes 4. 

Drawing on theory and evidence from reviewed studies, some research has pointed to the utility of the Surgical Stress Effects framework, illustrating how emotional and behavioral responses to stressors can influence individual surgical provider performance, team performance, and patient outcomes. Although coping strategies are not explicitly taught during surgical training, a framework for categorizing surgical stress may help clinicians develop effective coping strategies 5. 

Since stress has been shown to adversely impact multiple aspects critical to optimal performance, advancements in wearable technology have been put forth to reduce barriers to observing and monitoring stress during surgery 6. A number of options are continuously being developed to this end. 

Into the future, an increasingly clear understanding of the impacts of intraoperative stressors may be critical to reducing adverse events and improving outcomes. This will include a better understanding of key surgical stressors, their impact on surgeon performance, and surgeons’ coping strategies. In addition, it will be important to keep quantifying the association of preoperative depression and anxiety symptoms on postoperative complications, length of stay, pain levels, and the incidence of readmission. Future research efforts are certain to continue to minimize the impacts of stress on surgery outcomes. 

References 

  1. Linn, B. S., Linn, M. W. & Klimas, N. G. Effects of psychophysical stress on surgical outcome. Psychosom. Med. (1988). doi:10.1097/00006842-198805000-00002
  2. Geoffrion, R. et al. Preoperative Depression and Anxiety Impact on Inpatient Surgery Outcomes: A Prospective Cohort Study. Ann. Surg. (2021). doi:10.1097/AS9.0000000000000049
  3. Mavros, M. N. et al. Do psychological variables affect early surgical recovery? PLoS One (2011). doi:10.1371/journal.pone.0020306
  4. Chrouser, K. L., Xu, J., Hallbeck, S., Weinger, M. B. & Partin, M. R. The influence of stress responses on surgical performance and outcomes: Literature review and the development of the surgical stress effects (SSE) framework. American Journal of Surgery (2018). doi:10.1016/j.amjsurg.2018.02.017
  5. Wetzel, C. M. et al. The effects of stress on surgical performance. Am. J. Surg. (2006). doi:10.1016/j.amjsurg.2005.08.034
  6. Grantcharov, P. D., Boillat, T., Elkabany, S., Wac, K. & Rivas, H. Acute mental stress and surgical performance. BJS open (2019). doi:10.1002/bjs5.104