Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis.

BACKGROUND: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. METHODS: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. RESULTS: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). CONCLUSIONS: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.

Ultrasound practice for chronic pain procedures: A comprehensive review.

Chronic pain management techniques have evolved in recent years. With regard to this, ultrasound (US) technology has become a standard for most acute pain procedures and essential for postsurgical pain relief and enhanced recovery after surgery protocols. This manuscript summarizes clinical studies evaluating US use for chronic pain management and compares efficacy with standard techniques including fluoroscopy (FL). US possesses several unique benefits when compared with FL, including elimination of radiation exposure while providing similar clinical outcomes. In summary, US use for chronic pain procedures is emerging as a viable, safe, and effective modality. Additional studies are needed to best appreciate US and its role in chronic pain management.

Emerging Novel Pharmacological Non-opioid Therapies in Headache Management: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic headache is a significant worldwide problem despite advances in treatment options. Chronic headaches can have significant a detrimental impact on the activities of daily living. RECENT FINDINGS: Patients who do not obtain relief from chronic head and neck pain from conservative treatments are commonly being managed with interventional treatments. These interventional treatment options include botulinum toxin A, injections, local occipital nerve anesthetic and corticosteroid infiltration, occipital nerve subcutaneous stimulation and occipital nerve pulsed radiofrequency (PRF), sphenopalatine ganglion block, and radiofrequency techniques. Recently, evidence has emerged to support non-opioid-based drug and interventional approaches. Overall, more research is necessary to clarify the safety and efficacy of interventional treatments and to better understand the pathogenesis of chronic headache pain.

Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review.

PURPOSE OF REVIEW: Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia. RECENT FINDINGS: Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.

New anticoagulants, reversal agents, and clinical considerations for perioperative practice.

There are several new anticoagulants on the market that will impact perioperative care, including the use of these anticoagulant drugs in the setting of regional anesthesia. The ideal pharmacological agent would prevent pathological thrombosis and allow for a normal response to vascular injury to limit bleeding. At present, all antithrombotic agents have increased bleeding risk as their main side effect. We describe the different categories of drugs, e.g., antiplatelet, anticoagulant, and thrombolytic, with particular emphasis on the new drugs that have been introduced into the market. These agents can be evaluated by a number of methods including low-, medium-, or high-risk procedures and guidelines and best practice standards that have been published regarding the amount of time to wait after stopping the medication and before performing a procedure, e.g., the American Society of Regional Anesthesia and Pain Medicine recommendations. The present investigation will also describe new reversal agents for anticoagulants and the implications of all these drugs for regional anesthesia.