Weaning from mechanical ventilation in the operating room: a systematic review.

BACKGROUND: Postoperative pulmonary complications (PPCs) are associated with postoperative mortality and prolonged hospital stay. Although intraoperative mechanical ventilation (MV) is a risk factor for PPCs, strategies addressing weaning from MV are understudied. In this systematic review, we evaluated weaning strategies and their effects on postoperative pulmonary outcomes. METHODS: Our protocol was registered on PROSPERO (CRD42022379145). Eligible studies included randomised controlled trials and observational studies of adults weaned from MV in the operating room. Primary outcomes included atelectasis and oxygenation; secondary outcomes included lung volume changes and PPCs. Risk of bias was assessed using the Cochrane Risk of Bias (RoB2) tool, and quality of evidence with the GRADE framework. RESULTS: Screening identified 14 randomised controlled trials including 1719 patients; seven studies were limited to the weaning phase and seven included interventions not restricted to the weaning phase. Strategies combining pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and low fraction of inspired oxygen (FiO2) improved atelectasis, oxygenation, and lung volumes. Low FiO2 improved atelectasis and oxygenation but might not improve lung volumes. A fixed-PEEP strategy led to no improvement in oxygenation or atelectasis; however, individualised PEEP with low FiO2 improved oxygenation and might be associated with reduced PPCs. Half of included studies are of moderate or high risk of bias; the overall quality of evidence is low. CONCLUSIONS: There is limited research evaluating weaning from intraoperative MV. Based on low-quality evidence, PSV, individualised PEEP, and low FiO2 may be associated with reduced postoperative pulmonary outcomes. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022379145).

The Pectoralis Block: A Case Series of a Novel Modality for Acute Pain Control in the Emergency Department.

INTRODUCTION: Regional anesthesia has long been used in a perioperative setting for the treatment of both pre- and postoperative pain. Recently, this skill has been brought into the emergency department (ED) as a modality for treating acute pain as the pendulum shifts away from an opioid-based armamentarium and toward a multimodal future. In this case series, we describe a way to use the pectoralis nerve block I and II in the treatment of pain with regard to breast abscesses and/or breast cellulitis managed in the ED. CASE SERIES: This paper describes three cases, all of which consist of a painful complaint in the thoracic region. The first was a patient diagnosed with a breast abscess. The second patient was diagnosed with breast cellulitis. Finally, the third patient was diagnosed with a large breast abscess that extended into the axilla. All three sustained immense relief with the pectoralis block. CONCLUSION: While further research is needed on a larger scale, preliminary data suggests that the ultrasound-guided pectoralis nerve block is an effective and safe modality of acute pain control in regard to breast and axillary abscesses along with breast cellulitis.

"ContraceptED": A Multidisciplinary Framework for Emergency Department-Initiated Contraception.

Emergency departments (EDs) are common access points for patients who are at high risk for unintended pregnancy. Low-barrier access to effective contraception represents a crucial and low-cost intervention to address this public health need. Same-day initiation of contraception during an ED visit is a unique opportunity to provide reproductive health care for high-risk patients with otherwise limited health care access. We collaborated with our obstetrics and gynecology (OB/GYN) department, pharmacists, and a team of community health advocates to support emergency clinicians (namely, emergency physicians and advanced practice providers) in assessing pregnancy and contraceptive readiness, increasing proficiency in contraception counseling, prescribing hormonal contraception, counseling on barrier and emergency contraception, and inserting (and removing) the Nexplanon implant, a form of long-acting reversible contraception. With this novel approach, we found that emergency clinicians voluntarily participated in trainings on contraception, including low-threshold long-acting reversible contraception initiation; and, after completing these trainings, clinicians integrated these skills into their workflow in the ED. We report our results after screening 38 patients during our current Pilot Phase of implementing this program.

Ultrasound-Guided Erector Spinae Plane Block in Emergency Department for Abdominal Malignancy Pain: A Case Report.

INTRODUCTION: Severe breakthrough pain is a common occurrence in patients with cancer and is responsible for thousands of emergency department (ED) visits each year. While opioids are the current mainstay of treatment, they have multiple limitations including inadequate control for a quarter of patients with cancer. The ultrasound-guided erector spinae plane block (ESPB) has been used in the ED to effectively treat pain for pathologies such as acute pancreatitis, since it provides somatic and visceral analgesia. CASE REPORT: In this case report we describe the use of an ESPB to treat breakthrough pain safely and effectively in a 54-year-old female with a history of metastatic colon cancer. CONCLUSION: The ESPB may have utility in addressing well documented disparities in pain treatment in the ED, but additional research is needed to understand side effects, duration of pain control, and clinical outcomes of the ESPB.

Adaptations to jail-based buprenorphine treatment during the COVID-19 pandemic.

Correctional facilities are among the highest-risk settings for the spread of COVID-19. Prior to the COVID-19 pandemic, the Hennepin County Jail in Minneapolis, Minnesota, offered short-term methadone maintenance, buprenorphine initiation and maintenance, and naltrexone initiation and maintenance to all jail residents with moderate to severe opioid use disorder (OUD). In response to the pandemic, the jail reduced its population by 43%. The reduced jail census and relaxed federal telemedicine regulations in response to the COVID-19 public health emergency declaration allowed the jail to institute modifications that permitted individuals to start buprenorphine without an initial in-person visit with a clinician. The jail also instituted a buprenorphine taper to bridge individuals to maintenance or provide withdrawal management, depending on patient preference. With a decreased jail census, the use of remote visits, and modifications to the buprenorphine treatment program, clinicians are able to meet the OUD treatment demand. Some jails may need additional funding streams to offset pandemic-related health treatment costs.

"Can you tell me why you made that choice?": A qualitative study of the influences on treatment decisions in advance care planning among adolescents and young adults undergoing bone marrow transplant.

BACKGROUND: Adolescent and young adult advance care planning is beneficial in improving communication between patients, surrogates, and clinicians. The influences on treatment decisions among adolescents and young adults are underexplored in the literature. AIM: The aim of this study was to explore and better understand the influences on decision-making for adolescent and young adult bone marrow transplant patients about future medical care. DESIGN: Clinical case studies and qualitative inductive content analysis of treatment decisions made during the Respecting Choices® Next Steps Pediatric Advance Care Planning conversation as a component of the Family-Centered Advance Care Planning Intervention. SETTINGS/PARTICIPANTS: A total of 10 adolescent and young adult patients (aged 14-27 years) undergoing bone marrow transplant at an academic Midwest children's hospital were involved in the study. RESULTS: Influences on participants' decisions were consideration for family, quality of life, and awareness of self. Desire to avoid suffering and maintain an acceptable quality of life was often in competition with participant's concern over the perceived negative impact of discontinuing treatment on their families. CONCLUSION: This study highlights that adolescent and young adult bone marrow transplant patients are capable of meaningful deliberation about future treatment decisions. Influences on decision-making should be incorporated into advance care planning conversations to facilitate communication between patients and their surrogates. Longitudinal research is needed to explore these influences throughout the trajectory of illness.

Clinical instrument to retrospectively capture levels of EDSS.

BACKGROUND: The Expanded Disability Status Scale (EDSS), a common outcome measure in Multiple Sclerosis (MS), is obtained prospectively through a direct standardized evaluation. The objective of this study is to develop and validate an algorithm to derive EDSS scores from previous neurological clinical documentation. METHODS: The algorithm utilizes data from the history, review of systems, and physical exam. EDSS scores formally obtained from research patients were compared to captured EDSS (c-EDSS) scores. To test inter-rater reliability, a second investigator captured scores from a subset of patients. Agreement between formal and c-EDSS scores was assessed using a weighted kappa. Clinical concordance was defined as a difference of one-step in EDSS (0.5) and functional system (1.0) scores. RESULTS: Clinical documentation from 92 patients (EDSS range 0.0-8.5) was assessed. Substantial agreement between the c-EDSS and formal EDSS (kappa 0.80; 95% CI 0.74-0.86) was observed. The mean difference between scores was 0.16. The clinical concordance was 78%. Near-perfect agreement was found between the two raters (kappa 0.89; 95% CI 0.84-0.95). The mean inter-rater difference in c-EDSS was 0.23. CONCLUSIONS: This algorithm reliably captures EDSS scores retrospectively with substantial correlation with formal EDSS and high inter-rater agreement. This algorithm may have practical implications in clinic, MS research and clinical trials.