What Drives Opioid Prescriptions After Cardiac Surgery: Practice or Patient?

BACKGROUND: The objectives of this study were to describe opioid prescribing after hospitalization for elective cardiac operation, to identify factors associated with increased opioid prescriptions, and to develop procedure-specific opioid prescribing guidelines. METHODS: We analyzed data from all adults (≥18 years) undergoing elective cardiac operation for acquired heart disease from July 2014 to March 2017 at 3 affiliated hospitals. Opioid prescription data were abstracted and converted to morphine milligram equivalents (MME). Multivariable logistic regression was performed with the outcome of top-quartile prescriptions. RESULTS: There were 4145 study patients after exclusion of preoperative opioid users (10.5%). Mean ± SD patient age was 63.9 ± 13.2 years, and 68.4% (n = 2835) were male. The operation was the first in 87.3% (3617); the most common operative approach was sternotomy in 91.0% (n = 3773), followed by robot-assisted operation in 4.6% (n = 192). The majority of patients, 72.7%, received an opioid prescription at hospital dismissal, with a median opioid prescription of 200 MME (interquartile range 0 to 375 MME; range 0 to 6400 MME). This varied by hospital, with medians of 150, 450, and 600 MME (P < .001). On multivariable analysis, the factor with greatest association with top-quartile opioid prescription was hospital (odds ratio, 57.2, highest vs lowest; 95% confidence interval, 40.2-81.4; P < .001). CONCLUSIONS: Significant variation in opioid prescribing practices after cardiac operation was observed. The primary driver was hospital-centric as opposed to patient specific. Opioid prescribing guidelines were established to standardize posthospital pain management.

Left atrial ablation for atrial fibrillation: creating the "box lesion" with a bipolar radiofrequency device.

The maze procedure is the gold standard for the ablation of atrial fibrillation, and the "box lesion" around the pulmonary veins is the most important part of this procedure. We have created this lesion with a bipolar radiofrequency ablator, abandoning the usual use of this device (to achieve bilateral epicardial isolation of the pulmonary veins).From March 2004 through the end of May 2010, we performed surgical ablation of atrial fibrillation in 240 patients. Of this number, 205 underwent operation by a hybrid maze technique and the remaining 35 (our study cohort) underwent the creation of a box lesion around the pulmonary veins by means of a bipolar radiofrequency device. Ablation lines were created by connecting the left atriotomy to the amputated left atrial appendage, with 2 ablation lines made with a bipolar radiofrequency device above and below the pulmonary veins. Lesions were made along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar device. The left atrial isthmus was ablated by bipolar radiofrequency and cryoprobe. No complications were associated with the box lesion: 90% and 89% of patients were in sinus rhythm at 3 and 6 months of follow-up, respectively.By creating a box lesion around the pulmonary veins, we expect to improve transmurality by means of epicardial and endocardial ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. Isolation of the entire posterior wall of the left atrium is better electrophysiologically and renders dissection around the pulmonary veins unnecessary.

C-reactive protein relaxes human vessels in vitro.

OBJECTIVE: C-reactive protein (CRP) is a sensitive marker of inflammation and a prognostic marker in cardiovascular disease. Evidence suggests direct biological activities of CRP within the vascular wall. The study was designed to examine the vasoreactive effects of CRP. METHODS AND RESULTS: Human internal mammary artery rings were obtained during cardiovascular bypass surgery and suspended in an organ bath chamber. The rings were precontracted with endothelin-1, and response to cumulative concentrations of CRP was obtained. Experiments were repeated after initial incubation with 20, 40, and 60 mmol/L KCl, the potassium channel blockers BaCl, tetraethylammonium chloride, and glibenclamide, and the NO synthase inhibitor N-monomethyl-L-arginine and also after removal of the endothelium. CRP caused dose-dependent relaxation of human internal mammary artery rings, which was not affected by preincubation with N-monomethyl-L-arginine or removal of the endothelium. Maximum relaxation response to CRP (79.5+/-10%) was attenuated by KCl (2.5+/-11.5%, P<0.001), BaCl (24.5+/-7.5%, P<0.001), and tetraethylammonium chloride (34.9+/-8.25%, P<0.01) but not by glibenclamide. Conclusions- The present study demonstrates that CRP exerts an endothelium-independent vasorelaxing effect via potassium channels. Thus, the study suggests a role of CRP in the regulation of vascular tone.