Opioid-Sparing Anesthesia: Gabapentin and Postoperative Pain.

PURPOSE: Nonopioid analgesics are commonly used to augment or replace opioids in the perioperative setting. Perianesthesia nurses must consider timing and appropriateness when administering these medications to patients in the preoperative area or the postanesthesia care unit, particularly when other medications with sedative effects are being given. Gabapentin, originally proposed as an anticonvulsant medication, promotes analgesia and reduces risk for postoperative nausea and vomiting. This review examines the effect of gabapentin on postoperative pain. DESIGN: A systematic review. METHODS: CINAHL, PubMed, and Cochrane Review databases were searched to find a total of 93 sources that examined gabapentin and postoperative pain. After applying inclusion and exclusion criteria, four randomized controlled trials (RCT) were reviewed. Postoperative pain within the 24 hours of surgery was measured as the primary outcome using the visual analog scale in all sources FINDINGS: Three of the four reviewed RCTs determined gabapentin was both statistically and clinically significant in reducing postoperative pain, and all four sources showed a reduction in opioid consumption during the immediate postoperative period, which promoted patient satisfaction. CONCLUSIONS: Further study of gabapentin and postoperative pain is needed employing rigorous and robust methodology and diversity of the sample selections.

A randomized controlled trial of sleep study surveillance with targeted autoregulated positive airway pressure therapy for obstructive sleep apnea in pregnancy.

BACKGROUND: Obstructive sleep apnea is associated with adverse pregnancy outcomes. The impact therapy for obstructive sleep apnea has on these pregnancy outcomes remains under investigated. OBJECTIVE: This study aimed to determine the effects of targeted autoregulated positive airway pressure in women at risk of obstructive sleep apnea on adverse pregnancy outcomes, cost, and natural history of obstructive sleep apnea. STUDY DESIGN: Pregnant women at high risk of obstructive sleep apnea were randomized to either a sleep study screening group receiving autoregulated positive airway therapy or a group not screened for obstructive sleep apnea receiving standard obstetrical care (control). Women in the sleep study-screened group received a sleep study at 2 periods during pregnancy, early (6-16 weeks of gestation) and late (27-33 weeks of gestation), with initiation of autoregulated positive airway therapy if their Apnea Hypopnea Index indicated ≥5 events per hour. Women of both groups had a sleep study 3 months after delivery. The primary outcome was effect on adverse pregnancy outcomes, a composite of hypertension, preterm birth, low birthweight, stillbirth, and diabetes mellitus. The secondary outcomes included obstructive sleep apnea severity and hospital costs. RESULTS: Among 193 women randomized (100 in the sleep study-screened group and 93 in the control group; 6 lost to follow-up), there was no significant difference in composite adverse pregnancy outcomes (46.4% screened vs 43.3% control; P=.77), hypertension (23.7% screened vs 32.0% control; P=.25), preterm birth (13.4% screened vs 10.0% control; P=.5), low birthweight (5.2% screened vs 6.7% control; P=.76), stillbirth (1% screened vs 0% control; P=1), gestational diabetes (19.6% screened vs 13.3% control; P=.33), or mean cost ($12,185 screened vs $12,607 control). The Apnea Hypopnea Index increased throughout pregnancy, peaking at 3 months after delivery (P<.001). There were 24 subjects (25.8%) who had a new diagnosis of obstructive sleep apnea, with 6 in whom autoregulated positive airway was prescribed. The autoregulated positive airway compliance rates were poor with usage rates ranging from 2% (1 of 64 days) to 43% (6 of 14 days). CONCLUSION: Targeted autoregulated positive airway therapy for obstructive sleep apnea did not decrease composite adverse pregnancy outcomes or hospital costs in the sleep study-screened high-risk pregnancy group compared with the group that received no obstructive sleep apnea screening. However, a small sample size, low autoregulated positive airway prescription rates, and poor compliance resulted in difficulty in drawing a definitive conclusion. The prevalence and severity of obstructive sleep apnea worsened throughout pregnancy, with the highest rates detected in the postpartum period. Large, multicenter clinical trials that are adequately powered are needed.

Association of obstructive sleep apnea with adverse pregnancy-related outcomes in military hospitals.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with significant morbidity and mortality in non-obstetrical and obstetrical patients. OBJECTIVES: To estimate the prevalence of OSA and its relationship with pregnancy-related complications in a general obstetric population of Department of Defense beneficiaries receiving direct-care at military treatment facilities. STUDY DESIGN: A retrospective cohort study of all women (N=305,001) who gave birth at a military treatment facility from 2008 to 2014. OSA cases were randomly selected and matched on age (3:1 ratio) to non OSA cases. Multivariable logistic regression was used to examine the risks of adverse pregnancy outcomes (cesarean delivery, gestational diabetes, gestational hypertension, preeclampsia, postoperative wound complications, hospital stay greater than five days, acute renal failure, pulmonary edema, preterm delivery, poor fetal growth, and stillbirth) between pregnant women with and without a diagnosis of OSA. Cases were identified using ICD-9 codes, while controlling for demographics, obesity, and medical comorbidities associated with OSA and the outcomes of interest. RESULTS: We identified 266 cases of OSA (OSA rate=8.7 per 10,000; increased from 6.4 to 9.9 per 10,000 from 2009 to 2013). OSA was associated with a higher odds of cesarean delivery (AOR,1.60; 95% CI, 1.06-2.40), gestational hypertension, (AOR, 2.46; 95% CI, 1.30-4.68), preeclampsia (AOR, 2.42; 95% CI, 1.43-4.09), and preterm delivery (AOR, 1.90; 95% CI, 1.09-3.30). CONCLUSIONS: Obstructive sleep apnea is associated with adverse maternal and fetal outcomes.

Effects of a 30-mL Epidural Normal Saline Bolus on Time to Full Motor Recovery in Parturients Who Received Patient-Controlled Epidural Analgesia With 0.125% Bupivacaine With 2 µg/mL of Fentanyl.

Previous research suggests that an epidural bolus of 30 mL of normal saline after vaginal delivery may decrease the time for recovery from motor block. A double-blind, randomized controlled study was conducted in 46 parturients to determine if a 30-mL normal saline bolus or sham administered via epidural approach after delivery reduces the time to full motor recovery and the time to 2-dermatome regression. No significant difference was found in time to full motor recovery (saline group 83.18 ± 54 minutes vs control group 100.23 ± 48 minutes, P = .27) or time to 2-dermatome sensory regression (saline group 29.32 ± 16.35 minutes vs control group 36.14 ± 14.39 minutes, P = .15). Results suggest no advantage to the administration of a saline bolus after delivery to hasten the motor recovery in parturients. A post hoc power analysis suggested a sample size of 204 subjects would have been needed to show a difference for this dilute local anesthetic regimen. There were no complications to the technique, which suggests that it is safe to perform, but the difference in recovery (approximately 17 minutes) from a dilute local anesthetic dose may not be clinically significant.

Obstructive Sleep Apnea and the Adult Perioperative Patient.

Obstructive sleep apnea (OSA) is a chronic condition of upper airway obstruction during sleep. It is associated with significant morbidity and mortality and increases the perioperative risks of surgical patients. Thus, it is essential that perianesthesia nurses understand how to identify and manage patients with known or suspected OSA. This continuing education article will review the pathophysiology of OSA, discuss the effects of anesthesia and opioids on the sleep architecture of the OSA patients, describe the effects of OSA on postoperative complications, review the latest evidence on screening for undiagnosed OSA in the adult surgical patient, and review the perioperative management principles for patients with OSA.

Auricular acupuncture for sleep disturbance in veterans with post-traumatic stress disorder: a feasibility study.

The purpose of this study was to examine the feasibility and acceptability of an auricular acupuncture (AA) insomnia regimen among Operation Iraqi Freedom and Operation Enduring Freedom veterans with post-traumatic stress disorder and sleep disturbance. Secondarily, this study examined the effect of an AA insomnia regimen on objective sleep times by wrist actigraphy, subjective sleep times by sleep diary, and sleep quality ratings utilizing the Pittsburg Sleep Quality Index. Veterans (n = 30) were randomized to receive a 3-week AA insomnia regimen. Veterans receiving the AA insomnia regimen reported it as a more acceptable treatment for sleep disturbance than subjects in the control group (AA group median = 5 vs. control group median = 3, p = 0.004). Significant differences between groups were found on the sleep quality and daytime dysfunction components of the Pittsburgh Sleep Quality Index (p = 0.003, p = 0.004). No other significant differences between groups were found for objective and subjective sleep measures. These results suggest that an AA insomnia regimen may improve sleep quality and daytime dysfunction among veterans with post-traumatic stress disorder. Future, large-scale, prospective clinical trials are needed to examine AA effects on sleep.

A preoperative stress inquiry and a vulnerable US military population.

The preoperative setting is fraught with many stressors, often increasing in magnitude as patients progress through the perioperative environment. Individuals exposed to traumatic or threatening environments, such as US military personnel involved in combat operations, may be at increased risk of developing altered mental and physical health conditions. Collectively, this may result in a hyperarousal state significantly amplifying psychological symptoms and magnifying physiological alterations. The purposes of this article are to (1) describe stress-related concepts and preoperative stress, (2) discuss potential risk factors for preoperative stress in the adult surgical population, (3) present various psychological and physiological measures of preoperative stress, (4) explore preoperative stress interventions, and (5) discuss potential implications for future preoperative stress research in high-stressed populations.

Ensuring respect for persons when recruiting junior enlisted personnel for research.

Junior enlisted personnel in the Navy at training commands or recruit depots who are recruited for research can be considered a "captive audience" and therefore require special precautions to ensure that the ethical principle of respect for persons is maintained. Unfortunately, this can be difficult because of the hierarchical structure of the military and closed communities of junior enlisted personnel at training commands and recruit depots. This article provides a theoretical discussion of the ethical issue of autonomy and the essential elements of informed consent that Navy researchers need to address when recruiting subjects from this population. Two relevant policy statements to Navy researchers, Department of Defense Directive 3216.2 and Bureau of Medicine and Surgery Instruction 3900.6B, which provide guidance for protection of human subjects, are reviewed and critiqued, and a suggested plan to ensure the ethical principle of respect for persons is presented.