Peripartum cardiomyopathy and HELLP syndrome in a previously healthy multiparous woman: A case report.

Peripartum cardiomyopathy is a type of dilated cardiomyopathy in which the exact etiology is uncertain. HELLP syndrome is characterized by a constellation of different clinical and laboratory findings, including hemolysis, elevated liver enzymes, and low platelets. Few case reports exist detailing successful diagnosis and management of postpartum HELLP syndrome, peripartum cardiomyopathy, and multisystem organ failure in a previously healthy woman. We herein report the case of a 39-year-old multiparous female with mild gestational hypertension, who presented in the third trimester with vaginal bleeding and was subsequently suspected to have intrapartum placental abruption leading to immediate Cesarean section, complicated by massive postpartum hemorrhage, necessitating care in the intensive care unit. HELLP syndrome, disseminated intravascular coagulation, and acute kidney injury requiring hemodialysis subsequently developed along with respiratory failure and peripartum cardiomyopathy. After diagnosis and proper management, the patient made a full recovery. Peripartum cardiomyopathy should remain on the differential for women with heart failure symptoms.

Opiate Pain Medication Consumption in Cigarette Smokers following Total Hip Arthroplasty.

Purpose The purpose of the present study was to assess perception of pain and pain management in smokers versus nonsmokers who received a total hip arthroplasty (THA). Methods Patients who underwent THA from 2010 to 2016 were propensity score matched 1:1 based on race, body mass index, age, and sex. This yielded 124 smokers and 124 nonsmokers. Pain intensity was quantified using area under the curve for visual analog scale pain scores. Opioid consumption was determined using a morphine milliequivalent (mEq) conversion algorithm. An independent samples t -test and Chi-square analysis was conducted to assess continuous and categorical variables respectively. Results Smokers experienced a nonsignificantly increased pain intensity (198.1 vs. 185.7; p = 0.063). Smokers demonstrated significantly higher opioid consumption in both immediate postoperative (65.9 vs. 59.3 mEq; p = 0.045) and 90 days postoperative periods (619.9 vs. 458.9 mEq; p = 0.029). Conclusion Our study demonstrated a nonsignificantly increased pain intensity, and (in both the immediate and 90 days postoperative periods) a significantly higher opioid consumption following THA in patients who smoke cigarettes. This may be due to a relatively small effect size, warranting the need for larger prospective studies. Nevertheless, arthroplasty surgeons should encourage preoperative smoking cessation and alternative nonopioid analgesics to smoking patients receiving THA. Level of Evidence This is a level III, retrospective cohort study.

Trends in Total Hip Arthroplasty Under the Patient Protection and Affordable Care Act: A National Database Analysis Between 2008 and 2015.

The Patient Protection and Affordable Care Act expanded health coverage for low-earning individuals and families. With more Americans having access to care, the use of elective procedures, such as total hip arthroplasty (THA), was expected to increase. Therefore, the aim of this study was to evaluate trends in THA before and after the initiation of the Patient Protection and Affordable Care Act regarding race, age, body mass index, and sex between 2008 and 2015. The National Surgical Quality Improvement Program database was queried for all individuals who had undergone primary THA between 2008 and 2015. This yielded a total of 104,209 patients. Descriptive statistics were used to analyze patient-level data. A Cochran-Armitage test assessed trends in categorical data points over time. Analysis indicated an increased percentage of blacks or African Americans undergoing THA (7.8% vs 9.2%, P<.001), followed by Native Americans or Pacific Islanders (0.0% vs 0.4%, P<.001), American Indians or Alaskan Natives (0.3% vs 0.5%, P=.016), and Asians (1.4% vs 1.5%, P=.002). An increased percentage of patients 55 to 80 years old received THAs (68.6% vs 74.1%, P<.001). The percentage of patients with a body mass index of 25.0 to 29.9 kg/m2, 30.0 to 34.9 kg/m2, and 35.0 to 39.9 kg/m2 increased (32.9% vs 33.1%, 24.2% vs 25.6%, 12.6% vs 13.3%, respectively, P<.001 for all). These findings may provide insight on the changing patient characteristics for orthopedic surgeons performing THA. Furthermore, these findings may inform health policy makers interested in increasing access to procedures underutilized by specific patient populations and the creation of strategies to meet increased demand. [Orthopedics. 2018; 41(4):e534-e540.].

Opioids Consumed in the Immediate Post-Operative Period Do Not Influence How Patients Rate Their Experience of Care After Total Hip Arthroplasty.

BACKGROUND: Patient perception of care, commonly measured with Press Ganey (PG) surveys, is an important metric used to determine hospital and provider reimbursement. However, post-operative pain following total hip arthroplasty (THA) may negatively affect patient satisfaction. As a result, over-administration of opioids may occur, even without marked evidence of pain. Therefore, this study evaluated whether opioid consumption in the immediate postoperative period bears any influence on satisfaction scores after THA. Specifically, this study assessed the correlation between post-operative opioid consumption and 7 PG domains: (1) Overall hospital rating; (2) Communication with nurses; (3) Responsiveness of hospital staff; (4) Communication with doctors; (5) Hospital environment; (6) Pain Management; and (7) Communication about medicines. METHODS: Our institutional PG database was reviewed for patients who received THA from 2011 to 2014. A total of 322 patients (mean age = 65 years; 61% female) were analyzed. Patient's opioid consumption was measured using a morphine milli-equivalent conversion algorithm. Bivariate correlation analysis assessed the association between opioid consumption and Press-Ganey survey elements. Pearson's r assessed the strength of the association. RESULTS: No correlation was found between total opioid consumption and Overall hospital rating (r = 0.004; P = .710), Communication with nurses (r = 0.093; P = .425), Responsiveness of hospital staff (r = 0.104; P = .381), Communication with doctors (r = 0.009; P = .940), Hospital environment (r = 0.081; P = .485), and Pain management (r = 0.075; P = .536). However, there was a positive correlation between total opioid consumption and "Communication about medicines" (r = 0.262; P = .043). CONCLUSIONS: Our report demonstrates that PG patient satisfaction scores are not influenced by post-operative opioid use, with the exception of PG domain, "Communication about medications." These results suggest that opioid medications should be administered based solely on patient requirements without concern about patient satisfaction survey results.

Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty.

BACKGROUND: Pain in the immediate postoperative period following total joint arthroplasty is influenced by various patient factors, including major depressive disorder (MDD). Therefore, this study aimed to compare the patient perception of pain and opioid consumption between patients with and without MDD who received either a total knee arthroplasty (TKA) or total hip arthroplasty (THA). Specifically, we compared (1) pain intensity, (2) lengths of stay, (3) opioid consumption, and (4) patient perception of pain control. METHODS: We reviewed our institutional Press Ganey database to identify patients with a diagnosis of MDD who received a THA (n = 48) and TKA (n = 68) between 2012 and 2016. An independent samples t-test and chi-square analyses were conducted to assess continuous and categorical variables, respectively. Analysis of covariance assessed the effects of depression on postoperative pain intensity. Mixed-design analysis of variance assessed the difference in opioid consumption between groups. RESULTS: Patients with MDD who received THA or TKA demonstrated a higher mean pain intensity score when compared to those without MDD; however, this was not statistically different (235.6 vs 207.7; P = .264 and 214.8 vs 185.1; P = .055, respectively). Patients with MDD who received THA or TKA consumed more opioids when compared to those without MDD (P = .048 and P = .038, respectively). CONCLUSION: Patients with MDD undergoing total joint arthroplasty consume more opioids compared to their matched cohort during the immediate postoperative period. Identifying patient-specific factors, such as MDD, could help arthroplasty surgeons modulate patients' course of recovery. These findings warrant more cooperation between arthroplasty surgeons and primary care providers to optimize outcome.

The Effect of Preoperative Physical Status on Pain Management in Total Knee Arthroplasty Patients Receiving Adductor Canal Blockade.

INTRODUCTION: Managing postoperative pain can be challenging for arthroplasty surgeons. While pain control modalities, such as adductor canal blockade (ACB), have been proven effective, the multifactorial nature of pain perception may serve as an obstacle for optimizing pain control. This study assesses the effect of patient pre-operative physical status on patient perception of pain. Specifically, we compared 1) lengths of hospital stay (LOS), 2) pain levels, and 3) opioid consumption in patients receiving total knee arthroplasty (TKA) who presented with an American Society of Anesthesiologists physical status score (ASA) of 2 and 3. MATERIALS AND METHODS: A single hospital, single surgeon database was reviewed for patients who had TKA between January 2015 and April 2016. Only patients with an ASA class of 2 or 3 who received ACB were analyzed. This yielded 106 patients with a mean age of 63 years, comprised of 36 men and 70 women. Patients were stratified into those with an ASA class of 2 (n= 58) and those with an ASA class of 3 (n= 48). Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using Visual Analog Scale (VAS). Continuous variables were compared using the student' s t-test and analysis of variance, while categorical variables were compared using chi-square analysis. RESULTS: There was no significant difference found between the two groups in LOS (2.25 days vs. 2.19 days; p=0.805), VAS scores (4.95 vs. 5.75; p=0.306), and opioid consumption on day 0 (17.77 morphine eq vs. 23.49 morphine eq; p=0.233) and day 3 (9.11 morphine eq vs. 19.87 morphine eq; p=0.100). However, patients with an ASA score of 2 had a significantly lower opioid consumption on day 1 (32.20 morphine eq vs. 52.70 morphine eq; p=0.049), day 2 (19.21 morphine eq vs. 40.71 morphine eq; p=0.018), and overall (78.30 morphine eq vs. 135.77 morphine eq; p=0.024). CONCLUSION: Despite the effectiveness of ACB in controlling pain, patient pre-operative status may affect perception of pain. This study demonstrates that patients with a higher ASA physical status classification consumed more opioid medication postoperatively, despite having similar pain scores and lengths of stay to those with a lower classification. Future studies should assess all ASA classifications and stratify for preoperative opioid consumption and tolerance as a possible confounder.