Temporary diaphragm pacing for patients at risk of prolonged mechanical ventilation after extensive aortic repair.

Objective: Prolonged mechanical ventilation (MV) after extensive aortic reconstructive surgery is common. Studies have demonstrated that diaphragm pacing (DP) improves lung function in patients with unilateral diaphragm paralysis. The goal of this study is to determine whether this technology can be applied to complex aortic repair to reduce prolonged MV and other respiratory sequelae. Methods: A retrospective review was performed of patients who underwent temporary DP after extensive aortic reconstructive surgery between 2019 and 2022. The primary end point was prolonged MV incidence. Other measured end points included diaphragm electromyography improvement, length of hospitalization, duration of intensive care unit stay, and reintubation rates. Results: Fourteen patients deemed at high risk of prolonged MV based on their smoking and respiratory history underwent DP after extensive aortic repair. The mean age was 70.2 years. The indications for aortic repair were a thoracoabdominal aortic aneurysm (n = 8, including 2 ruptured, 2 symptomatic, and 1 mycotic), a perivisceral aneurysm (n = 4), and a perivisceral coral reef aorta (n = 2). All patients had a significant smoking history (active or former) or other risk factors for ventilator-induced diaphragmatic dysfunction and prolonged MV. The mean total duration of MV postoperatively was 31.9 hours (range, 8.1-76.5 hours). The total average pacing duration was 4.4 days. Two patients required prolonged MV, with an average of 75.4 hours. Two patients required reintubation. No complications related to DP wire placement or removal occurred. Conclusions: DP is safe and feasible for patients at high risk of pulmonary insufficiency after extensive aortic reconstructive surgery.

Management and Outcome of Non-Aneurysmal Primary Aortic Infection.

INTRODUCTION: Aortic infection without prior intervention or aneurysm is exceedingly rare. We report the presentation, diagnosis, management, and outcome of patients with this unusual entity. METHODS: Retrospective chart and imaging review of patients with primary aortic infection. RESULTS: 5 patients (3 male, mean age 71.2 years) presented between 2014 and 2022. All had abdominal, back, or flank pain. Four had constitutional symptoms. All were evaluated with a complete blood count; 3 had leukocytosis. Both serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated in the 4 patients evaluated with these tests. All were studied with peripheral blood culture on the first hospital day prior to any antibiotic administration. Blood culture was positive in only 1 patient. Computed tomography (CT) scan showed periaortic inflammation without aneurysm in all. Fluorodeoxyglucose positron emission tomography (PET) was obtained in 3 and a radiolabeled leukocyte single-photon emission CT (SPECT) scan was performed in 2. All demonstrated periaortic concentration of the radioisotope consistent with inflammation or infection. Intraoperative cultures were positive in 3. One patient who had a negative intraoperative culture was examined with broad range polymerase chain reaction (PCR) and DNA sequencing which identified a causative bacterium. The other patient with a negative intraoperative culture had periaortic abscess but was on antibiotics preoperatively, potentially confounding the culture. All patients underwent in-situ repair with rifampin impregnated polyester (N = 2), cryopreserved aortic allograft (N = 2), or autogenous femoral vein (N = 1). No patient developed recurrent infection or aortic related complications following surgery with an average follow up of 31.8 months (range 8-88 months). CONCLUSIONS: Patients with primary aortic infection present similarly with the triad of abdominal or back pain, laboratory markers of infection, and imaging demonstrating periaortic inflammation. Patients were treated successfully with in-situ repair. Preoperative identification of a causative organism was difficult, and PCR may be useful to help identify an organism.

Opioid Prescribing Patterns After Anorectal Surgery.

BACKGROUND: Anorectal procedures are frequently performed and have the potential to be particularly painful. There are no evidence-based guidelines regarding opioid prescribing after anorectal surgery and limited data on how surgeons determine opioid prescriptions after anorectal procedures. We hypothesize significant variations in prescribing practices. The aim of this study is to determine current opioid prescribing patterns after anorectal surgery. METHODS: A survey was sent to members of the American Society of Colon and Rectal Surgeons. It included demographics, opioid prescribing habits after anorectal procedures, and factors influencing prescribing. Median morphine equivalents were calculated. Respondents prescribing higher than the median for >4 procedures were considered high prescribers. RESULTS: 519 surveys were completed (3160 sent). 38.6% of respondents were high prescribers, and 61.4% were low prescribers. There were significant differences by years in practice (P = 0.049), hospital type (P = 0.037), region (P < 0.001), and procedures performed per month (P < 0.001). 73% prescribed a standard quantity of opioids for each procedure. The mean milligrams of ME prescribed overall was 129 (SD 82); by procedure the quantities were as follows: hemorrhoidectomy 188 (111), condyloma treatment 149 (105), fistulotomy 146 (98), advancement flap 144 (97), LIFT 140 (93), abscess drainage 107 (91), sphincterotomy 105 (85), chemodenervation 64 (34). Nearly, all (98%) surgeons used local anesthesia. 91% typically prescribed adjunctive medications. In multivariable analysis, performing <10 anorectal procedures per month or practicing in the Northeast or outside the US was associated with low prescribers. High prescribers were more likely to be in practice for >10 y, report >25% of patients request refills, or significantly consider patient satisfaction or phone calls when prescribing. CONCLUSIONS: Opioid prescribing patterns are highly variable after anorectal procedures. Creating opioid prescribing guidelines for anorectal surgery is important to improve patient safety and quality of care.