Code Blue in the Operating Room-pharmacy is on the way!

BACKGROUND: Pharmacists have become an integrated part of the cardiac arrest (Code Blue) response team in the emergency department and inpatient settings. However, the attendance of pharmacists at intraoperative codes is less established. OBJECTIVE: The purpose of this paper was to describe the creation of the Perioperative Pharmacy Attendance for Intraoperative Codes Safety Initiative, report the impact it had on the intraoperative emergency code team, and discuss the limitations and difficulties experienced by the pharmacy department so that other institutions may have a foundation on which to build similar programs. PRACTICE DESCRIPTION: A large academic medical center successfully incorporated pharmacists into the intraoperative emergency code team. PRACTICE INNOVATION: We began by obtaining collaborative leadership support by using a quality assurance and improvement focus. In an organized manner, we methodically developed workflow protocols, educational programming, and promotional material to ensure that our initiative was able to be effectively used by the institution. EVALUATION METHODS: A year after the implementation, clinicians evaluated the program and reported its impact on team performance. An evaluation regarding the difficulties experienced with the initiation of the program was also performed. RESULTS: Most clinicians stated that having pharmacists at intraoperative emergencies improved patient care as well as the code team's performance. The difficulties experienced during the development of this program included workflow disruptions and the need for a continued effort to effectively advertise it to clinicians. CONCLUSION: Our institution was able to create the successful Perioperative Pharmacy Attendance for Intraoperative Codes Safety Initiative. This paper describes the steps taken to create and implement this successful program as well as the integration of pharmacists into the intraoperative emergency setting.

Perioperative Emergencies: Who, What, When, Where, Why?

OBJECTIVE(S): Throughout the last several decades, the perioperative mortality rate from anesthesia care has declined, shifting focus to perioperative emergencies. Data on these emergencies, often referred to as "Anesthesia STAT" calls (STATs), are lacking at adult hospitals. The goal of this study was to determine the etiology of STATs at a major academic medical center and to determine surgical cases and patient comorbid conditions that increase the risk for STATs. DESIGN: This was a retrospective observational study. SETTING: This study took place at a large academic medical center. PARTICIPANTS: Patients who underwent anesthesia care were included in this study. INTERVENTIONS: No interventions were performed during this study. MEASUREMENTS AND MAIN RESULTS: Data collected included the etiologies of STATs, patient demographic information, patient comorbid conditions, and surgeries during which STATs occurred. Between February 1, 2019, and January 31, 2020, 92 STATs occurred during 58,547 anesthetic cases, with an incidence rate of 0.16%. The most common etiology for a STAT was cardiac arrest, followed by respiratory compromise. Surgical services associated with a significant increase of STATs included general, thoracic, oral/maxillofacial, and vascular surgery. Comorbid conditions that significantly increased the risk of STATs included hypertension, coronary artery disease, congestive heart failure, obstructive sleep apnea, diabetes, and chronic kidney disease. CONCLUSIONS: Cardiac arrest is the most common etiology of STATs. Specific surgical services and comorbid conditions are associated with an increased risk of STATs.

Socioeconomic Disparities in the Utilization of Spinal Cord Stimulation Therapy in Patients with Chronic Pain.

OBJECTIVES: Spinal cord stimulation (SCS) therapies are used in the management of patients with complex regional pain syndrome I (CRPS I) and failed back surgery syndrome (FBSS). The purpose of this study was to investigate the racial and health insurance inequalities with SCS therapy in patients with chronic pain who had CRPS I and FBSS. METHODS: Patients with chronic pain who had a discharge diagnosis of FBSS and CRPS I were identified using the National Inpatient Sample database. Our primary outcome was defined as the history of SCS utilization by race/ethnicity, income quartile, and insurance status. Multivariable logistic regression was used to determine the variables associated with utilization of SCS therapy. RESULTS: Between 2011 and 2015, 40,858 patients who were hospitalized with a primary diagnosis of FBSS and/or CRPS I were identified. Of these patients, 1,082 (2.7%) had a history of SCS therapy. Multivariable regression analysis revealed that compared to White patients, Black and Hispanic patients had higher odds of having SCS therapy (Black patients: odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.12 to 1.77; P = 0.003; Hispanic patients: OR = 1.41; 95% CI, 1.10 to 1.81; P = 0.007). Patients with private insurance had significantly higher odds of having SCS therapy compared with those with Medicare (OR = 1.24; 95% CI, 1.08 to 1.43; P = 0.003). Compared to patients with Medicare, Medicaid patients had lower odds of having SCS therapy (OR = 0.50; 95% CI, 0.36 to 0.70; P < 0.001). CONCLUSIONS: Our study suggests that socioeconomic disparities may exist in the utilization of SCS among hospitalized patients with CRPS I and FBSS the United States. However, confirming these data from other administrative databases, in the outpatient setting, may shed more insight.

Platelet-Rich Plasma for the Treatment of Low Back Pain: a Comprehensive Review.

PURPOSE OF REVIEW: Back pain is a growing problem worldwide, incurring enormous economic costs and disability. Current treatment modalities often provide adequate relief but fail to address underlying conditions. Regenerative cellular modalities aim to restore anatomical function in degenerative conditions which may cause low back pain. Platelet-rich plasma (PRP) consists of an increased concentration of autologous platelets suspended in a small amount of plasma. PRP can be administered via injection or topically and is prepared using various techniques. RECENT FINDINGS: While a unifying mechanism of action is not well understood, biochemical and cellular changes involved in inflammation and mechanical structure have been detected in both in vitro and in vivo studies. At a higher level, PRP injection research utilizing animal models and patient data have provided insights into pain relief, chondroprotection, and factors that impact the therapy's efficacy. Recently, a small number of studies have promoted PRP injection as a relatively safe means of treating patients with degenerative disc disease who have failed other means of managing their lower back pain. PRP injections for sacroiliac joint-related pain are not an accepted or common treatment modality; the evidence for their efficacy remains to be seen outside of small RCTs and case reports. A small number of prospective trials have suggested there may be some benefit to using PRP injection in the treatment of pain or functional decline caused by facet joint arthropathy. These commonly used modalities require further study to improve quality of evidence and to investigate the safety and efficacy of PRP injections for various common causes of chronic low back.

Loss of Efficacy to Spinal Cord Stimulator Therapy: Clinical Evidence and Possible Causes.

BACKGROUND: Although spinal cord stimulation (SCS) therapy has been shown to be efficacious in various pain conditions, the ability for SCS therapy to maintain long-term efficacy has been questioned. OBJECTIVE: The purpose of this study was to investigate whether a loss of efficacy (LOE) phenomenon exists with SCS therapy and to investigate if this phenomenon is more apparent in any specific patient population. STUDY DESIGN: A retrospective, observation chart review was conducted to evaluate the patient response to SCS therapy over time. SETTING: Massachusetts General Hospital, Boston, Massachusetts. METHODS: Patients who received a SCS at the Massachusetts General Hospital, between January 1, 2002 and December 31, 2012, were invited to participate. A total of 62 patients were included in this study. Various models were created to analyze pain score changes over time using 2-tailed statistical analysis. Additionally, one-way ANOVA and Pearson's chi-square tests were used to determine if certain patient characteristics were associated with LOE. RESULTS: Compared to the visual analog scale (VAS) score at one month after device implantation, pain scores increased 1.95 points after 2 years (95% CI: 1.06 to 2.84, P = < 0.001). There were no significant differences in baseline characteristics between the groups of patients who did and did not lose efficacy of their therapy. However, those who experienced LOE had a baseline SCS therapy VAS score 3.09 points lower than those who did not (95% CI: 1.69 to 4.48, P = < 0.001). LIMITATIONS: This study had several limitations including the retrospective nature of its design, confounders to VAS scores, small sample size, missing data points, and the evaluation of only conventional, low-frequency SCS therapy. CONCLUSIONS: Patients who received a SCS had a significant increase in VAS scores over time. Our data did not show any baseline patient characteristic that helped predict LOE. However, patients who have significant baseline response to therapy may be more likely to experience LOE. KEY WORDS: Spinal cord stimulation, chronic pain, retrospective study, low frequency electrical stimulation, efficacy, chronic pain therapy.

Outcomes of C1-2 joint injections.

OBJECTIVE: Intra-articular injections of the C1-2 joint are an effective therapeutic option for pain generated from degenerative and inflammatory conditions affecting the joint. Limited information exists about the adverse events (AEs) associated with these injections. The primary aim of this study is to describe the frequency and type of AEs associated with C1-2 joint injections. The secondary aim is to identify clinical factors associated with the occurrence of AEs of C1-2 joint injections. DESIGN/METHODS: A retrospective chart review was conducted on all C1-2 joint injections performed at the Mayo Pain Medicine Clinic in Rochester, MN, from January 1, 2005 through July 31, 2015. AE data were extracted from procedural and post-procedural clinical notes. Analysis was conducted to determine correlations between any AE and demographic and clinical characteristics. Using univariate and multivariate logistic regression analyses, associations were determined. RESULTS: From January 1, 2005 to July 31, 2015, 135 C1-2 injections were performed on 72 patients. Overall, at least 1 AE was reported in 18.5% of the injections. The most common AEs were post-procedural increase in pain and procedural vascular contrast uptake. There was a significant association between AE occurrence and greater pre-procedural maximum pain score. CONCLUSIONS: AEs from C1-2 joint injections occurred commonly, but there were no persistent or serious AEs associated with these injections. The data also demonstrate that patients with higher pre-procedural maximum pain scores are more likely to experience an AE.

A peer-designed selective in anesthesiology, critical care, and perioperative medicine for first- and second-year medical students.

STUDY OBJECTIVE: The objective of this study was to design and implement a preclinical elective (termed selective) in anesthesiology, critical care, and perioperative medicine and to report survey results assessing the impact of the selective on first- and second-year medical students' understanding of basic concepts, comfort with procedural skills, and interest in the specialty. DESIGN: Preinvention and postintervention survey evaluation was used as the design of this study. SETTING: The study was conducted at Mayo Medical School and Mayo Clinic. PARTICIPANTS: The participants in this study are first- and second-year medical students. INTERVENTIONS: A 1-week introductory anesthesiology curriculum was developed to include didactic sessions, shadowing experiences, lunch and dinner panels, mentorship and networking opportunities, and procedural workshops in airway management, ultrasound, and vascular access techniques. MEASUREMENTS: Preselective and postselective surveys using a 10-point scale (1, strongly disagree; 10, strongly agree) were administered 1 week before and after the selective. MAIN RESULTS: A total of 8 students participated in the selective, with a 100% survey response rate. Students reported significant increases for all survey questions regarding basic concepts and skills. The largest increases were reported in comfort with airway management skills, understanding of the perioperative surgical home model, and vascular access skills. All participants indicated a higher likelihood of pursuing anesthesiology as a career and attributed their increased interest in anesthesiology to the selective. CONCLUSIONS: This new selective was successful in giving first- and second-year medical students a comprehensive overview of anesthesiology and increasing medical student interest in the specialty. The success of this selective leads to promising belief that similar peer-designed educational experiences can be developed at other medical schools to improve education and interest in this area of medicine.

G protein beta 5 is targeted to D2-dopamine receptor-containing biochemical compartments and blocks dopamine-dependent receptor internalization.

G beta 5 (Gbeta5, Gß5) is a unique G protein ß subunit that is thought to be expressed as an obligate heterodimer with R7 regulator of G protein signaling (RGS) proteins instead of with G gamma (Gγ) subunits. We found that D2-dopamine receptor (D2R) coexpression enhances the expression of Gß5, but not that of the G beta 1 (Gß1) subunit, in HEK293 cells, and that the enhancement of expression occurs through a stabilization of Gß5 protein. We had previously demonstrated that the vast majority of D2R either expressed endogenously in the brain or exogenously in cell lines segregates into detergent-resistant biochemical fractions. We report that when expressed alone in HEK293 cells, Gß5 is highly soluble, but is retargeted to the detergent-resistant fraction after D2R coexpression. Furthermore, an in-cell biotin transfer proximity assay indicated that D2R and Gß5 segregating into the detergent-resistant fraction specifically interacted in intact living cell membranes. Dopamine-induced D2R internalization was blocked by coexpression of Gß5, but not Gß1. However, the same Gß5 coexpression levels had no effect on agonist-induced internalization of the mu opioid receptor (MOR), cell surface D2R levels, dopamine-mediated recruitment of ß-arrestin to D2R, the amplitude of D2R-G protein coupling, or the deactivation kinetics of D2R-activated G protein signals. The latter data suggest that the interactions between D2R and Gß5 are not mediated by endogenously expressed R7 RGS proteins.