RESUMO
PURPOSE: Postoperative ileus (POI) can delay gastrointestinal (GI) recovery after bowel resection. Alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, is thought to favorably reduce various outcome measures such as the length of stay (LOS) and time from surgery to hospital discharge following partial-bowel, large-bowel, or small-bowel resection surgery with primary anastomosis. We undertook a study to compare these outcome measures in alvimopan-treated patients undergoing laparoscopic or open-bowel resection against a control group. We also sought to determine whether any other factors-Diagnosis-Related Group (DRG) status, complications, inflammatory bowel disease, type of surgery, age, sex, intestinal cancer, diverticular disease, number of chronic conditions, and operative time-were predictive of a more favorable (shorter) time to GI recovery. METHODS: Patients' charts were retrospectively reviewed at a large 591-bed teaching hospital in suburban New York City between June and August 2010. We applied descriptive statistics for five outcome variables to compare alvimopan-treated patients with non-users. The main outcome variable was the time from surgery to hospital discharge. Secondary outcome variables were the time to pass gas, time to a liquid diet, time to a solid diet, and total LOS. We compared the outcome variables for three groups of DRG codes (329, the most complicated cases; 330, intermediate; and 331, least complicated) to determine which variables influenced these outcome measures. Multivariate analysis with stepwise multiple linear regression analysis was performed to determine independent predictors of shorter times of outcome variables. RESULTS: Of 80 patients, 43 received alvimopan (53.75%), and 37 (46.25%) did not. The female-to-male ratio was about 50:50 (56.25% vs. 43.75%). The mean age (standard deviation) was 66.0 (14.9) years (range, 30-92 years). In the multivariate analysis (adjusted for demographics, DRG status, type of surgery, complications, comorbidities, and operative time), for all of our outcome variables (except for time to a liquid diet), patients receiving alvimopan had shorter times to GI recovery (about 25% less) than controls did (p < 0.05). DRG status, complications, inflammatory bowel disease, type of surgery, and age were also significantly predictive of one or more outcome variables, whereas sex, intestinal cancer, diverticular disease, the number of chronic conditions, and operative time were not predictive of any outcomes. CONCLUSION: GI recovery times were generally shorter for alvimopan-treated patients than for those who did not receive the study drug (P < 0.05). Alvimopan improved quality of life and reduced the cost of surgical care. This medication was considered to be a good choice for the perioperative management of patients requiring segmental bowel resection with primary anastomosis.
RESUMO
A 2-year-old girl was found with an empty bottle of levothyroxine and blue coloring around her mouth. Forty tablets of 150-microg levothyroxine tablets were missing. Her 6-hour postingestion total thyroxine (T4) level was 68.1 microg/dL (normal range: 5-12 microg/dL), and her total triiodothyronine (T3) level was 472 ng/dL (normal range: 40-130 ng/dL). Serum levels of thyrotropin, T3, and T4 were then checked on days 3, 5, 7, and 10. On postingestion day 5, the child presented for follow-up with hyperthermia, vomiting, irritability, and increased lethargy. She was referred to the emergency department, where a heart rate of 220 beats per minute, a blood pressure of 130/80 mm Hg, and a temperature of 101 degrees F were recorded. She also had multiple episodes of diarrhea. The patient was treated with oral propranolol (0.8 mg/kg) every 6 hours, intravenous normal saline, and ibuprofen; all her vital signs improved. Serial T3, T4, and thyrotropin serum levels were measured. Her total T3 levels were >800, 798, 445, 446, and 98 ng/dL on days 3, 5, 6, 9, and 13, respectively. Total T4 measurement was repeated on day 13, and the concentration was found to be 11.9 microg/dL. Her thyrotropin levels remained undetectable throughout the course of treatment. The patient was discharged from the hospital after a 4-day PICU stay, in good condition, on oral propranolol 0.8 mg/kg every 8 hours. Propranolol administration was discontinued 8 days after initiation with no further tachycardia, hypertension, or hyperthermia. The child tolerated the recommended regimen.
