Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation.

OBJECTIVE: To evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation. METHODS: A retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre-multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks. RESULTS: For PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre-multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01). CONCLUSION: Implementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.

Risk factors and outcomes of postoperative emergency response team activation: a matched case-control study.

OBJECTIVE: To determine patient and perioperative characteristics associated with unexpected postoperative clinical deterioration as determined for the need of a postoperative emergency response team (ERT) activation. DESIGN: Retrospective case-control study. SETTING: Tertiary academic hospital. PARTICIPANTS: Patients who underwent general anaesthesia discharged to regular wards between 1 January 2013 and 31 December 2015 and required ERT activation within 48 postoperative hours. Controls were matched based on age, sex and procedure. MAIN OUTCOME MEASURES: Baseline patient and perioperative characteristics were abstracted to develop a multiple logistic regression model to assess for potential associations for increased risk for postoperative ERT. RESULTS: Among 105 345 patients, 797 had ERT calls, with a rate of 7.6 (95% CI, 7.1-8.1) calls per 1000 anaesthetics (0.76%). Multiple logistic regression analysis showed the following risk factors for postoperative ERT: cardiovascular disease (odds ratio [OR], 1.61; 95% CI, 1.18-2.18), neurological disease (OR, 1.57; 95% CI, 1.11-2.22), preoperative gabapentin (OR, 1.60; 95% CI, 1.17-2.20), longer surgical duration (OR, 1.06; 95% CI, 1.02-1.11, per 30 min), emergency procedure (OR, 1.54; 95% CI, 1.09-2.18), and intraoperative use of colloids (OR, 1.50; 95% CI, 1.17-1.92). Compared with control participants, ERT patients had a longer hospital stay, a higher rate of admissions to critical care (55.5%), increased postoperative complications, and a higher 30-day mortality rate (OR, 3.36; 95% CI, 1.73-6.54). CONCLUSION: We identified several patient and procedural characteristics associated with increased likelihood of postoperative ERT activation. ERT intervention is a marker for increased rates of postoperative complications and death.

Acute phenibut withdrawal: A comprehensive literature review and illustrative case report.

Phenibut is a glutamic acid derivative with activity on the γ-aminobutyric acid (GABA)B, A, and B-phenethylamine receptors. It is prescribed in former Communist Bloc countries for anxiolysis and related psychiatric disorders. It can be easily obtained in Western countries and is thought to have abuse potential. Abrupt discontinuation has been reported to precipitate an abstinence syndrome. A review of the literature identified 22 reported cases, many of which were notable for severe psychomotor agitation and requirements for aggressive pharmacologic treatment. Neurologic and autonomic signs and symptoms may mimic serotonin or neuroleptic malignant syndrome. Patients were typically younger and had coexisting substance abuse disorders to other drugs. Also presented is a case of a 23-year-old male with an acute phenibut abstinence syndrome. This patient exhibited severe psychomotor agitation requiring physical restraints, dexmedetomidine, lorazepam, haloperidol, diphenhydramine, cyproheptadine, melatonin, olanzapine, and baclofen for symptom control.