RESUMO
BACKGROUND: Baclofen, a gamma-aminobutyric acid receptor type B agonist in the central nervous system, is the first-line medication among central nervous system modulating agents for the treatment of neurogenic muscle spasticity. While baclofen is most often administered enterally, patients with severe spasticity may be candidates for baclofen delivered by intrathecal pump. Currently, there are only nine studies reporting on the use of intrathecal baclofen (ITB) during pregnancy and childbirth. CASE PRESENTATION: We described a female patient with a history of childhood idiopathic spasticity of the bilateral lower extremities that was controlled by ITB pump who became pregnant in her late third decade of life and delivered a healthy infant. The patient required multiple increases of her baclofen course over the course of her pregnancy. DISCUSSION: Our case, alongside the existing literature on ITB during pregnancy, suggests that ITB therapy in pregnancy poses a low risk of teratogenicity and infant withdrawal seizures; however, larger, controlled studies are necessary to make those conclusions with confidence. Healthcare providers caring for pregnant ITB patients should be cognizant of the potential for such patients to require increased doses of ITB during pregnancy to achieve adequate symptom control.
RESUMO
The most common postoperative complication for older adults is perioperative neurocognitive disorder (PNCD). Its greatest risk factor is preoperative cognitive impairment. Cognitive impairment also predicts higher likelihood of postoperative complications. While the cause of disparity in outcomes is likely multifactorial, the ability to correctly follow perioperative instructions may be one modifiable component. The purpose of this study was to determine whether cognitive impairment led to reduced preoperative instruction compliance and if so, identify barriers and enact a tailored care-plan to close the gap. Our preoperative clinic implemented routine Mini-Cog screening to identify older (age ≥ 65) surgical patients at increased risk. All patients received the same instructions and, on day of surgery, were surveyed to determine correct execution of nil per os guidelines, chlorhexidine wipe use and medication management. Data was stratified by cognitive status to evaluate whether impairment predicted instruction execution. Feedback from patients and families were compiled. Of those who screened negative for impairment, 68% correctly followed instructions, while 84.2% of those impaired struggled with ≥1 instruction(s); impaired patients were more likely to incorrectly follow instructions (OR = 10.5, p-value = 0.001). Areas for change were identified and team-based solutions were enacted with additional support for those with impairment. We found a clear difference in correct execution with respect to cognitive status. By improving instructions as an institution and adding additional support for those with impairment, the compliance gap was significantly reduced. Targeting perioperative instructions and tailoring care in this population may be one modifiable component in the outcome disparity they face.
