Intrathecal Morphine Versus Nerve Blocks in an Enhanced Recovery Pathway for Pancreatic Surgery.

BACKGROUND: Intrathecal morphine (ITM) and peripheral nerve blocks are accepted techniques for analgesia after abdominal surgery, but their efficacy has not been evaluated in the context of an enhanced recovery pathway (ERP) in pancreatic surgery. MATERIALS AND METHODS: We retrospectively compared postoperative analgesia (pain scores and opioid requirements) after open or robotic pancreatoduodenectomy or distal pancreatectomy among ERP patients receiving either ITM or transversus abdominis plane/quadratus lumborum (TAP/QL) nerve blocks. RESULTS: We identified 303 ERP patients who underwent pancreatectomy with either ITM (n = 251) or TAP/QL blocks (n = 52). Patient demographics and procedural variables were similar between groups. Few preoperative patient characteristics (preoperative stroke and pain medication intake) differed between the two groups. In an unmatched patient cohort, the median pain score on postoperative day (POD 0) zero was 4.5 (interquartile range [IQR] 2.3-5.8) in ITM patients compared with 5.7 (IQR, 3.4-6.9) in patients who received TAP/QL (P < 0.05). Median opioid consumption in intravenous morphine equivalents on POD 0 was 2.7 mg (IQR, 0-11.7) in ITM patients compared with 8.4 mg (IQR, 2.5-20.8) in TAP/QL patients (P < 0.001). After propensity matching for patient characteristics, pain scores and opioid consumption were significantly (P < 0.05) lower on POD 0 and POD 5 in patients who received ITM. The difference in quality of analgesia between ITM and TAP/QL was also maintained in the pancreaticoduodenectomy and distal pancreatectomy subgroups. Extubation in the operating room was achieved in a higher percentage of patients receiving ITM (92%) compared with those receiving TAP/QL (63%). The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSIONS: ITM was associated with reduced pain scores and opioid requirements compared with peripheral nerve blocks in an ERP for pancreatic surgery.

Defining the incidence and risk factors of colistin-induced acute kidney injury by KDIGO criteria.

BACKGROUND: Acute kidney injury (AKI) remains a treatment-limiting toxicity of colistin. Recently developed clinical practice guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) group have harmonized definitions of AKI, but have not been widely applied to patients receiving colistin. METHODS: We retrospectively defined AKI by KDIGO definitions among adult patients receiving intravenous colistin for ≥ 3 days. Risk factors for AKI within 48 hours and 7 days of initiating colistin were determined by multivariable logistic regression. RESULTS: Among 249 patients treated with colistin, rates of AKI were 12% and 29% at 48 hours and 7 days, respectively. At 48 hours, patients in the intensive care unit were at increased risk for AKI. Within 7 days, colistin daily doses >5mg/kg, chronic liver disease, and concomitant vancomycin were independent predictors. Seven percent of patients required renal replacement therapy at a median of 5 days (range: 3-7) following colistin initiation. CONCLUSION: Safe use of colistin is promoted by early detection of AKI with KDIGO criteria, avoiding nephrotoxins, and limiting duration of therapy.