Minimizing the Risk of Opioid Misuse and Abuse in the Surgical Setting.

The misuse of opioids continues to be a public health problem. Acute post-surgical pain management requires a careful balance between the benefits and risks of opioids. Opioids should be part of a multimodal treatment plan, including the use of nonopioid and nonpharmacologic treatment options. Multimodal pain management allows for individualized treatment and improved patient satisfaction while limiting the risks inherent to opioids, including diversion. Surgeons should avoid overprescribing opioids and have a plan for decreasing the use of opioids in the postsurgical time frame. With careful consideration of the risks, opioids can be prescribed to treat acute postsurgical pain effectively. [Orthopedics. 2021;44(6):353-359.].

Successful Development and Implementation of a Surgical Response Team for Emergent Surgical Cases.

: At our institution, we recognized a need for a standardized, efficient approach to safely evaluate, prepare, and transport patients in need of emergent surgery. With the establishment of an Emergency Surgery Transport and Assessment Team, we were able to substantially reduce our median transport time to the OR. We believe other institutions can establish an efficient team using existing resources to expedite care of the emergent surgical patient.

Emotional exhaustion among anesthesia providers at a tertiary care center assessed using the MBI burnout survey.

Burnout is characterized by three components: emotional exhaustion, depersonalization, and low personal accomplishment. Burnout in health professionals results in reduced job satisfaction, decreased mental health and decreased quality of care, with rates ranging from 30-65% across medical specialties. The purpose of this study was to evaluate the prevalence of burnout components and identify factors associated with these components in physicians, residents, and certified nurse anesthetists (CRNAs) in a large academic anesthesiology department. A survey consisting of the Maslach Burnout Inventory-Human Services Survey and additional demographic questions was distributed via email at 7-day intervals over 4 weeks to all anesthesia providers. Scores from individual questions on each of the three subscales were summed and sorted into low, medium, and high levels of each outcome variable. Fisher's exact chi-square tests were used for categorical data. Eighteen residents, 39 staff anesthesiologists, and 32 CRNAs comprised a total of 89 survey respondents. Rates of emotional exhaustion varied by provider types. Residents reported higher levels of emotional exhaustion than staff anesthesiologists and CRNAs. As a system, it is vital for leaders to identify those with or at risk for burnout, their risk factors, and strategies to mitigate risk. The goals of the healthcare system should aim to maintain both quality patient care and healthcare provider wellness.

Subfascial port placement in gastric banding surgery.

BACKGROUND: In some bariatric patients with predominantly intra-abdominal fat a shallow fat layer separates the gastric band access port from the skin. We hypothesise that subfascial port placement in these patients reduces skin erosions and port infections and improves cosmesis as weight loss occurs. AIM: This study aims to compare port complications, cosmetic outcome and ease of band adjustment with access ports in front of or behind the rectus muscle. METHOD: We retrospectively compared complications and cosmetic outcomes of patients with subfascial ports to a control group matched for gender, BMI and age. Each subject completed a questionnaire utilising a 1 to 10 scale for nine parameters related to comfort and cosmesis and two parameters related to discomfort during adjustments. RESULTS: Sixty-eight patients with subfascial ports were identified and the overall response rate was 84%. The groups were well matched for gender (m:f ratio 1.8:1 vs. 1.7:1, p = 1.000), age (51.0 vs. 49.6 years, p = 0.528) and BMI (39.8 vs. 40.3 kg/m², p = 0.585). There was no difference in port infection rates (0/68 vs. 1/68, p = 1.000) but the subfascial group had more hernias (3/68 vs. 0/68, p = 0.244). Subfascial patients experienced more pain during adjustments (score 4.3 vs. 2.6, p = 0.047) but a combined analysis of cosmesis showed a slight positive trend (1.58 vs. 1.76, p = 0.379). CONCLUSION: Both port locations are well tolerated. Subfascial placement is associated with more pain during adjustments but there is no difference in port infection or skin erosion rates.

Laparoscopic gastric banding in over 60s.

BACKGROUND: The aggressive pursuit of weight loss in the elderly remains a controversial objective. In this series of 113 patients over 60 years of age who underwent laparoscopic gastric banding surgery, we report on complications, co-morbidity change, quality-of-life improvement and changes in medication use over a median follow-up period of 25.5 months. METHODS: A prospectively kept database was reviewed from January 1999 to September 2008 identifying patients over 60 who underwent gastric banding surgery. Baseline and follow-up SF-36® survey scores were compared longitudinally. Co-morbidity change and medication use were assessed by questionnaire and electronic record review. RESULTS: Major complications were experienced by 7.1% over the follow-up period with a re-operation rate of 15.0%. Excess BMI loss was 44.1% after 5 years and combined mean SF-36® quality-of-life scores (out of 100) improved 22.1 points, achieving parity with age-matched norms for the general population. Diabetes improved in 74.2% with hypertension, hyperlipidaemia and depression improving in 57.1, 51.1 and 35.9% of cases. A significant drop in medication use was not seen, and cancer was responsible for three deaths over the follow-up period. No surgical mortality was incurred. CONCLUSION: Laparoscopic gastric banding can markedly improve quality of life for morbidly obese over 60s. Health gains are significant, but medication use is not substantially altered. Gastric banding is an ideal weight loss operation for this age group due to its safety and efficacy, and the primary goal should be quality-of-life improvement.