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Selected elderly trauma patients do well in non–ICU wards
CORONADO, CALIF. – When elderly patients are appropriately triaged, they can be selectively admitted to non–intensive care wards with acceptable outcomes, results from a single-center study showed.
“Trauma centers across the United States are caring for elderly trauma patients with greater frequency,” researchers led by Marc D. Trust, MD, wrote in an abstract presented during a poster session at the annual meeting of the Western Surgical Association.
“Previous literature showed improved outcomes in this population from aggressive care and invasive monitoring. This may have led to an increased utilization of intensive care resources for these patients,” they noted.
In an effort to assess the safety of admitting this population of patients to non–intensive care units, Dr. Trust, a surgery resident at the University of Texas at Austin, and his associates retrospectively reviewed the medical records of 3,682 trauma patients aged 65 and older who were admitted from 2006 to 2015. They compared demographic data and outcomes between patients admitted to the ICU and those admitted to the surgical ward. The primary endpoint was mortality, while secondary endpoints were transfer to higher level of care and hospital length of stay. Patients admitted only for comfort care and those with injuries thought to be terminal and irreversible were excluded from the analysis.
The mean age of the 3,682 patients was 76 years and 1,838 (50%) were admitted to the ICU, while the remaining 1,844 (50%) were admitted to the surgical ward. When the researchers compared patients admitted to the ICU with those admitted to the surgical ward, they observed significant differences in mortality (7% vs. 0.82%, respectively; P less than .001), as well as systolic blood pressure on admission (146 vs. 149 mm Hg, respectively; P = .0002), pulse (85 vs. 81 beats per minute; P less than .0001), Glasgow Coma Scale (14 vs. 15; P less than .001), Injury Severity Score (16 vs. 8; P less than .001), and hospital stay (a mean of 8 vs. 4 days; P less than .0001). In addition, fewer than 1% of patients admitted to the surgical ward required transfer to a higher level of care (P less than .0001).
Next, Dr. Trust and his associates conducted a subgroup analysis of 300 patients admitted to the ICU (28%) and 766 (72%) admitted to the surgical ward who had all-system Abbreviated Injury Scale scores of less than 3, no hypotension on admission, and a Glasgow Coma Scale of 14 or greater. Compared with those admitted to the surgical ward, those admitted to the ICU were older (77 vs. 76 years old, respectively; P = .003), more likely to be male (54% vs. 45%; P = .007), more tachycardic (HR 84 vs. 81; P = .004), more severely injured (ISS score of 5 vs. 4; P less than .0001), and more likely to have a longer hospital stay (a mean of 6 vs. 4 days; P less than .0001). Two patients admitted to the surgical ward died (0.26%; P = .0009) and none required transfer to a higher level of care.
The researchers reported having no financial disclosures.
CORONADO, CALIF. – When elderly patients are appropriately triaged, they can be selectively admitted to non–intensive care wards with acceptable outcomes, results from a single-center study showed.
“Trauma centers across the United States are caring for elderly trauma patients with greater frequency,” researchers led by Marc D. Trust, MD, wrote in an abstract presented during a poster session at the annual meeting of the Western Surgical Association.
“Previous literature showed improved outcomes in this population from aggressive care and invasive monitoring. This may have led to an increased utilization of intensive care resources for these patients,” they noted.
In an effort to assess the safety of admitting this population of patients to non–intensive care units, Dr. Trust, a surgery resident at the University of Texas at Austin, and his associates retrospectively reviewed the medical records of 3,682 trauma patients aged 65 and older who were admitted from 2006 to 2015. They compared demographic data and outcomes between patients admitted to the ICU and those admitted to the surgical ward. The primary endpoint was mortality, while secondary endpoints were transfer to higher level of care and hospital length of stay. Patients admitted only for comfort care and those with injuries thought to be terminal and irreversible were excluded from the analysis.
The mean age of the 3,682 patients was 76 years and 1,838 (50%) were admitted to the ICU, while the remaining 1,844 (50%) were admitted to the surgical ward. When the researchers compared patients admitted to the ICU with those admitted to the surgical ward, they observed significant differences in mortality (7% vs. 0.82%, respectively; P less than .001), as well as systolic blood pressure on admission (146 vs. 149 mm Hg, respectively; P = .0002), pulse (85 vs. 81 beats per minute; P less than .0001), Glasgow Coma Scale (14 vs. 15; P less than .001), Injury Severity Score (16 vs. 8; P less than .001), and hospital stay (a mean of 8 vs. 4 days; P less than .0001). In addition, fewer than 1% of patients admitted to the surgical ward required transfer to a higher level of care (P less than .0001).
Next, Dr. Trust and his associates conducted a subgroup analysis of 300 patients admitted to the ICU (28%) and 766 (72%) admitted to the surgical ward who had all-system Abbreviated Injury Scale scores of less than 3, no hypotension on admission, and a Glasgow Coma Scale of 14 or greater. Compared with those admitted to the surgical ward, those admitted to the ICU were older (77 vs. 76 years old, respectively; P = .003), more likely to be male (54% vs. 45%; P = .007), more tachycardic (HR 84 vs. 81; P = .004), more severely injured (ISS score of 5 vs. 4; P less than .0001), and more likely to have a longer hospital stay (a mean of 6 vs. 4 days; P less than .0001). Two patients admitted to the surgical ward died (0.26%; P = .0009) and none required transfer to a higher level of care.
The researchers reported having no financial disclosures.
CORONADO, CALIF. – When elderly patients are appropriately triaged, they can be selectively admitted to non–intensive care wards with acceptable outcomes, results from a single-center study showed.
“Trauma centers across the United States are caring for elderly trauma patients with greater frequency,” researchers led by Marc D. Trust, MD, wrote in an abstract presented during a poster session at the annual meeting of the Western Surgical Association.
“Previous literature showed improved outcomes in this population from aggressive care and invasive monitoring. This may have led to an increased utilization of intensive care resources for these patients,” they noted.
In an effort to assess the safety of admitting this population of patients to non–intensive care units, Dr. Trust, a surgery resident at the University of Texas at Austin, and his associates retrospectively reviewed the medical records of 3,682 trauma patients aged 65 and older who were admitted from 2006 to 2015. They compared demographic data and outcomes between patients admitted to the ICU and those admitted to the surgical ward. The primary endpoint was mortality, while secondary endpoints were transfer to higher level of care and hospital length of stay. Patients admitted only for comfort care and those with injuries thought to be terminal and irreversible were excluded from the analysis.
The mean age of the 3,682 patients was 76 years and 1,838 (50%) were admitted to the ICU, while the remaining 1,844 (50%) were admitted to the surgical ward. When the researchers compared patients admitted to the ICU with those admitted to the surgical ward, they observed significant differences in mortality (7% vs. 0.82%, respectively; P less than .001), as well as systolic blood pressure on admission (146 vs. 149 mm Hg, respectively; P = .0002), pulse (85 vs. 81 beats per minute; P less than .0001), Glasgow Coma Scale (14 vs. 15; P less than .001), Injury Severity Score (16 vs. 8; P less than .001), and hospital stay (a mean of 8 vs. 4 days; P less than .0001). In addition, fewer than 1% of patients admitted to the surgical ward required transfer to a higher level of care (P less than .0001).
Next, Dr. Trust and his associates conducted a subgroup analysis of 300 patients admitted to the ICU (28%) and 766 (72%) admitted to the surgical ward who had all-system Abbreviated Injury Scale scores of less than 3, no hypotension on admission, and a Glasgow Coma Scale of 14 or greater. Compared with those admitted to the surgical ward, those admitted to the ICU were older (77 vs. 76 years old, respectively; P = .003), more likely to be male (54% vs. 45%; P = .007), more tachycardic (HR 84 vs. 81; P = .004), more severely injured (ISS score of 5 vs. 4; P less than .0001), and more likely to have a longer hospital stay (a mean of 6 vs. 4 days; P less than .0001). Two patients admitted to the surgical ward died (0.26%; P = .0009) and none required transfer to a higher level of care.
The researchers reported having no financial disclosures.
AT WSA 2016
Key clinical point:
Major finding: Mortality rates were significantly higher among elderly trauma patients admitted to the ICU, compared with those admitted to the surgical ward (7% vs. 0.82%, respectively; P less than .001).
Data source: A retrospective review of 3,682 trauma patients aged 65 and older who were admitted from 2006 to 2015.
Disclosures: The researchers reported having no financial disclosures.
Sutureless aortic valve replacement: Is ease worth the cost?
CHICAGO – Rapid deployment sutureless valves can be a good option for some patients, providing a highly functional and nearly leakproof valve with less cardiopulmonary bypass and aortic cross-clamp times than those of conventional procedures.
“Why use a sutureless valve?” asked Vinod H. Thourani, MD, speaking at Heart Valve Summit 2016. He said that for many patients, there are abundant good reasons for the choice. The rapidity of the implantation procedure is a huge plus, he said. Cardiopulmonary bypass times are reduced when sutureless valve replacement is a stand-alone procedure, added Dr. Thourani, chief of cardiovascular surgery at Emory Hospital Midtown and codirector of the Structural Heart and Valve Center at Emory University, Atlanta.
Rapid deployment is also of benefit in combined cases, or when patients have multiple comorbidities or poor left ventricular function. Sutureless valves, he said, are “optimal for multiple valve or concomitant procedures.”
Hemodynamics also are favorable, said Dr. Thourani; sutureless valves produce lower gradients than do their sutured alternatives, and work well in patients with a small aortic root.
Both sutureless valves that are currently available use bovine tissue; one, Sorin’s Perceval, uses a nitinol stent, while the Edwards’ Intuity uses stainless steel. The Perceval stent requires no sutures, while the Intuity requires just three. Also, the Perceval is collapsible, while the Intuity is not.
Removal of the pathologic valve in the sutureless procedure, he said, may contribute to the lower paravalvular leak and stroke rates than are seen in transcatheter aortic valve replacement (TAVR).
Expanded indications for sutureless valves include a calcified aortic root or a homograft; sutureless valves also can be used as an aortic valve redo, with patent grafts. Dr. Thourani said that he favors a transverse incision with a high aortotomy, about 2 cm above the sinotubular junction (STJ). In addition, off-label indications have included bicuspid aortic valve, pure aortic insufficiency, a prior mitral prosthesis or a degenerated aortic bioprosthesis, and a rescue procedure for a failed TAVR.
Dr. Thourani cited results of a trial conducted by Theodor Fischlein, MD, of Paracelsus Medical University in Nuremberg, Germany, and coauthors. These 1-year follow-up data from 628 patients participating in CAVALIER (Perceval S Valve Clinical Trial for Extended CE Mark), an international multicenter prospective trial, were presented at AATS 2016 (J Thorac Cardiovasc Surg. 2016 Jun;51[6]:1617-26.e4).
Of the 658 patients who met enrollment criteria and had a Perceval valve placement attempted, 30 wound up with a different prosthesis, most often because the correct valve size was not available. The remaining 628 patients who received the Perceval valve were included in the study. At 1 year, 549 patients remained; 50 had died, 12 had undergone valve explantation, and the remainder withdrew or were lost to follow-up.
Of the original Perceval recipients, 219 had received their valve via minimally invasive access. At 1 year, effective orifice area remained stable at the same mean 1.5 cm2 that was seen at discharge, an improvement from the mean 0.7 cm2 effective orifice area seen preoperatively. The mean pressure gradient, which was 45 mm Hg preoperatively, dropped precipitously to 10.3 mm Hg at discharge, and dropped a bit more at 1 year, to 9.2 mm Hg.
“This is a rapid and reproducible procedure: Over 20,000 implants have been performed worldwide,” said Dr. Thourani. The procedure looks good for low- to medium-risk patients, and may be the first procedure to consider for patients with a small aortic root, who have had prior coronary artery bypass surgery with patent grafts, or those with a calcified aortic root and homografts.
Questions still to be answered, he said, include whether “the cost will justify the decrease in cross-clamp times.” Also, though midrange results are good, longitudinal follow-up to track long-term valve hemodynamics is still ongoing.
Although patient demand seems to be high for a minimally invasive approach, sutureless valves still have low adoption rates, he said.
Dr. Thourani reported multiple financial relationships with medical device companies.
[email protected]
On Twitter @karioakes
CHICAGO – Rapid deployment sutureless valves can be a good option for some patients, providing a highly functional and nearly leakproof valve with less cardiopulmonary bypass and aortic cross-clamp times than those of conventional procedures.
“Why use a sutureless valve?” asked Vinod H. Thourani, MD, speaking at Heart Valve Summit 2016. He said that for many patients, there are abundant good reasons for the choice. The rapidity of the implantation procedure is a huge plus, he said. Cardiopulmonary bypass times are reduced when sutureless valve replacement is a stand-alone procedure, added Dr. Thourani, chief of cardiovascular surgery at Emory Hospital Midtown and codirector of the Structural Heart and Valve Center at Emory University, Atlanta.
Rapid deployment is also of benefit in combined cases, or when patients have multiple comorbidities or poor left ventricular function. Sutureless valves, he said, are “optimal for multiple valve or concomitant procedures.”
Hemodynamics also are favorable, said Dr. Thourani; sutureless valves produce lower gradients than do their sutured alternatives, and work well in patients with a small aortic root.
Both sutureless valves that are currently available use bovine tissue; one, Sorin’s Perceval, uses a nitinol stent, while the Edwards’ Intuity uses stainless steel. The Perceval stent requires no sutures, while the Intuity requires just three. Also, the Perceval is collapsible, while the Intuity is not.
Removal of the pathologic valve in the sutureless procedure, he said, may contribute to the lower paravalvular leak and stroke rates than are seen in transcatheter aortic valve replacement (TAVR).
Expanded indications for sutureless valves include a calcified aortic root or a homograft; sutureless valves also can be used as an aortic valve redo, with patent grafts. Dr. Thourani said that he favors a transverse incision with a high aortotomy, about 2 cm above the sinotubular junction (STJ). In addition, off-label indications have included bicuspid aortic valve, pure aortic insufficiency, a prior mitral prosthesis or a degenerated aortic bioprosthesis, and a rescue procedure for a failed TAVR.
Dr. Thourani cited results of a trial conducted by Theodor Fischlein, MD, of Paracelsus Medical University in Nuremberg, Germany, and coauthors. These 1-year follow-up data from 628 patients participating in CAVALIER (Perceval S Valve Clinical Trial for Extended CE Mark), an international multicenter prospective trial, were presented at AATS 2016 (J Thorac Cardiovasc Surg. 2016 Jun;51[6]:1617-26.e4).
Of the 658 patients who met enrollment criteria and had a Perceval valve placement attempted, 30 wound up with a different prosthesis, most often because the correct valve size was not available. The remaining 628 patients who received the Perceval valve were included in the study. At 1 year, 549 patients remained; 50 had died, 12 had undergone valve explantation, and the remainder withdrew or were lost to follow-up.
Of the original Perceval recipients, 219 had received their valve via minimally invasive access. At 1 year, effective orifice area remained stable at the same mean 1.5 cm2 that was seen at discharge, an improvement from the mean 0.7 cm2 effective orifice area seen preoperatively. The mean pressure gradient, which was 45 mm Hg preoperatively, dropped precipitously to 10.3 mm Hg at discharge, and dropped a bit more at 1 year, to 9.2 mm Hg.
“This is a rapid and reproducible procedure: Over 20,000 implants have been performed worldwide,” said Dr. Thourani. The procedure looks good for low- to medium-risk patients, and may be the first procedure to consider for patients with a small aortic root, who have had prior coronary artery bypass surgery with patent grafts, or those with a calcified aortic root and homografts.
Questions still to be answered, he said, include whether “the cost will justify the decrease in cross-clamp times.” Also, though midrange results are good, longitudinal follow-up to track long-term valve hemodynamics is still ongoing.
Although patient demand seems to be high for a minimally invasive approach, sutureless valves still have low adoption rates, he said.
Dr. Thourani reported multiple financial relationships with medical device companies.
[email protected]
On Twitter @karioakes
CHICAGO – Rapid deployment sutureless valves can be a good option for some patients, providing a highly functional and nearly leakproof valve with less cardiopulmonary bypass and aortic cross-clamp times than those of conventional procedures.
“Why use a sutureless valve?” asked Vinod H. Thourani, MD, speaking at Heart Valve Summit 2016. He said that for many patients, there are abundant good reasons for the choice. The rapidity of the implantation procedure is a huge plus, he said. Cardiopulmonary bypass times are reduced when sutureless valve replacement is a stand-alone procedure, added Dr. Thourani, chief of cardiovascular surgery at Emory Hospital Midtown and codirector of the Structural Heart and Valve Center at Emory University, Atlanta.
Rapid deployment is also of benefit in combined cases, or when patients have multiple comorbidities or poor left ventricular function. Sutureless valves, he said, are “optimal for multiple valve or concomitant procedures.”
Hemodynamics also are favorable, said Dr. Thourani; sutureless valves produce lower gradients than do their sutured alternatives, and work well in patients with a small aortic root.
Both sutureless valves that are currently available use bovine tissue; one, Sorin’s Perceval, uses a nitinol stent, while the Edwards’ Intuity uses stainless steel. The Perceval stent requires no sutures, while the Intuity requires just three. Also, the Perceval is collapsible, while the Intuity is not.
Removal of the pathologic valve in the sutureless procedure, he said, may contribute to the lower paravalvular leak and stroke rates than are seen in transcatheter aortic valve replacement (TAVR).
Expanded indications for sutureless valves include a calcified aortic root or a homograft; sutureless valves also can be used as an aortic valve redo, with patent grafts. Dr. Thourani said that he favors a transverse incision with a high aortotomy, about 2 cm above the sinotubular junction (STJ). In addition, off-label indications have included bicuspid aortic valve, pure aortic insufficiency, a prior mitral prosthesis or a degenerated aortic bioprosthesis, and a rescue procedure for a failed TAVR.
Dr. Thourani cited results of a trial conducted by Theodor Fischlein, MD, of Paracelsus Medical University in Nuremberg, Germany, and coauthors. These 1-year follow-up data from 628 patients participating in CAVALIER (Perceval S Valve Clinical Trial for Extended CE Mark), an international multicenter prospective trial, were presented at AATS 2016 (J Thorac Cardiovasc Surg. 2016 Jun;51[6]:1617-26.e4).
Of the 658 patients who met enrollment criteria and had a Perceval valve placement attempted, 30 wound up with a different prosthesis, most often because the correct valve size was not available. The remaining 628 patients who received the Perceval valve were included in the study. At 1 year, 549 patients remained; 50 had died, 12 had undergone valve explantation, and the remainder withdrew or were lost to follow-up.
Of the original Perceval recipients, 219 had received their valve via minimally invasive access. At 1 year, effective orifice area remained stable at the same mean 1.5 cm2 that was seen at discharge, an improvement from the mean 0.7 cm2 effective orifice area seen preoperatively. The mean pressure gradient, which was 45 mm Hg preoperatively, dropped precipitously to 10.3 mm Hg at discharge, and dropped a bit more at 1 year, to 9.2 mm Hg.
“This is a rapid and reproducible procedure: Over 20,000 implants have been performed worldwide,” said Dr. Thourani. The procedure looks good for low- to medium-risk patients, and may be the first procedure to consider for patients with a small aortic root, who have had prior coronary artery bypass surgery with patent grafts, or those with a calcified aortic root and homografts.
Questions still to be answered, he said, include whether “the cost will justify the decrease in cross-clamp times.” Also, though midrange results are good, longitudinal follow-up to track long-term valve hemodynamics is still ongoing.
Although patient demand seems to be high for a minimally invasive approach, sutureless valves still have low adoption rates, he said.
Dr. Thourani reported multiple financial relationships with medical device companies.
[email protected]
On Twitter @karioakes
EXPERT ANALYSIS FROM THE HEART VALVE SUMMIT 2016
AGA Guideline: Preventing Crohn’s recurrence after resection
Patients whose Crohn’s disease fully remits after resection should not wait for endoscopic recurrence to start tumor-necrosis-factor inhibitors or thiopurines, according to a new guideline from the American Gastroenterological Association.
Patients who are low risk or worried about side effects, however, “may reasonably select endoscopy-guided pharmacological treatment,” the guidelines state (doi: 10.1053/j.gastro.2016.10.038).
Early pharmacologic prophylaxis usually begins within 8 weeks of surgery, they noted. Whether this approach bests endoscopy-guided treatment is unclear: In one small trial (Gastroenterology. 2013;145[4]:766-74.e1), early azathioprine therapy failed to best endoscopy-guided therapy for preventing clinical or endoscopic recurrence.
Early prophylaxis, however, is usually reasonable because most Crohn’s patients who undergo surgery have at least one risk factor for recurrence, Dr. Nguyen and his associates emphasize. They suggest reserving endoscopy-guided therapy for patients who have real concerns about side effects and are at low risk, such as nonsmokers who were diagnosed within 10 years and have less than 10-20 cm of fibrostenotic disease.
For prophylaxis, a moderate amount of evidence supports anti–tumor necrosis factor (TNF) agents, thiopurines, or combined therapy over other agents, the guideline also states. In placebo-controlled clinical trials, anti-TNF therapy reduced the chances of clinical recurrence by 49% and endoscopic recurrence by 76%, while thiopurines cut these rates by 65% and 60%, respectively. Evidence favors anti-TNF agents over thiopurines for preventing recurrence, but it is of low quality, the guideline says. Furthermore, only indirect evidence supports combined therapy in patients at highest risk of recurrence.
Among the antibiotics, only nitroimidazoles such as metronidazole have been adequately studied, and they posted worse results than anti-TNF agents or thiopurines. Antibiotic therapy decreased the risk of endoscopic recurrence of Crohn’s disease by about 50%, but long-term use is associated with peripheral neuropathy and disease usually recurs within 2 years of stopping treatment. Accordingly, the guidelines suggest using a nitroimidazole for only 3-12 months, and only in lower-risk patients who are concerned about the adverse effects of anti-TNF agents and thiopurines.
The AGA made a conditional recommendation against the prophylactic use of budesonide, probiotics, and 5-aminosalicylates such as mesalamine. Only low-quality evidence supports their efficacy after resection, and by using these agents, clinicians may inadvertently boost the risk of recurrence by forgoing better therapies, the guideline states.
The initial endoscopy should be timed for 6-12 months after resection, regardless of whether patients are receiving pharmacologic prophylaxis, the guideline states. If there is endoscopic recurrence, then anti-TNF or thiopurine therapy should be started or optimized.
In the Postoperative Crohn’s Endoscopic Recurrence (POCER) trial, endoscopic monitoring and treatment escalation in the face of endoscopic recurrence cut the risk of subsequent clinical and endoscopic recurrence by about 18% and 27%, respectively, compared with continuing the original treatment regimen. Most patients received azathioprine or adalimumab with 3 months of metronidazole postoperatively, so “even [those] who were already on postoperative prophylaxis benefited from endoscopic monitoring with colonoscopy at 6-12 months,” the guideline notes. However, patients who elect early prophylaxis after resection can reasonably forego colonoscopy if endoscopic recurrence is unlikely to affect their treatment plan, the AGA states. The guideline strongly recommends ongoing surveillance endoscopies if patients decide against early postresection prophylaxis, but notes a lack of evidence on how far to space out these procedures.
None of the authors had relevant financial disclosures.
Patients whose Crohn’s disease fully remits after resection should not wait for endoscopic recurrence to start tumor-necrosis-factor inhibitors or thiopurines, according to a new guideline from the American Gastroenterological Association.
Patients who are low risk or worried about side effects, however, “may reasonably select endoscopy-guided pharmacological treatment,” the guidelines state (doi: 10.1053/j.gastro.2016.10.038).
Early pharmacologic prophylaxis usually begins within 8 weeks of surgery, they noted. Whether this approach bests endoscopy-guided treatment is unclear: In one small trial (Gastroenterology. 2013;145[4]:766-74.e1), early azathioprine therapy failed to best endoscopy-guided therapy for preventing clinical or endoscopic recurrence.
Early prophylaxis, however, is usually reasonable because most Crohn’s patients who undergo surgery have at least one risk factor for recurrence, Dr. Nguyen and his associates emphasize. They suggest reserving endoscopy-guided therapy for patients who have real concerns about side effects and are at low risk, such as nonsmokers who were diagnosed within 10 years and have less than 10-20 cm of fibrostenotic disease.
For prophylaxis, a moderate amount of evidence supports anti–tumor necrosis factor (TNF) agents, thiopurines, or combined therapy over other agents, the guideline also states. In placebo-controlled clinical trials, anti-TNF therapy reduced the chances of clinical recurrence by 49% and endoscopic recurrence by 76%, while thiopurines cut these rates by 65% and 60%, respectively. Evidence favors anti-TNF agents over thiopurines for preventing recurrence, but it is of low quality, the guideline says. Furthermore, only indirect evidence supports combined therapy in patients at highest risk of recurrence.
Among the antibiotics, only nitroimidazoles such as metronidazole have been adequately studied, and they posted worse results than anti-TNF agents or thiopurines. Antibiotic therapy decreased the risk of endoscopic recurrence of Crohn’s disease by about 50%, but long-term use is associated with peripheral neuropathy and disease usually recurs within 2 years of stopping treatment. Accordingly, the guidelines suggest using a nitroimidazole for only 3-12 months, and only in lower-risk patients who are concerned about the adverse effects of anti-TNF agents and thiopurines.
The AGA made a conditional recommendation against the prophylactic use of budesonide, probiotics, and 5-aminosalicylates such as mesalamine. Only low-quality evidence supports their efficacy after resection, and by using these agents, clinicians may inadvertently boost the risk of recurrence by forgoing better therapies, the guideline states.
The initial endoscopy should be timed for 6-12 months after resection, regardless of whether patients are receiving pharmacologic prophylaxis, the guideline states. If there is endoscopic recurrence, then anti-TNF or thiopurine therapy should be started or optimized.
In the Postoperative Crohn’s Endoscopic Recurrence (POCER) trial, endoscopic monitoring and treatment escalation in the face of endoscopic recurrence cut the risk of subsequent clinical and endoscopic recurrence by about 18% and 27%, respectively, compared with continuing the original treatment regimen. Most patients received azathioprine or adalimumab with 3 months of metronidazole postoperatively, so “even [those] who were already on postoperative prophylaxis benefited from endoscopic monitoring with colonoscopy at 6-12 months,” the guideline notes. However, patients who elect early prophylaxis after resection can reasonably forego colonoscopy if endoscopic recurrence is unlikely to affect their treatment plan, the AGA states. The guideline strongly recommends ongoing surveillance endoscopies if patients decide against early postresection prophylaxis, but notes a lack of evidence on how far to space out these procedures.
None of the authors had relevant financial disclosures.
Patients whose Crohn’s disease fully remits after resection should not wait for endoscopic recurrence to start tumor-necrosis-factor inhibitors or thiopurines, according to a new guideline from the American Gastroenterological Association.
Patients who are low risk or worried about side effects, however, “may reasonably select endoscopy-guided pharmacological treatment,” the guidelines state (doi: 10.1053/j.gastro.2016.10.038).
Early pharmacologic prophylaxis usually begins within 8 weeks of surgery, they noted. Whether this approach bests endoscopy-guided treatment is unclear: In one small trial (Gastroenterology. 2013;145[4]:766-74.e1), early azathioprine therapy failed to best endoscopy-guided therapy for preventing clinical or endoscopic recurrence.
Early prophylaxis, however, is usually reasonable because most Crohn’s patients who undergo surgery have at least one risk factor for recurrence, Dr. Nguyen and his associates emphasize. They suggest reserving endoscopy-guided therapy for patients who have real concerns about side effects and are at low risk, such as nonsmokers who were diagnosed within 10 years and have less than 10-20 cm of fibrostenotic disease.
For prophylaxis, a moderate amount of evidence supports anti–tumor necrosis factor (TNF) agents, thiopurines, or combined therapy over other agents, the guideline also states. In placebo-controlled clinical trials, anti-TNF therapy reduced the chances of clinical recurrence by 49% and endoscopic recurrence by 76%, while thiopurines cut these rates by 65% and 60%, respectively. Evidence favors anti-TNF agents over thiopurines for preventing recurrence, but it is of low quality, the guideline says. Furthermore, only indirect evidence supports combined therapy in patients at highest risk of recurrence.
Among the antibiotics, only nitroimidazoles such as metronidazole have been adequately studied, and they posted worse results than anti-TNF agents or thiopurines. Antibiotic therapy decreased the risk of endoscopic recurrence of Crohn’s disease by about 50%, but long-term use is associated with peripheral neuropathy and disease usually recurs within 2 years of stopping treatment. Accordingly, the guidelines suggest using a nitroimidazole for only 3-12 months, and only in lower-risk patients who are concerned about the adverse effects of anti-TNF agents and thiopurines.
The AGA made a conditional recommendation against the prophylactic use of budesonide, probiotics, and 5-aminosalicylates such as mesalamine. Only low-quality evidence supports their efficacy after resection, and by using these agents, clinicians may inadvertently boost the risk of recurrence by forgoing better therapies, the guideline states.
The initial endoscopy should be timed for 6-12 months after resection, regardless of whether patients are receiving pharmacologic prophylaxis, the guideline states. If there is endoscopic recurrence, then anti-TNF or thiopurine therapy should be started or optimized.
In the Postoperative Crohn’s Endoscopic Recurrence (POCER) trial, endoscopic monitoring and treatment escalation in the face of endoscopic recurrence cut the risk of subsequent clinical and endoscopic recurrence by about 18% and 27%, respectively, compared with continuing the original treatment regimen. Most patients received azathioprine or adalimumab with 3 months of metronidazole postoperatively, so “even [those] who were already on postoperative prophylaxis benefited from endoscopic monitoring with colonoscopy at 6-12 months,” the guideline notes. However, patients who elect early prophylaxis after resection can reasonably forego colonoscopy if endoscopic recurrence is unlikely to affect their treatment plan, the AGA states. The guideline strongly recommends ongoing surveillance endoscopies if patients decide against early postresection prophylaxis, but notes a lack of evidence on how far to space out these procedures.
None of the authors had relevant financial disclosures.
Trump HHS nominee could curb regulations, reshape health insurance
Opinions are mixed on what the nominations of Rep. Tom Price (R-Ga.) as Secretary of Health & Human Services will mean for medicine and health care.
An orthopedic surgeon and six-term congressman, Dr. Price is an outspoken critic of the Affordable Care Act and has sponsored or cosponsored numerous bills to replace it. President-elect Trump called Rep. Price “a renowned physician” who has “earned a reputation for being a tireless problem solver and the go-to expert on health care policy,” according to a statement.
Not everyone agrees.
But Adam Gaffney, MD, a pulmonologist at the Cambridge (Mass.) Health Alliance, said physicians’ ability to care for their patients would be compromised if Rep. Price succeeds with many of his proposals, such as the privatization of Medicare and block grants for Medicaid.
“If these reforms go through, we’re going to see the insurance protections of our patients get worse,” said Dr. Gaffney, a board member for Physicians for a National Health Program, which advocates for a single-payer health care system. “If [his] agenda is successful, I think it’s going to have a detrimental impact on our ability to provide the care that our patients need.”
ACA repeal, malpractice reform
In the House, Rep. Price has introduced the Empowering Patients First Act, legislation, which would allow doctors to opt out of Medicare and enter into private contracts with Medicare patients. The bill is seen by many as a potential blueprint for Trump administration health reform. Rep. Price is also a proponent of malpractice reform that would make it tougher for patients to sue doctors and would lower liability insurance premiums.
The Empowering Patients First Act would repeal the ACA and offer tax credits for the purchase of individual and family health insurance policies. It would also create incentives for patients to contribute to health savings accounts, offer state grants to subsidize coverage for high-risk patients, and authorize businesses to cover members through association health plans.
The American Medical Association praised Rep. Price’s nomination, expressing support for ability to lead HHS.
“Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs,” AMA Board of Trustees Chair Patrice A. Harris, MD, said in a statement.
The American College of Surgeons' Executive Director, David B. Hoyt, MD, FACS, issued a supportive statement about the nomination of Dr. Price. "“Dr. Price is a stalwart champion for patients and their surgeons, and the ACS looks forward to working with him on key issues, such as the implementation of the Medicare Access and CHIP Reauthorization Act,” said Dr. Hoyt in a statement. “The ACS encourages the Senate to swiftly confirm Dr. Price’s nomination as Secretary of HHS."
But thousands of physicians disagree. Rep. Price’s proposals on Medicaid and Medicare threaten to harm vulnerable patients and limit access to healthcare, according to an open letter to the AMA published on Medium and credited to Clinician Action Network, a nonpartisan group that supports evidence-based policies. The group was started in opposition to the nomination of Rep. Price.
“We cannot support the dismantling of Medicaid, which has helped 15 million Americans gain health coverage since 2014,” the letter states. “We oppose Dr. Price’s proposals to reduce funding for the Children’s Health Insurance Program, a critical mechanism by which poor children access preventative care.”
Value-based payment or fee for service?
Rep. Price’s experience as a physician fuels his efforts to reduce burdensome regulations for doctors and enhance care efficiency, according to one of his predecessors, Louis W. Sullivan, MD. If confirmed, Rep. Price will become the third physician to be HHS secretary; Dr. Sullivan served in the George H.W. Bush administration and Otis R. Bowen, MD, served in the Reagan administration.
“He is very much aware of the challenges that physicians face in trying to delivery care,” said Dr. Sullivan. “I know that he’ll be working to reduce regulation when feasible so that the cost and delays that some regulatory issues present will hopefully be relieved,”
Some of those regulatory modifications could affect value-based care programs, Dr. Rodriguez said. Rep. Price has been critical of the move from fee for service to quality-based care and has opposed some corresponding programs, such as bundled payment initiatives. Rep. Price and members of the GOP Doctors Caucus wrote to Centers for Medicare & Medicaid Services in October to protest the regulations to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as too burdensome for smaller practices and calling for flexibility in quality reporting.
Rep. Price voted for passage of MACRA.
“He has been cautious about some of the changes that are being promoted in health care,” Dr. Rodriguez said. “He could slow that down – the processes being put in place. That might delay the impact those systems have in bringing about the improved quality that we want. [This would be] enormous, given the amount of work that we’ve been doing.”
A fair medical liability system also is a priority for Rep. Price, Dr. Sullivan said. His Empowering Patients First bill would require collaboration between HHS and physician associations to develop best practice guidelines that would provide a litigation safe harbor to physicians who practiced in accordance with the standards.
“I know that he will be working to develop strategies to reduce litigation in the health space,” Dr. Sullivan said in an interview. “That is one of the challenges that adds to health care costs, adds tension, and enhances an adversarial relationship between physicians and patients.”
But Dr. Gaffney said that he believes Rep. Price’s views on reproductive rights and gay marriage are regressive and that his agenda regarding health policy issues is bad for medicine.
“The overall [theme] of that agenda can be summed up as ‘take from the poor and sick and give to the rich,’ ” Dr. Gaffney said in an interview. “I think the financing of this [new health reform] system will be much more aggressive, and the result will be greater health care inequity.”
Rep. Price also has supported a ban on federal funding for Planned Parenthood, calling some of their practices barbaric. He has also voted to prohibit the importation of prescription drugs by nonsanctioned importers and has voted to repeal the medical device excise tax.
[email protected]
On Twitter @legal_med
Opinions are mixed on what the nominations of Rep. Tom Price (R-Ga.) as Secretary of Health & Human Services will mean for medicine and health care.
An orthopedic surgeon and six-term congressman, Dr. Price is an outspoken critic of the Affordable Care Act and has sponsored or cosponsored numerous bills to replace it. President-elect Trump called Rep. Price “a renowned physician” who has “earned a reputation for being a tireless problem solver and the go-to expert on health care policy,” according to a statement.
Not everyone agrees.
But Adam Gaffney, MD, a pulmonologist at the Cambridge (Mass.) Health Alliance, said physicians’ ability to care for their patients would be compromised if Rep. Price succeeds with many of his proposals, such as the privatization of Medicare and block grants for Medicaid.
“If these reforms go through, we’re going to see the insurance protections of our patients get worse,” said Dr. Gaffney, a board member for Physicians for a National Health Program, which advocates for a single-payer health care system. “If [his] agenda is successful, I think it’s going to have a detrimental impact on our ability to provide the care that our patients need.”
ACA repeal, malpractice reform
In the House, Rep. Price has introduced the Empowering Patients First Act, legislation, which would allow doctors to opt out of Medicare and enter into private contracts with Medicare patients. The bill is seen by many as a potential blueprint for Trump administration health reform. Rep. Price is also a proponent of malpractice reform that would make it tougher for patients to sue doctors and would lower liability insurance premiums.
The Empowering Patients First Act would repeal the ACA and offer tax credits for the purchase of individual and family health insurance policies. It would also create incentives for patients to contribute to health savings accounts, offer state grants to subsidize coverage for high-risk patients, and authorize businesses to cover members through association health plans.
The American Medical Association praised Rep. Price’s nomination, expressing support for ability to lead HHS.
“Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs,” AMA Board of Trustees Chair Patrice A. Harris, MD, said in a statement.
The American College of Surgeons' Executive Director, David B. Hoyt, MD, FACS, issued a supportive statement about the nomination of Dr. Price. "“Dr. Price is a stalwart champion for patients and their surgeons, and the ACS looks forward to working with him on key issues, such as the implementation of the Medicare Access and CHIP Reauthorization Act,” said Dr. Hoyt in a statement. “The ACS encourages the Senate to swiftly confirm Dr. Price’s nomination as Secretary of HHS."
But thousands of physicians disagree. Rep. Price’s proposals on Medicaid and Medicare threaten to harm vulnerable patients and limit access to healthcare, according to an open letter to the AMA published on Medium and credited to Clinician Action Network, a nonpartisan group that supports evidence-based policies. The group was started in opposition to the nomination of Rep. Price.
“We cannot support the dismantling of Medicaid, which has helped 15 million Americans gain health coverage since 2014,” the letter states. “We oppose Dr. Price’s proposals to reduce funding for the Children’s Health Insurance Program, a critical mechanism by which poor children access preventative care.”
Value-based payment or fee for service?
Rep. Price’s experience as a physician fuels his efforts to reduce burdensome regulations for doctors and enhance care efficiency, according to one of his predecessors, Louis W. Sullivan, MD. If confirmed, Rep. Price will become the third physician to be HHS secretary; Dr. Sullivan served in the George H.W. Bush administration and Otis R. Bowen, MD, served in the Reagan administration.
“He is very much aware of the challenges that physicians face in trying to delivery care,” said Dr. Sullivan. “I know that he’ll be working to reduce regulation when feasible so that the cost and delays that some regulatory issues present will hopefully be relieved,”
Some of those regulatory modifications could affect value-based care programs, Dr. Rodriguez said. Rep. Price has been critical of the move from fee for service to quality-based care and has opposed some corresponding programs, such as bundled payment initiatives. Rep. Price and members of the GOP Doctors Caucus wrote to Centers for Medicare & Medicaid Services in October to protest the regulations to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as too burdensome for smaller practices and calling for flexibility in quality reporting.
Rep. Price voted for passage of MACRA.
“He has been cautious about some of the changes that are being promoted in health care,” Dr. Rodriguez said. “He could slow that down – the processes being put in place. That might delay the impact those systems have in bringing about the improved quality that we want. [This would be] enormous, given the amount of work that we’ve been doing.”
A fair medical liability system also is a priority for Rep. Price, Dr. Sullivan said. His Empowering Patients First bill would require collaboration between HHS and physician associations to develop best practice guidelines that would provide a litigation safe harbor to physicians who practiced in accordance with the standards.
“I know that he will be working to develop strategies to reduce litigation in the health space,” Dr. Sullivan said in an interview. “That is one of the challenges that adds to health care costs, adds tension, and enhances an adversarial relationship between physicians and patients.”
But Dr. Gaffney said that he believes Rep. Price’s views on reproductive rights and gay marriage are regressive and that his agenda regarding health policy issues is bad for medicine.
“The overall [theme] of that agenda can be summed up as ‘take from the poor and sick and give to the rich,’ ” Dr. Gaffney said in an interview. “I think the financing of this [new health reform] system will be much more aggressive, and the result will be greater health care inequity.”
Rep. Price also has supported a ban on federal funding for Planned Parenthood, calling some of their practices barbaric. He has also voted to prohibit the importation of prescription drugs by nonsanctioned importers and has voted to repeal the medical device excise tax.
[email protected]
On Twitter @legal_med
Opinions are mixed on what the nominations of Rep. Tom Price (R-Ga.) as Secretary of Health & Human Services will mean for medicine and health care.
An orthopedic surgeon and six-term congressman, Dr. Price is an outspoken critic of the Affordable Care Act and has sponsored or cosponsored numerous bills to replace it. President-elect Trump called Rep. Price “a renowned physician” who has “earned a reputation for being a tireless problem solver and the go-to expert on health care policy,” according to a statement.
Not everyone agrees.
But Adam Gaffney, MD, a pulmonologist at the Cambridge (Mass.) Health Alliance, said physicians’ ability to care for their patients would be compromised if Rep. Price succeeds with many of his proposals, such as the privatization of Medicare and block grants for Medicaid.
“If these reforms go through, we’re going to see the insurance protections of our patients get worse,” said Dr. Gaffney, a board member for Physicians for a National Health Program, which advocates for a single-payer health care system. “If [his] agenda is successful, I think it’s going to have a detrimental impact on our ability to provide the care that our patients need.”
ACA repeal, malpractice reform
In the House, Rep. Price has introduced the Empowering Patients First Act, legislation, which would allow doctors to opt out of Medicare and enter into private contracts with Medicare patients. The bill is seen by many as a potential blueprint for Trump administration health reform. Rep. Price is also a proponent of malpractice reform that would make it tougher for patients to sue doctors and would lower liability insurance premiums.
The Empowering Patients First Act would repeal the ACA and offer tax credits for the purchase of individual and family health insurance policies. It would also create incentives for patients to contribute to health savings accounts, offer state grants to subsidize coverage for high-risk patients, and authorize businesses to cover members through association health plans.
The American Medical Association praised Rep. Price’s nomination, expressing support for ability to lead HHS.
“Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs,” AMA Board of Trustees Chair Patrice A. Harris, MD, said in a statement.
The American College of Surgeons' Executive Director, David B. Hoyt, MD, FACS, issued a supportive statement about the nomination of Dr. Price. "“Dr. Price is a stalwart champion for patients and their surgeons, and the ACS looks forward to working with him on key issues, such as the implementation of the Medicare Access and CHIP Reauthorization Act,” said Dr. Hoyt in a statement. “The ACS encourages the Senate to swiftly confirm Dr. Price’s nomination as Secretary of HHS."
But thousands of physicians disagree. Rep. Price’s proposals on Medicaid and Medicare threaten to harm vulnerable patients and limit access to healthcare, according to an open letter to the AMA published on Medium and credited to Clinician Action Network, a nonpartisan group that supports evidence-based policies. The group was started in opposition to the nomination of Rep. Price.
“We cannot support the dismantling of Medicaid, which has helped 15 million Americans gain health coverage since 2014,” the letter states. “We oppose Dr. Price’s proposals to reduce funding for the Children’s Health Insurance Program, a critical mechanism by which poor children access preventative care.”
Value-based payment or fee for service?
Rep. Price’s experience as a physician fuels his efforts to reduce burdensome regulations for doctors and enhance care efficiency, according to one of his predecessors, Louis W. Sullivan, MD. If confirmed, Rep. Price will become the third physician to be HHS secretary; Dr. Sullivan served in the George H.W. Bush administration and Otis R. Bowen, MD, served in the Reagan administration.
“He is very much aware of the challenges that physicians face in trying to delivery care,” said Dr. Sullivan. “I know that he’ll be working to reduce regulation when feasible so that the cost and delays that some regulatory issues present will hopefully be relieved,”
Some of those regulatory modifications could affect value-based care programs, Dr. Rodriguez said. Rep. Price has been critical of the move from fee for service to quality-based care and has opposed some corresponding programs, such as bundled payment initiatives. Rep. Price and members of the GOP Doctors Caucus wrote to Centers for Medicare & Medicaid Services in October to protest the regulations to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as too burdensome for smaller practices and calling for flexibility in quality reporting.
Rep. Price voted for passage of MACRA.
“He has been cautious about some of the changes that are being promoted in health care,” Dr. Rodriguez said. “He could slow that down – the processes being put in place. That might delay the impact those systems have in bringing about the improved quality that we want. [This would be] enormous, given the amount of work that we’ve been doing.”
A fair medical liability system also is a priority for Rep. Price, Dr. Sullivan said. His Empowering Patients First bill would require collaboration between HHS and physician associations to develop best practice guidelines that would provide a litigation safe harbor to physicians who practiced in accordance with the standards.
“I know that he will be working to develop strategies to reduce litigation in the health space,” Dr. Sullivan said in an interview. “That is one of the challenges that adds to health care costs, adds tension, and enhances an adversarial relationship between physicians and patients.”
But Dr. Gaffney said that he believes Rep. Price’s views on reproductive rights and gay marriage are regressive and that his agenda regarding health policy issues is bad for medicine.
“The overall [theme] of that agenda can be summed up as ‘take from the poor and sick and give to the rich,’ ” Dr. Gaffney said in an interview. “I think the financing of this [new health reform] system will be much more aggressive, and the result will be greater health care inequity.”
Rep. Price also has supported a ban on federal funding for Planned Parenthood, calling some of their practices barbaric. He has also voted to prohibit the importation of prescription drugs by nonsanctioned importers and has voted to repeal the medical device excise tax.
[email protected]
On Twitter @legal_med
Aspirin use linked to increased ICH in trauma patients
WAIKOLOA, HAWAII – Among a group of anticoagulated trauma patients, those on aspirin had the highest rate and risk of intracranial hemorrhage (ICH), while those on novel oral anticoagulants were not at higher risk for ICH, ICH progression, or death, a multicenter study found.
“The number of patients on warfarin and antiplatelet agents has significantly increased over time,” Leslie Kobayashi, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “These oral antithrombotic agents have been associated with poor outcomes following traumatic injury, including increased rates of intracranial hemorrhage, increased progression of intracranial hemorrhage, and increased mortality.”
In a prospective, multicenter observational study conducted by the AAST’s Multi-institutional Trials Committee, Dr. Kobayashi and her associates set out identify injury patterns and outcomes in trauma patients taking the NOAs, and to test their hypothesis that patients taking NOAs would have higher rates of ICH, ICH progression, and death, compared with patients taking traditional oral anticoagulant therapies (OATs). Patients were included if they were admitted to the trauma service on warfarin, aspirin, clopidogrel, dabigatran, apixaban, or rivaroxaban. Pregnant patients, prisoners, and minors were excluded from the study. Data collected included demographics, mechanism of injury, vitals on admission, injuries/injury severity scores, labs, interventions, and reversal agents used such as vitamin K, prothrombin complexes, dialysis, and transfusion of fresh frozen plasma (FFP). Outcomes studied included ICH, ICH progression, and death.
In all, 16 Level 1 trauma centers enrolled 1,847 patients over a 2-year period. Their average age was 75 years, 46% were female, 77% were white, their median Injury Severity Score (ISS) was 9, and 99% sustained a blunt mechanism of trauma. The top two causes of injury were falls (71%) and motor vehicle crashes (15%). One-third of patients (33%) were on warfarin, while the remainder were on aspirin (26%), clopidogrel (24%), NOAs (10%), and 7% took multiple or other agents.
The mechanism of injury pattern was similar between patients taking NOAs and those taking OATs, with the exception of patients on aspirin being significantly less likely to have sustained a fall. Patients on aspirin also had a significantly higher median ISS. “Patients on NOAs presented more frequently in shock as defined by a systolic blood pressure of less than 90 mmHg, but this was not associated with increased need for packed red blood cell transfusion, bleeding requiring an intervention, need for surgical procedure, hospital LOS, complications, or death,” Dr. Kobayashi said.
About 30% of all patients studied underwent an attempt at reversal. The types of agents used to reverse the patients differed depending on drug agent, with antiplatelet patients more frequently getting platelets, and patients on warfarin more frequently receiving FFP, vitamin K, and prothrombin complex. “Interestingly, patients on the anti-Xa inhibitors more frequently received prothrombin complex as well,” she said. “This likely reflects some of the recent literature which suggests that there may be a therapeutic benefit to using prothrombin complex in patients taking the oral anti-Xa inhibitors but not in patients on dabigatran.”
Overall, bleeding, need for surgical procedure, need for neurosurgical procedure, complications, length of stay, and death were similar between those on NOAs and those on OATs. However, the rate of ICH was significantly higher in patients on aspirin. “What is even more surprising is that 89% of the patients in the aspirin-only group were on an 81-mg baby aspirin rather than the larger 325-mg dose,” Dr. Kobayashi said. This difference was significant on univariate analysis and was retained after multivariate logistic regression adjusted for differences between populations, with an OR for aspirin of 1.7 and a P value of .024. “This is not to suggest that patients on aspirin are doing markedly worse, compared to their counterparts, but I think most of us would have assumed that aspirin patients would have done better,” she commented. “I think we’ve definitively shown that is not the case.” Other independent predictors of ICH were advanced age (OR, 1.02), Asian race (OR, 3.1), ISS of 10 or greater (OR, 2.2), and a Glasgow coma score (GCS) of 8 or less (OR, 5.6).
Despite their increased risk for ICH, patients on aspirin were significantly less likely to undergo an attempt at reversal with any type of agent, at 16% with a P value of less than .001, on univariate analysis. “This was significantly lower than all other medications and was retained after multivariate logistic regression, with an OR of 0.3 and a P value of less than .001,” she said.
Progression of ICH did not differ by medication group. Other independent predictors included intraparenchymal location of hemorrhage (OR, 2.2), need for a neurosurgical procedure (OR, 5.1), an attempt at reversal (OR, 2.3) and a GCS of 8 or lower at admission (OR, 4.3). Similarly, multivariate analysis of death showed no significant differences between the different medication groups. Independent predictors included advanced age (OR, 1.06), GCS of 8 or less (OR, 13), progression of head injury (OR, 10), bleeding (OR, 2.3), and complications (OR, 2.1).
Dr. Kobayashi acknowledged that the study’s observational design is a limitation, as well as the fact that it lacked a control group of age-matched patients who were not taking anticoagulants. “Additionally, we had a relatively low number of patients on NOAs, at only 10% of the study population,” she said. “Lastly, there is potential for enrollment bias as all sites involved in this study were level one trauma centers.” She reported having no financial disclosures.
WAIKOLOA, HAWAII – Among a group of anticoagulated trauma patients, those on aspirin had the highest rate and risk of intracranial hemorrhage (ICH), while those on novel oral anticoagulants were not at higher risk for ICH, ICH progression, or death, a multicenter study found.
“The number of patients on warfarin and antiplatelet agents has significantly increased over time,” Leslie Kobayashi, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “These oral antithrombotic agents have been associated with poor outcomes following traumatic injury, including increased rates of intracranial hemorrhage, increased progression of intracranial hemorrhage, and increased mortality.”
In a prospective, multicenter observational study conducted by the AAST’s Multi-institutional Trials Committee, Dr. Kobayashi and her associates set out identify injury patterns and outcomes in trauma patients taking the NOAs, and to test their hypothesis that patients taking NOAs would have higher rates of ICH, ICH progression, and death, compared with patients taking traditional oral anticoagulant therapies (OATs). Patients were included if they were admitted to the trauma service on warfarin, aspirin, clopidogrel, dabigatran, apixaban, or rivaroxaban. Pregnant patients, prisoners, and minors were excluded from the study. Data collected included demographics, mechanism of injury, vitals on admission, injuries/injury severity scores, labs, interventions, and reversal agents used such as vitamin K, prothrombin complexes, dialysis, and transfusion of fresh frozen plasma (FFP). Outcomes studied included ICH, ICH progression, and death.
In all, 16 Level 1 trauma centers enrolled 1,847 patients over a 2-year period. Their average age was 75 years, 46% were female, 77% were white, their median Injury Severity Score (ISS) was 9, and 99% sustained a blunt mechanism of trauma. The top two causes of injury were falls (71%) and motor vehicle crashes (15%). One-third of patients (33%) were on warfarin, while the remainder were on aspirin (26%), clopidogrel (24%), NOAs (10%), and 7% took multiple or other agents.
The mechanism of injury pattern was similar between patients taking NOAs and those taking OATs, with the exception of patients on aspirin being significantly less likely to have sustained a fall. Patients on aspirin also had a significantly higher median ISS. “Patients on NOAs presented more frequently in shock as defined by a systolic blood pressure of less than 90 mmHg, but this was not associated with increased need for packed red blood cell transfusion, bleeding requiring an intervention, need for surgical procedure, hospital LOS, complications, or death,” Dr. Kobayashi said.
About 30% of all patients studied underwent an attempt at reversal. The types of agents used to reverse the patients differed depending on drug agent, with antiplatelet patients more frequently getting platelets, and patients on warfarin more frequently receiving FFP, vitamin K, and prothrombin complex. “Interestingly, patients on the anti-Xa inhibitors more frequently received prothrombin complex as well,” she said. “This likely reflects some of the recent literature which suggests that there may be a therapeutic benefit to using prothrombin complex in patients taking the oral anti-Xa inhibitors but not in patients on dabigatran.”
Overall, bleeding, need for surgical procedure, need for neurosurgical procedure, complications, length of stay, and death were similar between those on NOAs and those on OATs. However, the rate of ICH was significantly higher in patients on aspirin. “What is even more surprising is that 89% of the patients in the aspirin-only group were on an 81-mg baby aspirin rather than the larger 325-mg dose,” Dr. Kobayashi said. This difference was significant on univariate analysis and was retained after multivariate logistic regression adjusted for differences between populations, with an OR for aspirin of 1.7 and a P value of .024. “This is not to suggest that patients on aspirin are doing markedly worse, compared to their counterparts, but I think most of us would have assumed that aspirin patients would have done better,” she commented. “I think we’ve definitively shown that is not the case.” Other independent predictors of ICH were advanced age (OR, 1.02), Asian race (OR, 3.1), ISS of 10 or greater (OR, 2.2), and a Glasgow coma score (GCS) of 8 or less (OR, 5.6).
Despite their increased risk for ICH, patients on aspirin were significantly less likely to undergo an attempt at reversal with any type of agent, at 16% with a P value of less than .001, on univariate analysis. “This was significantly lower than all other medications and was retained after multivariate logistic regression, with an OR of 0.3 and a P value of less than .001,” she said.
Progression of ICH did not differ by medication group. Other independent predictors included intraparenchymal location of hemorrhage (OR, 2.2), need for a neurosurgical procedure (OR, 5.1), an attempt at reversal (OR, 2.3) and a GCS of 8 or lower at admission (OR, 4.3). Similarly, multivariate analysis of death showed no significant differences between the different medication groups. Independent predictors included advanced age (OR, 1.06), GCS of 8 or less (OR, 13), progression of head injury (OR, 10), bleeding (OR, 2.3), and complications (OR, 2.1).
Dr. Kobayashi acknowledged that the study’s observational design is a limitation, as well as the fact that it lacked a control group of age-matched patients who were not taking anticoagulants. “Additionally, we had a relatively low number of patients on NOAs, at only 10% of the study population,” she said. “Lastly, there is potential for enrollment bias as all sites involved in this study were level one trauma centers.” She reported having no financial disclosures.
WAIKOLOA, HAWAII – Among a group of anticoagulated trauma patients, those on aspirin had the highest rate and risk of intracranial hemorrhage (ICH), while those on novel oral anticoagulants were not at higher risk for ICH, ICH progression, or death, a multicenter study found.
“The number of patients on warfarin and antiplatelet agents has significantly increased over time,” Leslie Kobayashi, MD, said at the annual meeting of the American Association for the Surgery of Trauma. “These oral antithrombotic agents have been associated with poor outcomes following traumatic injury, including increased rates of intracranial hemorrhage, increased progression of intracranial hemorrhage, and increased mortality.”
In a prospective, multicenter observational study conducted by the AAST’s Multi-institutional Trials Committee, Dr. Kobayashi and her associates set out identify injury patterns and outcomes in trauma patients taking the NOAs, and to test their hypothesis that patients taking NOAs would have higher rates of ICH, ICH progression, and death, compared with patients taking traditional oral anticoagulant therapies (OATs). Patients were included if they were admitted to the trauma service on warfarin, aspirin, clopidogrel, dabigatran, apixaban, or rivaroxaban. Pregnant patients, prisoners, and minors were excluded from the study. Data collected included demographics, mechanism of injury, vitals on admission, injuries/injury severity scores, labs, interventions, and reversal agents used such as vitamin K, prothrombin complexes, dialysis, and transfusion of fresh frozen plasma (FFP). Outcomes studied included ICH, ICH progression, and death.
In all, 16 Level 1 trauma centers enrolled 1,847 patients over a 2-year period. Their average age was 75 years, 46% were female, 77% were white, their median Injury Severity Score (ISS) was 9, and 99% sustained a blunt mechanism of trauma. The top two causes of injury were falls (71%) and motor vehicle crashes (15%). One-third of patients (33%) were on warfarin, while the remainder were on aspirin (26%), clopidogrel (24%), NOAs (10%), and 7% took multiple or other agents.
The mechanism of injury pattern was similar between patients taking NOAs and those taking OATs, with the exception of patients on aspirin being significantly less likely to have sustained a fall. Patients on aspirin also had a significantly higher median ISS. “Patients on NOAs presented more frequently in shock as defined by a systolic blood pressure of less than 90 mmHg, but this was not associated with increased need for packed red blood cell transfusion, bleeding requiring an intervention, need for surgical procedure, hospital LOS, complications, or death,” Dr. Kobayashi said.
About 30% of all patients studied underwent an attempt at reversal. The types of agents used to reverse the patients differed depending on drug agent, with antiplatelet patients more frequently getting platelets, and patients on warfarin more frequently receiving FFP, vitamin K, and prothrombin complex. “Interestingly, patients on the anti-Xa inhibitors more frequently received prothrombin complex as well,” she said. “This likely reflects some of the recent literature which suggests that there may be a therapeutic benefit to using prothrombin complex in patients taking the oral anti-Xa inhibitors but not in patients on dabigatran.”
Overall, bleeding, need for surgical procedure, need for neurosurgical procedure, complications, length of stay, and death were similar between those on NOAs and those on OATs. However, the rate of ICH was significantly higher in patients on aspirin. “What is even more surprising is that 89% of the patients in the aspirin-only group were on an 81-mg baby aspirin rather than the larger 325-mg dose,” Dr. Kobayashi said. This difference was significant on univariate analysis and was retained after multivariate logistic regression adjusted for differences between populations, with an OR for aspirin of 1.7 and a P value of .024. “This is not to suggest that patients on aspirin are doing markedly worse, compared to their counterparts, but I think most of us would have assumed that aspirin patients would have done better,” she commented. “I think we’ve definitively shown that is not the case.” Other independent predictors of ICH were advanced age (OR, 1.02), Asian race (OR, 3.1), ISS of 10 or greater (OR, 2.2), and a Glasgow coma score (GCS) of 8 or less (OR, 5.6).
Despite their increased risk for ICH, patients on aspirin were significantly less likely to undergo an attempt at reversal with any type of agent, at 16% with a P value of less than .001, on univariate analysis. “This was significantly lower than all other medications and was retained after multivariate logistic regression, with an OR of 0.3 and a P value of less than .001,” she said.
Progression of ICH did not differ by medication group. Other independent predictors included intraparenchymal location of hemorrhage (OR, 2.2), need for a neurosurgical procedure (OR, 5.1), an attempt at reversal (OR, 2.3) and a GCS of 8 or lower at admission (OR, 4.3). Similarly, multivariate analysis of death showed no significant differences between the different medication groups. Independent predictors included advanced age (OR, 1.06), GCS of 8 or less (OR, 13), progression of head injury (OR, 10), bleeding (OR, 2.3), and complications (OR, 2.1).
Dr. Kobayashi acknowledged that the study’s observational design is a limitation, as well as the fact that it lacked a control group of age-matched patients who were not taking anticoagulants. “Additionally, we had a relatively low number of patients on NOAs, at only 10% of the study population,” she said. “Lastly, there is potential for enrollment bias as all sites involved in this study were level one trauma centers.” She reported having no financial disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point:
Major finding: The rate of ICH was significantly higher in patients on aspirin, compared with those on novel oral anticoagulant therapies (OR, 1.7; P = .024).
Data source: A prospective evaluation of 1,847 patients treated at 16 level one trauma centers over a 2-year period.
Disclosures: Dr. Kobayashi reported having no financial disclosures.
The war on pain
When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.
Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.
These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.
It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.
In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.
The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.
So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.
The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.
The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.
Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.
These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.
It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.
In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.
The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.
So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.
The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.
The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.
Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.
These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.
It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.
In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.
The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.
So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.
The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.
The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”
Younger age, greater anxiety, affect pain after breast reconstruction
Younger age, bilateral procedure, and presurgery depression and anxiety are among the significant contributors to pain after breast reconstruction surgery, according to findings from a prospective study of 2,207 women who underwent several types of breast reconstruction procedures.
Although breast reconstruction is an important element of breast cancer treatment, and most acute postoperative pain resolves with time and pain management intervention, some patients suffer from persistent, severe postoperative pain that increases their risk for long-term pain and clinical morbidity, wrote Anita R. Kulkarni, MD, of Memorial Sloan-Kettering Cancer Center, New York, and her colleagues.
Overall, greater acute postoperative pain was significantly associated with younger age, bilateral procedures, higher levels of preoperative pain, and higher levels of preoperative anxiety and depression, the researchers said.
“Moreover, the degree of patients’ self-reported preoperative anxiety and depressive symptoms both appeared to bear a linear relationship with the magnitude of increased postoperative pain at 1 week” on the MPQ sensory pain rating, they noted.
Similarly, lower scores of physical well-being based on the BREAST-Q physical well-being scale were significantly associated with younger age, bilateral procedures, immediate reconstruction, and higher levels of preoperative pain, anxiety, and depression.
The average age of the women was 50 years, and 87% were white. Most patients (69%) had tissue expander (TE)/implant reconstruction procedures; 93% were immediate reconstruction; and 53% were bilateral reconstruction. The majority (90%) underwent surgery as part of breast cancer treatment.
“The comparative effect of procedure type on postoperative pain showed variable results across our multiple pain scales,” the researchers said.
The patients who underwent autologous flap reconstruction procedures – pedicled transverse rectus abdominis myocutaneous flap (PTRAMS), deep inferior epigastric perforator (DIEP), or superficial inferior epigastric artery (SIEA) – reported less-severe postoperative pain than did those who had TE/Implant procedures. Specifically, patients with SIEA and DIEP procedures reported significantly less pain 1 week after surgery than did those who had TE/Implant procedures, based on the MPQ sensory scale. In addition, patients with PTRAMS reported significantly less postoperative pain 1 week after surgery than did those who had TE/Implant procedures based on the NPRS scale. All three flap procedures were significantly associated with less-severe postoperative pain, compared with TE/Implant procedures.
The findings support data from previous studies that identified preoperative pain, mood disturbance, and age as factors for increased risk of acute postoperative pain, the researchers noted. In addition, “the findings have important implications for the identification of women who might be at risk for significant early postoperative pain following breast reconstruction, as acute postoperative pain is associated with poor functional outcomes, diminished quality of life, and the risk for development of persistent postsurgical pain,” they wrote.
The study results were limited by several factors, including the lack of standardization for postoperative pain treatment regimens, variability in the timing of preoperative assessment, and nonresponder bias, the researchers said.
However, “Once high-risk patients are identified, appropriate referrals can be considered to facilitate careful monitoring of postsurgical pain for selected patients,” they said. “Early intervention can give clinicians the opportunity to reduce postoperative morbidity and improve patients’ surgical experience and satisfaction with breast reconstruction outcome,” they added.
The researchers had no financial conflicts to disclose. The study was supported in part by a grant from the National Institutes of Health/National Cancer Institute.
Younger age, bilateral procedure, and presurgery depression and anxiety are among the significant contributors to pain after breast reconstruction surgery, according to findings from a prospective study of 2,207 women who underwent several types of breast reconstruction procedures.
Although breast reconstruction is an important element of breast cancer treatment, and most acute postoperative pain resolves with time and pain management intervention, some patients suffer from persistent, severe postoperative pain that increases their risk for long-term pain and clinical morbidity, wrote Anita R. Kulkarni, MD, of Memorial Sloan-Kettering Cancer Center, New York, and her colleagues.
Overall, greater acute postoperative pain was significantly associated with younger age, bilateral procedures, higher levels of preoperative pain, and higher levels of preoperative anxiety and depression, the researchers said.
“Moreover, the degree of patients’ self-reported preoperative anxiety and depressive symptoms both appeared to bear a linear relationship with the magnitude of increased postoperative pain at 1 week” on the MPQ sensory pain rating, they noted.
Similarly, lower scores of physical well-being based on the BREAST-Q physical well-being scale were significantly associated with younger age, bilateral procedures, immediate reconstruction, and higher levels of preoperative pain, anxiety, and depression.
The average age of the women was 50 years, and 87% were white. Most patients (69%) had tissue expander (TE)/implant reconstruction procedures; 93% were immediate reconstruction; and 53% were bilateral reconstruction. The majority (90%) underwent surgery as part of breast cancer treatment.
“The comparative effect of procedure type on postoperative pain showed variable results across our multiple pain scales,” the researchers said.
The patients who underwent autologous flap reconstruction procedures – pedicled transverse rectus abdominis myocutaneous flap (PTRAMS), deep inferior epigastric perforator (DIEP), or superficial inferior epigastric artery (SIEA) – reported less-severe postoperative pain than did those who had TE/Implant procedures. Specifically, patients with SIEA and DIEP procedures reported significantly less pain 1 week after surgery than did those who had TE/Implant procedures, based on the MPQ sensory scale. In addition, patients with PTRAMS reported significantly less postoperative pain 1 week after surgery than did those who had TE/Implant procedures based on the NPRS scale. All three flap procedures were significantly associated with less-severe postoperative pain, compared with TE/Implant procedures.
The findings support data from previous studies that identified preoperative pain, mood disturbance, and age as factors for increased risk of acute postoperative pain, the researchers noted. In addition, “the findings have important implications for the identification of women who might be at risk for significant early postoperative pain following breast reconstruction, as acute postoperative pain is associated with poor functional outcomes, diminished quality of life, and the risk for development of persistent postsurgical pain,” they wrote.
The study results were limited by several factors, including the lack of standardization for postoperative pain treatment regimens, variability in the timing of preoperative assessment, and nonresponder bias, the researchers said.
However, “Once high-risk patients are identified, appropriate referrals can be considered to facilitate careful monitoring of postsurgical pain for selected patients,” they said. “Early intervention can give clinicians the opportunity to reduce postoperative morbidity and improve patients’ surgical experience and satisfaction with breast reconstruction outcome,” they added.
The researchers had no financial conflicts to disclose. The study was supported in part by a grant from the National Institutes of Health/National Cancer Institute.
Younger age, bilateral procedure, and presurgery depression and anxiety are among the significant contributors to pain after breast reconstruction surgery, according to findings from a prospective study of 2,207 women who underwent several types of breast reconstruction procedures.
Although breast reconstruction is an important element of breast cancer treatment, and most acute postoperative pain resolves with time and pain management intervention, some patients suffer from persistent, severe postoperative pain that increases their risk for long-term pain and clinical morbidity, wrote Anita R. Kulkarni, MD, of Memorial Sloan-Kettering Cancer Center, New York, and her colleagues.
Overall, greater acute postoperative pain was significantly associated with younger age, bilateral procedures, higher levels of preoperative pain, and higher levels of preoperative anxiety and depression, the researchers said.
“Moreover, the degree of patients’ self-reported preoperative anxiety and depressive symptoms both appeared to bear a linear relationship with the magnitude of increased postoperative pain at 1 week” on the MPQ sensory pain rating, they noted.
Similarly, lower scores of physical well-being based on the BREAST-Q physical well-being scale were significantly associated with younger age, bilateral procedures, immediate reconstruction, and higher levels of preoperative pain, anxiety, and depression.
The average age of the women was 50 years, and 87% were white. Most patients (69%) had tissue expander (TE)/implant reconstruction procedures; 93% were immediate reconstruction; and 53% were bilateral reconstruction. The majority (90%) underwent surgery as part of breast cancer treatment.
“The comparative effect of procedure type on postoperative pain showed variable results across our multiple pain scales,” the researchers said.
The patients who underwent autologous flap reconstruction procedures – pedicled transverse rectus abdominis myocutaneous flap (PTRAMS), deep inferior epigastric perforator (DIEP), or superficial inferior epigastric artery (SIEA) – reported less-severe postoperative pain than did those who had TE/Implant procedures. Specifically, patients with SIEA and DIEP procedures reported significantly less pain 1 week after surgery than did those who had TE/Implant procedures, based on the MPQ sensory scale. In addition, patients with PTRAMS reported significantly less postoperative pain 1 week after surgery than did those who had TE/Implant procedures based on the NPRS scale. All three flap procedures were significantly associated with less-severe postoperative pain, compared with TE/Implant procedures.
The findings support data from previous studies that identified preoperative pain, mood disturbance, and age as factors for increased risk of acute postoperative pain, the researchers noted. In addition, “the findings have important implications for the identification of women who might be at risk for significant early postoperative pain following breast reconstruction, as acute postoperative pain is associated with poor functional outcomes, diminished quality of life, and the risk for development of persistent postsurgical pain,” they wrote.
The study results were limited by several factors, including the lack of standardization for postoperative pain treatment regimens, variability in the timing of preoperative assessment, and nonresponder bias, the researchers said.
However, “Once high-risk patients are identified, appropriate referrals can be considered to facilitate careful monitoring of postsurgical pain for selected patients,” they said. “Early intervention can give clinicians the opportunity to reduce postoperative morbidity and improve patients’ surgical experience and satisfaction with breast reconstruction outcome,” they added.
The researchers had no financial conflicts to disclose. The study was supported in part by a grant from the National Institutes of Health/National Cancer Institute.
FROM THE JOURNAL OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY OPEN
Key clinical point: Identifying women at increased risk for severe acute postoperative pain allows clinicians the opportunity to reduce postoperative morbidity and improve patients’ surgical experience.
Major finding: Younger age (P = .002), bilateral procedures (P less than .0001), higher levels of preoperative pain (P less than .0001), and higher levels of preoperative anxiety (P less than .01) were among the strongest factors significantly associated with acute postoperative pain.
Data source: A prospective study of 2,207 women who underwent several types of breast reconstruction procedures.
Disclosures: The researchers had no financial conflicts to disclose. The study was supported in part by a grant from the National Institutes of Health/National Cancer Institute.
Lower analgesic use after robotic pelvic surgery
Postoperative use of both opioid and nonopioid analgesics was lower after robotic surgery than after laparotomy for endometrial cancer, according to a report published in Gynecologic Oncology.
Researchers assessed the use of postoperative pain medication in a single-center retrospective study involving 340 consecutive robotically assisted surgeries for endometrial cancer during a 6-year period. The mean patient age was 65 years, and more than one-third of the women were aged 70 or older. Slightly more than half were obese, and 19% were morbidly obese, said Jeremie Abitbol, PhD, of the division of gynecologic oncology, Jewish General Hospital and McGill University, Montreal, and his associates.
This benefit in the use of pain medication occurred regardless of the patient’s obesity status or age, which is particularly helpful in view of the increased risk of adverse events in these two patient populations, Dr. Abitbol and his associates reported (Gynecol Oncol. 2016. doi: 10.1016/jgyno.2016.11.014).
The direct costs associated with postoperative analgesia also were commensurately lower for robotically assisted surgery ($2.52 per day) than for laparotomy ($7.89 per day).
This study was supported by grants from the Israel Cancer Research Foundation, the Gloria’s Girls Fund, the Levi Family Fund, and the Weekend to End Women’s Cancers. Dr. Abitbol reported having no relevant financial disclosures; one of his associates reported receiving a grant from Intuitive Surgical.
Postoperative use of both opioid and nonopioid analgesics was lower after robotic surgery than after laparotomy for endometrial cancer, according to a report published in Gynecologic Oncology.
Researchers assessed the use of postoperative pain medication in a single-center retrospective study involving 340 consecutive robotically assisted surgeries for endometrial cancer during a 6-year period. The mean patient age was 65 years, and more than one-third of the women were aged 70 or older. Slightly more than half were obese, and 19% were morbidly obese, said Jeremie Abitbol, PhD, of the division of gynecologic oncology, Jewish General Hospital and McGill University, Montreal, and his associates.
This benefit in the use of pain medication occurred regardless of the patient’s obesity status or age, which is particularly helpful in view of the increased risk of adverse events in these two patient populations, Dr. Abitbol and his associates reported (Gynecol Oncol. 2016. doi: 10.1016/jgyno.2016.11.014).
The direct costs associated with postoperative analgesia also were commensurately lower for robotically assisted surgery ($2.52 per day) than for laparotomy ($7.89 per day).
This study was supported by grants from the Israel Cancer Research Foundation, the Gloria’s Girls Fund, the Levi Family Fund, and the Weekend to End Women’s Cancers. Dr. Abitbol reported having no relevant financial disclosures; one of his associates reported receiving a grant from Intuitive Surgical.
Postoperative use of both opioid and nonopioid analgesics was lower after robotic surgery than after laparotomy for endometrial cancer, according to a report published in Gynecologic Oncology.
Researchers assessed the use of postoperative pain medication in a single-center retrospective study involving 340 consecutive robotically assisted surgeries for endometrial cancer during a 6-year period. The mean patient age was 65 years, and more than one-third of the women were aged 70 or older. Slightly more than half were obese, and 19% were morbidly obese, said Jeremie Abitbol, PhD, of the division of gynecologic oncology, Jewish General Hospital and McGill University, Montreal, and his associates.
This benefit in the use of pain medication occurred regardless of the patient’s obesity status or age, which is particularly helpful in view of the increased risk of adverse events in these two patient populations, Dr. Abitbol and his associates reported (Gynecol Oncol. 2016. doi: 10.1016/jgyno.2016.11.014).
The direct costs associated with postoperative analgesia also were commensurately lower for robotically assisted surgery ($2.52 per day) than for laparotomy ($7.89 per day).
This study was supported by grants from the Israel Cancer Research Foundation, the Gloria’s Girls Fund, the Levi Family Fund, and the Weekend to End Women’s Cancers. Dr. Abitbol reported having no relevant financial disclosures; one of his associates reported receiving a grant from Intuitive Surgical.
FROM GYNECOLOGIC ONCOLOGY
Key clinical point: Postoperative use of both opioid and nonopioid analgesics was lower after robotic surgery than after laparotomy for endometrial cancer.
Major finding: The robotic surgery cohort required significantly less opioids (12 mg vs. 71 mg), acetaminophen (2,151 mg vs. 4,810 mg), ibuprofen (377 mg vs. 1,892 mg), and naproxen (393 mg vs 1,470 mg), compared with an historical cohort of 59 women who underwent laparotomy.
Data source: A single-center retrospective cohort study involving 340 consecutive robotically assisted pelvic surgeries during a 6-year period.
Disclosures: This study was supported by grants from the Israel Cancer Research Foundation, the Gloria’s Girls Fund, the Levi Family Fund, and the Weekend to End Women’s Cancers. Dr. Abitbol reported having no relevant financial disclosures; one of his associates reported receiving a grant from Intuitive Surgical.
Halogenated anesthetic linked to less chronic postop mastectomy pain
The use of halogenated agents for anesthetic during a mastectomy operation may be associated with a lower incidence of long-term chronic postmastectomy pain (CPMP), according to a paper published in the the Journal of Clinical Anesthesia.
The retrospective cross-sectional survey of 128 women who underwent mastectomy with axillary lymph node dissection set out to determine whether the anesthetic or analgesic regimen used perioperatively had any impact on the risk of long-term chronic postoperative pain.
Overall, 43.8% of the women reported chronic pain, and nearly half of these showed neuropathic characteristics with an ID Pain score greater than or equal to 2 (J Clin Anesthesia. 2016;33:20-25. doi: 10.1016/j.jclinane.2015.07.010).
Those who were given a halogenated agent for anesthesia during the operation – 64% of patients in the survey - had a significant 19% lower incidence of chronic long-term postoperative mastectomy pain (95% CI, 0.70-0.95; P = .012).
Arnaud Steyaert, MD, and colleagues at the Catholic University of Louvain (Belgium) described this result as surprising, noting that sevoflurane use was recently found to be a risk factor for chronic pain after breast cancer surgery.
“An explanation for this discrepancy could be that the influence of sevoflurane on the development of CPMP depends on the other components of the anesthetic regimen,” the authors wrote, pointing out that the aforementioned study included the use of remifentanil in all patients, which can trigger acute opioid-induced hyperalgesia and chronic pain after surgery.
Apart from this effect, the authors said they did not see any impact from other analgesics – which included sufentanil, ketamine, clonidine, NSAIDs, and/or magnesium sulfate – on the risk of long-term chronic pain. However, patients treated with piritramide in the recovery room did have a significant 30% greater risk of chronic postoperative pain.
The study also found that patients who needed strong opioids in the postanesthesia care unit had a 30% higher risk of chronic long-term pain (95% CI, 1.11-1.53). “This was expected, as more intense acute postoperative pain is a known risk factor for developing chronic postsurgical pain, including CPMP,” the authors wrote.
Patients who had received adjuvant chemotherapy had a 32% higher incidence of chronic long-term pain, but there was no increase in risk associated with adjuvant radiotherapy. Both are known to cause neurotoxicity and therefore neuropathic pain, the authors commented.
No conflicts of interest were declared.
The use of halogenated agents for anesthetic during a mastectomy operation may be associated with a lower incidence of long-term chronic postmastectomy pain (CPMP), according to a paper published in the the Journal of Clinical Anesthesia.
The retrospective cross-sectional survey of 128 women who underwent mastectomy with axillary lymph node dissection set out to determine whether the anesthetic or analgesic regimen used perioperatively had any impact on the risk of long-term chronic postoperative pain.
Overall, 43.8% of the women reported chronic pain, and nearly half of these showed neuropathic characteristics with an ID Pain score greater than or equal to 2 (J Clin Anesthesia. 2016;33:20-25. doi: 10.1016/j.jclinane.2015.07.010).
Those who were given a halogenated agent for anesthesia during the operation – 64% of patients in the survey - had a significant 19% lower incidence of chronic long-term postoperative mastectomy pain (95% CI, 0.70-0.95; P = .012).
Arnaud Steyaert, MD, and colleagues at the Catholic University of Louvain (Belgium) described this result as surprising, noting that sevoflurane use was recently found to be a risk factor for chronic pain after breast cancer surgery.
“An explanation for this discrepancy could be that the influence of sevoflurane on the development of CPMP depends on the other components of the anesthetic regimen,” the authors wrote, pointing out that the aforementioned study included the use of remifentanil in all patients, which can trigger acute opioid-induced hyperalgesia and chronic pain after surgery.
Apart from this effect, the authors said they did not see any impact from other analgesics – which included sufentanil, ketamine, clonidine, NSAIDs, and/or magnesium sulfate – on the risk of long-term chronic pain. However, patients treated with piritramide in the recovery room did have a significant 30% greater risk of chronic postoperative pain.
The study also found that patients who needed strong opioids in the postanesthesia care unit had a 30% higher risk of chronic long-term pain (95% CI, 1.11-1.53). “This was expected, as more intense acute postoperative pain is a known risk factor for developing chronic postsurgical pain, including CPMP,” the authors wrote.
Patients who had received adjuvant chemotherapy had a 32% higher incidence of chronic long-term pain, but there was no increase in risk associated with adjuvant radiotherapy. Both are known to cause neurotoxicity and therefore neuropathic pain, the authors commented.
No conflicts of interest were declared.
The use of halogenated agents for anesthetic during a mastectomy operation may be associated with a lower incidence of long-term chronic postmastectomy pain (CPMP), according to a paper published in the the Journal of Clinical Anesthesia.
The retrospective cross-sectional survey of 128 women who underwent mastectomy with axillary lymph node dissection set out to determine whether the anesthetic or analgesic regimen used perioperatively had any impact on the risk of long-term chronic postoperative pain.
Overall, 43.8% of the women reported chronic pain, and nearly half of these showed neuropathic characteristics with an ID Pain score greater than or equal to 2 (J Clin Anesthesia. 2016;33:20-25. doi: 10.1016/j.jclinane.2015.07.010).
Those who were given a halogenated agent for anesthesia during the operation – 64% of patients in the survey - had a significant 19% lower incidence of chronic long-term postoperative mastectomy pain (95% CI, 0.70-0.95; P = .012).
Arnaud Steyaert, MD, and colleagues at the Catholic University of Louvain (Belgium) described this result as surprising, noting that sevoflurane use was recently found to be a risk factor for chronic pain after breast cancer surgery.
“An explanation for this discrepancy could be that the influence of sevoflurane on the development of CPMP depends on the other components of the anesthetic regimen,” the authors wrote, pointing out that the aforementioned study included the use of remifentanil in all patients, which can trigger acute opioid-induced hyperalgesia and chronic pain after surgery.
Apart from this effect, the authors said they did not see any impact from other analgesics – which included sufentanil, ketamine, clonidine, NSAIDs, and/or magnesium sulfate – on the risk of long-term chronic pain. However, patients treated with piritramide in the recovery room did have a significant 30% greater risk of chronic postoperative pain.
The study also found that patients who needed strong opioids in the postanesthesia care unit had a 30% higher risk of chronic long-term pain (95% CI, 1.11-1.53). “This was expected, as more intense acute postoperative pain is a known risk factor for developing chronic postsurgical pain, including CPMP,” the authors wrote.
Patients who had received adjuvant chemotherapy had a 32% higher incidence of chronic long-term pain, but there was no increase in risk associated with adjuvant radiotherapy. Both are known to cause neurotoxicity and therefore neuropathic pain, the authors commented.
No conflicts of interest were declared.
FROM THE JOURNAL OF CLINICAL ANESTHESIA
Key clinical point: The use of halogenated agents for anesthetic during a mastectomy operation may be associated with a lower incidence of long-term chronic postmastectomy pain.
Major finding: Patients given a halogenated agent for anesthesia during a mastectomy had a significant 19% lower incidence of chronic long-term postoperative mastectomy pain.
Data source: A retrospective cross-sectional survey.
Disclosures: No conflicts of interest were declared.
Tips for avoiding nerve injuries in gynecologic surgery
Upper- and lower-extremity injuries can occur during gynecologic surgery. The incidence of lower-extremity injury is 1.1%-1.9% and upper-extremity injuries can occur in 0.16% of cases.1-5 Fortunately, most of the injuries are transient, sensory injuries that resolve spontaneously. However, a small percentage of injuries result in long-term sequelae.
The pathophysiology of the nerve injuries can be mechanistically separated into three categories: neuropraxia, axonotmesis, and neurotmesis. Neuropraxia results from nerve demyelination at the site of injury because of compression and typically resolves within weeks to months as the nerve is remyelinated. Axonotmesis results from severe compression with axon damage. This may take up to a year to resolve as axonal regeneration proceeds at the rate of 1 mm per day. This can be separated into second and third degree and refers to the severity of damage and the resultant persistent deficit. Neurotmesis results from complete transection and is associated with a poor prognosis without reparative surgery.
Brachial plexus
Stretch injury is the most common reason for a brachial plexus injury. This can occur if the arm board is extended to greater than 90 degrees from the patient’s torso or if the patient’s arm falls off of the arm board. Careful positioning and securing the patient’s arm on the arm board before draping can avoid this injury. A brachial plexus injury can also occur if shoulder braces are placed too laterally during minimally invasive surgery. Radial nerve injuries can occur if there is too much pressure on the humerus during positioning. Ulnar injuries arise from pressure placed on the medial aspect of the elbow.
Tip #1: When tucking a patient’s arm for minimally invasive surgery, appropriate padding should be placed around the elbow and wrist, and the arm should be in the “thumbs-up” position.
Tip #2: Shoulder blocks should be placed over the acromioclavicular (AC) joint.
Lumbosacral plexus
The femoral nerve is the nerve most commonly injured during gynecologic surgery and this usually occurs because of compression of the nerve from the lateral blades of self-retaining retractors. One study showed an 8% incidence of injury from self-retaining retractors, compared with less than 1% when the retractors were not used.6 The femoral nerve can also be stretched when patients are placed in the lithotomy position and the hip is hyperflexed.
As with brachial injury prevention, patients should be positioned prior to draping and care must be taken to not hyperflex or externally rotate the hip during minimally invasive surgical procedures. With the introduction of robot-assisted surgery, care must be taken when docking the robot and surgeons must resist excessive movement of the stirrups.
Tip #3: During laparotomy, surgeons should use the shortest blades that allow for adequate visualization and check the blades during the procedure to ensure that excessive pressure is not placed on the psoas muscle. Consider intermittently releasing the pressure on the lateral blades during other portions of the procedure.
Tip #4: Make sure the stirrups are at the same height and that the leg is in line with the patient’s contralateral shoulder.
Obturator nerve injuries can occur during retroperitoneal dissection for pelvic lymphadenectomy (obturator nodes) and can be either a transection or a cautery injury. It can also be injured during urogynecologic procedures including paravaginal defect repairs and during the placement of transobturator tapes.
The sciatic nerve and its branch, the common peroneal, are generally injured because of excessive stretch or pressure. Both nerves can be injured from hyperflexion of the thigh and the common peroneal can suffer a pressure injury as it courses around the lateral head of the fibula. Therefore, care during lithotomy positioning with both candy cane and Allen stirrups is critical during vaginal surgery.
Tip #5: Ensure that the lateral fibula is not touching the stirrup or that padding is placed between the fibular head and the stirrup.
The ilioinguinal and iliohypogastric nerves are typically injured via suture entrapment from low transverse skin incisions, though laparoscopic injury has also been reported. The incidence after a Pfannenstiel incision is about 3.7%.7
Tip #6: Avoid extending the low transverse incision beyond the lateral margin of the rectus muscle, and do not extend the fascial closure suture more than 1.5 cm from the lateral edge of the fascial incision to avoid catching the nerve with the suture.
The pudendal nerve is most commonly injured during vaginal procedures such as sacrospinous fixation. Pain is typically worse when seated.
The genitofemoral nerve is typically injured during retroperitoneal lymph node dissection, particularly the external iliac nodes. The nerve is small and runs lateral to the external iliac artery. It can suffer cautery and transection injuries. Usually, the paresthesias over the mons pubis, labia majora, and medial inner thigh are temporary.
Tip #7: Care should be taken to identify and spare the nerve during retroperitoneal dissection or external iliac node removal.
Nerve injuries during gynecologic surgery are common and are a significant cause of potential morbidity. While occasionally unavoidable and inherent to the surgical procedure, many times the injury could be prevented with proper attention and care to patient positioning and retractor use. Gynecologists should be aware of the risks and have a through understanding of the anatomy. However, should an injury occur, the patient can be reassured that most are self-limited and full recovery is generally expected. In a prospective study, the median time to resolution of symptoms was 31.5 days (range, 1 day to 6 months).5
References
1. The Obstetrician & Gynaecologist 2014;16:29-36.
2. Gynecol Oncol. 1988 Nov;31(3):462-6.
3. Fertil Steril. 1993 Oct;60(4):729-32.
4. J Minim Invasive Gynecol. 2007 Sep-Oct;14(5):664-72.
5. Am J Obstet Gynecol. 2009 Nov;201(5):531.e1-7.
6. Eur J Obstet Gynecol Reprod Biol. 1985 Dec;20(6):385-92.
7. Obstet Gynecol. 2008 Apr;111(4):839-46.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no financial disclosures relevant to this column. Email her at [email protected].
Upper- and lower-extremity injuries can occur during gynecologic surgery. The incidence of lower-extremity injury is 1.1%-1.9% and upper-extremity injuries can occur in 0.16% of cases.1-5 Fortunately, most of the injuries are transient, sensory injuries that resolve spontaneously. However, a small percentage of injuries result in long-term sequelae.
The pathophysiology of the nerve injuries can be mechanistically separated into three categories: neuropraxia, axonotmesis, and neurotmesis. Neuropraxia results from nerve demyelination at the site of injury because of compression and typically resolves within weeks to months as the nerve is remyelinated. Axonotmesis results from severe compression with axon damage. This may take up to a year to resolve as axonal regeneration proceeds at the rate of 1 mm per day. This can be separated into second and third degree and refers to the severity of damage and the resultant persistent deficit. Neurotmesis results from complete transection and is associated with a poor prognosis without reparative surgery.
Brachial plexus
Stretch injury is the most common reason for a brachial plexus injury. This can occur if the arm board is extended to greater than 90 degrees from the patient’s torso or if the patient’s arm falls off of the arm board. Careful positioning and securing the patient’s arm on the arm board before draping can avoid this injury. A brachial plexus injury can also occur if shoulder braces are placed too laterally during minimally invasive surgery. Radial nerve injuries can occur if there is too much pressure on the humerus during positioning. Ulnar injuries arise from pressure placed on the medial aspect of the elbow.
Tip #1: When tucking a patient’s arm for minimally invasive surgery, appropriate padding should be placed around the elbow and wrist, and the arm should be in the “thumbs-up” position.
Tip #2: Shoulder blocks should be placed over the acromioclavicular (AC) joint.
Lumbosacral plexus
The femoral nerve is the nerve most commonly injured during gynecologic surgery and this usually occurs because of compression of the nerve from the lateral blades of self-retaining retractors. One study showed an 8% incidence of injury from self-retaining retractors, compared with less than 1% when the retractors were not used.6 The femoral nerve can also be stretched when patients are placed in the lithotomy position and the hip is hyperflexed.
As with brachial injury prevention, patients should be positioned prior to draping and care must be taken to not hyperflex or externally rotate the hip during minimally invasive surgical procedures. With the introduction of robot-assisted surgery, care must be taken when docking the robot and surgeons must resist excessive movement of the stirrups.
Tip #3: During laparotomy, surgeons should use the shortest blades that allow for adequate visualization and check the blades during the procedure to ensure that excessive pressure is not placed on the psoas muscle. Consider intermittently releasing the pressure on the lateral blades during other portions of the procedure.
Tip #4: Make sure the stirrups are at the same height and that the leg is in line with the patient’s contralateral shoulder.
Obturator nerve injuries can occur during retroperitoneal dissection for pelvic lymphadenectomy (obturator nodes) and can be either a transection or a cautery injury. It can also be injured during urogynecologic procedures including paravaginal defect repairs and during the placement of transobturator tapes.
The sciatic nerve and its branch, the common peroneal, are generally injured because of excessive stretch or pressure. Both nerves can be injured from hyperflexion of the thigh and the common peroneal can suffer a pressure injury as it courses around the lateral head of the fibula. Therefore, care during lithotomy positioning with both candy cane and Allen stirrups is critical during vaginal surgery.
Tip #5: Ensure that the lateral fibula is not touching the stirrup or that padding is placed between the fibular head and the stirrup.
The ilioinguinal and iliohypogastric nerves are typically injured via suture entrapment from low transverse skin incisions, though laparoscopic injury has also been reported. The incidence after a Pfannenstiel incision is about 3.7%.7
Tip #6: Avoid extending the low transverse incision beyond the lateral margin of the rectus muscle, and do not extend the fascial closure suture more than 1.5 cm from the lateral edge of the fascial incision to avoid catching the nerve with the suture.
The pudendal nerve is most commonly injured during vaginal procedures such as sacrospinous fixation. Pain is typically worse when seated.
The genitofemoral nerve is typically injured during retroperitoneal lymph node dissection, particularly the external iliac nodes. The nerve is small and runs lateral to the external iliac artery. It can suffer cautery and transection injuries. Usually, the paresthesias over the mons pubis, labia majora, and medial inner thigh are temporary.
Tip #7: Care should be taken to identify and spare the nerve during retroperitoneal dissection or external iliac node removal.
Nerve injuries during gynecologic surgery are common and are a significant cause of potential morbidity. While occasionally unavoidable and inherent to the surgical procedure, many times the injury could be prevented with proper attention and care to patient positioning and retractor use. Gynecologists should be aware of the risks and have a through understanding of the anatomy. However, should an injury occur, the patient can be reassured that most are self-limited and full recovery is generally expected. In a prospective study, the median time to resolution of symptoms was 31.5 days (range, 1 day to 6 months).5
References
1. The Obstetrician & Gynaecologist 2014;16:29-36.
2. Gynecol Oncol. 1988 Nov;31(3):462-6.
3. Fertil Steril. 1993 Oct;60(4):729-32.
4. J Minim Invasive Gynecol. 2007 Sep-Oct;14(5):664-72.
5. Am J Obstet Gynecol. 2009 Nov;201(5):531.e1-7.
6. Eur J Obstet Gynecol Reprod Biol. 1985 Dec;20(6):385-92.
7. Obstet Gynecol. 2008 Apr;111(4):839-46.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no financial disclosures relevant to this column. Email her at [email protected].
Upper- and lower-extremity injuries can occur during gynecologic surgery. The incidence of lower-extremity injury is 1.1%-1.9% and upper-extremity injuries can occur in 0.16% of cases.1-5 Fortunately, most of the injuries are transient, sensory injuries that resolve spontaneously. However, a small percentage of injuries result in long-term sequelae.
The pathophysiology of the nerve injuries can be mechanistically separated into three categories: neuropraxia, axonotmesis, and neurotmesis. Neuropraxia results from nerve demyelination at the site of injury because of compression and typically resolves within weeks to months as the nerve is remyelinated. Axonotmesis results from severe compression with axon damage. This may take up to a year to resolve as axonal regeneration proceeds at the rate of 1 mm per day. This can be separated into second and third degree and refers to the severity of damage and the resultant persistent deficit. Neurotmesis results from complete transection and is associated with a poor prognosis without reparative surgery.
Brachial plexus
Stretch injury is the most common reason for a brachial plexus injury. This can occur if the arm board is extended to greater than 90 degrees from the patient’s torso or if the patient’s arm falls off of the arm board. Careful positioning and securing the patient’s arm on the arm board before draping can avoid this injury. A brachial plexus injury can also occur if shoulder braces are placed too laterally during minimally invasive surgery. Radial nerve injuries can occur if there is too much pressure on the humerus during positioning. Ulnar injuries arise from pressure placed on the medial aspect of the elbow.
Tip #1: When tucking a patient’s arm for minimally invasive surgery, appropriate padding should be placed around the elbow and wrist, and the arm should be in the “thumbs-up” position.
Tip #2: Shoulder blocks should be placed over the acromioclavicular (AC) joint.
Lumbosacral plexus
The femoral nerve is the nerve most commonly injured during gynecologic surgery and this usually occurs because of compression of the nerve from the lateral blades of self-retaining retractors. One study showed an 8% incidence of injury from self-retaining retractors, compared with less than 1% when the retractors were not used.6 The femoral nerve can also be stretched when patients are placed in the lithotomy position and the hip is hyperflexed.
As with brachial injury prevention, patients should be positioned prior to draping and care must be taken to not hyperflex or externally rotate the hip during minimally invasive surgical procedures. With the introduction of robot-assisted surgery, care must be taken when docking the robot and surgeons must resist excessive movement of the stirrups.
Tip #3: During laparotomy, surgeons should use the shortest blades that allow for adequate visualization and check the blades during the procedure to ensure that excessive pressure is not placed on the psoas muscle. Consider intermittently releasing the pressure on the lateral blades during other portions of the procedure.
Tip #4: Make sure the stirrups are at the same height and that the leg is in line with the patient’s contralateral shoulder.
Obturator nerve injuries can occur during retroperitoneal dissection for pelvic lymphadenectomy (obturator nodes) and can be either a transection or a cautery injury. It can also be injured during urogynecologic procedures including paravaginal defect repairs and during the placement of transobturator tapes.
The sciatic nerve and its branch, the common peroneal, are generally injured because of excessive stretch or pressure. Both nerves can be injured from hyperflexion of the thigh and the common peroneal can suffer a pressure injury as it courses around the lateral head of the fibula. Therefore, care during lithotomy positioning with both candy cane and Allen stirrups is critical during vaginal surgery.
Tip #5: Ensure that the lateral fibula is not touching the stirrup or that padding is placed between the fibular head and the stirrup.
The ilioinguinal and iliohypogastric nerves are typically injured via suture entrapment from low transverse skin incisions, though laparoscopic injury has also been reported. The incidence after a Pfannenstiel incision is about 3.7%.7
Tip #6: Avoid extending the low transverse incision beyond the lateral margin of the rectus muscle, and do not extend the fascial closure suture more than 1.5 cm from the lateral edge of the fascial incision to avoid catching the nerve with the suture.
The pudendal nerve is most commonly injured during vaginal procedures such as sacrospinous fixation. Pain is typically worse when seated.
The genitofemoral nerve is typically injured during retroperitoneal lymph node dissection, particularly the external iliac nodes. The nerve is small and runs lateral to the external iliac artery. It can suffer cautery and transection injuries. Usually, the paresthesias over the mons pubis, labia majora, and medial inner thigh are temporary.
Tip #7: Care should be taken to identify and spare the nerve during retroperitoneal dissection or external iliac node removal.
Nerve injuries during gynecologic surgery are common and are a significant cause of potential morbidity. While occasionally unavoidable and inherent to the surgical procedure, many times the injury could be prevented with proper attention and care to patient positioning and retractor use. Gynecologists should be aware of the risks and have a through understanding of the anatomy. However, should an injury occur, the patient can be reassured that most are self-limited and full recovery is generally expected. In a prospective study, the median time to resolution of symptoms was 31.5 days (range, 1 day to 6 months).5
References
1. The Obstetrician & Gynaecologist 2014;16:29-36.
2. Gynecol Oncol. 1988 Nov;31(3):462-6.
3. Fertil Steril. 1993 Oct;60(4):729-32.
4. J Minim Invasive Gynecol. 2007 Sep-Oct;14(5):664-72.
5. Am J Obstet Gynecol. 2009 Nov;201(5):531.e1-7.
6. Eur J Obstet Gynecol Reprod Biol. 1985 Dec;20(6):385-92.
7. Obstet Gynecol. 2008 Apr;111(4):839-46.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no financial disclosures relevant to this column. Email her at [email protected].