ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting.

Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient.

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice.

Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine.

Ambulatory Pain Management in the Pediatric Patient Population.

Purpose Of Review: Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review.

Purpose Of Review: Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Recent Findings: Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols.

Enhanced Recovery After Surgery: Opioid Sparing Strategies After Discharge: A Review.

PURPOSE OF REVIEW: Many surgical subspecialties have developed enhanced recovery after surgery (ERAS) protocols that focus on multimodal analgesia to limit opioid use during a hospital stay and improve patient recovery. Unfortunately, ERAS protocols do not extend to post-discharge patient care, and opioids continue to be over prescribed. The primary reason seems to be a lack of good quality research evaluating extended use of a multimodal analgesic approach.

Does Choice of Steroid Matter for Treatment of Chronic Low Back Pain with Sacroiliac Joint Injections: a Retrospective Study.

Purpose Of Review: Prevalence of chronic low back pain (cLBP) is increasing. Sacroiliac joint (SIJ) is a common source of cLBP, but data behind its diagnosis and treatment is controversial. There is moderate quality evidence for effectiveness of therapeutic SIJ injections.

Acute Pain Management of Chronic Pain Patients in Ambulatory Surgery Centers.

Purpose Of Review: With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids.

Ultrasound-Guided Neuraxial Anesthesia.

Purpose Of Review: There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia.

Recent Findings: Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space.

Endometriosis Pain Management: a Review.

Purpose Of Review: The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis.

Recent Findings: The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny.

Ultrasound for peripheral and arterial access.

Peripheral venous access is perhaps the most commonly performed procedure in hospitals, urgent care, or surgical centers across the country. The ability to obtain peripheral intravenous (IV) access, and in a timely manner, is arguably one of the most important skill sets to be mastered by health care professionals. While skill and experience play a role in successful and timely vascular access, numerous patient factors such as obesity, diabetes, IV drug use, and chronic kidney disease may pose unique challenges to even the most skilled health care professional.

Novel Regional Anesthesia for Outpatient Surgery.

Purpose Of Review: Peripheral nerve blocks are effective and safe modalities for perioperative analgesia. But it remains unclear what blocks are adequate for ambulatory surgeries, as well as the proper patient management before and after discharge.

Recent Findings: Emerging nerve blocks have sparked interests due to ease to perform under ultrasound guidance and lower risks of adverse events.

Challenges of Robotic Gynecologic Surgery in Morbidly Obese Patients and How to Optimize Success.

Purpose Of Review: Robotic surgery has been shown to have a significant benefit in obese gynecologic patients over open surgery. However, robotic surgery in these patients requires a thorough understanding of the physiologic adaptations caused by obesity, adequate preoperative optimization, specialized equipment and techniques, and careful attention to intra- and postoperative management in order to minimize complications. This article reviews the benefits of a minimally invasive approach in obese patients and provides a thorough guide to perioperative management of obese patients undergoing robotic gynecologic surgery.

Perioperative Pain Management in the Critically Ill Patient.

Purpose Of Review: The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain.

Analysis of Multiple Routes of Analgesic Administration in the Immediate Postoperative Period: a 10-Year Experience.

Purpose Of Review: An increasing amount of literature supports a multimodal approach to analgesic administration in the management of postoperative pain. The purpose of this study and review was to further evaluate the differences in efficacy in controlling immediate postoperative pain among the various routes of analgesia administration.

Recent Findings: This study consisted of an analysis of the various routes of analgesic administration (parental, neuraxial, and oral/rectal) in 107,671 consecutive surgical cases performed over a 10-year period at Yale New Haven Hospital.

Perioperative Considerations in the Management of Anticoagulation Therapy for Patients Undergoing Surgery.

Purpose Of Review: As ambulatory surgery has become increasingly more common, the appropriate management of anticoagulation therapy in patients undergoing invasive procedures has become progressively more relevant to healthcare professionals. The purpose of this literature review is to provide an overview of current common anaticoagulants and their pharmacological properties and to evaluate recent relevant literature and bridging therapy and provide recommendations on risk-guided therapy.

Recent Findings: With the development of new drugs and the advancing study and practice of anticoagulation use, clinicians must keep up-to-date on the optimal management of patients requiring anticoagulation.

Safety of Deep Sedation in Patients Undergoing Full-Thickness Skin Graft Harvesting and Skin Graft Reconstruction for Limb Salvage .

Background:: Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit.

Methods:: Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed.

New opioid receptor modulators and agonists.

There has been significant research to develop an ideal synthetic opioid. Opioids with variable properties possessing efficacy and with reduced side effects have been synthesized when compared to previously used agents. An opioid modulator is a drug that can produce both agonistic and antagonistic effects by binding to different opioid receptors and therefore cannot be classified as one or the other alone.

Perioperative Management of Patients with Addiction to Opioid and Non-opioid Medications.

Purpose Of Review: With the rise of the opioid epidemic, anesthesiologists will find themselves faced with opioid-addicted patients more frequently. Addiction to opioids may also occur concurrently with abuse of other non-opioid medications. Our review article seeks to outline an armamentarium of pain management strategies in the perioperative period for these patients with addiction to opioid and non-opioid medications.

Functional Connectivity Alterations: Novel Therapy and Future Implications in Chronic Pain Management.

Background: Chronic pain is a major public health problem resulting in physical and emotional pain for individuals and families, loss of productivity, and an annual cost of billions of dollars. The lack of objective measures available to aid in diagnosis and evaluation of therapies for chronic pain continues to be a challenge for the clinician.

Objectives: Functional magnetic resonance imaging (fMRI) is an imaging technique that can establish regional areas of interest and examine synchronous neuronal activity in functionally related but anatomically distinct regions of the brain, known as functional connectivity.

Elevated International Normalized Ratio Is Not Associated With Increased Perioperative Morbidity in Podiatric Limb Salvage Surgery: A Retrospective Analysis.

The risk of hemorrhage always exists in anticoagulated patients with an elevated international normalized ratio (INR), a risk that must be measured against the necessity for surgical procedures. The objective of the present retrospective medical record study was to assess the safety with which limb salvage procedures can be conducted in patients with an INR >1.4.

Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship.

Purpose Of Review: We performed a systematic review to elucidate the current guidelines on weaning patients from opioids in the post-operative ambulatory surgery setting, and how pain management intraoperatively can impact this process.

Design: The review highlights the most up-to-date research from clinical trials, patient reports, and retrospective studies regarding both the current guidelines and weaning of opioid analgesia in ambulatory surgery setting.

Recent Findings: A striking paucity of convincing evidence exists on ambulatory postoperative pain management discontinuation or weaning of pain medications.

New Advances in Acute Postoperative Pain Management.

Purpose Of Review: Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management.

Global Supply and Demand of Opioids for Pain Management.

Purpose Of Review: The goal of this review is to evaluate the global supply and demand of opioids used for pain management and discuss how it relates to the utilization of opioids around the world. The purpose of the review is also to determine the factors that contribute to inappropriate pain management.

Recent Findings: The total global production of opium for opioid manufacturing is enough to supply the growing global demands.

Recommendations for Substance Abuse and Pain Control in Patients with Chronic Pain.

Purpose Of Review: In the present investigation, current literature on the relationship between substance abuse and pain is evaluated in order to improve clinical management and its implications on the increasingly challenging chronic pain and substance abuse epidemic. The relationship between substance abuse and chronic pain are evaluated, and this review provides recommendations on the management of this special patient population.

Recent Findings: Currently, there are limited guidelines for prescribing opioids and other analgesics in the chronic pain population.