Perioperative and Pain Medicine

Palo Alto, CA, United States

Perioperative and Pain Medicine

Palo Alto, CA, United States

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Butwick A.J.,Perioperative and Pain Medicine
Anesthesia and Analgesia | Year: 2017

BACKGROUND:: Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype. METHODS:: To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ≥1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models. RESULTS:: For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI] = 4.9–99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI = 4.2–15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI = 3.4–11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI = 1.7–17.1), multiple pregnancies (aOR = 3.2; 95% CI = 1.7–6.3), and a predelivery hemoglobin ≤ 9.9 g/dL (aOR = 3.0; 95% CI = 1.3–6.9; reference group = predelivery hemoglobin ≥ 11 g/dL). CONCLUSIONS:: Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD. © 2017 International Anesthesia Research Society

BACKGROUND:: In 2005, physician and nursing leaders at Brigham and Women’s Hospital initiated structured interprofessional rounds (SIPRs) on the labor and delivery (L&D) suite to improve team communication. We performed a cross-sectional analysis of providers’ perceptions of SIPRs and their effectiveness in improving teamwork. We hypothesized that on average, providers would perceive SIPRs as being effective in promoting teamwork, but ratings would differ among professional groups. METHODS:: After a factor analysis and internal consistency assessment, a 19-item paper-based questionnaire was used to evaluate providers’ perceptions using a 5-point Likert scale. Respondents included L&D nurses, midwives, obstetricians, and anesthesiologists who participate in SIPRs. The primary aim was to evaluate the providers’ perceptions of SIPRs and their association with professional roles. The outcome was total response score for each provider, ranging from 19 to 95; perception of SIPRs as being effective in promoting teamwork was defined as having a total response score of >66.5 (mean score, >3.5 per question). A univariable linear regression model was performed, followed by a multivariable analysis adjusting for predictors that modified the outcome; predictors included years of professional practice, years of experience on the L&D suite, number of clinical work hours worked weekly, and principal shift assignment among nurses. The associations between these predictors and providers’ perceptions were assessed as a secondary aim. RESULTS:: A total of 234 practitioners responded (100% response rate). The mean total response score (SD) for all providers was 73.3 (9.5). After multivariable adjustment, the mean total response scores were significantly higher for obstetric providers than for anesthesia (Δ mean, 6.5, 95% CI, 0.3, 12.7 P = .036) and midwifery (Δ mean, 12.5, 95% CI, 2.0, 23.0, P = .009) providers. Providers scored significantly lower if they worked >60 clinical hours per week compared with ≤20 (Δ mean, −13.7, 95% CI, −25.3, −2.1, P = .009), 21–40 (Δ mean, −8.0, 95% CI, −15.8, −0.09, P = .049), or 41–60 hours (Δ mean, −8.1, 95% CI, −14.5, −1.7, P = .004). Duration of practice in professional role and experience on the L&D suite were not predictive of SIPRs ratings. CONCLUSIONS:: On average, providers on the L&D suite perceive SIPRs as being effective in promoting teamwork. Perception ratings were significantly influenced by professional role and number of clinical hours worked weekly, suggesting that these factors should be explored in future research to minimize perception gaps and support a dynamic culture of interprofessional collaboration. © 2017 International Anesthesia Research Society

PubMed | Brigham and Women's Hospital and Perioperative and Pain Medicine.
Type: | Journal: Journal of cardiothoracic and vascular anesthesia | Year: 2017

To test whether a model using a historical average of a surgeons surgical times for primary aortic valve replacements is a more accurate predictor of actual surgical times than solely relying on a surgeons estimate.Retrospective review.Single university hospital that serves as a tertiary referral center.All patients undergoing primary aortic valve replacement between October 2008 and September 2014.None.Estimation biases, calculated as the difference between actual and predicted surgical time, were compared between the surgeon and the model, which included between 2 and 20 cases in the historical average. Kruskal-Wallis analysis of variance was used to compare all values. Pairwise comparisons were made using the Steel-Dwass test to determine whether using more cases in the model resulted in smaller estimation biases. Using the historical model reduced mean overestimation bias from 55.30 minutes to 0.90-to-4.67 minutes. No significant difference was seen based on the number of cases used.An uncomplicated model can assist in providing comparatively unbiased estimations of surgical time for aortic valve replacements. The model can rely on a fewer number of cases (eg, 5) and does not benefit from including more cases (eg, 20).

PubMed | Perioperative and Pain Medicine., Bristol Myers Squibb and Gunma University
Type: | Journal: The Journal of neuroscience : the official journal of the Society for Neuroscience | Year: 2017

The superficial dorsal horn is the synaptic termination site for many peripheral sensory fibers of the somatosensory system. A wide range of sensory modalities are represented by these fibers including pain, itch and temperature. Because local inhibition in the dorsal horn, specifically that mediated by the inhibitory amino acids GABA and glycine, is importantly involved in signal processing there, we investigated regional inhibitory control of excitatory interneurons under control conditions and peripheral inflammation-induced mechanical allodynia. We found that excitatory interneurons and projection neurons in lamina I and IIo are dominantly inhibited by GABA while those in lamina IIi and III are dominantly inhibited by glycine. This was true of identified neuronal subpopulations: neurokinin 1 receptor expressing (NK1R+) neurons in lamina I were GABA dominant while protein kinase C gamma expressing (PKC+) neurons at the lamina IIi/III border were glycine dominant. We found this pattern of synaptic inhibition to be consistent with the distribution of GABAergic and glycinergic neurons identified by immunohistochemistry. Following Complete Freunds Adjuvant (CFA) injection into mouse hindpaw, the frequency of spontaneous excitatory synaptic activity increased and inhibitory synaptic activity decreased. Surprisingly, these changes were accompanied by an increase in GABA dominance in lamina IIi. Because this shift in inhibitory dominance was not accompanied by a change in the number of inhibitory synapses or the overall postsynaptic expression of glycine receptor 1 subunits, we propose that the dominance shift is due to glycine receptor modulation and the depressed function of glycine receptors is partially compensated by GABAergic inhibition.Pain associated with inflammation is a sensation we would all like to minimize. Persistent inflammation leads to cellular and molecular changes in the spinal cord dorsal horn, including diminished inhibition, which may be responsible for enhance excitability. Investigating inhibition in the dorsal horn following peripheral inflammation is essential for development of improvements to control the associated pain. In this study, we have elucidated regional differences in inhibition of excitatory interneurons in mouse dorsal horn. We have also discovered switching of the dominating inhibitory neurotransmission within specific regions of dorsal horn following peripheral inflammation and the accompanying hypersensitivity to thermal and mechanical stimuli. Our novel findings contribute to a more complete understanding of inflammatory pain.

News Article | November 15, 2016

Placebos are essential in any controlled clinical trial, providing a yardstick against which the test drug is measured. Placebos are even starting to be used as a treatment in their own right, as studies show that they make people feel better via a "mind-body" healing effect. But do parents find placebos acceptable for their children? A study led by Boston Children's Hospital found the answer is mostly yes, provided ethical guidelines are followed. Findings will appear online November 15 in The Journal of Pediatrics. "The question of placebos is more complex when it comes to children, since parents must make medical decisions on their behalf," says Vanda Faria, PhD, a research fellow at Boston Children's Hospital's Center for Pain and the Brain. "Large placebo responses have been seen in a variety of pediatric conditions, and parent's perceptions can influence how well placebos work. At the same time, little is still known about the potential harms of prolonged drug therapy on children's development. Sometimes, the best intervention might not involve pharmacotherapy." The researchers used an online survey to ask 1,000 U.S. parents about their attitudes toward placebos. Their findings: When parents were given a list of 17 conditions, a majority considered placebo acceptable for only seven: the common cold, ear infection, occasional pain, anxiety disorders, mood disorders, sleep disturbance and ADHD. As the researchers note, the study had a number of limitations. The survey respondents were mostly white, half were college graduates and nearly all of their children were in good health. Also, the survey did not distinguish between honesty toward parents or honesty toward the children in disclosing that the treatment is placebo; parents might have different views on that. "We need to refresh traditional pediatric therapeutic models to best support parental decisions around the potential use of placebos," says Faria. "Open-label placebo seems to be a promising adjuvant therapy with the potential to improve pediatric care, as acknowledged by the great majority of the parents we surveyed. Future studies should continue to investigate its therapeutic role." David Borsook, MD, PhD, co-director of the Center for Pain and the Brain, was senior author on the paper. Co-authors were Joe Kossowsky, PhD, Ted J. Kaptchuk, Irving Kirsch, PhD, and Alyssa Lebel, MD, PhD, of Boston Children's Department of Anesthesiology, Perioperative and Pain Medicine, and Mike Petkov of the Center for Pain and the Brain. Faria, Kaptchuk, Kirsch and Kossowsky are also affiliated with the Program in Placebo Studies at Beth Israel Deaconess Medical Center. The study was supported by the Swedish Research Council, the Swiss National Science Foundation and the National Institutes of Health (NIH)/National Center for Complimentary and Integrative Health (NCCIH). Boston Children's Hospital is home to the world's largest research enterprise based at a pediatric medical center, where its discoveries have benefited both children and adults since 1869. More than 1,100 scientists, including seven members of the National Academy of Sciences, 11 members of the Institute of Medicine and 10 members of the Howard Hughes Medical Institute comprise Boston Children's research community. Founded as a 20-bed hospital for children, Boston Children's today is a 404-bed comprehensive center for pediatric and adolescent health care. Boston Children's is also the primary pediatric teaching affiliate of Harvard Medical School. For more, visit our Vector and Thriving blogs and follow us on our social media channels: @BostonChildrens, @BCH_Innovation, Facebook and YouTube.

Dickinson J.R.,Perioperative and Pain Medicine | Dickinson J.R.,Stanford University | Scherrer G.,Perioperative and Pain Medicine
Neuron | Year: 2015

In this issue of Neuron, Santello and Nevian (2015) report HCN channel plasticity and increased temporal summation in layer 5 ACC neurons following nerve injury. They are able to restore HCN channel function and reduce behavioral hypersensitivity with selective serotonin receptor targeting. © 2015 Elsevier Inc.

Chu Sin Chung P.,University of Strasbourg | Boehrer A.,University of Strasbourg | Stephan A.,University of Strasbourg | Matifas A.,University of Strasbourg | And 6 more authors.
Behavioural Brain Research | Year: 2015

The delta opioid receptor (DOR) has raised much interest for the development of new therapeutic drugs, particularly to treat patients suffering from mood disorders and chronic pain. Unfortunately, the prototypal DOR agonist SNC80 induces mild epileptic seizures in rodents. Although recently developed agonists do not seem to show convulsant properties, mechanisms and neuronal circuits that support DOR-mediated epileptic seizures remain to be clarified. DORs are expressed throughout the nervous system. In this study we tested the hypothesis that SNC80-evoked seizures stem from DOR activity at the level of forebrain GABAergic transmission, whose inhibition is known to facilitate the development of epileptic seizures. We generated a conditional DOR knockout mouse line, targeting the receptor gene specifically in GABAergic neurons of the forebrain (Dlx-DOR). We measured effects of SNC80 (4.5, 9, 13.5 and 32. mg/kg), ARM390 (10, 30 and 60. mg/kg) or ADL5859 (30, 100 and 300. mg/kg) administration on electroencephalograms (EEGs) recorded in Dlx-DOR mice and their control littermates (Ctrl mice). SNC80 produced dose-dependent seizure events in Ctrl mice, but these effects were not detected in Dlx-DOR mice. As expected, ARM390 and ADL5859 did not trigger any detectable change in mice from both genotypes. These results demonstrate for the first time that SNC80-induced DOR activation induces epileptic seizures via direct inhibition of GABAergic forebrain neurons, and supports the notion of differential activities between first and second-generation DOR agonists. © 2014 .

Gaillard S.,Aix - Marseille University | Lo L.R.,Aix - Marseille University | Mantilleri A.,Aix - Marseille University | Hepp R.,Paris-Sorbonne University | And 20 more authors.
Neuron | Year: 2014

One feature of neuropathic pain is a reduced GABAergic inhibitory function. Nociceptors have been suggested to play a key role in this process. However, the mechanisms behind nociceptor-mediated modulation of GABA signaling remain to be elucidated. Here we describe the identification of GINIP, aGαi-interacting protein expressed in two distinct subsets of nonpeptidergic nociceptors. GINIP null mice develop a selective and prolonged mechanical hypersensitivity in models of inflammation and neuropathy. GINIP null mice show impaired responsiveness to GABAB, but not to delta or mu opioid receptor agonist-mediated analgesia specifically in the sparednerve injury (SNI) model. Consistently, GINIP-deficientdorsal root ganglia neurons had lower baclofen-evoked inhibition of high-voltage-activated calcium channels and a defective presynaptic inhibition of lamina IIi interneurons. These results further support the role of unmyelinated C fibers in injury-induced modulation of spinal GABAergic inhibition and identify GINIP as a key modulator of peripherally evoked GABAB-receptors signaling. © 2014 Elsevier Inc.

Mehta N.M.,Critical Care Medicine | Mehta N.M.,Boston Childrens Hospital | Mehta N.M.,Harvard University | Bechard L.J.,Boston Childrens Hospital | And 7 more authors.
American Journal of Clinical Nutrition | Year: 2015

Background: The impact of protein intake on outcomes in pediatric critical illness is unclear. Objective: We examined the association between protein intake and 60-d mortality in mechanically ventilated children. Design: In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. Results: We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. Conclusions: Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. © 2015 American Society for Nutrition.

Murthy S.,University of Pennsylvania | Hepner D.L.,Perioperative and Pain Medicine | Cooper Z.,Brigham and Women's Hospital | Bader A.M.,Perioperative and Pain Medicine | Neuman M.D.,University of Pennsylvania
British Journal of Anaesthesia | Year: 2015

As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing. Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical issues specific to older surgical patients are reviewed, with a special emphasis on areas of debate related to anaesthesia care in this group. These issues include the role of frailty and disability in preoperative assessment, choice of anaesthesia technique for hip fracture, postoperative delirium, and approaches to shared decision-making before surgical procedures. © 2015 The Author.

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