Ochsner Journal最新文献

Background: Osteoarthritis pain results from articular cartilage degeneration that leads to the breakdown and ulceration of the joint surface accompanied by hypertrophic bone changes with osteophyte formation. Steroids are commonly used to treat osteoarthritis pain.

Case report: An 81-year-old female with a medical history of bilateral knee osteoarthritis presented to the outpatient physical medicine and rehabilitation clinic for management of chronic bilateral knee pain and effusion. The patient had historically been managed with short-acting steroids, viscosupplementation, and deep genicular radiofrequency ablation. After changing providers, the patient underwent a series of image-guided intra-articular injections with the steroids Kenalog (triamcinolone) and Zilretta (triamcinolone acetonide extended-release injectable suspension) and was also treated with Monovisc (hyaluronic acid viscosupplementation). In addition, the patient underwent cryoneurolysis treatment (iovera° [Pacira BioSciences, Inc]). Injections were administered bilaterally when indicated, while cryoneurolysis was limited to the left knee. A substantial reduction in aspirated effusion volume was observed following Zilretta injections, with 92.6% and 88.1% reductions in aspirate volume in the patient's left and right knees, respectively.

Conclusion: Steroids have anti-inflammatory properties that reduce pain and improve function in patients with osteoarthritis, but steroid use for chronic effusion management also needs to be considered. Given our patient's knee effusion reduction after Zilretta injection, research is needed to confirm the ability of Zilretta to effectively reduce chronic effusion.

Background: Pain management after sternotomy in cardiac surgery is vital for recovery. Opioids are commonly used, but they carry risk. Central neuraxial techniques and nerve blocks are options for a multimodality approach. Fascial plane blocks such as the transversus thoracic muscle plane block (TTMPB) and the pecto-intercostal fascial block (PIFB) are a relatively new way to relieve pain, and their popularity has increased with the use of ultrasound for precise anatomic visualization. Because the effectiveness of both blocks is similar, we conducted this study to compare the pain management of the TTMPB and the PIFB after sternotomy in cardiac surgery.

Methods: This randomized double-blind study included 118 patients who underwent cardiac surgery. In the TTMPB group (n=59), 20 mL of 0.2% ropivacaine was injected bilaterally using ultrasound assistance in the transversus thoracic plane. In the PIFB group (n=59), 20 mL of 0.2% ropivacaine was injected in the pecto-intercostal plane. Study outcomes were opioid consumption in the first 24 hours and pain scores at 0, 3, 6, 12, and 24 hours postoperatively.

Results: Patient characteristics in the 2 groups were similar. Opioid consumption was similar in both groups (P=0.672), and we found no difference in pain scores between the 2 groups at any of the time intervals.

Conclusion: The TTMPB and the PIFB were similarly effective in treating acute poststernotomy pain in our patient population.

Background: Overcoming challenges to effective clinical practice depends on finding dynamic solutions to issues such as physician burnout and patient safety. This study evaluated the impact of an artificial intelligence (AI)-driven scheduling system on physician burnout and patient safety, using intraoperative transitions of care as an operative metric for patient safety.

Methods: In May 2019, the Department of Anesthesiology at Ochsner Health in New Orleans, Louisiana, implemented an AI-driven scheduling system called Lightning Bolt Scheduling (PerfectServe, Inc). Utilizing an idealized design framework, the department steering committee analyzed 12 months of historic operating room data and developed more than 400 scheduling rules to optimize staffing. The scheduling rules, representing the steering committee's new work model, were provided as inputs into Lightning Bolt Scheduling, which then used combinatorial optimization to recommend an ideal staff schedule. Preimplementation and postimplementation data were collected on physician satisfaction, vacation approval rates, and intraoperative transitions of care.

Results: Six months postimplementation, physician satisfaction scores and vacation approvals increased, reflecting improved work-life balance, schedule flexibility, and decreased symptoms of burnout. Additionally, 1,072 fewer handoffs occurred, equating to 71.5 fewer adverse events and a savings of approximately $335,550 in health care costs during the 21 months after implementation.

Conclusion: Our study findings underscore the potential of data-driven scheduling systems to enhance physician well-being and patient safety, thereby promoting continuous improvement and adaptability in health care operations.

Background: The development of cardiac complications is common in patients with muscular dystrophy. However, advanced heart failure therapies such as implantation of durable ventricular assist devices and transplant are infrequently used in patients who develop cardiomyopathy, often because of comorbid impairments in mobility and respiratory function.

Case report: A 16-year-old male with limb-girdle muscular dystrophy type R4 presented with chronic decompensated heart failure. Recent worsening of his respiratory function and mobility were confounded by severe heart failure. In addition to our core advanced heart failure team, multidisciplinary assessment preoperatively included Neurology, Pulmonology, Genetics, and Physical Medicine and Rehabilitation. The patient underwent implantation of a HeartMate 3 left ventricular assist device and had an uneventful postoperative course. After intensive inpatient physical and occupational therapy, he was discharged home on postoperative day 16 with minimal residual heart failure symptoms and plans to continue robust outpatient physical therapy.

Conclusion: Patients with muscular dystrophy often have cardiac involvement; however, certain subtypes of muscular dystrophy are associated with an earlier presentation of severe life-limiting cardiomyopathy. Pediatric patients with muscular dystrophy should be considered for advanced heart failure therapies such as implantation of a durable left ventricular assist device at an appropriate center. Carefully selected patients may experience substantial improvements in their quality of life. Given the variable disease progression and life expectancy of patients with subtypes of muscular dystrophy, a thorough assessment by a multidisciplinary team is critical.

Background: Carbidopa/levodopa is a vital medication administered to patients with Parkinson disease. In some clinical situations, oral administration of the medication is not feasible, so alternative routes for medication delivery must be explored to prevent severe complications.

Case report: A 90-year-old male with Parkinson disease presented from a nursing home with worsening confusion and agitation. Because of the patient's condition and the inability to obtain enteric access, carbidopa/levodopa was administered rectally, resulting in an observed reduction of the patient's Parkinson symptoms.

Conclusion: When patients with Parkinson disease cannot take their medications orally, rectal administration of carbidopa/levodopa may be a reasonable and effective alternative route of administration.

Background: Reported rates of unintended dural puncture during performance of continuous epidural anesthesia (CEA) or combined spinal-epidural anesthesia (CSEA) have remained steady at approximately 0.5% to 1% since the 1970s.

Methods: A modified method of inserting the Tuohy epidural catheterization needle was used during performance of CSEA in 393 parturients. A single staff/faculty anesthesiologist performed or supervised resident use of a flush-measure-check-advance Tuohy needle insertion algorithm.

Results: The rate of evident Tuohy needle dural puncture during the series was 0%. One parturient experienced a post-dural puncture headache possibly because of intentional subarachnoid puncture with a very small diameter (25 gauge) needle during 2 CSEAs. In 19 parturients, the initial spinal anesthesia portion of CSEA failed, prompting conversion to CEA in 18 parturients and to spinal anesthesia in 1 parturient.

Conclusion: The use of a flush-measure-check-advance Tuohy needle insertion algorithm to reduce the likelihood of unintended dural puncture during performance of CSEA in parturients deserves further study.

Background: Statins help prevent cardiac allograft vasculopathy (CAV) and rejection in heart transplant recipients. Whether these adverse outcomes can be further attenuated with higher potency statins is unknown.

Methods: In this single-center, retrospective study, we compared outcomes of heart transplant patients who received either a higher dose statin (HDS) or a lower dose statin (LDS) at discharge after transplant. Exclusion criteria were age <18 years old, not prescribed a statin, and any of the following within 1 year: death, loss to follow-up, or incomplete data to determine the primary outcome. The primary outcome was CAV at 1 year, defined as International Society for Heart and Lung Transplantation CAV grade ≥1 on angiography or intravascular ultrasound demonstrating rapid coronary intimal thickening (0.5-mm increase in coronary maximal intimal thickness at 1 year). Secondary outcomes were biopsy-proven acute rejection, treated rejection, hemodynamically unstable rejection, and adverse effects.

Results: The study population consisted of 81 patients in the HDS group and 103 patients in the LDS group. The incidence of CAV was not different in the HDS vs LDS group (32.1% vs 31.1%, respectively; P=0.881) despite less biopsy-proven acute rejection (2.5% vs 12.6%, respectively; P=0.013) and less treated rejection (2.5% vs 17.5%, respectively; P=0.001) in the HDS group. All other secondary outcomes were similar between groups.

Conclusion: Increasing statin intensity in heart transplant patients appears to be safe and may reduce rejection but did not attenuate CAV at 1 year in our population.

Background: Ischemic necrosis of the gastric remnant following Roux-en-Y gastric bypass (RYGB) surgery is a rare but life-threatening complication. The etiology remains poorly understood, and delayed presentation can result in poor outcomes. Prompt recognition and intervention are critical, particularly in patients with a remote history of bariatric surgery.

Case report: A 78-year-old male (body mass index 28.73 kg/m²) with a history of RYGB performed 42 years prior presented to the emergency department with nausea, diffuse abdominal pain, and signs of septic shock. Physical examination revealed abdominal distension, peritonitis, tachycardia, and hypotension. Laboratory findings showed elevated lactate and lipase levels. Imaging demonstrated a dilated gastric remnant and free intra-abdominal fluid. Emergent exploratory laparotomy identified a necrotic gastric remnant, necessitating remnant gastrectomy. The patient initially stabilized postoperatively but developed pneumonia on postoperative day 6, followed by a duodenal stump leak. Despite conservative management, his condition deteriorated, and comfort care measures were initiated. He died on postoperative day 13.

Conclusion: This case highlights the importance of maintaining a high index of suspicion for rare complications such as gastric remnant necrosis in patients with a history of RYGB and a low threshold for surgical exploration. Timely diagnosis and surgical intervention are essential for improving outcomes in these critically ill patients.