Kraus, Molly B.

Achondroplasia accounts for approximately 70% of all forms of dwarfism. Cesarean delivery is often required in parturients with achondroplasia due to cephalopelvic disproportion. There is no consensus on the optimal management for cesarean delivery considering the difficulties in both general and regional anesthesia in patients with achondroplasia. The aim of this study was to explore the literature for prior case reports and series to determine the optimum anesthetic management for cesarean delivery in achondroplastic patients. We conducted a review of the literature using Embase, Medline, Scopus, and Web of Science database searches for case series and case reports on achondroplasia and pregnancy through January 2024. Conference abstracts >3 years old were excluded, as well as data on forms of dwarfism other than achondroplasia, patients taller than 147 cm, and non-English language papers. Extracted data included demographic information, anesthetic management, and reported complications. The literature review resulted in 57 manuscripts with a total of 80 anesthetics. Anesthetic management consisted of planned general anesthesia (n = 16), single injection spinal (n = 28), epidural (n = 17), combined spinal-epidural (n = 12), and intrathecal catheter (n = 1). Six patients required conversion from neuraxial anesthesia to general anesthesia due to failed neuraxial placement (n = 3), inadequate blockade (n = 2), and high neuraxial block (n = 1). Reduced dose of intrathecal bupivacaine was common in this population. Complications such as hypotension (4 in 64), inadvertent dural puncture (1 in 64), and transient paresthesia (3 in 64) during neuraxial technique were reported but were infrequent. Neuraxial anesthesia is more common and a viable option in carefully selected parturients with achondroplasia. We recommend reduction of intrathecal local anesthetic as part of a titratable neuraxial technique (ie, combined spinal-epidural) that minimizes the risk of hypotension, high spinal, and emergent intubation.

BACKGROUND: Sugammadex, aprepitant, and fosaprepitant are increasingly used perioperatively. These medications may interfere with the effectiveness of hormonal contraception. This study assessed anesthesia providers’ use of sugammadex and aprepitant, their knowledge of interactions with hormonal birth control, and patient counseling practices to identify possible knowledge gaps or opportunities for practice improvement. METHODS: In January 2023, an electronic survey was distributed to all anesthesia providers at Mayo Clinic sites (Mayo Clinic Rochester, Mayo Clinic Arizona, Mayo Clinic Florida, and Mayo Clinic Health System hospitals). The survey included 32 questions assessing providers’ use of sugammadex and aprepitant, their knowledge of the medications’ interactions with hormonal contraceptives (HC), their perceptions regarding education of these interactions during training, and their perioperative patient counseling practices. The collected data were analyzed using descriptive statistics. RESULTS: A total of 337 of 1092 (31%) providers completed the survey. While almost all respondents (324; 96%) knew that sugammadex may interfere with oral contraceptive effectiveness, only 158 (47%) knew about aprepitant’s potential contraceptive interference. Only 176 providers (52%) knew the recommended duration for alternative contraceptive methods after use after sugammadex, and 119 providers (35%) knew the recommended duration after aprepitant exposure. Most respondents considered the interference of these perioperative drugs with HCs to be clinically relevant (sugammadex, 217, 64%; aprepitant, 191, 58%). Despite the common belief that the decision between these medications and alternatives should be shared between provider and patient, most providers reported rarely engaging in such shared decision-making (SDM) in practice. Most providers recognized the need for preoperative discussions on sugammadex (280, 83%) and aprepitant (257, 76%), yet 184 providers (73%) never or rarely discussed contraception use before surgery for aprepitant, and 135 (36%) never or rarely did so for sugammadex. Lastly, many providers believed that the interference between sugammadex, aprepitant, and HC was poorly taught during training. CONCLUSIONS: The results of this study highlight the need for increased education and awareness among anesthesia providers regarding drug interactions with HCs during the perioperative period. To facilitate SDM, it is imperative that providers discuss alternative medications and the potential need for additional contraception methods after drug administration and communicate the risks with patients preoperatively to enable informed and SDM. The patient’s preferences should be accounted for, especially if they are unwilling or unable to use an alternative contraceptive for 7 to 30 days, thereby avoiding the complexities and burdens of altering birth control methods.

Purpose of review The use of implantable medical devices (IMDs) continues to increase with estimates that 10% of the American population will have an IMD in their lifetime. IMDs require special considerations for management in the perioperative period to ensure optimal patient care and patient safety. This review summarizes the current perioperative considerations for IMDs. Recent findings This review summarizes perioperative recommendations for spinal cord stimulators, deep brain stimulators, peripheral nerve stimulators, vagus nerve stimulators, muscle stimulators, intrathecal drug delivery systems, implantable infusion pumps, artificial pancreas devices, continuous glucose monitors, and cochlear implants. There are multiple publications and guidelines regarding the perioperative considerations of cardiac implantable electronic devices; thus, this review excludes those devices. This review includes recommendations on management of the device perioperatively, the potential complications, and postoperative care of the device. Summary There are very few guidelines regarding the perioperative management of IMDs. Given the significant impact that these devices have on patient care and safety, evidence-based guidelines should be established.

This cross-sectional study evaluates the consistency of US medical license renewal applications with the Federation of State Medical Boards recommendations for questions regarding physician mental health.

Abstract Background Pharmacogenomics is an emerging and affordable tool that may improve postoperative pain control. One challenge to successful pain control is the large interindividual variability among analgesics in their efficacy and adverse drug events. Whether preoperative pharmacogenomic testing is worthwhile for patients undergoing TKA is unclear. Questions/purposes (1) Are the results of preoperative pharmacogenetic testing associated with lower postoperative pain scores as measured by the Overall Benefit of Analgesic Score (OBAS)? (2) Do the results of preoperative pharmacogenomic testing lead to less total opioids given? (3) Do the results of preoperative pharmacogenomic testing lead to changes in opioid prescribing patterns? Methods Participants of this randomized trial were enrolled from September 2018 through December 2021 if they were aged 18 to 80 years and were undergoing primary TKA under general anesthesia. Patients were excluded if they had chronic kidney disease, a history of chronic pain or narcotic use before surgery, or if they were undergoing robotic surgery. Preoperatively, patients completed pharmacogenomic testing (RightMed, OneOME) and a questionnaire and were randomly assigned to the experimental group or control group. Of 99 patients screened, 23 were excluded, one before randomization; 11 allocated patients in each group did not receive their allocated interventions for reasons such as surgery canceled, patients ultimately undergoing spinal anesthesia, and change in surgery plan. Another four patients in each group were excluded from the analysis because they were missing an OBAS report. This left 30 patients for analysis in the control group and 38 patients in the experimental group. The control and experimental groups were similar in age, gender, and race. Pharmacogenomic test results for patients in the experimental group were reviewed before surgery by a pharmacist, who recommended perioperative medications to the clinical team. A pharmacist also assessed for clinically relevant drug-gene interactions and recommended drug and dose selection according to guidelines from the Clinical Pharmacogenomics Implementation Consortium for each patient enrolled in the study. Patients were unaware of their pharmacogenomic results. Pharmacogenomic test results for patients in the control group were not reviewed before surgery; instead, standard perioperative medications were administered in adherence to our institutional care pathways. The OBAS (maximum 28 points) was the primary outcome measure, recorded 24 hours postoperatively. A two-sample t-test was used to compare the mean OBAS between groups. Secondary measures were the mean 24-hour pain score, total morphine milligram equivalent, and frequency of opioid use. Postoperatively, patients were assessed for pain with a VAS (range 0 to 10). Opioid use was recorded preoperatively, intraoperatively, in the postanesthesia care unit, and 24 hours after discharge from the postanesthesia care unit. Changes in perioperative opioid use based on pharmacogenomic testing were recorded, as were changes in prescription patterns for postoperative pain control. Preoperative characteristics were also compared between patients with and without various phenotypes ascertained from pharmacogenomic test results. Results The mean OBAS did not differ between groups (mean ± SD 4.7 ± 3.7 in the control group versus 4.2 ± 2.8 in the experimental group, mean difference 0.5 [95% CI -1.1 to 2.1]; p = 0.55). Total opioids given did not differ between groups or at any single perioperative timepoint (preoperative, intraoperative, or postoperative). We found no difference in opioid prescribing pattern. After adjusting for multiple comparisons, no difference was observed between the treatment and control groups in tramadol use (41% versus 71%, proportion difference 0.29 [95% CI 0.05 to 0.53]; nominal p = 0.02; adjusted p > 0.99). Conclusion Routine use of pharmacogenomic testing for patients undergoing TKA did not lead to better pain control or decreased opioid consumption. Future studies might focus on at-risk populations, such as patients with chronic pain or those undergoing complex, painful surgical procedures, to test whether pharmacogenomic results might be beneficial in certain circumstances. Level of Evidence Level I, therapeutic study.

AbstractIntroductionAdverse reactions to pain medication and pain can delay discharge after outpatient knee arthroplasty (TKA). Pharmacogenomics is an emerging tool that might help reduce adverse events by tailoring medication use based on known genetic variations in the CYP genes determining drug metabolism. This study was undertaken to evaluate whether pre-operative pharmacogenomic testing could optimize peri-operative pain management in patients undergoing total knee arthroplasty (TKA).MethodsThis prospective, randomized study was performed in adults undergoing primary TKA. Patients in the experimental group underwent pre-operative pharmacogenomic evaluation and medication adjustments. Medications were not optimized for control patients. The Overall Benefit of Analgesic Score (OBAS) at 24 hours post-op was the primary outcome. Postoperative pain scores (VAS scale), total opioid use, time in recovery, and time to discharge were also compared.Results76 patients enrolled. 93% of patients had a poor-intermediate phenotype for at least one of four CYP genes. OBAS did not differ significantly between the two groups (4.2 control vs. 4.7 experimental; 95% CI −1.1 to 2.1) and was below the minimum clinically important difference of 2.0 points. Furthermore, there were no differences in any OBAS subscale including pain, satisfaction, or nausea. There were no differences in time in the recovery area or to discharge from hospital, or narcotic use.ConclusionsDespite many patients having a poor-intermediate phenotype for a CYP gene, pharmacogenomic testing prior to TKA and medication adjustment did not improve anesthesia or pain management outcomes, time to discharge or mean total opioid use after surgery.