From Myron: Best wishes for a Happy and Healthy New Year (Rosh Hashanah) to all of our Jewish friends and colleagues. The holiday starts tonight and ends on Saturday or Sunday evening.
From Kyle J. Kramer, DDS, MS, Editor-in-Chief, Anesthesia Progress (and our new PAAD executive council member).
I read the thoughtful response from Dr. Karen L Schneider on the recent PAAD article (08/31/2023) covering opioid prescribing patterns for oral maxillofacial surgeons (OMS) in CT and NJ. Her personal anecdotes on being prescribed 30 Vicodin and the tragic patient who intentionally overdosed on Vicodin were quite telling. However, I am confident that those prescribing patterns she detailed fail to accurately reflect contemporary prescribing of opioids for most OMS/dentists (see data from the OMS article). I have no doubt that there are outliers who do overprescribe opioids likely for convenience, in response to patient pressures, or simply out of habit, reflecting potential pitfalls all of healthcare combats when prescribing opioids.
Dentistry/oral surgery certainly has its role to play in the opioid crisis and must ensure opioids are prescribed appropriately and responsibly. Much effort has been spent to educate not only dental students and residents but also retraining current practitioners in hopes of reducing excessive/irresponsible opioid prescribing. The general approach that I helped develop and currently teach at Indiana University School of Dentistry essentially mirrors that discussed by Dr. Schneider. Patients likely to experience significant postop pain are prescribed a combination of NSAIDs and APAP (e.g., ibuprofen 600 mg + APAP 1000 mg q6h). An opioid/APAP combo (e.g., hydrocodone 5 mg/APAP 325 mg x1-2 q6h) prescription may be written for breakthrough pain should it occur with a typical length being 2-3 days (e.g., 10-12 tabs). Explicit instructions are given to stop the APAP if using the opioid/APAP combo of course. Patients are to be seen for re-eval postoperatively if substantial pain requiring additional opioids persists beyond that time. Along with the usual local anesthetics, we also use bupivacaine in almost every oral surgery case that I see. In my experience, most patients do exceptionally well with this type of conservative approach. There are on occasion patients with severe postop pain and higher opioid requirements (e.g., hydrocodone 10 mg or oxycodone 5 mg) due to more invasive/extensive surgical procedures but these tend to be the exception rather than the rule (note: not all extractions are the same as some teeth “pop” right out easily while others are buried in bone and require extensive bone removal and surgical sectioning).
My intent in writing is not to point fingers but to simply highlight that dentistry/oral surgery, just like the rest of medicine, has responded to its role in the opioid crisis. We continue to review prescribing practices and reinforce contemporary responsible acute pain management. Long gone are the days where students might be directed to prescribe 30+ Vicodin tablets for postop pain with little to no thought of alternative non-opioid approaches. Does dentistry still have outliers? Absolutely, and based on seeing the prescriptions some our dental patients get after visiting the ER for dental pain, so does medicine. We all have our part to play in fighting the opioid crisis, and while I agree with Dr. Schneider and her concerns, it seems clear the work to be done is shared across the board.
From Mark Rockoff MD
I greatly enjoyed reading the recent commentary about “ACGME Accreditation for Pediatric Cardiac Anesthesiology Fellowships” and appreciate all the hard work that went into establishing these programs. I just want to make one, very minor, correction to a statement in the first sentence. The first successful ligation of a patent ductus arteriosus occurred on August 26, 1938, not in 1939 when the report of this case was published (1). This was indeed a major milestone in the beginning of surgery for congenital heart disease, and many of the individuals involved, in addition to the surgeon, Robert E. Gross, were remarkable people. Anesthesia for this procedure was provided by nurse Betty Lank; physicians were not involved in anesthesia care at Boston Children’s Hospital and most other hospitals at the time (2). In addition, the patient herself was extraordinary (3). She was only 7-years-old when she underwent this procedure, and she was the longest survivor of cardiac surgery until her death in 2020 at the age of 89. Fittingly, she was honored the summer beforehand by the Boston Red Sox, coming out on the field before one of its home games with her family, including her great-grandchildren. Mark
References
1- Gross RE, Hubbard JP. Surgical ligation of a patent ductus arteriosus: report of first successful case. JAMA 1939; 112(8): 729-731.
2- Galvin S, Dewan J, Rockoff, MA. Betty Lank: A kind and gentle anesthetist devoted to children. AANA Journal(2009; 76(3): 176-180.
3- Murray L, Hendren WH, Mayer JE, Rockoff, MA. “A thrill of extreme magnety”: Robert E. Gross and the beginnings of cardiac surgery. J Ped Surg 2013; 48: 1822-1825.
From Francine S Yudkowitz, MD FAAP FASA, Medical Director of Children’s Anesthesiology (MDCA), Mount Sinai Kravis Children’s Hospital
As you are, I am very skeptical about matching intraoperative usage of opioids to the opioid epidemic. I am a firm believer that it is the postoperative use that may lead to chronic use, sometimes depending on the patient’s relationship to pain and opioid use.
But what I do firmly believe is that we as anesthesiologist need to start the management of pain intraoperatively for postoperative management such as regional anesthesia, peripheral nerve blocks, and/or other adjuvant medications such as acetaminophen and NSAIDs. And importantly, not sending these patients home with opioid prescriptions when they are not needed and for large amounts. I know that for many of our bread and butter peds cases we do peripheral nerve blocks, acetaminophen, and NSAIDS with minimal opioids (not because we are stingy but because they are not needed) and they all go home on alternating acetaminophen and NSAIDs. That is what I think we should concentrate on and not focus on the amount of opioids administered intraoperatively.
Just my humble opinion.
From Bishr Haydar MD on medication error
That was a helpful reminder about the danger associated with neuraxial medications and a good discussion of countermeasures. I wanted to offer some other neuraxial medication drug horror stories as well.
There has been a worrisome spate of intrathecal (IT) tranexamic acid administrations. These were lookalike vial swaps similar to the PAAD case, some of which resulted in death. (>20 references on this, but you can start with PMID 36877159 / DOI:10.1097/eja.0000000000001812 )
I found this reference on other fatal iatrogenic drug errors reported to poison control (PMID 32463298 / DOI: 10.1080/15563650.2020.1766691) including chemo intended to be IV; morphine; baclofen and gadolinium. As we are often providing anesthesia care for IT chemo injections, we should do whatever we can to make sure chemo is safely administered. At our institution we use barcode scanning for IT chemo administration without exception. Perhaps we should also use a "sterile cockpit" model to minimize distractions during chemo check and administration.
Separately, I recall a case report from the 90's of an IT morphine pump whose catheter/reservoir was flushed leading to massive IT morphine overdose. The patient was intubated and given supportive care, and despite this she succumbed. I wasn't able to find the reference. Even medications that are normally appropriate for IT use can be dangerous in the setting of a dose or concentration error.
All of this is a reminder that while neuraxial anesthesia is wonderful, it is also quite delicate. Our patients are sometimes fearful of the neuraxial route. We should honor their preference/fear by increasing our vigilance when giving neuraxial medications.