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Objective The purpose of this study was to determine the duration, intensity, location, and usual treatment of pain throughout hospitalization following subarachnoid hemorrhage. Background Headache following subarachnoid hemorrhage can be sudden and severe. Little is known about the longitudinal course of headache or its analgesic therapy following the initial diagnosis of subarachnoid hemorrhage. Methods A prospectively maintained database of 564 patients diagnosed with cerebral aneurysms collected from 10/2009 to 2/2013 was searched for conscious patients with subarachnoid hemorrhage. Available electronic records were queried for pain scores (0-10/10), location, and analgesic consumption. Results Forty-six adults with subarachnoid hemorrhage met eligibility criteria for inclusion. Mean [CI 95] daily pain was 3.8 [3.2, 4.4] and maximal daily pain was 5.8 [5.1, 6.6]. Eighty-nine percent of patients reported severe pain of 7-10/10, and 63% of patients reported 10/10 pain at some point during hospitalization. While mean [CI 95] pain declined over the course of hospital stay at a rate of 0.06 [0.04, 0.07] units/day (P

Objectives/Hypothesis To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. Study Design Descriptive review of quality improvement project. Methods A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. Results Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. Conclusion The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety. Level of Evidence 2b. Laryngoscope, 124:1794–1800, 2014

OBJECTIVE The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING Single-center, major university hospital. PATIENTS The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy.Case series with planned data collection.Urban, academic, tertiary care medical center.Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost.Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center.Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.

Object Opioid administration following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurological examination. Nevertheless, evidence is accumulating that these patients suffer moderate to severe postoperative pain and that this pain is often undertreated. The authors hypothesized that intravenous patient-controlled analgesia (PCA) would safely and more effectively treat postoperative supratentorial craniotomy pain than conventional as needed (PRN) therapy. Methods Following a standardized course of general anesthesia, adult patients who underwent elective supratentorial intracranial surgery were randomized in the neurosciences intensive care unit to receive either PRN intravenous fentanyl 25–50 μg every 30 minutes or PCA intravenous fentanyl 0.5 μg/kg every 15 minutes (maximum 4 doses/hour). The authors measured pain (self-reported scale score [0–10]), sedation (Ramsay Sedation Scale score), Glasgow Coma Scale score, fentanyl use, and major adverse events (excessive sedation, respiratory depression, pruritus, nausea, or vomiting) hourly. Results Sixty-four patients with a mean age of 48 years (range 22–77 years) were randomized to intravenous PCA (29 patients) or PRN fentanyl (35 patients) groups. There were no statistically significant demographic differences between the 2 groups. Patients receiving intravenous PCA had significantly lower pain scores than those receiving intravenous PRN fentanyl (2.53 ± 1.96 vs 3.62 ± 2.11 [p = 0.039]) and received significantly more fentanyl than the PRN group (44.1 ± 34.5 vs 23.6 ± 23.7 μg/hour [p = 0.007]). There were no differences between the 2 groups regarding the number of patients with adverse events. Conclusions Intravenous PCA more effectively treats the pain of supratentorial intracranial surgery than PRN fentanyl, and patients in the former group did not experience any untoward events related to the self-administration of opioids.

Surgery of the posterior fossa often produces intense postoperative pain. However, this pain is infrequently treated because of concern that opioid administration may mask the postoperative neurologic examination and/or produce hypercarbia. In this prospective, randomized controlled trial, we sought to determine whether IV patient-controlled analgesia (PCA) would lead to reductions in postoperative pain after neurosurgical procedures of the posterior fossa compared with conventional IV nurse-administered as-needed (PRN) therapy.Eighty patients (age range, 18-82 years) undergoing elective posterior fossa surgery were randomized to receive postoperative IV fentanyl PRN 25 to 50 μg every 30 minutes or via PCA 0.5 μg/kg/dose, with a maximal dose limit of 50 μg, and 15-minute lockout (4 doses/hour). We measured pain (Numerical Rating Scale, 0-10), analgesic use, sedation (Ramsay Sedation Scale and Glasgow Coma Scale), respiration, hemodynamics, and adverse events hourly.Sixty-five patients completed the study. Thirty-one patients received IV PCA and 34 received PRN analgesia. Patient demographics did not differ between groups. Patients in the PCA group reported less pain at rest (mean [95% confidence interval]: 3.7 [3.0, 4.4] vs 5.2 [4.5, 5.8], P = 0.003) and received more fentanyl (mean [95% confidence interval]: 54.8 [42.1, 67.6] vs 29.9 [24.2, 35.7] μg/h, P = 0.002) than those in the PRN group. There were no differences in side effects and no adverse events related to analgesic therapy.IV PCA use resulted in reduction in postoperative pain compared with PRN analgesic therapy after surgery of the posterior fossa. Larger studies will be required to determine the safety of IV PCA in this patient population.