Enhanced Recovery After Surgery (ERAS) in Head and Neck Oncologic Surgery: A Case-Matched Analysis of Perioperative and Pain Outcomes
ANNALS OF SURGICAL ONCOLOGY
Authors: Kiong, Kimberley L.; Vu, Catherine N.; Yao, Christopher M. K. L.; Kruse, Brittany; Zheng, Gang; Yu, Peirong; Weber, Randal S.; Lewis, Carol M.
Background Enhanced recovery after surgery (ERAS) pathways are well established in certain surgical specialties because findings have shown significant improvements in outcomes. Convincing literature in head and neck cancer (HNC) surgery is lacking. This study aimed to assess the effect of an ERAS pathway on National Surgical Quality Improvement Program (NSQIP)-based occurrences and pain-related outcomes in HNC surgery. Methods The study matched 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between 1 March 2016 and 31 March 2019 with control subjects (1:1 ratio) during the same period. Demographic and perioperative data collected from the NSQIP database were extracted. Pain scores and medication usage were electronically extracted from our electronic medical record system and compared. Risk factors for high opioid usage also were assessed. Results Both groups were statistically similar in baseline characteristics. The ERAS group had fewer planned intensive care unit (ICU) admissions (4% vs. 14%;p < 0.001), a shorter mean hospital stay (7.2 +/- 2.3 vs. 8.7 +/- 4.2 days;p < 0.001), and fewer overall complications (18.6% vs. 27.0%;p = 0.045). Morphine milligram equivalent requirements over 72 h were significantly reduced during 72 h in the ERAS group (138.8 +/- 181.5 vs. 207.9 +/- 205.5;p < 0.001). In the multivariate analysis, the risk factors for high opioid analgesic usage included preoperative opioid usage, age younger than 65 years, race, patient-controlled analgesia use, and ICU admission. Conclusion The study findings showed that ERAS in HNC surgery can result in improved outcomes and resource use, and that these results are sustainable. The outcomes described in this report can be further used to optimize ERAS pathways.
Mechanism of atmospheric pressure chemical ionization of morphine, codeine, and thebaine in corona discharge-ion mobility spectrometry: Protonation, ammonium attachment, and carbocation formation
JOURNAL OF MASS SPECTROMETRY
Authors: Valadbeigi, Younes; Ilbeigi, Vahideh; Mirsharifi, Maryam S.
Atmospheric pressure chemical ionizations (APCIs) of morphine, codeine, and thebaine were studied in a corona discharge ion source using ion mobility spectrometry (IMS) at temperature range of 100 degrees C-200 degrees C. Density functional theory (DFT) at the B3LYP/6-311++G(d,p) and M062X/6-311++G(d,p) levels of theory were used to interpret the experimental data. It was found that in the presence of H(3)O(+)as reactant ion (RI), ionization of morphine and codeine proceeds via both the protonation and carbocation formation, whereas thebaine participates only in protonation. Carbocation formation (fragmentation) was diminished with decrease in the temperature. At lower temperatures, proton-bound dimers of the compounds were also formed. Ammonia was used as a dopant to produce NH(4)(+)as an alternative RI. In the presence of NH4+, proton transfer from ammonium ion to morphine, codeine, and thebaine was the dominant mechanism of ionization. However, small amount of ammonium attachment was also observed. The theoretical calculations showed that nitrogen atom of the molecules is the most favorable proton acceptor site while the oxygen atoms participate in ammonium attachment. Furthermore, formation of the carbocations is because of the water elimination from the protonated forms of morphine and codeine.