Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mantar Zehirlenmesinde Erken Başlangıçlı Muskarinik Bulgular ve Sendromik Sınıflandırma

Mushroom poisoning is a frequently encountered health problem around the globe. Depending on its type and toxin, it results in a wide spectrum of issues that range from asymptomatic findings to fatal organ failure. Since the toxin of the mushroom leading to poisoning is often unidentified, syndromic classification may benefit clinical management according to the findings of target organ system toxicity. A 64-year-old female patient with comorbidities such as diabetes mellitus, coronary artery disease, hypertension and hyperlipidemia was admitted to the intensive care unit. Approximately four hours after consuming wild mushrooms the patient's diarrhea, muscle cramps, cold sweating, blurry vision, coughing and shortness of breath complaints have been begun. Her respiratory system examination revealed tachypnea, generalized bilateral rhonchus, bronchorrhea and wheezing. Patient was normotensive and had bradycardia (heart rate 35 beats/minute). She had anxiety and the Glasgow Coma score was 15. Her pupillary bilateral isochoric, miotic and light reflexes were diminished. In her arterial blood gas pH level 7.26, partial carbon dioxide pressure: 34 mmHg, potassium: 5.3 mmol/L, sodium: 130 mmol/L, lactate: 5.3 mmol/L, bicarbonate: 16 mEq/L and base excess: -10,3 mmol/L was found. Target organ system toxicity findings and timing of occurrence indicated early-onset cholinergic syndrome. Treatments that consisted of intravenous atropine, fluid, electrolytes and sodium bicarbonate alleviated the toxicity in a short period of time. Late mycologic examination results that followed the treatment revealed that the patient was poisoned by Inocybe lacera, a mushroom type that contains muscarine. With this case presentation, we summarized the syndromic classification that we use in the clinical management in the light of current information in the literature