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Article ; Online: Direct oral anticoagulants and their antagonists in perioperative practice.

Levy, Jerrold H / Mamoun, Negmeldeen

2023 Volume 36, Issue 4, Page(s) 394–398

Abstract: Purpose of review: Review management strategies for patients receiving nonvitamin K direct-acting oral anticoagulants (DOACs).: Recent findings: Updated clinical trials and guidelines continue to further define optimal management for patients on ... ...

Abstract	Purpose of review: Review management strategies for patients receiving nonvitamin K direct-acting oral anticoagulants (DOACs). Recent findings: Updated clinical trials and guidelines continue to further define optimal management for patients on DOACs requiring emergency surgery or procedural interventions. In addition, specific bleeding management strategies that include either specific or nonspecific antagonists are becoming available. Summary: Most currently used DOACs are factor Xa inhibitors and should be stopped for 24-48 h for elective surgical procedures in patients at risk for bleeding and potentially longer for dabigatran, depending on renal function. Idarucizumab, a specific dabigatran reversal agent, has been studied in surgical patients and is currently approved for use. For Xa inhibitors apixaban and rivaroxaban, although andexanet alfa is approved for medical bleeds, it is not approved for surgical patients, has a short duration of effect, and costs $12 500 per gram. When managing DOAC-treated patients requiring emergency surgery, when stopping the DOAC and delaying surgery is not feasible, standard approaches should include hemostatic, hemodynamic, and transfusional support. Due to higher risk associated with therapeutic agents used to manage DOAC-related bleeding, increasing data supports the potential off-label use of prothrombin complex concentrate (PCC).
MeSH term(s)	Humans ; Dabigatran/adverse effects ; Anticoagulants/adverse effects ; Rivaroxaban/adverse effects ; Hemorrhage/chemically induced ; Hemorrhage/drug therapy ; Factor Xa Inhibitors/adverse effects ; Administration, Oral
Chemical Substances	Dabigatran (I0VM4M70GC) ; Anticoagulants ; Rivaroxaban (9NDF7JZ4M3) ; Factor Xa Inhibitors
Language	English
Publishing date	2023-06-06
Publishing country	United States
Document type	Review ; Journal Article
ZDB-ID	645203-6
ISSN	1473-6500 ; 0952-7907
ISSN (online)	1473-6500
ISSN	0952-7907
DOI	10.1097/ACO.0000000000001275
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Zs.A 2564: Show issues

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Article ; Online: Albumin vs Crystalloid Fluid for Resuscitation in Cardiac Surgery: New Evidence and Arguments in the Timeless Debate.

Podgoreanu, Mihai V / Mamoun, Negmeldeen

JAMA

2022 Volume 328, Issue 3, Page(s) 246–248

MeSH term(s)	Albumins/therapeutic use ; Cardiac Surgical Procedures ; Colloids ; Crystalloid Solutions/therapeutic use ; Fluid Therapy/methods ; Isotonic Solutions/therapeutic use ; Resuscitation/methods
Chemical Substances	Albumins ; Colloids ; Crystalloid Solutions ; Isotonic Solutions
Language	English
Publishing date	2022-07-19
Publishing country	United States
Document type	Comparative Study ; Journal Article ; Comment
ZDB-ID	2958-0
ISSN	1538-3598 ; 0254-9077 ; 0002-9955 ; 0098-7484
ISSN (online)	1538-3598
ISSN	0254-9077 ; 0002-9955 ; 0098-7484
DOI	10.1001/jama.2022.10113
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Article ; Online: Intravenous acetaminophen: Can the benefit outweigh the cost in selected patients?

Mamoun, Negmeldeen F

The Journal of thoracic and cardiovascular surgery

2016 Volume 153, Issue 1, Page(s) 149–150

MeSH term(s)	Acetaminophen ; Administration, Intravenous ; Analgesics, Non-Narcotic ; Humans
Chemical Substances	Analgesics, Non-Narcotic ; Acetaminophen (362O9ITL9D)
Language	English
Publishing date	2016-12-15
Publishing country	United States
Document type	Letter ; Comment
ZDB-ID	3104-5
ISSN	1097-685X ; 0022-5223
ISSN (online)	1097-685X
ISSN	0022-5223
DOI	10.1016/j.jtcvs.2016.09.055
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Uk I Zs.104: Show issues

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Article ; Online: Pain trajectories after bilateral orthotopic lung transplantation surgery performed via a clamshell incision.

Mamoun, Negmeldeen / Rosser, Morgan A / Manning, Michael / Raghunathan, Karthik / McCartney, Sharon / Mehta, Sachin / Ingle, Krista / Bottiger, Brandi

Clinical transplantation

2024 Volume 38, Issue 2, Page(s) e15262

Abstract: Introduction: The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using ... ...

Abstract	Introduction: The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using pain trajectories for the study cohort, in addition to stratifying patients into separate pain trajectory groups and investigating their association with donor and recipient perioperative variables. Methods: After obtaining IRB approval, we retrospectively included all patients ≥18 years old who underwent primary BOLT via clamshell incision at a single center between January 1, 2017, and June 30, 2022. We modeled the overall pain trajectory using pain scores collected over the first seven postoperative days and identified separate pain trajectory classes via latent class analysis. Results: Three hundred one adult patients were included in the final analysis. Three separate pain trajectory groups were identified, with most patients (72.8%) belonging to a well-controlled, stable pain trajectory. Uncontrolled pain was either observed in the early postoperative period (10%), or in the late postoperative period (17.3%). Late postoperative peaking trajectory patients were younger (p = .008), and sicker with a higher lung allocation score (p = .005), receiving preoperative mechanical ventilation (p < .001), or VV-ECMO support (p < .001). Conclusion: Despite the extensive nature of a clamshell incision, most pain trajectories in BOLT patients had a well-controlled stable pain profile. The benign nature of pain profiles in our patient population may be attributed to the routine institutional practice of early thoracic epidural analgesia for BOLT patients unless contraindicated.
MeSH term(s)	Adult ; Humans ; Adolescent ; Retrospective Studies ; Acute Pain ; Thoracotomy ; Lung Transplantation/adverse effects ; Pain Management ; Pain, Postoperative/etiology
Language	English
Publishing date	2024-02-19
Publishing country	Denmark
Document type	Journal Article
ZDB-ID	639001-8
ISSN	1399-0012 ; 0902-0063
ISSN (online)	1399-0012
ISSN	0902-0063
DOI	10.1111/ctr.15262
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Article ; Online: Commentary: Patient blood management in the era of coronavirus disease 2019-is anything really different?

Levy, Jerrold H / Mamoun, Negmeldeen / Shaz, Beth

JTCVS open

2021 Volume 5, Page(s) 97–98

Language	English
Publishing date	2021-01-13
Publishing country	Netherlands
Document type	Editorial
ISSN	2666-2736
ISSN (online)	2666-2736
DOI	10.1016/j.xjon.2021.01.004
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Article ; Online: Higher Cardiovagal Baroreflex Sensitivity Predicts Increased Pain Outcomes After Cardiothoracic Surgery.

Suarez-Roca, Heberto / Mamoun, Negmeldeen / Watkins, Lana L / Bortsov, Andrey V / Mathew, Joseph P

The journal of pain

2023 Volume 25, Issue 1, Page(s) 187–201

Abstract: Excessive postoperative pain can lead to extended hospitalization and increased expenses, but factors that predict its severity are still unclear. Baroreceptor function could influence postoperative pain by modulating nociceptive processing and vagal- ... ...

Abstract	Excessive postoperative pain can lead to extended hospitalization and increased expenses, but factors that predict its severity are still unclear. Baroreceptor function could influence postoperative pain by modulating nociceptive processing and vagal-mediated anti-inflammatory reflexes. To investigate this relationship, we conducted a study with 55 patients undergoing minimally invasive cardiothoracic surgery to evaluate whether cardiovagal baroreflex sensitivity (BRS) can predict postoperative pain. We assessed the spontaneous cardiovagal BRS under resting pain-free conditions before surgery. We estimated postoperative pain outcomes with the Pain, Enjoyment, and General Activity scale and pressure pain thresholds on the first (POD1) and second (POD2) postoperative days and persistent pain 3 and 6 months after hospital discharge. We also measured circulating levels of relevant inflammatory biomarkers (C-reactive protein, albumin, cytokines) at baseline, POD1, and POD2 to assess the contribution of inflammation to the relationship between BRS and postoperative pain. Our mixed-effects model analysis showed a significant main effect of preoperative BRS on postoperative pain (P = .013). Linear regression analysis revealed a significant positive association between preoperative BRS and postoperative pain on POD2, even after adjusting for demographic, surgical, analgesic treatment, and psychological factors. Moreover, preoperative BRS was linked to pain interfering with general activity and enjoyment but not with other pain parameters (pain intensity and pressure pain thresholds). Preoperative BRS had modest associations with postoperative C-reactive protein and IL-10 levels, but they did not mediate its relationship with postoperative pain. These findings indicate that preoperative BRS can independently predict postoperative pain, which could serve as a modifiable criterion for optimizing postoperative pain management. PERSPECTIVE: This article shows that preoperative BRS predicts postoperative pain outcomes independently of the inflammatory response and pain sensitivity to noxious pressure stimulation. These results provide valuable insights into the role of baroreceptors in pain and suggest a helpful tool for improving postoperative pain management.
MeSH term(s)	Humans ; Baroreflex/physiology ; C-Reactive Protein/pharmacology ; Blood Pressure/physiology ; Pain Threshold ; Pain, Postoperative ; Heart Rate/physiology
Chemical Substances	C-Reactive Protein (9007-41-4)
Language	English
Publishing date	2023-08-09
Publishing country	United States
Document type	Journal Article
ZDB-ID	2018789-0
ISSN	1528-8447 ; 1526-5900
ISSN (online)	1528-8447
ISSN	1526-5900
DOI	10.1016/j.jpain.2023.08.002
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Zs.A 5237: Show issues

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Article ; Online: Baroreceptor Modulation of the Cardiovascular System, Pain, Consciousness, and Cognition.

Suarez-Roca, Heberto / Mamoun, Negmeldeen / Sigurdson, Martin I / Maixner, William

Comprehensive Physiology

2021 Volume 11, Issue 2, Page(s) 1373–1423

Abstract: Baroreceptors are mechanosensitive elements of the peripheral nervous system that maintain cardiovascular homeostasis by coordinating the responses to external and internal environmental stressors. While it is well known that carotid and cardiopulmonary ... ...

Abstract	Baroreceptors are mechanosensitive elements of the peripheral nervous system that maintain cardiovascular homeostasis by coordinating the responses to external and internal environmental stressors. While it is well known that carotid and cardiopulmonary baroreceptors modulate sympathetic vasomotor and parasympathetic cardiac neural autonomic drive, to avoid excessive fluctuations in vascular tone and maintain intravascular volume, there is increasing recognition that baroreceptors also modulate a wide range of non-cardiovascular physiological responses via projections from the nucleus of the solitary tract to regions of the central nervous system, including the spinal cord. These projections regulate pain perception, sleep, consciousness, and cognition. In this article, we summarize the physiology of baroreceptor pathways and responses to baroreceptor activation with an emphasis on the mechanisms influencing cardiovascular function, pain perception, consciousness, and cognition. Understanding baroreceptor-mediated effects on cardiac and extra-cardiac autonomic activities will further our understanding of the pathophysiology of multiple common clinical conditions, such as chronic pain, disorders of consciousness (e.g., abnormalities in sleep-wake), and cognitive impairment, which may result in the identification and implementation of novel treatment modalities. © 2021 American Physiological Society. Compr Physiol 11:1373-1423, 2021.
MeSH term(s)	Consciousness ; Heart ; Humans ; Pain/etiology ; Parasympathetic Nervous System ; Pressoreceptors ; Sympathetic Nervous System
Language	English
Publishing date	2021-02-12
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't
ISSN	2040-4603
ISSN (online)	2040-4603
DOI	10.1002/cphy.c190038
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Article ; Online: Health care resource utilization and clinical outcomes for adult heart transplant recipients with primary graft dysfunction.

McCartney, Sharon L / Peskoe, Sarah / Wright, Mary Cooter / Mamoun, Negmeldeen / Schroder, Jacob N / DeVore, Adam D / Nicoara, Alina

Clinical transplantation

2023 Volume 37, Issue 10, Page(s) e15048

Abstract: Introduction: The advent of new technologies to reduce primary graft dysfunction (PGD) and improve outcomes after heart transplantation are costly. Adoption of these technologies requires a better understanding of health care utilization, specifically ... ...

Abstract	Introduction: The advent of new technologies to reduce primary graft dysfunction (PGD) and improve outcomes after heart transplantation are costly. Adoption of these technologies requires a better understanding of health care utilization, specifically the costs related to PGD. Methods: Records were examined from all adult patients who underwent orthotopic heart transplantation (OHT) between July 1, 2013 and July 30, 2019 at a single institution. Total costs were categorized into variable, fixed, direct, and indirect costs. Patient costs from time of transplantation to hospital discharge were transformed with the z-score transformation and modeled in a linear regression model, adjusted for potential confounders and in-hospital mortality. The quintile of patient costs was modeled using a proportional odds model, adjusted for confounders and in-hospital mortality. Results: 359 patients were analyzed, including 142 with PGD and 217 without PGD. PGD was associated with a .42 increase in z-score of total patient costs (95% CI: .22-.62; p < .0001). Additionally, any grade of PGD was associated with a 2.95 increase in odds for a higher cost of transplant (95% CI: 1.94-4.46, p < .0001). These differences were substantially greater when PGD was categorized as severe. Similar results were obtained for fixed, variable, direct, and indirect costs. Conclusions: PGD after OHT impacts morbidity, mortality, and health care utilization. We found that PGD after OHT results in a significant increase in total patient costs. This increase was substantially higher if the PGD was severe. Summary: Primary graft dysfunction after heart transplantation impacts morbidity, mortality, and health care utilization. PGD after OHT is costly and investments should be made to reduce the burden of PGD after OHT to improve patient outcomes.
Language	English
Publishing date	2023-06-26
Publishing country	Denmark
Document type	Journal Article
ZDB-ID	639001-8
ISSN	1399-0012 ; 0902-0063
ISSN (online)	1399-0012
ISSN	0902-0063
DOI	10.1111/ctr.15048
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Article ; Online: Reduce intraoperative albumin utilisation in cardiac surgical patients: a quality improvement initiative.

Savadjian, André J / Taicher, Brad M / La, Jong Ok / Podgoreanu, Mihai / Miller, Timothy E / McCartney, Sharon / Raghunathan, Karthik / Shah, Nirav / Mamoun, Negmeldeen

BMJ open quality

2024 Volume 13, Issue 2

Abstract: Background: Albumin continues to be used routinely by cardiac anaesthesiologists perioperatively despite lack of evidence for improved outcomes. The Multicenter Perioperative Outcomes Group (MPOG) data ranked our institution as one of the highest ... ...

Abstract	Background: Albumin continues to be used routinely by cardiac anaesthesiologists perioperatively despite lack of evidence for improved outcomes. The Multicenter Perioperative Outcomes Group (MPOG) data ranked our institution as one of the highest intraoperative albumin users during cardiac surgery. Therefore, we designed a quality improvement project (QIP) to introduce a bundle of interventions to reduce intraoperative albumin use in cardiac surgical patients. Methods: Our institutional MPOG data were used to analyse the FLUID-01-C measure that provides the number of adult cardiac surgery cases where albumin was administered intraoperatively by anaesthesiologists from 1 July 2019 to 30 June 2022. The QIP involved introduction of the following interventions: (1) education about appropriate albumin use and indications (January 2021), (2) email communications reinforced with OR teaching (March 2021), (3) removal of albumin from the standard pharmacy intraoperative medication trays (April 2021), (4) grand rounds presentation discussing the QIP and highlighting the interventions (May 2021) and (5) quarterly provider feedback (starting July 2021). Multivariable segmented regression models were used to assess the changes from preintervention to postintervention time period in albumin utilisation, and its total monthly cost. Results: Among the 5767 cardiac surgery cases that met inclusion criteria over the 3-year study period, 16% of patients received albumin intraoperatively. The total number of cases that passed the metric (albumin administration was avoided), gradually increased as our interventions went into effect. Intraoperative albumin utilisation (beta=-101.1, 95% CI -145 to -56.7) and total monthly cost of albumin (beta=-7678, 95% CI -10712 to -4640) demonstrated significant decrease after starting the interventions. Conclusions: At a single academic cardiac surgery programme, implementation of a bundle of simple and low-cost interventions as part of a coordinated QIP were effective in significantly decreasing intraoperative use of albumin, which translated into considerable costs savings.
MeSH term(s)	Humans ; Cardiac Surgical Procedures/methods ; Cardiac Surgical Procedures/statistics & numerical data ; Quality Improvement ; Albumins/therapeutic use ; Female ; Male ; Intraoperative Care/methods ; Intraoperative Care/statistics & numerical data ; Intraoperative Care/standards ; Middle Aged ; Aged
Chemical Substances	Albumins
Language	English
Publishing date	2024-04-24
Publishing country	England
Document type	Journal Article
ISSN	2399-6641
ISSN (online)	2399-6641
DOI	10.1136/bmjoq-2023-002726
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Article ; Online: Pain Trajectories After Valve Surgeries Performed via Midline Sternotomy Versus Mini-Thoracotomy.

Mamoun, Negmeldeen / Wright, Mary Cooter / Bottiger, Brandi / Plichta, Ryan / Klinger, Rebecca / Manning, Michael / Raghunathan, Karthik / Gulur, Padma

Journal of cardiothoracic and vascular anesthesia

2022 Volume 36, Issue 9, Page(s) 3596–3602

Abstract: Objectives: Controlling moderate-to-severe pain remains a major challenge after cardiothoracic surgery. Several outcomes have been compared extensively after valve surgery performed via midline sternotomy versus mini-thoracotomy, but postoperative pain ( ...

Abstract	Objectives: Controlling moderate-to-severe pain remains a major challenge after cardiothoracic surgery. Several outcomes have been compared extensively after valve surgery performed via midline sternotomy versus mini-thoracotomy, but postoperative pain (POP) was not adequately examined. Therefore, the authors tested the hypothesis that there is no difference in POP trajectories in patients undergoing valve surgery via midline sternotomy versus mini-thoracotomy. Design: An Institutional Review Board-approved retrospective study. Setting: At a single, large academic medical center. Participants: Adult patients who underwent mitral or aortic valve surgeries over a 5-year period. Interventions: The authors compared the characteristics of pain between valve surgery patients receiving either midline sternotomy or mini-thoracotomy. To identify pain score trajectories, the authors employed latent class linear mixed models and then used multinomial regression models to study the association between incision type and pain trajectory class. Measurements and main results: The authors' cohort consisted of 1,660 surgical patients-544 (33%) received a midline sternotomy, and 1,116 (66%) received a mini-thoracotomy. The authors identified the following 4 pain trajectory classes: stationary, rapidly improving, slowly improving, and acute worsening pain. Compared to the rapidly improving class, the odds of belonging to the stationary (adjusted odds ratio [aOR] [95% CI] 1.45 [1.01- 2.08]; p = 0.04) or the acute worsening class (aOR [95% CI] 1.71 [1.10-2.67] p = 0.02) were significantly higher for sternotomy patients compared to mini-thoracotomy. Conclusions: Midline sternotomies are associated with higher odds of having an acute worsening or stationary versus a rapidly improving pain trajectory compared to mini-thoracotomies. Therefore, the choice of incision may play an important role in determining POP trajectory after valve surgery.
MeSH term(s)	Heart Valve Prosthesis Implantation ; Humans ; Minimally Invasive Surgical Procedures ; Pain ; Retrospective Studies ; Sternotomy/adverse effects ; Thoracotomy/adverse effects ; Treatment Outcome
Language	English
Publishing date	2022-05-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	1067317-9
ISSN	1532-8422 ; 1053-0770
ISSN (online)	1532-8422
ISSN	1053-0770
DOI	10.1053/j.jvca.2022.05.007
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