Baclofen bridging, weaning protocol and pain management of a person with T6 paraplegia who required removal of intrathecal baclofen pump due to wound infection.

Intrathecal baclofen is recognised as an effective treatment option for severe symptoms of segmental spasticity after spinal cord injury. We present our experience of a case of a patient who was admitted to our centre for elective intrathecal baclofen pump revision surgery, but postsurgical complications of a blocked catheter and subsequent wound infections meant the pump had to be removed. In this case, treatment of severe spasticity and nociceptive pain was required while avoiding potentially lethal side effects of sudden baclofen withdrawal. We suggest an effective bridging and weaning protocol for oral drug titration to treat spasticity and pain as a blended syndrome in this challenging situation.

Quantitative assessment of expert and novice surgeons' thinking processes: an application to hernia repair.

BACKGROUND: The aim of this study was to capture quantitatively surgeons' decision making when faced with a choice of open or laparoscopic inguinal hernia repair. METHODS: Twenty-one general surgeons (10 consultants or attending surgeons, 11 registrars or residents) were presented with 46 clinical vignettes differing in clinical and patient factors. Surgeons' choices of open or laparoscopic repair were submitted to multiple regression. Beta coefficients were computed for each factor and compared across expert and novice participants. RESULTS: Consultants and attending surgeons considered the nature of the hernia (primary or recurrent; ß = .40), the site of the hernia (unilateral or bilateral; ß = .27), American Society of Anesthesiologists score (ß = -.25), and previous abdominal surgery (ß = .20). Trainees weighted most the site of the hernia (ß = .30), previous abdominal surgery (ß = .23), the nature of the hernia (ß = .20), and American Society of Anesthesiologists score (ß = -.10). CONCLUSIONS: This study offers an objective assessment of surgeons' decision making, with specific application to hernia repair. Further research into quantitative methods that capture surgeons' thinking processes could distill factors that expert surgeons consider important in a number of key situations and assist in trainees' decision making.