Efficacy of Continuous Intrathecal Infusion Trialing with a Mixture of Fentanyl and Bupivacaine in Chronic Low Back Pain Patients.

Intrathecal trialing is used as a screening prognostic measure prior to intrathecal drug delivery system implant. The purpose of this study was to determine the efficacy of a continuous intrathecal infusion of an admixture of bupivacaine and fentanyl in patients with chronic low back pain. Patients with refractory chronic low back pain in the setting of previous lumbar spine surgery and/or chronic vertebral compression fracture(s) were enrolled in a randomized double blind cross-over study comparing saline infusion to infusion of a solution containing bupivacaine combined with low-dose fentanyl over a 14-18 hour period. The primary outcome measure was the change in pain intensity at the end of the screening trial. Patients who experienced significant pain reduction from either infusion relative to baseline pain were offered a permanent implant. In total, 36 patients were enrolled, with 31 patients trialed and 25 implanted. At the end of the screening trial, pain scores, at rest or with activity, decreased appreciably in both groups; however, significantly better improvements occurred in the fentanyl/bupivacaine group compared to saline both with activity and at rest (P = .016 and .006, respectively). Treatment order appeared to affect outcome with saline demonstrating a placebo response. At 12 months following implant, primary and secondary outcome measures continued to be significantly reduced from baseline. Continuous intrathecal delivery of a combination of zlow-dose fentanyl with bupivacaine is superior to saline in screening intrathecal trialing for back pain reduction. With longer term delivery, a sustained reduction of chronic low back pain was also observed.

Radiographic Templating for Calcaneus Operative Fixation: How Similar Is Side-to-Side Comparison?

OBJECTIVES: Calcaneal fractures often require contralateral, uninjured calcaneus radiographs as a template. The purpose of this study was to establish mean values for calcaneal radiographic parameters in an uninjured urban American population and perform side-by-side comparison with respect to age, sex, laterality, and radiograph obliquity (XRO). DESIGN: Retrospective analysis of consecutive patients. SETTING: Fourteen hospitals including Level 1 trauma center. PATIENTS/PARTICIPANTS: Retrospective review of >800 uninjured patients with bilateral foot and calcaneus radiographs obtained between June and December 2019 was performed. Inclusion criteria were the following: age 18-89 years without fracture; previous foot surgical procedures; radiographic evidence of arthrosis in ankle, hindfoot, or midfoot; osteomyelitis; tumor; or foot deformities. INTERVENTION: The lateral radiographs were independently reviewed by 3 observers, measuring Böhler angle (BA), crucial angle of Gissane (CAG), calcaneal length (CL), calcaneal height (CH), calcaneotalar ratio (CTR), and XRO. MAIN OUTCOME MEASUREMENTS: The mean values of BA, CAG, CL, CH, and CTR were established. Side-by-side comparisons were completed with respect to age, sex, laterality, and XRO. RESULTS: There were no statistically significant differences in side-by-side measurements of the BA, CAG, CL, or CH. XRO had significant effects on the measurements of BA, CAG, CH, and CTR. Side-by-side comparisons showed greater intersubject variability than within-subject differences. CONCLUSIONS: We did not observe any differences in commonly measured calcaneal radiographic parameters. CAG is not a reliable parameter for diagnostic and operative planning purposes. We conclude that the use of contralateral calcaneus radiographs as templates for calcaneus fractures is a valid technique.

Incidence of missing pathology specimens in dermatology.

BACKGROUND: Occasionally specimen containers are received in the dermatopathology laboratory without an accompanying specimen. The consequences in this scenario can range from delay in care and inconvenience to patients to increased morbidity and even mortality. Data regarding incidence and associated characteristics of missing specimens are scant. METHODS: Over a 10-year period (7 January 2010 to 7 January 2020) all cases with a missing specimen in a single academic dermatopathology laboratory and a single dermatopathology practice embedded within a dermatology practice were reviewed. RESULTS: Out of 270,754 specimens received, 83 empty specimen containers were identified for an incidence of 0.031%. There were 14 (0.005%) cases in which patients had a separate procedure and a second container with both specimens in it accompanying the empty container. The most common missing specimen-generating procedures were shave biopsies (51%) with most common clinical diagnosis being unspecified (30%). The most common specimen location from the 97 total specimen bottles containing either zero or two specimens was head/neck (53%). Although no further procedures were performed after the specimen was lost for 48% of cases, re-biopsy occurred for 28%. CONCLUSIONS: Failure to insert specimens into the correct container is rare, but represents a potential significant negative event where vigilance and improvement is required.

Effects of Bupivacaine on Opioid Patient-Controlled Intrathecal Analgesia in Chronic Pain Patients Implanted with Drug Delivery Systems.

BACKGROUND: Combining neuraxial opioids and local anesthetics in acute pain results in improved duration of analgesia and reduced dosages and adverse effects. Although commonly used in intrathecal drug delivery systems (IDDS) for chronic pain, the effectiveness of this admixture has not been examined specifically in relation to patient-controlled intrathecal analgesia (PCIA). METHODS: IDDS-implanted chronic noncancer pain patients receiving opioids with bupivacaine (O + B) were randomized to receive either opioids without bupivacaine (O) or O + B in a double-blind manner, at IDDS refills, for one week and then crossed over to the other solution for another week. Primary outcome measures included numeric rating scale (NRS) pain scores before and within 30 minutes after PCIA boluses. Secondary outcome measures included average NRS scores and functional outcome measures. RESULTS: Seventeen patients were enrolled, and 16 patients completed the study. There were no differences in NRS scores before and after PCIA boluses between the O and O + B conditions, though pain scores improved significantly (average decrease in NRS scores: O 1.81 ± 1.47 vs O + B 1.87 ± 1.40, P = 0.688). No differences were noted in speed of onset or duration of analgesia. Although more patients subjectively preferred the O + B treatment, the difference was not statistically significant. No differences were noted in secondary outcome measures, with the exception of global impression of change having higher scores in O compared with O + B. CONCLUSIONS: Acutely removing bupivacaine from a chronic intrathecal infusion of opioids and bupivacaine in patients with chronic noncancer pain did not adversely affect PCIA effectiveness, nor did it affect speed of onset or duration of effect. These findings are divergent from those in acute pain and may have to do with study conditions and pain phenotypes.

Comparative Effectiveness of Targeted Intrathecal Drug Delivery Using a Combination of Bupivacaine with Either Low-Dose Fentanyl or Hydromorphone in Chronic Back Pain Patients with Lumbar Postlaminectomy Syndrome.

OBJECTIVE: Targeted intrathecal drug delivery (TIDD) is an effective interventional pain management modality often used in postlaminectomy patients with refractory chronic low back pain. A combination of intrathecal bupivacaine with an opioid is often used. However, intrathecal catheter tip granulomas have occurred with use of morphine or hydromorphone but generally not with fentanyl. The objective of this study was to compare the efficacy of TIDD using bupivacaine/fentanyl vs bupivacaine/hydromorphone in patients with chronic intractable low back pain postlaminectomy. MATERIALS AND METHODS: A retrospective comparative analysis of consecutive patients with lumbar postlaminectomy syndrome who were trialed and later received TIDD with a combination of bupivacaine/hydromorphone or bupivacaine/fentanyl between June 2009 and May 2016 at a single tertiary medical center. RESULTS: We identified a cohort of 58 lumbar postlaminectomy patients receiving a TIDD admixture of either hydromorphone/bupivacaine (30 patients) or low-dose fentanyl/bupivacaine (28 patients) with at least two years of follow-up. The fentanyl group had significantly lower baseline opioid consumption and a lower rate of intrathecal opioid dose escalation. Both groups had similar and significant reductions in pain scores over the two-year follow-up period. No granulomas were observed. CONCLUSION: TIDD using a low-dose fentanyl admixture with bupivacaine in patients with postlaminectomy syndrome and refractory chronic low back pain results in similar pain relief to TIDD with hydromorphone and bupivacaine. Low-dose intrathecal fentanyl leads to a lower rate of opioid escalation and may be safer than hydromorphone.

Factors Predictive of Ventilator-associated Pneumonia in Critically Ill Trauma Patients.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation. We sought to investigate factors associated with the development of VAP in critically ill trauma patients. METHODS: We conducted a retrospective review of trauma patients admitted to our trauma intensive care unit between 2016 and 2018. Patients with ventilator-associated pneumonia were identified from the trauma database. Data collected from the trauma database included demographics (age, gender and race), mechanism of injury (blunt, penetrating), injury severity (injury severity score "ISS"), the presence of VAP, transfused blood products and presenting vital signs. RESULTS: A total of 1403 patients were admitted to the trauma intensive care unit (TICU) during the study period; of these, 45 had ventilator-associated pneumonia. Patients with VAP were older (p = 0.030), and they had a higher incidence of massive transfusion (p = 0.015) and received more packed cells in the first 24 h of admission (p = 0.028). They had a higher incidence of face injury (p = 0.001), injury to sternum (p = 0.011) and injury to spine (p = 0.024). Patients with VAP also had a higher incidence of acute kidney injury (AKI) (p < 0.001) and had a longer ICU (p < 0.001) and hospital length of stay (p < 0.001). Multiple logistic regression models controlling for age and injury severity (ISS) showed massive transfusion (p = 0.017), AKI (p < 0.001), injury to face (p < 0.001), injury to sternum (p = 0.007), injury to spine (p = 0.047) and ICU length of stay (p < 0.001) to be independent predictors of VAP. CONCLUSIONS: Among critically ill trauma patients, acute kidney injury, injury to the spine, face or sternum, massive transfusion and intensive care unit length of stay were associated with VAP.