Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery.

BACKGROUND: Enhanced recovery after surgery protocols increasingly use multimodal analgesia after major surgeries with intravenous acetaminophen and ketorolac, despite no documented cost-effectiveness of these strategies. AIMS: The goal of this prospective cohort study was to model cost-effectiveness of adding acetaminophen or acetaminophen + ketorolac to opioids for postoperative outcomes in children having scoliosis surgery. METHODS: Of 106 postsurgical children, 36 received only opioids, 26 received intravenous acetaminophen, and 44 received acetaminophen + ketorolac as analgesia adjuncts. Costs were calculated in 2015 US $. Decision analytic model was constructed with Decision Maker® software. Base-case and sensitivity analyses were performed with effectiveness defined as avoidance of opioid adverse effects. RESULTS: The groups were comparable demographically. Compared with opioids-only strategy, subjects in the intravenous acetaminophen + ketorolac strategy consumed less opioids (P = .002; difference in mean morphine consumption on postoperative days 1 and 2 was -0.44 mg/kg (95% CI -0.72 to -0.16); tolerated meals earlier (P < .001; RR 0.250 (0.112-0.556)) and had less constipation (P < .001; RR 0.226 (0.094-0.546)). Base-case analysis showed that of the 3 strategies, use of opioids alone is both most costly and least effective, opioids + intravenous acetaminophen is intermediate in both cost and effectiveness; and opioids + intravenous acetaminophen and ketorolac is the least expensive and most effective strategy. The addition of intravenous acetaminophen with or without ketorolac to an opioid-only strategy saves $510-$947 per patient undergoing spine surgery and decreases opioid side effects. CONCLUSION: Intravenous acetaminophen with or without ketorolac reduced opioid consumption, opioid-related adverse effects, length of stay, and thereby cost of care following idiopathic scoliosis in adolescents compared with opioids-alone postoperative analgesia strategy.

A bleeding assessment tool correlates with intraoperative blood loss in children and adolescents undergoing major spinal surgery.

Screening laboratory studies for bleeding disorders are of little predictive value for operative bleeding risk in adults. Predicting perioperative bleeding in pediatric patients is particularly difficult as younger patients often have not had significant hemostatic challenges. This issue is distinctly important for high bleeding risk surgeries, such as major spinal procedures. The aim of this study was to determine if the score of a detailed bleeding questionnaire (BQ) correlated with surgical bleeding in pediatric patients undergoing major spinal surgery. A total of 220 consecutive pediatric patients (mean age 14.2years) undergoing major spinal surgery were administered the BQ preoperatively, as well as having routine screening laboratory studies (i.e., PT, aPTT, PFA) drawn. A retrospective analysis was conducted to determine if there was a correlation between either the results of the BQ and/or laboratory studies with operative outcomes. A BQ score>2 showed a strong positive correlation with intraoperative bleeding based on both univariate and multivariate analyses. In contrast, abnormalities in screening laboratory studies showed no significant correlation with operative bleeding outcomes. Relying on screening laboratory studies alone is inadequate. The BQ used here correlated with increased intraoperative hemorrhage, suggesting this tool may be useful for assessing pediatric surgical bleeding risk, and may also be useful in identifying a subset of patients with a very low bleeding risk that may not require laboratory screening.

Upper extremity inverse dynamics model for crutch-assisted gait assessment.

Current inverse dynamics models of the upper extremity (UE) are limited for the measurement of Lofstrand crutch-assisted gait. The objective of this study is to develop, validate, and demonstrate a three-dimensional (3-D) UE motion assessment system to quantify crutch-assisted gait in children. We propose a novel 3-D dynamic model of the UEs and crutches for quantification of joint motions, forces, and moments during Lofstrand crutch-assisted gait. The model is composed of the upper body (i.e., thorax, upper arms, forearms, and hands) and Lofstrand crutches to determine joint dynamics of the thorax, shoulders, elbows, wrists, and crutches. The model was evaluated and applied to a pediatric subject with myelomeningocele (MM) to demonstrate its effectiveness in the characterization of crutch gait during multiple walking patterns. The model quantified UE dynamics during reciprocal and swing-through crutch-assisted gait patterns. Joint motions and forces were greater during swing-through gait than reciprocal gait. The model is suitable for further application to pediatric crutch-user populations. This study has potential for improving the understanding of the biomechanics of crutch-assisted gait and may impact clinical intervention strategies and therapeutic planning of ambulation.

Lagrangian dispersion modeling of vehicular emissions from a highway in complex terrain.

Transit traffic through the Austrian Alps is of major concern in government policy. Pollutant burdens resulting from such traffic are discussed widely in Austrian politics and have already led to measures to restrict traffic on transit routes. In the course of an environmental assessment study, comprehensive measurements were performed. These included air quality observations using passive samplers, a differential optical absorption spectroscopy system, a mobile and a fixed air quality monitoring station, and meteorological observations. As was evident from several previous studies, dispersion modeling in such areas of complex terrain and, moreover, with frequent calm wind conditions, is difficult to handle. Further, in the case presented here, different pollutant sources had to be treated simultaneously (e.g., road networks, exhaust chimneys from road tunnels, and road tunnel portals). No appropriate system for modeling all these factors has so far appeared in the literature. A prognostic wind field model coupled with a Lagrangian dispersion model is thus presented here and is designed to treat all these factors. A comparison of the modeling system with results from passive samplers and from a fixed air quality monitoring station proved the ability of the model to provide reasonable figures for concentration distributions along the A10.