Continuous peripheral nerve block catheter infections in combat-related injuries: a case report of five soldiers from Operation Enduring Freedom/Operation Iraqi Freedom.

DESIGN: Case series. SETTING: Military medical facility providing acute care for soldiers injured while fighting in the war in Iraq and Afghanistan. OBJECTIVE: To report a series of infections related to use of continuous peripheral nerve catheters for postoperative pain control in the military polytraumatic setting. The analysis of the above infections includes similarities and differences in infection patterns and attempts to clarify possible risk factors for such infections to include duration of catheter placement, type of catheter, preprocedural antibiotics, and tunnel vs nontunneled catheters. The goal of this analysis is to assist in the development of protocols that may prevent future catheter infections. METHODS: Clinical data were obtained from five previously healthy male soldiers receiving acute care at Brooke Army Medical Center using continuous peripheral nerve catheters for postoperative pain for multiple and frequent procedures. RESULTS: In a total of six catheter infections, two were noted to have superficial skin infections while four were shown to have deep tissue involvement confirmed by imaging studies. All patients were started on initial or additional antibiotics after catheter removal. Three catheter infections, all with stimulating catheters, required surgical irrigation and debridement in the operating room. CONCLUSIONS: Continuous peripheral nerve catheters are not without complications and risks including infection. Duration of catheter use was the most significant factor with the development of a catheter-related infection in our series. This series also highlights how stimulating and nonstimulating catheter infections may present differently, as stimulating catheters may have a greater tendency to present as deep space infections with minimal superficial findings.

Intradiscal quantitative chemical exchange saturation transfer MRI signal correlates with discogenic pain in human patients.

Low back pain (LBP) is often a result of a degenerative process in the intervertebral disc. The precise origin of discogenic pain is diagnosed by the invasive procedure of provocative discography (PD). Previously, we developed quantitative chemical exchange saturation transfer (qCEST) magnetic resonance imaging (MRI) to detect pH as a biomarker for discogenic pain. Based on these findings we initiated a clinical study with the goal to evaluate the correlation between qCEST values and PD results in LBP patients. Twenty five volunteers with chronic low back pain were subjected to T2-weighted (T2w) and qCEST MRI scans followed by PD. A total of 72 discs were analyzed. The average qCEST signal value of painful discs was significantly higher than non-painful discs (p = 0.012). The ratio between qCEST and normalized T2w was found to be significantly higher in painful discs compared to non-painful discs (p = 0.0022). A receiver operating characteristics (ROC) analysis indicated that qCEST/T2w ratio could be used to differentiate between painful and non-painful discs with 78% sensitivity and 81% specificity. The results of the study suggest that qCEST could be used for the diagnosis of discogenic pain, in conjunction with the commonly used T2w scan.

Tactical emergency casualty care?pediatric appendix: novel guidelines for the care of the pediatric casualty in the high-threat, prehospital environment.

BACKGROUND: Active shooter events and active violent incidents are increasingly targeting civilians, placing children at heightened risk for complex and devastating trauma. The U.S. Department of Homeland Security has identified as a priority preparing domestic first responders to manage complex mass casualty incidents as a primary step in strengthening our medical system. Existing literature suggests that many prehospital providers are uncomfortable treating critically ill or injured pediatric patients and that there is a gap in the consistent provision of high-quality trauma care to these patients. The success of threat-based care developed by the military has led to an exponential rise in the familiarity and utilization of these concepts within certain specialized elements of civilian care. Evolution of these concepts is accelerating to meet the demands of the nonmilitary civilian environment through the formation and subsequent work of the Committee for Tactical Emergency Casualty Care (C-TECC). However, a gap remains in the available literature describing the application of these principles to specialized populations. METHODS: In the absence of an evidence-based set of guidelines for prehospital care of the pediatric casualty, the C-TECC sought to establish a set of peer-reviewed guidelines to serve as a foundation describing current best practices. The Pediatric Working Group (PWG) utilized the adult TECC guidelines as a starting point and identified a series of key questions regarding trauma interventions. The PWG conducted a standard PubMed search to identify key relevant or potentially relevant literature. The literature review was presented to the C-TECC Guidelines Committee for review and approval of recommended principles. RECOMMENDATIONS: Given the dearth of supporting literature on the subject, the TECC committee was purposefully conservative in the adaptation of the adult TECC guidelines to a pediatric standard. The guidelines highlight information tailored to the pediatric population and were designed to be a resource for individual agencies seeking guidance for high-threat operations. To our knowledge, the TECC Pediatric Appendix is the first published recommendation for the widespread use of tourniquets in pediatric hemorrhage. In addition, the Guidelines are meant to highlight gaps in trauma literature and stimulate discussion regarding future research in the area of prehospital care of the pediatric casualty.