Management of high-dose intrathecal baclofen pump explant: A case report.

BACKGROUND: Intrathecal baclofen (ITB) is a proven, effective treatment for refractory spasticity and chronic pain, with applications ranging from spinal cord injury to amyotrophic lateralsclerosis (ALS). Despite its effectiveness, the withdrawal syndrome of intrathecal baclofen can be life-threatening. CASE REPORT: This case describes the treatment of a patient with chronic spasticity related to ALS with an ITB pump infection requiring explant and a prolonged period of antibiotics before reimplantation. A 62-year-old man with ALS-related spasticity maintained on high-dose ITB for 20 years presented to the emergency department with one week of fever, confusion, and localized erythema to the R-side of his abdomen. Laboratories indicated a mild leukocytosis 12.9 K/uL and imaging showed a 2.9-cm fluid collection with fat stranding surrounding the ITB pump. The pack was explanted, and the patient started on intravenous antibiotics. Due to the high baclofen dosage, our pain service recommended PO (per os) baclofen 30 mg every 6 h via gastrostomy and PO diazepam 10 mg every 6 h via gastrostomy. These doses were titrated carefully to avoid oversedation while preventing withdrawal symptoms. On Day 23 postexplant, the patient had the baclofen pump reimplanted and baclofen titrated over three days to his previous dose of ITB. CONCLUSION: This case demonstrates a successful approach to avoiding severe baclofen withdrawal using PO baclofen combined with PO diazepam. The high dose of maintenance ITB (1188.8 mcg/day), the inability to reinsert the patient's intrathecal pump, and the high risk of intubation in a patient with severe neuromuscular dysfunction all made this a challenging case.

Knowledge Gaps in Anesthetic Gas Utilization in a Large Academic Hospital System: A Multicenter Survey.

Inhaled anesthetics account for a significant portion of the greenhouse gases generated by perioperative services within the healthcare systems. This cross-sectional study aimed to identify knowledge gaps and practice patterns related to carbon dioxide (CO2) absorbents and intraoperative delivery of fresh gas flows (FGF) for future sustainability endeavors. Secondary aims focused on differences in these knowledge gaps based on the level of training. Surveys were distributed at five large academic medical centers. In addition to site-specific CO2 absorbent use and practice volume and experience, respondents at each institution were queried about individual practice with FGF rates during anesthetic maintenance as well as the cost-effectiveness and environmental impact of different volatile anesthetics. Results were stratified and analyzed by the level of training. In total, 368 (44% physicians, 30% residents, and 26% nurse anesthetists) respondents completed surveys. Seventy-six percent of respondents were unaware or unsure about which type of CO2 absorbent was in use at their hospital. Fifty-nine percent and 48% of respondents used sevoflurane and desflurane with FGF ≥1 L/min, respectively. Most participants identified desflurane as the agent with the greatest environmental impact (89.9%) and a greater proportion of anesthesiologists correctly identified isoflurane as a cost-effective anesthetic (78.3%, p=0.02). Knowledge gaps about in-use CO2 absorbent and optimal FGF usage were identified within the anesthesia care team. Educational initiatives to increase awareness about the carbon emissions from anesthesia and newer CO2 absorbents will impact the environmental and economic cost per case and align anesthesia providers toward healthcare decarbonization.

An Accessible Clinical Decision Support System to Curtail Anesthetic Greenhouse Gases in a Large Health Network: Implementation Study.

BACKGROUND: Inhaled anesthetics in the operating room are potent greenhouse gases and are a key contributor to carbon emissions from health care facilities. Real-time clinical decision support (CDS) systems lower anesthetic gas waste by prompting anesthesia professionals to reduce fresh gas flow (FGF) when a set threshold is exceeded. However, previous CDS systems have relied on proprietary or highly customized anesthesia information management systems, significantly reducing other institutions' accessibility to the technology and thus limiting overall environmental benefit. OBJECTIVE: In 2018, a CDS system that lowers anesthetic gas waste using methods that can be easily adopted by other institutions was developed at the University of California San Francisco (UCSF). This study aims to facilitate wider uptake of our CDS system and further reduce gas waste by describing the implementation of the FGF CDS toolkit at UCSF and the subsequent implementation at other medical campuses within the University of California Health network. METHODS: We developed a noninterruptive active CDS system to alert anesthesia professionals when FGF rates exceeded 0.7 L per minute for common volatile anesthetics. The implementation process at UCSF was documented and assembled into an informational toolkit to aid in the integration of the CDS system at other health care institutions. Before implementation, presentation-based education initiatives were used to disseminate information regarding the safety of low FGF use and its relationship to environmental sustainability. Our FGF CDS toolkit consisted of 4 main components for implementation: sustainability-focused education of anesthesia professionals, hardware integration of the CDS technology, software build of the CDS system, and data reporting of measured outcomes. RESULTS: The FGF CDS system was successfully deployed at 5 University of California Health network campuses. Four of the institutions are independent from the institution that created the CDS system. The CDS system was deployed at each facility using the FGF CDS toolkit, which describes the main components of the technology and implementation. Each campus made modifications to the CDS tool to best suit their institution, emphasizing the versatility and adoptability of the technology and implementation framework. CONCLUSIONS: It has previously been shown that the FGF CDS system reduces anesthetic gas waste, leading to environmental and fiscal benefits. Here, we demonstrate that the CDS system can be transferred to other medical facilities using our toolkit for implementation, making the technology and associated benefits globally accessible to advance mitigation of health care-related emissions.

Occipital Nerve Blocks in the Emergency Department for Initial Medication-Refractory Acute Occipital Migraines.

Migraines are consistently among the top 20 primary coded diagnoses in emergency departments, constituting 4.5% of all chief complaints. In a significant subset of these, pain arises from the occipital region innervated by the greater (GON) and lesser occipital nerve. In this case series, we present three patients with occipital migraines who received GON blockade with 1% lidocaine. The blockade was performed only after first-line treatment with metoclopramide and possibly additional medications as ordered by triage physician, failed to adequately alleviate pain by 40 minutes after medication administration. Patients were contacted a minimum of seven days following treatment. All three patients experienced significant analgesia and relief of symptoms within 15 minutes of blockade and sustained relief through a seven-day follow-up period.