ABSTRACT
Intrawound liposomal bupivacaine is a long-acting local anesthetic used to decrease postoperative pain in various procedures. Although it is used in posterior cervical and suboccipital approaches in the adult population, it is currently off-label for pediatrics. This quality improvement (QI) project examines intrawound liposomal bupivacaine for pediatric Chiari decompression and evaluates its role in postoperative opioid consumption. METHODS: We retrospectively analyzed all patients 0-18 years old of age who underwent Chiari decompression from January 2017 to July 2019 at our tertiary care hospital. Demographic and clinical data regarding postoperative opioid use, subjective and objective pain control, length of stay, discharge medications, and comorbid conditions were collected. RESULTS: We included 30 patients in this study: 19 females and 11 males. Of these, 6 received an intrawound injection of liposomal bupivacaine. PATIENTS: treated with liposomal bupivacaine require fewer opioids while admitted. There was no apparent difference in pain control immediately postoperatively, pain control at clinical follow-up, or inpatient length of stay between each group. Patients who received liposomal bupivacaine did not require opioid analgesics at the time of discharge from the hospital. CONCLUSION: The use of intrawound liposomal bupivacaine may decrease inpatient and outpatient postoperative opioid consumption amongst pediatric patients following Chiari decompression while providing adequate pain control. We investigate liposomal bupivacaine perioperative blockade in this QI project as a viable option for opioid-sparing pain control in the postoperative setting for the pediatric population. Future investigation via clinical trials and more extensive prospective studies may glean further insights into efficacy.
Subject(s)
Breast Neoplasms/epidemiology , Female , Humans , Life Tables , Middle Aged , Risk , Risk FactorsSubject(s)
Black or African American , Child Welfare/economics , Family , Poverty , Boston , Child , Housing , Humans , Minority Groups , Socioeconomic FactorsABSTRACT
High-intensity reverberation artifacts frequently occur within the fetal cranium during obstetric ultrasound examinations. One hundred ninety-six static ultrasonograms obtained from 100 consecutive obstetric patients were reviewed to determine the incidence, shape, and location of high-intensity reverberation artifacts within the fetal head. Such artifacts occurred in one-third of the fetuses examined. The most common appearance was an arc-shaped artifact that occurred most frequently in the fetal hemicranium farthest from the maternal skin surface. Such an artifact can mimic epidural fluid collections and cause confusion for examiners not familiar with this finding. A discussion of this "pseudoepidural" artifact, its cause, and ways of excluding underlying intracranial pathology is presented.
Subject(s)
Fetus/anatomy & histology , Prenatal Diagnosis , Skull/anatomy & histology , Ultrasonography , Brain Diseases/diagnosis , Diagnostic Errors , Epidural Space , Evaluation Studies as Topic , Female , Fetal Diseases/diagnosis , Gestational Age , Humans , Parietal Lobe/anatomy & histology , PregnancyABSTRACT
Comprehensive data on 3,579 patients in Baltimore nursing homes were collected by trained teams of reliable observers. The data included an implicit judgment about the level of care (LOC) deemed most appropriate for each patient. Two different approaches were used to fit the patient data to the LOC judgments: Several versions of an algorithm adapted from a utilization review scheme based on simple clinical criteria and a series of mathematical equations based on logistic regression were each tested. In the case of the latter, each equation was derived from a random half of the data and tested on the remaining half. Both approaches yielded comparable results. The best variation of the algorithm correctly identified 71 per cent of patients needing skilled care and 69 per cent of those needing unskilled care. The equations based on the logistic regressions could correctly classify 86 per cent of those needing skilled care and 63 per cent of those not needing such care. Further improvements in accuracy of prediction on one group came at the cost of less accurate identification of the other. In general, the simplest models proved the most useful. These techniques are recommended as useful for preliminary screening of nursing home patients for appropriate LOC but should not be used as a basis for final judgments. The advantages offered by this approach are the reduction of workload demands for skilled professional judgment and the availability of a very reliable preliminary screening judgment in a highly politicized atmosphere.
