Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. A randomized clinical trial.

We performed a prospective, randomized clinical trial to determine whether continuous infusion of bupivacaine hydrochloride decreased the use of narcotics for the relief of pain after an amputation. Twenty-one patients who were to have an amputation of the lower extremity because of ischemic necrosis secondary to peripheral vascular disease were divided into two groups with use of a table of random numbers. Group A (the treatment group) included nine patients who were to have a transtibial amputation, one patient who was to have a disarticulation at the knee, and one patient who was to have a transfemoral amputation. Group B (the control group) included seven patients, two patients, and one patient, respectively. After the amputation had been performed, a Teflon catheter was placed adjacent to the transected end of the sciatic or posterior tibial nerve. Postoperatively, the patients received continuous infusion of either bupivacaine (Group A) or normal saline solution (Group B) for seventy-two hours. Intravenous administration of morphine with use of a patient-controlled pump also was permitted during this period. The amount of morphine that was used was recorded meticulously. The patients in Group A used less morphine during the first and second days after the operation than did those in Group B. There was no difference between the groups with regard to the amount of morphine used on the third postoperative day. Over-all, eleven of fourteen patients who completed questionnaires reported a decrease in pain between the three and six-month evaluations. We concluded that continuous perineural infusion of an anesthetic appears to be a safe, effective method for the relief of postoperative pain but that it does not prevent residual or phantom-limb pain in patients who have had an amputation of the lower extremity because of ischemic changes secondary to peripheral vascular disease.

Comparison of measures of lead exposure, dose, and chelatable lead burden after provocative chelation in organolead workers.

OBJECTIVES: To describe 6 h urinary lead excretion (6 h PbU) after 1 g intravenous ethylene diamine tetraacetic acid (EDTA) in organolead manufacturing workers with mixed exposure to organic and inorganic lead; to determine the predictors of lead excretion (PbU); and to determine the extent to which internal lead stores and ongoing external exposure govern blood concentrations of lead (PbB). METHODS: A case series of 21 active workers were studied. Personal industrial hygiene data, grouped by 29 exposure zones, in combination with personal interviews about work location and times were used to derive several measures of recent and cumulative exposure to organic and inorganic lead. The average exposure intensities assigned to the 29 zones ranged from 4 to 119 micrograms/m3 (0.02-0.57 mumol/m3 as lead) for organic lead and from 1 to 56 micrograms/m3 (0.004-0.27 mumol/m3) for inorganic lead. RESULTS: After controlling for age, 6 h PbU was significantly and positively correlated with summary measures of PbB--for example, lifetime peak PbB, time weighted PbB--and zinc protoporphyrin concentrations--for example, lifetime peak zinc protoporphyrin, time weighted zinc protoporphyrin--but not with measures of estimated external exposure--for example, duration of exposure and cumulative exposure to inorganic or organic lead. Among workers with higher chelatable lead burdens (6 h PbU > or = 212.4 micrograms (1.03 mumol) divided at the median), there was no apparent relation between recent inorganic lead exposure and PbB at the time of chelation. Among workers with lower chelatable lead burdens (6 h PbU < 212.4 micrograms (1.03 mumol) however, there was a significant relation between exposure and effect between recent exposure to inorganic lead and PbBs. CONCLUSION: These findings are consistent with the concept of physiological dampening. The high chelatable lead burden, a source of internal exposure, dampens the effect of external exposure on PbBs. The data suggest that in organolead workers with high chelatable lead burdens, PbBs may be more influenced by internal lead stores than by variations in airborne exposure to organic and inorganic lead.

Functional outcome following traumatic upper limb amputation and prosthetic limb fitting.

Nineteen consecutive patients underwent traumatic upper limb amputation for nonreconstructible or replantible upper limb injury at a Level I trauma center over a 9-year-period. Eleven amputations were at the transradial level, five were transhumeral, and three were shoulder disarticulation. Eighteen patients underwent prosthetic limb fitting. Fifteen of the 18 initially underwent preparatory prosthetic limb fitting within 30 days following amputation with a body-powered, cable-driven prosthesis. Seventeen of the 18 achieved sufficient proficiency with their prostheses to allow them to return to work. Of these, 15 maintained daily functional prosthetic use of at least 8 hours daily at a followup examination of 12 to 110 months. Use of prosthetic limb following traumatic upper limb amputation carries a high probability for functional rehabilitation if limb fitting and prosthetic training are instituted as soon as the residual limb can tolerate the prosthetic socket as opposed to waiting for the residual limb to "mature".

Managing orthopedics and neurosciences costs through standard treatment protocols.

High-cost, high-volume specialty programs such as orthopedics and neurosciences find themselves in a position of evaluating the costs and in some cases the appropriateness of medical practices in response to payer scrutiny and provider selection processes. Orthopedics and neurosciences programs are at a stage of development analogous to that of cardiovascular care several years ago. Many of the same trends have come into play, such as payer "carve-outs" for orthopedic services, payer selection of centers of excellence based on cost and quality, reduction of Medicare reimbursement, greater use of high-cost technology, the decline of profitability due to "older, sicker, and tougher" patients, and the recent emergence of national orthopedic specialty networks oriented to national contracts for care. In an era in which payers demand value on both sides of the cost-plus-quality equation, programs are challenged to maximize the return on a patient population rife with "no-win" situations. In the orthopedic service line these include a high proportion of Medicare patients and chronic conditions such as workers' compensation medical back cases or repetitive motion injuries, which can be elusive to diagnose and expensive to treat. Many hospitals continue to lose money on joint replacement surgeries, the largest-volume orthopedic inpatient service, primarily because of the high Medicare population and the cost of implants. Neuroservices, while still relatively well reimbursed, face a rising proportion of Medicare payments as patients live longer and develop chronic, degenerative conditions. Inpatient days are decreasing due to payer pressures to limit hospital stays and to shift inpatient care to outpatient services. Some hospitals "have lost interest in (the orthopedic) service line during the last five years because of recent trends in orthopedic-related inpatient volume and payment." But by managing costs strategically, both the neurosciences and orthopedics service lines can provide substantial revenue as well as the opportunity to achieve a "center of excellence" competitive position in a managed care environment. This Special Report outlines the process and advantages of managing costs and quality of care strategically, that is, in a manner which helps these programs meet internal cost and clinical goals while responding to market situations. The hospital, physicians, and patients all benefit as costs are reduced, quality is enhanced, and the service line's competitive position is strengthened.