Use of a stimulating catheter for total knee replacement surgery: preliminary results.

BACKGROUND: There is continuing debate as to whether the use of electrical stimulation that aids in localizing nerves is also beneficial for optimizing placement of nerve catheters and lead to improved clinical outcomes, such as reductions in pain scores and opioid consumption. METHODS: We undertook a retrospective, non-randomized comparison of stimulating and non-stimulating nerve catheters in 419 patients undergoing total knee replacement between December 2002 and July 2004. Before surgery, patients received sciatic and femoral nerve blocks with a catheter for the femoral nerve. In 159 patients a stimulating catheter system (Stimucath; Arrow International, Reading, PA, USA) and in 260 patients a non-stimulating catheter system (Contiplex; B. Braun, Melsungen, Germany) was used. After surgery, pain scores and morphine consumption were recorded at 4-h intervals until the first postoperative morning. In a subset of 85 patients, the postoperative evaluation period was lengthened to 3 days. RESULTS: Postoperative visual analogue scores (VAS) for pain were similar in the two groups during the first 24 h (P=0.305). In patients followed for 3 days, VAS scores did not differ on any of the days (P=0.427). Total morphine consumption did not differ on the first postoperative day (mean [95% CI]: stimulating, 12.4 [10.1-14.7] mg; non-stimulating 10.4 [8.9-11.8] mg; P=0.140) or on subsequent days. CONCLUSIONS: The practical advantages of the stimulating catheter, as reported by previous investigators, were not obvious in this clinical situation. In terms of outcome measures such as pain scores and morphine consumption, we found no significant differences between stimulating and non-stimulating catheters.

Representation of clinical practice guidelines through an interactive World-Wide-Web interface.

The widespread utility of clinical practice guidelines is greatly dependent on the ease with which they can be accessed, used, and applied. Because it supports hyperlinking and is widely accessible, the World-Wide Web is a medium that is well suited for browsing through guidelines. We have developed a process for implementing algorithmic guidelines into a graphical format that allows the user to browse these guidelines in an interactive fashion. The guidelines we used were already in or could be transformed to an algorithmic format that lends itself well to analysis with decision table techniques, which in turn permits a fairly straightforward conversion into a graphical representation. The results of this process allow a user to browse a particular guideline algorithm and to visualize the traversed parts of the algorithm by flowcharts. Our first experiences with this method of representing a few sample clinical practice guidelines have been encouraging, and we hope to extend this method to other guidelines.

Integrating QMR with a computer-based patient record.

Most diagnostic decision support (DDS) systems are used as stand-alone applications. At present, the physician can only benefit from the suggestions of a DDS system if he is sufficiently motivated to re-enter patient data and run a diagnostic case analysis. If data from a computer-based patient record (CBPR) could be made available electronically to a DDS system, the use of that DDS system may become much more practical. Integrating a CBPR with a DDS system requires a mapping between two different data structures and dictionaries. We have explored a strategy to create a mapping between our CBPR and QMR. Our research has provided more general insight in the potential and limitations of such a mapping.