Polyclonal, nonspecific 111In-IgG scintigraphy in the evaluation of complicated osteomyelitis and septic arthritis.

BACKGROUND: In this investigation we tested the hypothesis that 111In-IgG scintigraphy can differentiate infectious from sterile inflammatory processes in patients with complicated osteomyelitis or septic arthritis. METHODS: A prospective university hospital based study was performed over 18 months. We studied 31 sites of suspected infection, in 25 adult patients, (age 18 to 74 years, 12 females and 13 males) referred with clinical presentations compatible with complicated osteomyelitis or septic arthritis and in whom proof of the infection was likely to be obtained. The clinical setting in these patients was previous trauma, recent surgery, peripheral vascular disease or adjacent soft tissue infection. Whole body scintigraphy was performed at 1-6, 18-24 and 42-48 hours after administration of 55 MBq of 111In-IgG and results were compared to radiographs, 99mTc-MDP skeletal scintigraphy, biopsy specimens (9 sites) or synovial fluid aspirates (4 sites) and clinical follow-up. RESULTS: Of the 31 sites evaluated, 68% (21/31) were interpreted as negative for abnormal tracer accumulation and 32% (10/31) were considered positive. In patients who underwent biopsy and/or synovial fluid aspiration, 6 of 7 sites were correctly interpreted as positive; sensitivity 86%. Five of 6 sites were correctly interpreted as negative; specificity 83%. When all patients were considered using clinical follow-up in addition to culture results, 9 of 10 sites were correctly interpreted as positive (sensitivity 90%) and 20 of 21 patients were correctly interpreted as negative (specificity 95%). CONCLUSIONS: 111In-IgG scintigraphy is useful for detection of musculoskeletal infection in patients in whom sterile inflammatory events simulate infectious processes.

Patient-controlled analgesia with epidural meperidine after elective cesarean section.

BACKGROUND AND OBJECTIVES: We report the first controlled analysis of the use of patient-controlled epidural meperidine. This randomized, prospective study compares the efficacy and safety of patient-controlled epidural meperidine to conventional intramuscular meperidine for the management of postoperative pain after elective cesarean delivery. METHODS: After delivery, 60 patients were randomly assigned to receive either conventional intramuscular meperidine therapy or epidural meperidine by a patient-controlled analgesia pump, which was programmed to deliver bolus doses in addition to a continuous background infusion. RESULTS: Patients in the patient-controlled epidural analgesia group used significantly less meperidine in the first 24 hours after surgery (p < 0.05) and had significantly lower visual analog pain scores (p < 0.05) from three hours postoperatively until study completion at 24 hours. Patients in the patient-controlled epidural analgesia group ambulated sooner (19 +/- 7.8 versus 29.2 +/- 2.2 hours, p < 0.005) and cared for their infants earlier (4.6 +/- 0.9 versus 8.1 +/- 6.8 hours, p < 0.05) than patients receiving intramuscular meperidine. One patient developed a respiratory rate of four breaths per minute, 25 minutes after receiving 75 mg epidural meperidine in the operating room. This was treated with intravenous naloxone. No other serious side effects occurred in either group. Both groups were similar with regard to minor intraoperative and postoperative side effects. CONCLUSIONS: Patient-controlled epidural meperidine after cesarean delivery more effectively manages postoperative pain than conventional intramuscular use. The technique is preferred by both patients and nursing staff and can be used in the ward setting with appropriate organization and education. Respiratory depression, if it occurs, should present early after epidural bolus administration.