Postlaparotomy pain management: Comparison of patient-controlled analgesia pump alone, with subcutaneous bupivacaine infusion, or with injection of liposomal bupivacaine suspension.

OBJECTIVE: Efforts to achieve balance between effective pain management and opioid-related adverse events (ORAEs) have led to multimodal analgesia regimens. This study compared opioids delivered via patient-controlled analgesia (PCA) plus liposomal bupivacaine, a long-acting local anesthetic with potential to be an effective component of such regimens, to opioids delivered through PCA alone or PCA plus subcutaneous bupivacaine infusion (ONQ), following laparotomy. DESIGN: Prospective, randomized controlled trial. SETTING: Single, tertiary-care institution. PATIENTS: One hundred patients undergoing nonemergent laparotomy. INTERVENTIONS: Patients were randomly assigned to one of three study treatments: PCA only (PCAO), PCA with ONQ, or PCA with injectable liposomal bupivacaine suspension (EXP). MAIN OUTCOME MEASURES: Cumulative opioid use, daily mean patient-reported pain scores, and ORAEs through 72 hours postoperatively. RESULTS: On average, the EXP (n = 31) group exhibited less than 50 percent of the total opioid consumption of the PCAO (n = 36) group, and less than 60 percent of that for the ONQ (n = 33) group. Postoperative days 1 and 3 pain scores were significantly lower for the EXP group as compared to the ONQ and PCAO groups (p ≤ 0.005). Fewer patients in the EXP group (19.4 percent) experienced ORAEs compared to the PCAO (41.1 percent) and ONQ (45.5 percent) groups (p = 0.002). CONCLUSIONS: Laparotomy patients treated with liposomal bupivacaine as part of a multimodal regimen consumed less opioids, had lower pain scores, and had fewer ORAEs. The role of liposomal bupivacaine in the postoperative care of laparotomy patients merits further study.

Improving Outcomes for Lower Extremity Amputations Using Intraoperative Fluorescent Angiography to Predict Flap Viability.

OBJECTIVES: Nearly 25% of vascular surgery patients operated on for peripheral vascular disease are readmitted within 30 days. Development of adjuncts to minimize wound complications remains an area of great interest. Here, we present our experience with intraoperative fluorescent angiography (IFA) as a tool to predict skin flap viability following lower extremity amputations (LEAs). METHODS: Experience with IFA using indocyanine green (ICG) dye was reviewed retrospectively at a single institution. Records of patients undergoing LEA with use of IFA by 2 vascular surgeons from 2013 to 2014 were reviewed. Absolute and relative tissue perfusion values were evaluated for sensitivity and specificity in regard to skin flap viability. RESULTS: Thirteen patients with a mean age of 70.5 years (standard deviation [SD] = 12.0, range: 49-93 years) underwent 17 amputations. Indications included rest pain, tissue gangrene, and vascular disease unsuitable for revascularization. Amputation levels included toe (23%), transmetatarsal (18%), below knee (41%), and above knee (18%). Six (35%) amputations required revision with a mean time-to-revision of 26.1 days (SD = 19.9, range: 9-61 days). Of these revisions, 14 (83%) patients proceeded to a proximal-level amputation. Mean follow-up was 235 days (SD = 148, range: 5-448 days), and IFA was used in all cases. Absolute perfusion values (APVs) between 5 and 9 displayed sensitivity and specificity of 50% and 64%, respectively. Additionally, a relative perfusion value (RPV) of ≤31% displayed 100% sensitivity and specificity. Sensitivity and specificity fell to 83% at a relative perfusion of ≤27% and ≤35%, respectively. CONCLUSION: IFA during LEA is safe and easily performed by the vascular surgeon. The RPVs as a predictor of skin flap viability correlate well with those reported in breast reconstructive surgery. Unfortunately, APVs fail to support any predication for flap failure or success. Patient comorbidities and intraoperative variables such as vasopressor use may contribute to this finding.

A microanatomical map of the structures hidden in the middle fossa based on the facial nerve hiatus: measurements and their variability.

The aim of this study was to investigate the relationships/variations between the facial nerve hiatus (FNH) and middle cranial fossa neuro-vascular structures. Twenty CT-scanned middle cranial fossae of fresh adult cadavers were used; the greater superficial petrosal nerves, and critical neuro-vascular structures were identified. Using the FNH as a reference point, a neuronavigation system was used to measure the distance between each structure and the FNH. The coefficient of variation (CV) was used to quantify the degree of variation among each distance. The mean distances and standard deviations between the various landmarks and the FNH, and the associated CV were analyzed. Furthermore, a microanatomical map of the structures hidden in the middle fossa based on the greater superficial petrosal nerve was generated. The most reliable relationships of the FNH were with the internal auditory canal (CV = 14.59), and with the vertical portion of the intrapetrous internal carotid artery (CV = 15.54). Our data demonstrate that the FNH can be used as anatomical landmark to plot the position of several hidden neurovascular structures when performing a middle-fossa skull base approach. However, the pattern and the variation of these structures had to be recognized.

Decompressive craniectomy and early cranioplasty for the management of severe head injury: a prospective multicenter study on 147 patients.

OBJECTIVE: In emergency care of patients with severe blunt head injury, uncontrollable high intracranial pressure is one of major causes of morbidity and mortality. The purpose of this study was to evaluate the efficacy of aggressive surgical treatment in managing uncontrollable elevated intracranial pressure coupled with early skull reconstruction. METHODS: This was a prospective study on a series of 147 consecutive patients, managed according to the same protocol by five different neurosurgical units, for severe head injuries (Glasgow coma scale score ≤8/15 and high intracranial pressure >25 mm Hg) during a five-year period. All patients received a wide decompressive craniectomy and duroplasty in the acute phase, and a cranioplasty was also performed within 12 weeks (median 6 weeks, range 4-12 weeks). RESULTS: The emergency decompressive surgery was performed within 28 hours (median 16 hours, range 6-28 hours) after sustaining the head injury. The median preoperative Glasgow coma scale score was 6/15 (range 3-8/15). At a mean follow-up of 26 months (range 14-74 months) 14 patients were lost to long-term follow-up, leaving only 133 patients available for the study. The outcome was favorable in 89 (67%, Glasgow outcome score 4 or 5), it was not favorable in 25 (19%, Glasgow outcome score 2 and 3), and 19 patients (14%) died. A younger age (<50 years) and earlier operation (within 9 hours from trauma) had a significant effect on positive outcomes (P < 0.0001 and P < 0.03, respectively). CONCLUSIONS: A prompt aggressive surgery, including a wide decompressive craniectomy coupled with early cranioplasty, could be an effective treatment method to improve the outcome after a severe closed head injury reducing, perhaps, many of the complications related to decompressive craniectomy.