Ambulatory Infusion Research Articles

Continuous Interscalene Nerve Block Following Adhesive Capsulitis Manipulation

To the Editor: We report on a prospective series of patients who were treated with a 3-day ambulatory perineural local anesthetic infusion in addition to the customary single-injection brachial plexus block for shoulder manipulation, using specific prospectively-defined endpoints. Shoulder adhesive capsulitis may be treated with manipulation under anesthesia to physically break up scar tissue associated with the joint capsule. After manipulation, frequent intensive range-of-motion exercises are critical to prevent recurrence of pathology.1,2 Unfortunately, shoulder motion following manipulation is often painful, greatly limiting adherence to the exercise regimen and resulting in a return of capsular adhesions.3 While treating shoulder pain with continuous interscalene nerve blocks has been studied previously following invasive surgical procedures in the immediate postoperative period,4 their application in non-surgical patients—and any longer-term, post-infusion effects on range-of-motion—remain uninvestigated.

Inverted stress cardiomyopathy during monitored anesthesia care for endoscopic sinus surgery

Inverted stress cardiomyopathy during monitored anesthesia care for endoscopic sinus surgery

Anemia in Pregnancy & Parenteral Iron Therapy

Anemia is common in pregnancy and iron deficiency is the most common cause. Oral iron is the standard therapy, but there is a problem of adherence due the gastrointestinal side effects. Intravenous iron therapy has more advantages, therefore, intravenous iron therapy is the best treatment for pregnant women during the third trimester. We reviewed the statistics of deliveries of the fiscal year 2012, the cases of anemia in pregnancy as in patients provided by Record Room from the calendar year 2012 and the patient cases that used sodium ferric gluconate complex in sucrose injection (FERRLECIT) from the Obstetrics/Gynecology Ward from the fiscal year 2012 provided by the Department of Pharmacy of the Ashford Presbyterian Community Hospital (APCH). A review of the records of pregnant women receiving iron dextran injection (INFeD) intravenously in our ambulatory infusion center was also performed. Our data confirmed that either presentations elevated the hemoglobin and they were well tolerable. Iron sucrose is the preferred and it has demonstrated a high success rate. I recommend considering this alternative earlier at the third trimester and establishing guidelines using parenteral iron and erythropoietin in combination in refractory cases.

Ambulatory infusion suite: pre- and post-occupancy evaluation

An evaluation is presented of the experience of patients, families and staff in two infusion suites. One infusion suite was a facility occupied until 2009 and the other suite was the replacement for that facility. The primary design objectives of the new facility were to support social interaction, provide opportunities for privacy and provide visual access to nature. The effectiveness of the new facility relative to the old facility with regard to these three design objectives served as the source of hypotheses for the study. Using a Likert-style survey and open-ended questions, the findings suggest that the new facility was successful at addressing these design goals. Subjects were also queried regarding whether these design objectives were important in an infusion suite. The vast majority of the respondents in the new facility indicated that social interaction, privacy and access nature were important in this setting. Il est présenté une évaluation de l'expérience vécue par les patients, les familles et les employés dans deux centres de perfusion. L'un des centres de perfusion était un établissement occupé jusqu'en 2009 et l'autre centre était celui qui a remplacé cet établissement. Les principaux objectifs de conception du nouvel établissement étaient de favoriser l'interaction sociale, de fournir des possibilités de vie privée et d'assurer un accès visuel à la nature. L'efficacité du nouvel établissement par rapport à l'ancien du point de vue de ces trois objectifs de conception a servi d'hypothèse pour l'étude. Obtenus en utilisant une enquête basée sur l'échelle de Likert et des questions ouvertes, les résultats suggèrent que le nouvel établissement a réussi à satisfaire à ces objectifs de conception. Il a également été demandé aux sujets de l'étude si ces objectifs de conception avaient de l'importance dans un centre de perfusion. La grande majorité des personnes interrogées dans le nouvel établissement ont indiqué que l'interaction sociale, la vie privée et l'accès à la nature étaient des éléments importants dans ce contexte. Mots clés: établissement de lutte contre le cancer, évaluation d'établissement, soins de santé, centre de perfusion, occupation, vie privée, interaction sociale

Phase I Study of On 01910.Na (rigosertib), a Multikinase PI3K Inhibitor in Relapsed/Refractory B-Cell Malignancies

AbstractAbstract 1803 Background:Chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL), and related B-cell malignancies are incurable diseases that universally relapse after initial therapy. Resultant cytopenias in refractory patients are a common barrier to salvage therapy. Innovative targeted agents with favorable tolerability profiles that can overcome acquired mechanisms of resistance are urgently needed. ON 01910.Na (rigosertib) is a selective non-ATP competitive multikinase inhibitor that potently inhibits PI3 kinase and induces reactive oxygen species and NOXA-dependent apoptosis in vitro. Pre-clinical testing of rigosertib demonstrated selective cytotoxicity against CLL and MCL cells with minimal effects on normal B and T cells (Chapman et al 2012). Extensive clinical testing of rigosertib in patients with solid tumors or myelodysplastic syndromes (MDS) has indicated lack of myelosuppression and overall good tolerability (Raza et al ASH 2011 #3822). Here, we present the results from the phase I study assessing the safety and maximum tolerated dose (MTD) of intravenous rigosertib in patients with relapsed CLL, MCL, and related B-cell malignancies. Materials and Methods:phase I dose-escalation clinical trial was conducted to evaluate the safety and efficacy of rigosertib in patients with CLL, MCL, MM, and HCL who were refractory or relapsed after ≥1 lines of therapy. Baseline cytopenias were permitted unless ANC < 500 or platelets were < 10K and unable to be supported with transfusion. Pts with GFR < 40ml/min, serum sodium < 134meq/L, and active ascites were excluded. Dose escalation followed a traditional 3+3 design and dosing cohorts were 1200mg/m2, 1500mg/m2 and 1800mg/m2 over 48 hours and 1800mg (flat dose), and 2100mg (flat dose) over 72 hours. Infusions were delivered via an ambulatory infusion pump and repeated in 14 day cycles for up to 4 cycles. Response was determined in patients who completed 4 cycles. Pts who demonstrated a biologic response without DLT were allowed to continue infusions until disease progression. Primary endpoint was toxicity after 2 cycles. Secondary endpoints included the toxicity with extended dosing and measures of biologic activity after 4 cycles. Results:Increasing doses of rigosertib were evaluated in 16 pts with relapsed CLL (10), MCL (2), MM (2), and HCL (2). All patients were evaluated for toxicity, while 10 patients completed 4 cycles of therapy and were evaluable for secondary endpoints. Median age was 61 yrs [range 52–65]. Drug-related adverse events (AEs) were reported in 15 pts (94%) and were almost exclusively grade ≤2. Most frequent drug-related AEs were fatigue 31%, musculoskeletal pain 31%, nausea 19%, constipation 19%, and diarrhea 12%. Grade 3/4 drug-related AEs included 2 cases of G4 neutropenia (both patients had neutropenia at baseline) and 1 case of syncope; there was 1 cardiac death in a patient with pre-existing heart disease that was classified as unrelated. No dose-limiting toxicities (DLTs) were observed. Analysis of blood samples collected for pharmacokinetics is planned. Response data in the 13 patients evaluable for response indicated that 7 had stable disease and 6 had disease progression. No clinical responses or evidence of biologic activity was observed. Conclusions:Escalating doses of rigosertib were well tolerated in patients with relapsed/refractory B-cell malignancies with rare G3/G4 toxicities. Of note, most patients with baseline cytopenias tolerated the therapy well. The highest dose level studied in this study is one step up from the dose level of the ongoing pivotal trial of rigosertib in MDS. However, as a single agent no clinical responses were observed with rigosertib in B-cell malignancies. Further development of rigosertib in lymphoid malignancies will require either combination therapy or alternative dosing schedules. Disclosures:Wilhelm:Onconova: Employment, Equity Ownership.

Treatment of bone marrow edema syndrome with intravenous Ibandronate

In this pilot study, we investigated the therapeutic efficacy of intravenous Ibandronate compared to pain medication on the outcome of bone marrow edemas (BME) of the knee and talus. Fifteen patients with a painful BME of the knee and 15 patients with a BME of the ankle, confirmed on MRI, were enrolled and treated with three ambulatory infusions of each 6mg Ibandronate (group 1). A control group (group 2) of 10 patients with a BME of the knee and 10 patients with a BME of the talus was treated with pain medication and partial weight bearing. Patients were evaluated clinically at baseline and at 1, 3, 6 and 12months after therapy start with a visual analog pain-scale (VAS) and specific joint scores (Larson knee- and Mazur ankle-score). BMEs were assessed with MRI at baseline and after 6months in both groups. In the knee group, the mean VAS pain score decreased from 8.5 at baseline to 1.2 at 12months (p<0.0001) in patients treated with Ibandronate and, respectively, from 8.1 to 4.0 in the control group (p<0.001). In the ankle group, the mean VAS pain score decreased from 8.2 at baseline to 0.9 at 12months (p<0.0001) in patients treated with Ibandronate and, respectively, from 7.9 to 3.9 in the control group (p<0.001). The mean Mazur ankle score increased from 51 to 91points (p<0.001) in group 1, and from 52 to 72points in group 2 (p<0.01). The mean Larson knee score increased from 54 to 89points (p<0.001) at 12months in group 1, and from 51 to 70points in group 2 (p<0.01). For both joints, we observed a significant clinical improvement in the Ibandronate treatment group and in the control group, but functional results were significantly more improved in the Ibandronate treatment group. Only the Ibandronate treatment group showed a significant BME regression at the 6months MRI follow-up. Intravenous Ibandronate therapy showed significantly better clinical results and BME regression rates on MR-imaging compared to analgesic medication in combination with partial weight bearing in the treatment of BME of the knee and talus and shortens the natural course of the disease.

A Clinical Evaluation of the Gemstar® and the Ambit® Pumps for Patient-Controlled Epidural Analgesia

: Background:Â Patient-controlled analgesia is used for both labor and postoperative analgesia. Objectives:Â This study aimed to assess user satisfaction and functionality of two ambulatory, electronic patient controlled analgesia devices, the GemStar pump Hospira Inc., Illinois, USA) and the ambIT Ambulatory Infusion Therapy pump (Sorenson Medical Products, Utah, USA). Patients and Methods:Â It was a randomized clinical trial of laboring women and postoperative gynecology patients receiving patient-controlled epidural analgesia. Patients were randomized to use one of the pumps and both anesthesiologists and patients completed questionnaires about aspects of pump function, and rated their satisfaction with the equipment. Midwives and high-dependency unit nurses also evaluated the pumps in each clinical setting. Results:Â Forty patients, 20 laboring women and 20 postoperative patients were randomized and completed the study. The pumps were compared by nine anesthesiologists. Patient and staff satisfaction with both devices was high. Patient satisfaction did not significantly differ between groups (median 10 [8, 10] for the GemStar and 10 [9, 10] for the ambIT, P = 0.525]. The median staff satisfaction score was 8 [6, 8] for the GemStar and 7 [5, 8] for the ambIT (P = 0.154). Both patient cohorts rated each pump highly for most aspects of clinical function. Staff rated the ambIT pump more favourably with respect to portability and storage at the bedside whilst the GemStar had better assessments with respect to its consumables and interactions involving the electronic interface. Conclusions:Â Both devices were well-rated by patients and staff, with no significant difference between them for overall satisfaction, and only minor differences with respect to their respective strengths and weaknesses.

Bimonthly Regimen of High-Dose Leucovorin, Infusional 5-Fluorouracil, Epirubicin and Cisplatin (Modified ECF) as Adjuvant Chemotherapy in Resected Gastric Adenocarcinoma

Background: The administration of the de Gramont regimen in combination with cisplatin and epirubicin (modified ECF) has previously been reported as a treatment for advanced gastric cancer, but here we report this regimen combination in an adjuvant setting for the first time. Methods: Forty-eight patients with curatively resected gastric cancer were treated. Each 2-week cycle consisted of epirubicin (50 mg/m²), cisplatin (50 mg/m²), 5-fluorouracil (5-FU) IV bolus (400 mg/m²) and 5-FU IV (2,400 mg/m²) over 46 h plus leucovorin IV (400 mg/m²) over 2 h. Postoperative chemoradiotherapy was also administered to the patients when indicated. We retrospectively reviewed the patients who were treated with modified ECF. Results: The median disease-free survival (DFS) was 40.7 months and the 1-, 3- and 5-year DFS rates were 78.5, 55.7 and 44.6%, respectively. The most common grade 3–4 toxicities were hematological and gastrointestinal. Conclusion: A modified ECF regimen may be an effective and convenient treatment with tolerable toxicities for the adjuvant treatment of gastric cancer. It may provide an alternative regimen to the standard ECF when a continuous ambulatory infusion pump is not feasible or not preferred by the patient.

Safety evaluation of ambulatory infusion in socialised cynomolgus monkeys

Safety evaluation of ambulatory infusion in socialised cynomolgus monkeys

A systematic review of the effectiveness of double checking in preventing medication errors

BackgroundMedication errors are unfortunately a constant problem in the medication treatment process. Different interventions are available to reduce or prevent medication errors from reaching the patient. Double checking by two...

Patient Management, and Time and Health Care Resource Utilization Associated with the Use of Intravenous Bisphosphonates For Patients with Metastatic Bone Disease: A Delphi Study

Objective: To identify patient management patterns in patients with solid tumors and metastatic bone disease who are receiving intravenous (IV) bisphosphonates (zoledronic acid and pamidronate), and to estimate the time and health care resources used for preparation and administration of zoledronic acid and pamidronate in patients with metastatic bone disease in Canada. Methods: A modified 2-round Delphi technique was used, which was composed of 7 clinical experts. The first round was performed through telephone interviews with individual clinical experts to assess the management of patients with bone metastases receiving IV zoledronic acid and pamidronate. The interviews focused on qualitative issues, such as drugs administered, cancers identified, and the method of drug administration. The information obtained from the first round was used to describe typical patient management patterns. The information obtained from the second round was done by a face-to-face meeting involving all expert members, with the aim of confirming the management patterns, and identifying commonality and uniqueness across institutions. The time and health care resources needed for preparation and administration of the IV bisphosphonates were estimated. Results: The expert panel comprised 4 pharmacists and 3 nurses from 2 centers in Ontario and 3 centers in Quebec. The main stages identified, which were associated with the preparation and administration of pamidronate and zoledronic acid, included preinfusion activities, IV access set-up, IV bisphosphonate preparation, chemotherapy infusion (if applicable), IV bisphosphonate infusion, and postinfusion activities. Five patient management patterns were identified and varied with respect to inclusion of chemotherapy and the use of ambulatory infusion devices. Without chemotherapy, the mean time for preparation and administration of zoledronic acid ranged from 38 minutes in a community service center to 85 minutes in a hospital-based cancer center. With chemotherapy, the total mean time increased to 119 minutes for patients with prostate cancer and 173 minutes for patients with breast cancer. The mean time for preparation and administration of pamidronate was 159 minutes with the use of a regular infusion device, and the time in the clinic was only 14 minutes with the use of an ambulatory infusion device. If chemotherapy was scheduled on the same visits, the mean time increased substantially, and varied depending on the type of cancer being treated. Conclusion: Preparation and administration of IV bisphosphonates are associated with notable burden to health care providers and patients, even if the waiting time, including preinfusion (eg, IV access set-up, serum creatinine level monitoring) and postinfusion activities, were excluded. Variations in the time and health care resources utilized for preparing and administering IV bisphosphonates were observed across the centers in Canada. The variation could be primarily due to the difference in patient management patterns.

Peri-operative ketamine with the ambulatory elastometric infusion pump as an adjuvant to manage acute postoperative pain after spinal fusion in adults: a prospective randomized trial

BackgroundIn this study, we assessed the effectiveness of ketamine as an alternative to non-steroidal anti-inflammatory drugs (NSAID), to manage acute postoperative pain after spinal fusion when given intravenously via a patient-controlled analgesia (PCA) pump in which the dose was proportional to that of fentanyl.MethodsForty patients undergoing 1-2 level spinal fusion were enrolled in this study. Patients were intraoperatively randomized into two groups to receive intravenous PCA consisting either of fentanyl 0.4 µg/ml/kg (control group) or fentanyl 0.4 µg/ml/kg with ketamine 30 µg/ml/kg (ketamine group) after intravenous injection of a loading dose. The loading dose in the control group was fentanyl 1 µg/kg with normal saline equal to ketamine volume and in the ketamine group it was fentanyl 1 µg/kg with ketamine 0.2 mg/kg. The verbal numerical rating scale (NRS), fentanyl and ketamine infusion rate, and side effects were evaluated at 1, 24, and 48 hours after surgery.ResultsThere were no significant differences in patient demographics, duration of surgery and anesthesia or intra-operative opioids administration. We did not find any significant differences in the mean infusion rate of intraoperative remifentanil or postoperative fentanyl or in the side effects between the groups, but we did find a significant difference in the NRS between the groups.ConclusionsBased on our results, we conclude that a small dose of ketamine (0.5-2.5 µg/kg/min) proportional to fentanyl is not only safe, but also lowers postoperative pain intensity in patients undergoing spinal fusion, although the opioid-sparing effects of ketamine were not demonstrated.

A Clinical Evaluation of the Gemstar® and the Ambit® Pumps for Patient-Controlled Epidural Analgesia

BackgroundPatient-controlled analgesia is used for both labor and postoperative analgesia.ObjectivesThis study aimed to assess user satisfaction and functionality of two ambulatory, electronic patient controlled analgesia devices, the GemStar pump Hospira Inc., Illinois, USA) and the ambIT Ambulatory Infusion Therapy pump (Sorenson Medical Products, Utah, USA).Patients and MethodsIt was a randomized clinical trial of laboring women and postoperative gynecology patients receiving patient-controlled epidural analgesia. Patients were randomized to use one of the pumps and both anesthesiologists and patients completed questionnaires about aspects of pump function, and rated their satisfaction with the equipment. Midwives and high-dependency unit nurses also evaluated the pumps in each clinical setting.ResultsForty patients, 20 laboring women and 20 postoperative patients were randomized and completed the study. The pumps were compared by nine anesthesiologists. Patient and staff satisfaction with both devices was high. Patient satisfaction did not significantly differ between groups (median 10 [8, 10] for the GemStar and 10 [9, 10] for the ambIT, P = 0.525]. The median staff satisfaction score was 8 [6, 8] for the GemStar and 7 [5, 8] for the ambIT (P = 0.154). Both patient cohorts rated each pump highly for most aspects of clinical function. Staff rated the ambIT pump more favourably with respect to portability and storage at the bedside whilst the GemStar had better assessments with respect to its consumables and interactions involving the electronic interface.ConclusionsBoth devices were well-rated by patients and staff, with no significant difference between them for overall satisfaction, and only minor differences with respect to their respective strengths and weaknesses.

Assessment of infliximab utilization for Crohnʼs disease and Ulcerative Colitis patients across different sites-of-care

Currently, there are limited data characterizing infliximab (IFX) utilization across different sites-of-care. The purpose of this analysis was to explore IFX vial utilization patterns for Crohn's disease (CD) and ulcerative colitis (UC) patients in hospital outpatient departments (HOPD), in-office infusion settings (IOI), and alternate sites of care (ASOC), such as community-based ambulatory infusion centers. This study analyzed IFX claims between 1/1/2009 and 12/31/2010 from data provided by 72 U.S. commercial insurers representing approximately 192 million covered lives throughout the United States. IFX claims were identified for this analysis by J Code (1745) and claims specifically for CD and UC were further identified by ICD-9 codes (CD-555.x; UC-556.x). The number of IFX vials per infusion (VPI) was derived from Health Care Procedure Code System entries and verified by associated charges. Mean VPI was analyzed across the aforementioned sites-of-care in the 2009-2010 study period. Of the 766,297 IFX infusion claims identified, approximately 276,717 (36%) were associated with a diagnosis of CD or UC and included in the analysis. For CD patients, there was an average of 95,158, and 118,091 infusions in 2009 and 2010, respectively. For UC patients, the average number of infusions was 25,357 and 38,111 in 2009 and 2010, respectively. IFX vial utilization per infusion was consistent between 2009 and 2010 for CD and UC patients across sites-of-care. The 2009 mean VPI for CD patients was 4.96 in IOI, 4.89 in HOPD, and 4.88 in ASOC. For UC patients, the 2009 mean VPI was 4.65 in IOI, 4.92 in HOPD, and 4.67 in ASOC. The 2010 mean VPI values for CD and UC patients were similar to those observed in 2009 (Table 1). Mean Vials per Infusion (VPI) Mean Vials per Infusion (VPI) These findings indicate that IFX utilization for CD and UC patients was stable from 2009 to 2010 and was consistent across different sites-of-care (i.e., IOI, HOPD, and ASOC). While this analysis indicated consistent IFX vial utilization per infusion across different sites-of-care, further research exploring additional measures, such as patient adherence and patient satisfaction, may provide further insight into the complete patient care experience across sites and support optimal site of care decision making.

Infliximab utilization patterns within an alternate site of care setting among patients with Inflammatory Bowel Disease

To examine infliximab dosing patterns among patients with inflammatory bowel disease (IBD) receiving therapy in an alternate site-of-care setting (i.e., ambulatory infusion centers). A retrospective analysis of drug utilization data from nine ambulatory infusion centers (AIC) was conducted. Patients were required to be aged ≥18, have ≥ 2 ICD-9 codes for Crohn's disease (555.x) or ulcerative colitis (556.x), and have ≥3 infusions administered at an AIC during the measurement period (6/2008 - 3/2010). Both “new’ patients (those receiving their first infliximab dose within the AIC) and “existing” patients (those receiving infliximab doses at another site prior to the AIC) were included in the analysis. Available data included demographic information, diagnosis fields, and infliximab infusion information. Patient weight was also available, allowing for direct calculation of infliximab dose. Dosing intervals were calculated as the number of days between infusions. Mean and median infusion intervals and infliximab doses were compared to FDA prescribing information. To measure possible interval and dose changes over time, repeated-measures analyses of covariance (ANCOVA) were conducted. A total of 167 patients with IBD were included in the analysis (Crohn's disease=107, ulcerative colitis=60). Of these patients, 84 were new patients and 83 were existing patients. Approximately 56% of the new patients were male, mean age was 45 years, mean weight was 82 kg, and mean number of infusions during the measurement period was seven. Among existing patients, 45% were male, mean age was 40 years, mean weight was 74 kg, and mean number of infusions during the study period was eight. Approximately 94% of new patients (n = 79/84) received a starting infliximab dose of 5mg/kg. Over the first eight infusions, the mean infliximab dose for new patients ranged from 4.94 mg/kg to 5.18 mg/kg. Among existing patients, the mean infliximab dose ranged from 5.52 mg/kg to 5.77 mg/kg over the first eight infusions received within the AIC setting. Among new patients, the median number of days between the 1st and 2nd infusion was 14 days, and between the 2nd and 3rd infusion was 28 days. For the third through eighth infusions, the median number of days between infusions ranged from 55 to 56 days. Similarly, among existing patients, the median number of days between the first eight infusions ranged from 50 to 56 days. Based on ANCOVA results, there was no evidence of systematic change in dose or dosing interval over time. Among IBD patients receiving infusions in an AIC, the infliximab dose and dosing frequency were consistent with FDA prescribing information and there was no evidence of systematic dose or dosing frequency change over time. Infliximab utilization patterns within the AIC setting, as identified in this analysis, appear to be consistent with the in-office infusion setting1. Evaluation of other factors, such as patients' preferences, may be useful in further characterizing this site of care and supporting optimal site-of-care decision-making.

Introducing the accufuser: a new solution for ambulatory continuous epidural infusion

IntroductionEpidural analgesia is useful for some patients with refractory cancer pain. However delivering a continuous epidural infusion can raise some challenges regarding safety and practicality. We present our experience of...

Continuous Peripheral Nerve Blocks

A continuous peripheral nerve block, also termed "perineural local anesthetic infusion," involves the percutaneous insertion of a catheter adjacent to a peripheral nerve, followed by local anesthetic administration via the catheter, providing anesthesia/analgesia for multiple days or even months. Continuous peripheral nerve blocks may be provided in the hospital setting, but the use of lightweight, portable pumps permits ambulatory infusion as well. This technique's most common application is providing analgesia after surgical procedures. However, additional indications include treating intractable hiccups; inducing a sympathectomy and vasodilation to increase blood flow after a vascular accident, digit transfer/replantation, or limb salvage; alleviating vasospasm of Raynaud disease; and treating peripheral embolism and chronic pain such as complex regional pain syndrome, phantom limb pain, trigeminal neuralgia, and cancer-induced pain. After trauma, perineural infusion can provide analgesia during transportation to a distant treatment center, or while simply awaiting surgical repair. Catheter insertion may be accomplished using many possible modalities, including nerve stimulation, ultrasound guidance, paresthesia induction, fluoroscopic imaging, and simple tactile perceptions ("facial click"). Either a nonstimulating epidural-type catheter may be used, or a "stimulating catheter" that delivers electrical current to its tip. Administered infusate generally includes exclusively long-acting, dilute, local anesthetic delivered as a bolus only, basal only, or basal-bolus combination. Documented benefits appear to be dependent on successfully improving analgesia, and include decreasing baseline/breakthrough/dynamic pain, supplemental analgesic requirements, opioid-related side effects, and sleep disturbances. In some cases, patient satisfaction and ambulation/functioning may be improved; an accelerated resumption of passive joint range-of-motion realized; and the time until discharge readiness as well as actual discharge from the hospital or rehabilitation center achieved. Lastly, postoperative joint inflammation and inflammatory markers may be decreased. Nearly all benefits occur during the infusion itself, but several randomized controlled trials suggest that in some situations there are prolonged benefits after catheter removal as well. Easily rectified minor complications occur somewhat frequently, but major risks including clinically relevant infection and nerve injury are relatively rare. This article is an evidence-based review of the published literature involving continuous peripheral nerve blocks.

Feasibility of a four-week ambulatory intravenous infusion in the dog for preclinical safety assessment: Impact on toxicological and histopathological endpoints

Feasibility of a four-week ambulatory intravenous infusion in the dog for preclinical safety assessment: Impact on toxicological and histopathological endpoints

Curlin Ambulatory Infusion Pumps

Biomedical Safety & Standards 41(11):p 83, June 15, 2011. | DOI: 10.1097/01.BMSAS.0000398924.30584.11

The Analysis of Apomorphine Formulations for Ambulatory Infusions

An HPLC assay has been developed for the specific determination of apomorphine hydrochloride in ambulatory infusions. This assay was able to resolve a degradation peak of apomorphine which rapidly formed under the acidic conditions commonly used in liquid-liquid extraction procedures for apomorphine, as well as in alkaline conditions. The adduct formed from the reaction of apomorphine with sodium metabisulphite was also separated in this assay. The presence of a chelating agent (EDTA, 0·003% w/v) in the mobile phase prevented interference by secondary degradation products postulated to be formed by M2+-catalysed auto-oxidation of degraded apomorphine on the HPLC system. Apomorphine injection (10 mg mL−1) (Manor Park Pharmaceuticals, formulated with EDTA, 0·05% w/v, and ascorbic acid, 0·1% w/v) was found to be unstable over a 7-day incubation period in Graseby 9000 series infusion reservoir cassettes, both at 8 and 37°C, with drug solutions rapidly darkening over time, pH values lowering, and unpleasant odours developing, although the measured apomorphine concentrations did not significantly alter. However, apomorphine injection (10 mg mL−1) from Brittania Pharmaceuticals (formulated with sodium metabisulphite, 0·1% w/v) did not show any colour or pH changes under the same incubation conditions, with 98% remaining after 14 days at 8°C, and 96% remaining after 7 days at 37°C. The Britaject formulation could therefore be recommended for use in the Graseby 9000 series infusion device.