Elastomeric Pump Research Articles

Opioid-Free Segmental Thoracic Spinal Anesthesia with Intrathecal Sedation for Breast and Axillary Surgery: Report of Four Cases

PurposeFew studies have described segmental thoracic spinal anesthesia (STSA) as primary anesthesiologic method in breast and axillary surgery, documenting the association of intrathecal local anesthetics and opioids. This case series reports an opioid-free scheme of STSA in four elderly patients undergoing major breast and axillary oncological surgery.Patients and MethodsSTSA was performed in three female patients undergoing unilateral mastectomy ± axillary lymph node dissection (ALND) or sentinel lymph node biopsy for invasive ductal carcinoma and in one male patient undergoing ALND for melanoma metastases. The level of needle insertion was included between T6-8, via a median or paramedian approach. Midazolam (2 mg) and ketamine (20 mg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 8 mg. The level of sensory blockade achieved was comprised between C2-3 and T11-12. Postoperative analgesia was maintained through continuous intravenous administration of Ketorolac by an elastomeric pump (90 mg over 24 hrs.).ResultsSpinal anesthesia was completed without complications in all patients. Conversion to general anesthesia (GA) and perioperative intravenous sedation were not required. No major postoperative complications and no episodes of postoperative nausea and vomiting (PONV) were reported. No rescue analgesic was administered. All patients were discharged in postoperative day 2 and are alive at 30, 29, 27 and 13 months after surgery, respectively. High grade of satisfaction on the anesthesiologic method was expressed by all cases.ConclusionSTSA with local anesthetic plus midazolam and ketamine might be considered a safe and effective alternative to GA, even in surgeries involving the breast and axillary region, particularly in elderly and frail patients. Larger prospective studies are required to validate these findings.

Implementation and Postoperative Management of Continuous Adductor Canal Catheters for Total Knee Arthroplasty to Reduce Surgical Backlog Related to the COVID-19 Pandemic: An Acute Pain Service Nursing Perspective and Educational Resource

PurposeIn response to the surgical backlog created by the COVID-19 pandemic and to spare valuable hospital resources, we developed and implemented a continuous adductor canal catheter (CACC) program for total knee arthroplasty (TKA) patients. CACC's offer superior analgesia, decrease opioid use, and increase patient satisfaction while simultaneously promoting a decreased length of hospital stay and even same day discharges. The implementation of analgesia protocols using continuous peripheral nerve catheters and isometric pumps has been described for other surgical procedures and populations; however, the role of the Acute Pain Service Nurse (APS RN) in the implementation of such a program has not been described. DesignAn best practice initiative for TKA patients receiving CACC was developed and implemented for patients recovering both in the hospital and at home. MethodsWe describe the development and implementation of a CACC program for TKA patients in response to the surgical backlog created by the COVID-19 pandemic from the perspective of the APS RN. We provide a detailed narrative description of our postoperative assessment and experience, and offer practical insights for the postoperative care of these patients. We share the educational resources and assessment tools we developed to ensure consistent, safe, and effective clinical management of CACC patients in the hospital and at home. FindingsCACCs via elastomeric pumps have been shown to offer significant advances to pain control following TKA, decrease opioid use, enable earlier discharge, and improve patient satisfaction, all of which we observed unequivocally in our patients. In our experience, implementation of a daily telephone follow up by an APS RN for discharged TKA patients with a CACC was crucial for patient safety, patient satisfaction, and reducing emergency phone calls and emergency room visits. ConclusionsWe anticipate this description will provide an invaluable educational resource for other Acute Pain Service programs as similar outpatient peripheral nerve catheter programs are developed in response to the pandemic.

Neuromuscular activation of quadriceps bellies during tasks performed in the same biomechanical condition in patients undergoing total knee arthroplasty

ObjectiveTo investigate neuromuscular activation of quadriceps bellies during different tasks in patients before and after total knee arthroplasty (TKA). MethodsTwenty-six patients scheduled for TKA and 16 control subjects performed three isometric tasks: knee extension (KE), hip flexion (HF), hip flexion with contralateral hip extension (HFE). Surface electromyography signals of rectus femoris, vastus medialis and vastus lateralis were collected the day before (T0), at one (T1) and three (T2) days after surgery, whereas control subjects underwent a single evaluation. The Root Mean Square peak normalized for its highest value during the three tasks (nRMS-peak) was used as index of maximum neuromuscular activation for each belly. Sixteen patients performed the postoperative assessment, due to the placement of an elastomeric pump aimed at reducing pain in 10 patients. ResultsPatients showed lower rectus femoris nRMS-peak during KE compared to HF and HFE before and after surgery (p < 0.001), as occurred in control subjects. Differently from control subjects, patients showed higher vastus medialis and vastus lateralis nRMS-peak during HF compared to KE at T1 (p = 0.008) and T2 (p = 0.039). ConclusionTKA modified quadriceps neuromuscular activation during different tasks performed the same biomechanical condition. These findings may be considered in planning physiotherapy interventions after TKA.

Addiction of High Dose of Benzodiazepine: Verona Detox Approach With Flumazenil.

IntroductionSince the 1990s there has been evidence of the significant role Flumazenil (FLU) has in benzodiazepines (BZD) detoxes. The Verona Detox approach has been developed for high dose BZD and Z-drug detoxification via continuous subcutaneous infusion of FLU, a selective BZD receptor antagonist acting on the BZD subunit of the GABA-A receptor. Flumazenil is licensed in the United Kingdom and other countries to treat only BZD overdose although numerous studies have demonstrated its effectiveness in rapidly resetting GABA-A receptors, quickly reducing tolerance and dependence from BZD, and providing a safe and rapid detox from benzodiazepines.ObjectiveThe aim of this article is to provide all healthcare professional who are interested in BZD detoxification with an approach and clear practical information on how to administer FLU.MethodIn this article we outline the approach in detail, describing all medical and nursing procedures day by day. This detox treatment is indicated for patients abusing from at least 5 Defined Daily Dose (DDD) of BZDs or Z-drugs. The process lasts 7 days, and is conducted under medical supervision (daily reviews) and continuous nursing (24/7). During this period, 7mg of FLU is administered (1 mg/24) through an elastomeric pump, via continuous subcutaneous infusion.ConclusionTo this day, the largest database of FLU detoxification was published by our group, showing how this treatment is safe, with very little side effects even in patients with significant medical comorbidities.

51 Case of stevens-johnson syndrome caused by ondansetron administered by elastomeric pump in the late-stage ovarian cancer patient

Introduction: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous reactions, which are considered a delayed-type hypersensitivity reaction to medication and are characterized by extensive necrosis and detachment of the epidermis. Both are rare diseases, uncommon in the field of gynaecological oncology. They are associated with a wide array of medications, ondansetron being a possible, but quite rare cause of the disease. Treatment of this condition requires a multidisciplinary approach and consists of supportive treatment, local skin and mucosal membranes care, ocular management and different adjunctive therapies.

Infectious complications of intercostal nerve cryoablation mediated by perioperative hypothermia during pediatric Nuss procedure

BackgroundIntercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in minimally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalgesia effects on infectious complications following MIRPE. MethodWe performed a retrospective review of patients undergoing MIRPE at our institution. Patients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/- elastomeric pain pumps (Non-cryo). Core body and intraoperative minimum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value ≤ 0.05 being significant. Results80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p =0.86), number of bars inserted (2[1,2];p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4°C [35.0,35.8];p = 0.76), median change in intraoperative temperature (-0.13°C [-0.44,0.00];p = 0.94) or median recovery temperature (-1.10°C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4°C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%,p = 0.31) or median[IQR] for LOS (4[3,4];p = 0.57), between Cryo and Non-cryo patients. ConclusionAlthough cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications.

Prepared omadacycline for injection: Nine-day stability and sterility in an elastomeric pump.

To investigate compatibility, stability, and microbiologic risk of omadacycline 1 mg/mL when prepared in an elastomeric infusion pump and stored under refrigeration for 9 days based upon requests for information from healthcare providers. Omadacycline was reconstituted to 1 mg/mL with sodium chloride 0.9% w/v or dextrose 5% w/v in SMARTeZ® elastomeric infusion pumps and refrigerated for up to 9 days. Samples were taken daily and tested for appearance, pH, osmolality, chemical composition, and particulate matter. For a microbial challenge study, the pumps were spiked with a challenge microorganism (Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Candida albicans, or Aspergillus brasiliensis) and samples were plated daily for 9 days to assess microbial survival. Appearance, pH, osmolality, percent label claim, and particulate matter results remained essentially unchanged for omadacycline solutions in either diluent over the 9-day study. No > 0.5-log day-to-day increases in the challenge-microorganism populations were measured in diluted omadacycline pumps or positive controls. With omadacycline, no growth was seen for S. aureus or E. coli in either diluent, nor for P. aeruginosa in dextrose 5% w/v. Reduction of C. albicans and A. brasiliensis populations over time was similar between omadacycline solutions and positive controls. After reconstitution, omadacycline for injection was stable and remained within specifications for use for up to 9 days when refrigerated.

Stability of Antimicrobials in Elastomeric Pumps: A Systematic Review.

Outpatient parenteral antimicrobial therapy (OPAThttp) programs have become an important healthcare tool around the world. Portable elastomeric infusion pumps are functional devices for ambulatory delivery of antimicrobial drugs, and their stability is an essential point to guarantee an appropriate infusion administration. We conducted a systematic review to provide a synthesis and a critical evaluation of the current evidence regarding antimicrobial stability in elastomeric pumps. Data sources were PubMed, EMBASE, and Web of Sciences. The review protocol was registered on the Center for Open Science, and it was carried out following the PRISMA guidelines. Studies were eligible if the aim was the evaluation of the physicochemical stability of an antimicrobial agent stored in an elastomeric device. Of the 613 papers identified, 33 met the inclusion criteria. The most studied group of antimicrobials was penicillins, followed by cephalosporins and carbapenems. In general, the stability results of the antimicrobials that have been studied in more than one article agree with each other, with the exception of ampicillin, flucloxacillin, and ceftazidime. The antibiotics that displayed a longer stability were glycopeptides and clindamycin. Regarding the stability of antifungals and antivirals, only caspofungin, voriconazole, and ganciclovir have been investigated. The information provided in this article should be considered in patient treatments within the OPAT setting. Further stability studies are needed to confirm the appropriate use of the antimicrobials included in this program to ensure optimal patient outcomes.

Postoperative prolonged epidural analgesia using disposable elastomeric pumps in elderly patients after spinal neurosurgery

BACKGROUND: Postoperative pain is a significant problem in patients that causes various complications.&#x0D; AIM: To evaluate the efficacy and safety of prolonged epidural analgesia using&#x0D; disposable elastomeric pumps in elderly patients undergoing spinal neurosurgery and its comparison with the traditional method of postoperative analgesia in 80 patients.&#x0D; MATERIALS AND METHODS: Hemodynamic parameters were recorded and the efficiency of pain relief and nature of postoperative complications were assessed in comparable groups. The concentration of interleukin-6 (IL-6) and IL-2 were determined.&#x0D; RESULTS: In the group with prolonged epidural analgesia with 0.2% ropivacaine solution, an adequate level of analgesia was achieved in 92% of the patients. The revealed changes in the blood serum levels of cytokines IL-6 and IL-2 may indicate a balanced response of the immune system in the group with prolonged epidural analgesia.&#x0D; CONCLUSIONS: Prolonged epidural analgesia using disposable elastomeric pumps provides complete pain relief for patients and correction of individual links of the surgical stress response.

Implementing the First Outpatient Parenteral Antimicrobial Therapy (OPAT) Program to Utilize Disposable Elastomeric Pumps in the Gulf Region: Results From a Tertiary Teaching Hospital in the Kingdom of Saudi Arabia.

ObjectivesTo describe the implementation process, safety, and efficacy outcomes, as well as cost-effectiveness, of the first outpatient parenteral antimicrobial therapy (OPAT) program to utilize disposable elastomeric pumps in the Kingdom of Saudi Arabia and the entire Gulf region.MethodsThis OPAT program was initiated in May 2018 and was administered through a multidisciplinary team that included the home medicine department, pharmacy department, nursing department, and the infectious diseases service. The device used was the Intermate® (Baxter, Deerfield, Illinois) elastomeric pump. After consultation with an infectious diseases physician, eligible patients were discharged home to complete the remainder of their antimicrobial treatment, which was self-administered via the elastomeric devices.ResultsFrom May 2018 to December 2019, 47 patients received 55 courses of OPAT via the new program. A total of 2,869 pumps were used during that period to provide 927 days of antimicrobial therapy in the home setting. Most patients completed the program successfully with no reported significant OPAT-related complications such as catheter-related infections. Four patients were re-admitted for relapse of infections and one patient was re-admitted for colistin-induced nephrotoxicity. No mortality was reported for any patient during OPAT treatment and 30 days after program completion.ConclusionsThe implementation of this novel OPAT program was safe, effective, and offered significant cost-savings to our institution. The entire process was very dynamic and was centered around proper patient selection and education as well as excellent communication between patients and the entire multidisciplinary team involved in the program. We hope that these results will encourage other institutions in the region to implement similar OPAT programs to alleviate the existing bed crisis due to the ongoing COVID-19 pandemic.

129. Safety and Cost-effectiveness Analysis Outpatient Continuous Parenteral Antibiotics via a Disposable Elastomeric Pump at Two County Hospitals in Houston, Texas

BackgroundOutpatient parenteral antibiotic therapy (OPAT) is a therapeutic option for patients who require longer intravenous (IV) antimicrobial courses, yet do not need to remain hospitalized. HarrisHealth system OPAT programs implement a disposable elastomeric continuous infusion pump (eCIP) for IV antibiotics. Here we report the clinic-demographic features, outcomes of a cohort of patients receiving OPAT via eCIP (OPAT-eCIP), as well as the cost-effectiveness of OPAT in comparison to standard inpatient care. MethodsWe retrospectively obtained the clinic-demographic characteristics and outcomes of 91 patients discharged from HarrisHealth-affiliated hospitals from December 2018 to February 2021 who underwent OPAT-eCIP. We then compared the total costs associated with home OPAT-eCIP care with that of an equivalent of inpatient IV antimicrobial treatment based on previous studies.ResultsWe identified 481 total OPAT patients; 91 (18.9%) received intravenous antibiotics via eCIP, with two initiating therapy outpatient. In total, 1925 days of IV antimicrobial therapy were administered outpatient by OPAT-eCIP, with a median treatment course of 12 days. Eighty-three (92.2%) patients completed their antimicrobial course, with 85 (93.4%) cured of respective infections (Table 1). Antimicrobial-associated adverse events and PICC line associated complications were 6.6% and 14.3% respectively. 30-day hospital readmission rates were under 10% with 21 patients (23.1%, 28 total visits) presenting to the emergency room over the course of IV therapy. Estimated costs of OPAT-eCIP care over the study period ranged from &417,000-&576,750 with costs of equivalent inpatient care estimated at &2,945,250 to &3,927,000; estimated overall cost savings of OPAT-eCIP were &2,368,500 to &3,509,900 (Table 2).Table 1. Characteristics and Outcomes of Patients Receiving Continuous IV Antibiotics via Disposable Elastomeric Pump Table 2. Cost Analysis Comparison of OPAT-eCIP therapy versus inpatient antimicrobial therapy in patients from December 2018 from February 2021 ConclusionOPAT-eCIP therapy in a cohort of patients was highly effective and well-tolerated. While ED visit frequency indicates the necessity of close patient monitoring, low 30-day hospital readmission rates were encouraging. Along with the above, the significant cost savings demonstrated when compared with standard inpatient antimicrobial therapy suggest that OPAT-eCIP should be increasingly utilized as an effective therapeutic option.Disclosures All Authors: No reported disclosures

Effects of modified multimodal analgesia on postoperative pain, sedation, and prognosis of gynecological patients.

Patient-controlled intravenous analgesia is one of the most common pain relief methods in the postoperative period, but its adverse reactions remain high. This study aimed to explore the role of improved combined analgesia methods in pain, sedation, postoperative nausea, and vomiting (PONV) in patients undergoing gynecological surgeries. This study was a prospective, randomized, double-blind controlled study. A study population of 72 patients undergoing gynecological surgery were randomly assigned to either the TAPB + S group or the TAPB + N group. All patients in both groups underwent a transversus abdominis plane block (TAPB) after induction of anesthesia. The TAPB + S group received a continuous intravenous infusion (2 ml/h) of sufentanil (1 μg/kg) plus metoclopramide (30 mg) through 100 ml elastomeric pumps postoperatively. The TAPB + N group received a continuous intravenous infusion (2 ml/h) of nalbuphine hydrochloride (1 mg/kg) plus metoclopramide (30 mg) postoperatively. The main outcome measures were as follows: postoperative pain intensity, Ramsay sedation score (RSS) after surgery, PONV occurrence rate, and rescue analgesics. The RSS of the TAPB + S group was significantly higher than that of the TAPB + N group at 2, 4, and 6 h after the operation. However, the visual analog scale score of the TAPB + S group was much higher than that of the TAPB + N group. No significant differences were found between the two groups in terms of consumption of opioids and other narcotic drugs at 2, 4, 6, 24, and 48 h after the operation. No statistically significant differences were found with respect to PONV and other adverse events in both groups. Taken together, our data indicate that the TAPB + N program can provide better postoperative analgesia and also reduce the use of strong opioids. The more optimized scheme of perioperative analgesia still needs to be researched further.

Liquid chromatographic method to follow-up ceftazidime and pyridine in portable elastomeric infusion pumps over 24 h.

Portable infusion pumps are an interesting solution to continue outpatient parenteral antimicrobial therapy (OPAT) at the patient's home. However, the use of ceftazidime for such applications is challenging in view of its relatively poor stability in solution. In this study, elastomeric infusion pumps with 6 or 7g of ceftazidime were deflated over 24 h in an oven at 33°C while ceftazidime and its degradation product, pyridine, were regularly monitored. Hereto, a fast and sensitive liquid chromatographic (LC) method has been developed using a Kinetex® C18 (150× 3mm, 2.6μm) column with gradient elution. Ammonium formate 20mM and acetonitrile (ACN) were mixed in a ratio of 98:2 v/v for mobile phase A and 85:15 v/v for mobile phase B. Both were adjusted to pH 4.5 with formic acid. The flow rate was set at 0.4mL/min. The solution with a starting dose of 6g ceftazidime was found to be degraded 10% after an average of 19 h 11 min so that an administration of 6g to the patient was not reached. For the solution with a starting dose of 7g of ceftazidime, 10% degradation was observed after an average of 18 h 42 min. However, by starting from a higher dose, an average of 6.56g of ceftazidime could be administered over 24 h. In addition, 1.0% of pyridine versus ceftazidime pentahydrate with sodium carbonate (=mixture for injection) was formed over 24 h.

Retrospective analysis of failures of ambulatory elastomeric pumps containing 5-FU in a hospital pharmacy unit.

Ambulatory chemotherapy is an important and major advance in clinical oncology practice since it allows the administration of chemotherapy in the comfort of the patient's home without the assistance of a health professional by means of an elastomeric pump. However, these pumps are not without risks and can be the cause of incidents due to technical failures. Our objective is to study the technical failures of elastomeric pumps in the Cytotoxic Preparation Unit and in the patient's home, to evaluate the possible impact of these failures on the patient and on the staff and to propose measures to reduce them. This is a retrospective study conducted at the pharmacy of the National Institute of Oncology in Rabat. It gathered all the specific reports on elastomeric pumps issued during the period (January 2017-May 2021) by the cytotoxic preparation unit to the materiovigilance cell via a notification form. 205 cases of elastomeric pump materialovigilance were identified during the study period. The main technical failures were: chemotherapy product leakage (44%), flow rate anomalies (30%) and injection difficulties (20%). Following these incidents, certain actions were undertaken such as alerts sent to the supplier and letters sent to the competent health authorities. Despite the failures that may have occurred, elastomeric pumps have revolutionized home chemotherapy delivery. They are considered reliable, consistent, easy to use and handle, and are well accepted in the population.

Characteristics, safety and cost-effectiveness analysis of self-administered outpatient parenteral antibiotic therapy via a disposable elastomeric continuous infusion pump at two county hospitals in Houston, Texas, United States.

Outpatient parenteral antibiotic therapy (OPAT) is an attractive option for patients who require parenteral antimicrobials as outpatients. Few OPAT studies have assessed the impact of IV antibiotic therapy via elastomeric continuous pumps, with most having been conducted outside the United States and few in county hospitals. The OPAT program in Harris Health system, the county hospital system of Houston, Texas, United States, has implemented a disposable elastomeric continuous infusion pump (eCIP) for self-administered intravenous antibiotics (s-OPAT) since December 2018. Our goal was to describe the clinical characteristics of patients discharged with an eCIP, as well as the safety and cost-effectiveness of this pump. We retrospectively analysed patients discharged from Harris Health hospitals between 12/2018 and 02/2021 with s-OPAT via eCIP at home. We extracted various patient characteristics and outcomes related to OPAT. Among 481 OPAT patients during the study period, 91 patients received s-OPAT via eCIP. A total of 1925days of s-OPAT were administered at home, with a median duration of 12days. Eighty-three patients (93.4%) achieved a cure from infection, six patients (6.6%) had side effects, and nine patients (9.9%) experienced 30-day hospital readmission. Twenty-two patients (24.2%) presented to the ED during s-OPAT, with 13 patients (14.3%) presenting with PICC line concerns. We estimated that s-OPAT via eCIP saved $2,360,500 to $3,503,900 compared to inpatient-only therapy. Our study showed that patients with s-OPAT via eCIP had a high cure rate with a relatively low incidence of side effects and 30-day hospital readmission. ED visits during therapy were relatively high, which indicates the necessity of close patient monitoring via the OPAT program. eCIP appears to be a good option to facilitate an early disposition of patients in county hospitals.

Efficacy and Safety of Subcutaneous Infusion of Non-formulated Furosemide in Patients with Worsening Heart Failure: a Real-World Study

We aimed to evaluate the efficacy (short-term changes in surrogates of decongestion) and safety following the ambulatory administration of subcutaneous furosemide (SCF) in patients with WHF. Fifty-five ambulatory patients were treated with SCF administered by an elastomeric pump for at least 72 h. Surrogates of congestion were assessed at baseline, 72 h, and 30 days. Spot urinary sodium (uNa+) was assessed at baseline, 24-48-72 h, and 30 days. The median (IQI) of NT-proBNP and uNa+ at baseline was 5218 pg/mL (2856-10878) and 68±3 mmol/L, respectively. Following administration of SCF (median dose of 100 mg/daily), we found a sustained increase in uNa+ during the first 72 h of treatment compared to baseline, paralleled with evidence of decongestion at 72 h, and 30 days. No significant safety concerns were observed. SCF was an effective and safe diuretic strategy for outpatient congestion management.Graphical abstractNon-formulated subcutaneous furosemide in patients with WHF. Efficacy and safety.

Administration of Subcutaneous Furosemide in Elastomeric Pump vs. Oral Solution for the Treatment of Diuretic Refractory Congestion.

The most common symptom in heart failure (HF) is congestion, which can be refractory to diuretic treatment. To verify whether, in patients with advanced HF and diuretic resistance, subcutaneous furosemide or furosemide in an oral solution can improve the clinical-analytical status. From 2018 to 2020, 27 consecutive outpatients with diuretic resistance, not candidates for other alternatives, were recruited. Patients were treated either with subcutaneous furosemide in elastomeric pump (n: 10) or with oral solution (n: 17) for 5 days. The functional status (NYHA) improved with subcutaneous administration (predose: 3.8 ± 0.5 vs. postdose: 3.1 ± 0.7; p: 0.02) and oral solution (predose: 3.7 ± 0.3 vs. postdose: 2.5 ± 0.7; p: 0.0001). Weight loss was greater with the oral solution (predose: 85.5 ± 19.5 vs. postdose: 81.3 ± 18.8Kg; p: 0.0001) than subcutaneous (predose: 81.6 ± 15.9 vs. postdose: 80.4 ± 15.1kg; p: 0.16). Creatinine showed a non-significant increase in both groups. The number of hospital visits showed no difference between both options. The administration of furosemide, both subcutaneously by elastomeric pump or drinking the oral solution, is effective for the treatment of congestion in advanced HF refractory to diuretic treatment.

Safe disconnection of 5-fluorouracil elastomeric pumps: The benefit of a closed-system-transfer device designed for cytotoxic drug administration/perfusion.

Occupational exposure to cytotoxic drugs can lead to significant health problems. This study was designed to evaluate the risk of 5-fluorouracil (5-FU) contamination for nurses when disconnecting the infusion line of an elastomeric pump from a non-coring needle, by comparing three configurations: the first one using standard Male and Female Luer lock (Group 1), the second one using a needle-free connector (NFC) and a Male Luer lock (Group 2) and the third one using a closed-system transfer device (CSTD), Qimono® (Group 3). In this in vitro study, 10 elastomeric pumps for each of the three groups were filled with 5-FU and a tissue mimicking the patient's arm was placed below the connection between the infusion line and the tubing of non-coring needle. After 48 h of infusion, disconnection was performed by a nurse with a wipe soaked in a mix of chlorhexidine and isopropyl alcohol in order to mimic care practices. For each pump, the tissue, the pair of gloves and the wipes used during the disconnection were collected for analysis. Median level of overall 5-FU contamination (gloves + wipes + tissues) in group 3 was significantly lower than in group 1 (p = 0.018) and group 2 (p = 0.036). There was no difference between groups 1 and 2. Results per sample type showed no difference in contamination between the three configurations for the gloves as well as for the tissues. Concerning the wipes, the lowest contamination was observed in group 3, representing a mean reduction of 61% compared to group 1 and a mean reduction of 43% compared to group 2. The use of Qimono® appears to significantly reduce 5-FU contamination when disconnecting infusion lines of an elastomeric pump unlike NFC and standard Luer lock.

Elastomeric Pump Infusion Failures Caused by Inadequate Luer Lock Connector Engagement to Needleless Connectors

Needleless connectors are used widely across all types of vascular access devices and provide safe, needleless administration of intravenous fluids and medications. An analysis of patients from an outpatient parenteral antimicrobial therapy program is presented in which elastomeric pumps had failed to flow due to incomplete tightening of Luer lock needleless connections. An alert was issued to community nursing staff responsible for daily elastomeric pump changes to ensure that needleless connectors were properly checked for full tightening. The frequency of failure of flow events before and after the alert was reviewed. Force and torque profiles required to activate the internal mechanism of connectors were measured in the 4 most frequently used needleless connectors in the outpatient parenteral antimicrobial therapy program. The degree of torque and force required to activate the different needleless connectors varied and was identified as a factor contributing to inadequate connection with the elastomeric pump and consequent failure of flow. Repeated feedback to nursing staff over the study period about the force and torque required for needleless connector flow activation resulted in a highly significant decrease in the rate of failure of flow events per elastomeric pump from a rate of 0.0147 events per elastomeric pump per year in the last 3 months of 2018 to 0.0003 in the first 6 months of 2020 (difference = 0.0144 [CI, 0.0097–0.02]; P &lt; .0001).

Our experience in comparative evaluation of dexmedetomidine and ketamine for epidural analgesia in lower limb orthopedic surgeries

Introduction: The combined spinal epidural anesthesia (CSE) plays a unique role in management of perioperative analgesia. It is associated with early postoperative mobilization and rehabilitation with minimally associated pain and discomfort, which is the most desirable feature in modern surgery. We designed this study for comparative evaluation of dexmedetomidine and ketamine for epidural analgesia in lower limb orthopedic surgeries in patients operated under CSE. Materials and Methods: The study included 50 patients divided into two groups (25 each). Group D: Patient received bolus dose of dexmedetomidine 1 µg/kg after spinal anesthesia followed by bupivacaine 0.125% with dexmedetomidine 1 µg/ml epidurally using 240 ml elastomeric pump at 5ml/ hr till 48 hours. Group K: Patient received bolus dose of ketamine 0.5 mg/kg after spinal anesthesia followed bupivacaine 0.125% with ketamine 0.5mg/ml epidurally using elastomeric pump at 5ml/hr till 48 hours. Results: There was no significant difference between the two groups (p>0.05) in terms of highest sensory level achieved and time for complete motor block. The patients in both the groups were hemodynamicaly stable throughout the study. The duration of analgesia was longer with dexmedetomidine however, none of the patients in both the groups required rescue analgesic. The time to regression of sensory level to L5 in Group D was found to be 594 ± 63.04 minutes as compared to 362.4 ± 45.76 minutes in Group K (p<.001) while, the time to regression of motor block to Bromage scale 1 in Group D was 488.4 ± 42.88 minutes whereas, in Group K it was 303.6 ± 36.04 minutes (p<0.001). The incidence of sedation, nausea, vomiting and other side effects were comparable. Conclusion: We conclude that continuous epidural infusion with dexmedetomidine and ketamine effectively reduced the postoperative rescue analgesics requirements and provided good patient satisfaction in patients undergoing lower limb orthopedic surgery.