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Kumar R, Nath SS, Agarwal A. Intraperitoneal nebulization versus intraperitoneal instillation of ropivacaine for postoperative pain management following laparoscopic donor nephrectomy. Korean J Anesthesiol 2019; 72:357-365. [PMID: 30987415 PMCID: PMC6676037 DOI: 10.4097/kja.d.18.00290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 04/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Laparoscopic donor nephrectomy is considered less painful than open nephrectomy but is still associated with significant postoperative pain. Studies reported that intraperitoneal instillation of local anesthetics provides uncertain pain relief after laparoscopic surgery. This randomized, double-blind study evaluated the effect of intraperitoneal nebulization of ropivacaine on postoperative pain relief after laparoscopic donor nephrectomy. METHODS Sixty patients undergoing elective laparoscopic donor nephrectomy were randomly assigned to receive either an instillation of 20 ml 0.5% ropivacaine after the induction of pneumoperitoneum or nebulization of 5 ml 1% ropivacaine before and after surgery. The primary outcome was the degree of pain relief (static and dynamic) after surgery. The secondary outcomes were postoperative fentanyl consumption, incidence of shoulder pain, unassisted walking and postoperative nausea and vomiting (PONV). Data were collected in the postanesthesia care unit (PACU) and at 6, 24, and 48 h after surgery. RESULTS Compared to patients in the instillation group, those in the nebulization group showed significant reductions in postoperative pain and fentanyl consumption, and none complained of significant shoulder pain (visual analog scale score ≥ 30 mm). Within 20 h of surgery, 13.3% of patients in the instillation group and 93.3% in the nebulization group started unassisted walking (absolute risk reduction, 38%; P = 0.001). In the nebulization group, PONV was significantly reduced in the PACU and at 6 h. CONCLUSIONS Intraperitoneal nebulization of ropivacaine reduced postoperative pain, fentanyl consumption, referred shoulder pain, and PONV while enabling earlier mobility without any difference in the length of hospital stay.
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Affiliation(s)
- Rajeev Kumar
- Department of Anesthesiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Soumya Shankar Nath
- Department of Anesthesiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anil Agarwal
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Bykowski MR, Sivak W, Garland C, Cladis FP, Goldstein JA, Losee JE. A Multimodal Preemptive Analgesic Protocol for Alveolar Bone Graft Surgery: Decreased Pain, Hospital Stay, and Health Care Costs. Cleft Palate Craniofac J 2018; 56:479-486. [PMID: 30071750 DOI: 10.1177/1055665618791943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate postoperative pain, hospital length of stay (LOS), and associated costs of multiple perioperative analgesic strategies following alveolar bone grafting (ABG). DESIGN Retrospective comparative cohort study. SETTING Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS Iliac crest bone graft (ICBG) harvest techniques: "Open Harvest" (n = 22), "Trephine Only" (n = 14), or "Trephine + Pain Pump" (n = 25). INTERVENTION The "Open Harvest" group underwent open ICBG harvest with 3-walled osteotomies. For the other 2 treatment groups, a trephine drill was used to harvest iliac crest bone with a ropivacaine infusion pump into the hip donor site ("Trephine + Pain Pump") or without ("Trephine Only"). Patients who underwent ABG with only cadaveric allograft were analyzed as a comparison group ("No Harvest"). MAIN OUTCOMES MEASURES Outcomes were planned prior to data collection: maximum pain score, hospital LOS, and associated health care costs. RESULTS Maximum pain scores were significantly higher in the "Open Harvest" group (7.3/10) compared to "Trephine + Pain Pump" (1.8/10; P < .0001) and "No Harvest" groups (2.8/10; P < .01). Hospital LOS decreased from 2.4 days ("Open Harvest") to 0.5 days (Trephine + Pain Pump"; P < .0001). Twelve (48%) patients from "Trephine + Pain Pump" were discharged on the day of surgery. The "Trephine + Pain Pump" saved an estimated $5336 for a unilateral ABG and $7265 for a bilateral ABG compared to "Open Harvest." CONCLUSIONS The combined use of the trephine ICBG technique and ropivacaine infusion catheter effectively decreased pain, shortened hospital stay, and improved cost saving compared to patients who have undergone other methods of ICBG.
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Affiliation(s)
- Michael R Bykowski
- 1 Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wesley Sivak
- 1 Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catharine Garland
- 1 Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Franklyn P Cladis
- 2 Department of Anesthesiology, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jesse A Goldstein
- 1 Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,3 Division of Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph E Losee
- 1 Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,3 Division of Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Muzaffar AR, Warren A, Baker L. Use of the On-Q Pain Pump in Alveolar Bone Grafting: Effect on Hospit Length of Stay. Cleft Palate Craniofac J 2018; 53:e23-7. [DOI: 10.1597/14-174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Alveolar bone grafting (ABG) with iliac crest bone graft can be associated with significant pain at the donor site. The On-Q pain pump has been shown to be efficacious in treating postsurgical pain. The aim of this study was to compare the length of postoperative hospital stay in patients undergoing ABG who received the On-Q pain pump at the iliac crest donor site (On-Q+) with that of patients who did not receive the On-Q pain pump (On-Q-). Design A retrospective, cohort study, approved by institutional review board, was performed. Thirty-one consecutive patients in the On-Q- group were compared with 38 consecutive patients in the On-Q– group. The two cohorts were assessed for length of stay. Statistical analysis was performed using the Fisher exact probability test. Setting Tertiary care academic medical center. Patients Sixty-nine patients with cleft lip and/or cleft palate (CL/P) undergoing secondary ABG with iliac crest bone graft were operated on between May 1993 and January 2014. Main Outcome Measure Length of postoperative hospital stay. Result Mean length of stay in the On-Q– patients was 0.52 days versus 0.37 days for the On-Q– patients. This difference between the two cohorts was not statistically significant (P = .234). Conclusion Although there is a trend toward a shorter length of stay in our patients who received the On-Q pump, this finding was not statistically significant. Given the expense and additional burden of care associated with the device, we have become more selective in its utilization.
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Smith EB, Kazarian GS, Maltenfort MG, Lonner JH, Sharkey PF, Good RP. Periarticular Liposomal Bupivacaine Injection Versus Intra-Articular Bupivacaine Infusion Catheter for Analgesia After Total Knee Arthroplasty: A Double-Blinded, Randomized Controlled Trial. J Bone Joint Surg Am 2017; 99:1337-1344. [PMID: 28816893 DOI: 10.2106/jbjs.16.00571] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intra-articular bupivacaine hydrochloride (HCl) infusion catheters and periarticular injections of liposomal bupivacaine are often used as postoperative local anesthetics. The purpose of this study was to compare the efficacies of these local anesthetics following total knee arthroplasty. METHODS This study was a superiority trial with a randomized, controlled, double-blinded design. Patients were randomly assigned to either delivery of bupivacaine HCl by the ON-Q* Pain Relief System pump (n = 96) or by an injection of Exparel (liposomal bupivacaine) (n = 104). The primary outcome of this study was cumulative narcotic consumption on postoperative days 0 through 3. Narcotic consumption data were collected retrospectively from in-hospital records while patients were in the hospital. Following discharge, narcotic consumption data were gathered from patient surveys, as were secondary outcomes measures. RESULTS We did not identify greater narcotic use in the ON-Q* group compared with the Exparel group (p = 0.641). The mean difference between the groups was 0.5 morphine equivalent (95% confidence interval [CI] = -1.7 to +2.8), with the ON-Q* group consuming an average 10.4 morphine equivalents (95% CI = 8.7 to 12.0) compared with 10.9 (95% CI = 9.3 to 12.5) in the Exparel group. There were no significant differences between groups with regard to any of the secondary measures of pain with the exception of pain while walking and pain with physical therapy (p = 0.019 and p = 0.010, respectively), both of which showed an approximately 1-point difference in favor of the ON-Q* group on a visual analog scale (VAS). There were also no differences in the postoperative side effects, including nausea, constipation, or vomiting, or in the rates of study-related complications, patient satisfaction, or length of hospital stay. CONCLUSIONS Exparel did not have superior efficacy compared with the ON-Q* Pain Relief System as reflected by narcotic consumption, our primary outcome. There were small significant differences, in favor of the ON-Q* group, in 2 secondary measures of pain during activity, but these approximately 1-point VAS differences are unlikely to be clinically relevant. The choice of a local anesthetic modality should be based on a combination of safety, convenience, and cost considerations. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eric B Smith
- 1The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Batley SE, Prasad V, Vasdev N, Mohan-S G. Post-Operative Pain Management in Patients Undergoing Robotic Urological Surgery. Curr Urol 2016; 9:5-11. [PMID: 26989364 DOI: 10.1159/000442843] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/20/2015] [Indexed: 11/19/2022] Open
Abstract
Robotic urological surgery is being increasingly performed worldwide. The main focus currently is on the operative technique but post operative patient care is an essential part of the process to make this technique safe and successful. We present a review on multiple analgesic techniques available to prevent and treat pain specifically caused after by urological robotic surgery; this article will explain the mechanism of pain pathways involved in laparoscopic procedures and review current evidence pertaining to systemic and regional analgesia methods.
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Affiliation(s)
- Sian E Batley
- Department of Anesthetics, Lister Hospital, Stevenage, UK
| | - Venkat Prasad
- Department of Anesthetics, Lister Hospital, Stevenage, UK
| | - Nikhil Vasdev
- Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
| | - Gowrie Mohan-S
- Department of Anesthetics, Lister Hospital, Stevenage, UK
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Evolving Role of Local Anesthetics in Managing Postsurgical Analgesia. Clin Ther 2015; 37:1354-71. [DOI: 10.1016/j.clinthera.2015.03.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 02/09/2015] [Accepted: 03/11/2015] [Indexed: 11/20/2022]
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Regional anesthesia for laparoscopic surgery: a narrative review. J Anesth 2013; 28:429-46. [PMID: 24197290 DOI: 10.1007/s00540-013-1736-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 10/14/2013] [Indexed: 12/26/2022]
Abstract
Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed "too sick" for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.
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Soliz JM, Gebhardt R, Feng L, Dong W, Reich M, Curley S. Comparing epidural analgesia and ON-Q infiltrating catheters for pain management after hepatic resection. ACTA ACUST UNITED AC 2013; 3:3-7. [PMID: 25580374 DOI: 10.4236/ojanes.2013.31002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Pain control after hepatic resection presents unique challenges as subcostal incisions, rib retraction, and diaphragmatic irritation can lead to significant pain. Both epidural analgesia and ON-Q catheters have been used for postoperative pain management after hepatic surgery, but to our knowledge have not been directly compared. METHODS The records of 143 patient between the ages 18 and 70 were reviewed who underwent hepatic resection by a single surgeon. Patients were categorized according to method of postoperative pain control. Average pain scores for both study groups were collected until POD#3. RESULTS Demographic data and the length of surgery were similar between the groups (all p>0.05). On the day of surgery and POD#1, average pain scores for the epidural group were lower than the ON-Q group (P<0.0001 and P=0.0008 respectively). There was no difference in pain scores on POD #2 (P=.2369) or POD #3 (P=0.2289). CONCLUSIONS Epidural analgesia provides superior pain control on the day of surgery and POD#1 when compared to On-Q catheter with IV PCA. There was no difference in pain scores on POD#2 or POD#3. Future prospective randomized trials comparing these analgesic methods will be required to further evaluate enhanced recovery after hepatic surgery.
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Affiliation(s)
- Jose M Soliz
- M.D. Anderson Cancer Center, Department of anesthesiology and Perioperative Medicine, 1515 Holcombe Blvd. Unit 409, Houston, TX 77030, , ,
| | - Rodolfo Gebhardt
- M.D. Anderson Cancer Center, Department of Pain Medicine, 1515 Holcombe Blvd. Unit 409, Houston, TX 77030, (713) 563-5764 office,
| | - Lei Feng
- M.D. Anderson Cancer Center, Department of Biostatistics, 1515 Holcombe Blvd. Unit 1411, Houston, TX 77030, (713) 794-4169 office,
| | - Wenli Dong
- M.D. Anderson Cancer Center, Department of Biostatistics, 1515 Holcombe Blvd. Unit 1411, Houston, TX 77030, (713) 563-4291,
| | - Margaret Reich
- U.T. Health Science Center-San Antonio, Medical School, 7703 Floyd Curl Drive, San Antonio, TX, USA 78229, 713-301-7831,
| | - Steven Curley
- M.D. Anderson Cancer Center, Department of Surgical Oncology, 1515 Holcombe Blvd. Unit 444, Houston, TX 77030, (713) 794-4957,
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Haas E, Onel E, Miller H, Ragupathi M, White PF. A Double-Blind, Randomized, Active-Controlled Study for Post-Hemorrhoidectomy Pain Management with Liposome Bupivacaine, a Novel Local Analgesic Formulation. Am Surg 2012; 78:574-81. [DOI: 10.1177/000313481207800540] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This randomized, active-controlled study evaluated the extent and duration of analgesia after administration of liposome bupivacaine (LB), a novel formulation of bupivacaine, compared with bupivacaine HCl given via local infiltration in excisional hemorrhoidectomy. One hundred patients were randomly assigned to receive a single dose of bupivacaine HCl 75 mg (0.25% with 1:200,000 epinephrine) or LB 66, 199, or 266 mg upon completion of hemorrhoidectomy. Postoperative pain intensity was assessed using a numeric rating scale at rest to calculate a cumulative pain score (area under the curve). Cumulative pain scores were significantly lower with LB at each study dose ( P < 0.05) compared with bupivacaine HCl 72 hours after surgery. Post hoc analysis showed that mean total postoperative opioid consumption was statistically significantly lower for the LB 266-mg group compared with the bupivacaine HCl group during the 12- to 72-hour postoperative period ( P = 0.019). Median time to first opioid use was 19 hours for LB 266 mg versus 8 hours for bupivacaine HCl ( P = 0.005). Incidence of opioid-related adverse events was 4 per cent for LB 266 mg compared with 35 per cent for bupivacaine HCl ( P = 0.007). Local infiltration with LB resulted in significantly reduced postsurgical pain compared with bupivacaine HCl in patients after hemorrhoidectomy surgery.
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Affiliation(s)
- Eric Haas
- Colorectal Surgical Associates, Ltd, LLP, Houston, Texas
| | - Erol Onel
- Pacira Pharmaceuticals, Inc., Parsippany, New Jersey
| | - Howard Miller
- The Woman's Hospital of Texas and Fannin Surgicare, Houston, Texas; and the, California
| | | | - Paul F. White
- Cedars-Sinai Medical Center, Los Angeles, California
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Bergese SD, Ramamoorthy S, Patou G, Bramlett K, Gorfine SR, Candiotti KA. Efficacy profile of liposome bupivacaine, a novel formulation of bupivacaine for postsurgical analgesia. J Pain Res 2012; 5:107-16. [PMID: 22570563 PMCID: PMC3346068 DOI: 10.2147/jpr.s30861] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Liposome bupivacaine is a novel formulation of the local anesthetic bupivacaine, designed to provide prolonged postsurgical analgesia. This analysis examined pooled efficacy data as reflected in cumulative pain scores from 10 randomized, double-blind liposome bupivacaine clinical studies in which the study drug was administered via local wound infiltration. Methods A total of 823 patients were exposed to liposome bupivacaine in 10 local wound infiltration studies at doses ranging from 66 mg to 532 mg in five surgical settings; 446 patients received bupivacaine HCl (dose: 75–200 mg) and 190 received placebo. Efficacy measures were assessed through 72 hours after surgery. Results Overall, 45% of patients were male and 19% were ≥65 years of age. In the analysis of cumulative pain intensity scores through 72 hours, liposome bupivacaine was associated with lower pain scores than the comparator in 16 of 19 treatment arms assessed, achieving statistically significant differences compared with bupivacaine HCl (P < 0.05) in five of 17 treatment arms. These results were supported by results of other efficacy measures, including time to first use of opioid rescue medication, proportion of patients avoiding opioid rescue medication, total postsurgical consumption of opioid rescue medication, and patient/care provider satisfaction with postoperative analgesia. Local infiltration of liposome bupivacaine resulted in significant systemic plasma levels of bupivacaine, which could persist for 96 hours; systemic plasma levels of bupivacaine following administration of liposome bupivacaine were not correlated with local efficacy. Liposome bupivacaine and bupivacaine HCl were generally well tolerated. Conclusion Based on this integrated analysis of multiple efficacy measures, liposome bupivacaine appears to be a potentially useful therapeutic option for prolonged reduction of postsurgical pain in soft tissue and orthopedic surgeries.
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Affiliation(s)
- Sergio D Bergese
- Department of Anesthesiology and Neurological Surgery, Ohio State University, Columbus, OH, USA
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Fifty ways to reduce length of stay: an inventory of how hospital staff would reduce the length of stay in their hospital. Health Policy 2012; 104:222-33. [PMID: 22304781 DOI: 10.1016/j.healthpol.2011.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 12/18/2011] [Accepted: 12/26/2011] [Indexed: 11/21/2022]
Abstract
PURPOSE AND SETTING In this study we present a bottom up approach to developing interventions to shorten lengths of stay. Between 1999 and 2009 we applied the approach in 21 Dutch clinical wards in 12 hospitals. We present the complete inventory of all interventions. DESIGN We organised, on the hospital ward level, structured meetings with the staff in order to first identify barriers to reduce the length of stay and then later to link them to interventions. The key components of the approach were a benchmark with the fifteenth percentile and the use of a matrix, that on one side was arranged along the main phases of the care process--the admission, stay and discharge--and on the other side to the degree to which the length of stay could be shortened by the medical specialists and nurses themselves or by involving others. FINDINGS AND CONCLUSIONS The matrix consists of a wide variety of interventions that mainly cover what we found in published research. As a bottom up approach is more likely to succeed, we would advise wards that have to reduce length of stay to make the inventory themselves, using appropriate benchmark data, and by using the matrix.
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Birrer KL, Anderson RL, Liu-DeRyke X, Patel KR. Measures to improve safety of an elastomeric infusion system for pain management. Am J Health Syst Pharm 2011; 68:1251-5. [DOI: 10.2146/ajhp100558] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | - Xi Liu-DeRyke
- Surgical Critical Care, Department of Pharmacy Services, Orlando Regional Medical Center (Orlando Health), Orlando, FL
| | - Kuldip R. Patel
- Department of Pharmacy, Duke University Hospital, Durham, NC; at the time of writing he was Pharmacy Operations Coordinator, Department of Pharmacy Services, Orlando Health
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