SABER-Bupivacaine Reduces Postoperative Pain and Opioid Consumption After Arthroscopic Subacromial Decompression: A Randomized, Placebo-Controlled Trial

INTRODUCTION

Shoulder arthroscopy can result in substantial postoperative pain. Sucrose acetate isobutyrate extended-release bupivacaine (SABER-Bupivacaine; trade name Posimir) is a novel depot formulation of bupivacaine designed to provide analgesia at the surgical site for up to 72 hours. The objective of this study was to evaluate the effect of SABER-Bupivacaine on pain and opioid consumption after arthroscopic subacromial decompression and to assess short-term and long-term safety.

METHODS

In this double-blind, placebo-controlled trial, 78 subjects were randomized in a 2:1 ratio to SABER-Bupivacaine 5 mL or SABER-placebo 5 mL injected into the subacromial space just before skin closure. Twenty-nine additional subjects were randomized on an exploratory basis to bupivacaine hydrochloride 20 mL, also injected subacromially. Subjects rated pain intensity on a 0 to 10 scale over the first 3 postoperative days and received intravenous or oral morphine for breakthrough pain. The coprimary efficacy end points were pain intensity on 90° shoulder flexion and cumulative morphine intake from 0 to 72 hours after surgery. The time to first use of opioid rescue analgesia was a secondary end point.

RESULTS

The mean (SD) pain intensity was 5.16 (1.94) for SABER-Bupivacaine and 6.43 (1.77) for placebo (P = 0.012). The median consumption of intravenous morphine equivalents was 4.0 mg for SABER-Bupivacaine and 12.0 mg for placebo (P = 0.010). The median time to first use of morphine rescue was 12.4 hours for SABER-Bupivacaine and 1.2 hours for placebo (P = 0.014). The corresponding values for bupivacaine hydrochloride were 5.16 (2.38), 8.0 mg, and 1.4 hours. The incidence and severity of treatment-emergent adverse events were similar for all treatment groups, and no functional or radiographic differences were noted at the 6-month follow-up.

DISCUSSION

Compared with placebo, SABER-Bupivacaine reduced pain and opioid analgesic consumption over 72 hours after arthroscopic subacromial decompression and prolonged the time to first use of opioid rescue analgesia. No safety signals were noted during the immediate postoperative period or at 6-month follow-up.

Minimally invasive repair of post-pneumonectomy syndrome

We report on a 42-year-old female who underwent right pneumonectomy for hemoptysis from an aspergilloma cavity. Several years postoperatively she complained of increasing shortness of breath, wheezing, and dyspnea upon exertion. Chest computed tomography showed a counterclockwise rotation of the mediastinum with obstruction of the left lower lobe bronchus. Minimally invasive repair was carried out using an intrapleural tissue expander for dissection and an adjustable saline prosthesis for mediastinal centralization. Intraoperative bronchoscopy showed complete resolution of the left lower lobe bronchial obstruction, and postoperatively her symptoms resolved completely. This is the first reported case of a minimally invasive approach for the treatment of post-pneumonectomy syndrome in the United States.

A pharmacoeconomic analysis of Neoral without intravenous cyclosporine in liver transplantation in Canada

Neoral, a microemulsion formulation of cyclosporin A (CsA), has improved absorption compared to Sandimmune and has allowed induction of immunosuppression in liver transplantation (LT) without the use of intravenous (i.v.) CsA. The improved bioavailability with less inter- and intra-patient dosing variability coupled with the lack of requirement for i.v. CsA may provide a mechanism for cost savings when Neoral is used for induction immunosuppression. This retrospective case-control study compares the relative costs associated with Neoral induction without i.v. CsA versus induction with i.v. CsA followed by oral CsA in adult liver transplant recipients. Twenty consecutive patients receiving Neoral 12-15 mg/kg per d were compared to a control group of 21 patients receiving i.v. CsA followed by oral CsA for induction. Both groups received the same rapidly tapered dose of methyl-prednisilone. Health care resource utilization was assigned based on days in hospital and acute rejection episodes (ARE). Hospital per diem rates at specified care levels were used to assign costs associated with hospital stay, while a previously developed case-costing model was used to assign costs to episodes of acute rejection. All patients were followed for a 3-month period post-transplant. Although there was a trend towards shorter hospital stay in the Neoral group the majority of cost savings were achieved by reducing costs associated with episodes of acute rejection. There were seven and 19 episodes of ARE in the Neoral and i.v. CsA groups respectively (p < 0.05.) A separate cost effective assessment of the effect of reducing rejection by decision tree analysis demonstrated a cost reduction of $2162 per patient. The savings achieved with Neoral proved robust on sensitivity analysis. The change of practice to an induction immunosuppression regimen of Neoral without i.v. CsA has achieved a cost savings in adult liver transplantation at our center.

A complication of tongue piercing

The trend of tongue piercing is becoming more popular. A patient with Ludwig's angina, secondary to recent tongue piercing, is presented. The management of the patients and the implications of tongue piercing are discussed.

Maxillary antral bone grafts for repair of orbital fractures

Use of bone from the maxillary antrum to repair defects in the orbital floor was described more than 20 years ago but has not been reported for correction of orbital rim fractures. The method is appealing because the source is contiguous with the recipient site; enhanced exposure might allow better fracture reduction and evacuation of debris and hematoma from the maxillary sinus. The intraoral approach also avoids an external incision and scar, prevents such complications as pneumothorax or dural perforation, and reduces postoperative pain. In 60 cases of orbital and zygomatic complex fractures seen between 1985 and 1990, less than 8% required more extensive graft material than the maxillary antra could provide. To assess the potential advantages of local over extraanatomical bone grafts, we evaluated maxillary antral bone grafts obtained through buccal sulcus incisions in 14 patients for restoration following fractures of the orbit. Several of these patients are described. Bone union was complete in all patients and there was no morbidity related to infection, oroantral fistula formation, dehiscence, or disfigurement. Sufficient bone was available from the uninvolved contralateral side to repair even severely comminuted fractures. In zygomatic complex fractures, maxillary antral grafts appeared to provide additional strength in the region of the fractured maxillary buttress. The success of the procedure in our experience, coupled with the safety of bone harvesting from this source, and the avoidance of an external scar make maxillary antral bone well suited to reconstruction of all areas of the orbit.

The significance of preoperative hysterosalpingography and laparoscopy for predicting the pregnancy outcome in patients with a bilateral hydrosalpinx

We analyzed the importance of 3 factors derived from the HSG (nature of the mucosal pattern, diameter of the hydrosalpinx, expandability of the ampulla) and of four factors from the findings at laparoscopy (extent of adhesions, nature of adhesions, thickness of tubal wall and diameter of the hydrosalpinx) for predicting the pregnancy outcome in 98 patients with bilateral hydrosalpinx. Each factor was categorized into 3 scores and each patient was scored for both the right and the left tube, resulting in 6 score-combinations. An association between the pregnancy prospects based on the score-combinations and the actual pregnancy outcome seemed to be present for all factors evaluated, except for the extent of adhesions and the diameter of the hydrosalpinx (laparoscopy). The results further indicate that a favourable score on the nature of mucosal pattern in one or both tubes concurs with good pregnancy prospects. In contrast, the presence of an unfavourable score for most of the other factors in at least one tube is associated with a poor fertility prognosis, regardless of the condition of the other tube.

Compliance, mass, and shape of the canine left ventricle after global ischemia analyzed with two-dimensional echocardiography

End-diastolic pressure (EDP)-volume (EDV) curves were constructed for the left ventricle (LV) in 10 dogs on cardiopulmonary bypass before and after 45 min of normothermic ischemic arrest. LVEDV and mass were calculated from three perpendicular two-dimensional echocardiographic sections using a Simpson's rule algorithm. The echocardiographic method employed was specially developed in earlier work for physiologic studies in dogs. Postmortem pressure-volume curves were measured for comparison by direct saline infusion into sealed ventricles. LVEDV was plotted against LVEDP (0-20 mm Hg) and data were analyzed by two-way analysis of variance and also by exponential curve fitting to the relation EDP = alpha e beta EDV, where beta is the derived exponential constant reflecting slope and thereby ventricular stiffness. Postischemic EDP-EDV curves shifted to the left and the beta constant increased (beta = 0.02 +/- 0.005 (SE) vs 0.05 +/- 0.01, P less than 0.05). LV eccentricity, the ratio between long- and short-axis measurements, was unchanged (1.43 +/- 0.05 vs 1.46 +/- 0.06 postischemia, NS), but LV mass increased (105 +/- 7 vs 128 +/- 9 g postischemia, P less than 0.001). Postischemic LV mass by echo was not significantly different from measured postmortem LV mass (r = 0.87). The nonparallel alteration in the EDP-EDV curves, lack of change in LV shape (eccentricity), and increase in LV mass in the postischemic ventricle suggest that increased ventricular stiffness rather than direct encroachment by the edematous endocardium on chamber volume is responsible for postischemic changes in LV diastolic properties.