Postamputation pain is highly prevalent. Opioids are often utilized postoperatively; however, they have significant side effects. Liposomal bupivacaine (LB) was introduced to extend nerve blocks from hours into days. Regional nerve blocks with LB for below knee amputation (BKA) is a novel approach which may reduce opioid use after surgery. A retrospective review was conducted for patients who had received LB nerve blocks compared to none for postoperative pain control in BKAs. Daily average opioid consumption was evaluated from the time in postoperative acute care unit until day of discharge in oral morphine equivalents (OME). 69 patients who underwent below knee amputations were reviewed. The mean average daily OME was lower in the LB group compared to control group(25.0 vs 50.5 OME, respectively; P = .002) A higher percentage of patients in the study group were categorized in the minimal opioid use when compared to the control group LB regional nerve blocks for the BKA population are considered a novel approach in pain control. Our exploratory study shows that patients who received LB nerve blocks may have decreased opioid consumption after surgery.
The recent restructuring of the healthcare reimbursement system has led to financial pressure on all aspects of healthcare delivery. Naturally, this financial pressure will also trickle down to graduate medical education, resulting in mergers of residency programs. Historical examples of residency mergers will be presented and discussed in this chapter. Guidelines for merging residencies will be suggested for those programs undertaking this difficult process. These guidelines will address aspects of organization and leadership, educational philosophies and environment, program goals, culture, interpersonal relationships, communication, day-to-day operations, and finances. Special considerations for program mergers will also be discussed, including cultural differences, medical students, and surgical programs. The chapter concludes with a discussion on the relevancy of this information and important key concepts.
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