We randomised 24 patients before they had a cemented hemiarthroplasty for hip fracture to receive either thorough or minimal saline lavage of the femoral canal. We then determined the effect in each group on the thromboembolic and cardiopulmonary responses to the pressurised insertion of cement, using transoesophageal echocardiography to show the echogenic embolic response. We found a statistically significant reduction in both the duration of the response and the number of large emboli in patients who had had thorough lavage as compared with the control group with minimal lavage. There was also less disturbance of pulmonary function, as assessed by the change in end-tidal CO2 levels and oxygen saturation, in patients who had thorough lavage. Three patients had a significant fall in blood pressure during cement insertion; all had only minimal lavage. We consider that thorough lavage should be an essential part of the preparation of the proximal femur before cement insertion.

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Background: The management of chronic nonmalignant pain with high-dose opioids has partially contributed to the current opioid epidemic, with some responsibility shared by chronic pain clinics. Traditionally, both primary care providers and patients used chronic pain clinics as a source for continued medical management of patients on high-dose opioids, often resulting in tolerance and escalating doses. Although opioids continue to be an important component of the management of some chronic pain conditions, improvement in function and comfort must be documented. Pain clinics are ideally suited for reducing opioid usage while improving pain and function with the use of a multimodal approach to pain management. We assessed whether the application of multimodal treatment directed by pain specialists in a pain clinic provides for improved function and reduced dosages of opioid analgesics. Objective: We evaluated the role of a pain clinic staffed by fellowship-trained pain physicians in reducing pain and opioid use in chronic nonmalignant pain patients. Study Design: This study used a retrospective design. Setting: The research took place in an outpatient pain clinic in a tertiary referral center/teaching hospital. Methods: Of 1268 charts reviewed, 296 patients were on chronic opioids at the time of first evaluation. After a thorough evaluation, the patients were treated with nonopioid pharmacotherapy and interventional pain procedures as necessary. The data utilized from patients’ latest follow-up visit included current pain level using the Numerical Rating Scale (NRS-11), opioid usage, and various functional parameters. Results: NRS-11 scores decreased by 33.8% from 6.8 (± 0.1)/10 to 4.5 (± 0.2)/10. The pain frequency and number of pain episodes improved by 36.8 ± 2 and 36.2 ± 2.1, respectively. Additionally, the ability to sleep, work, and perform chores significantly improved. Total opioid use decreased by about 55.4% from 53.8 ± 4 to about 24 ± 2.8 MME/patient/day. Limitation: This study is not a randomized prospective controlled study. The patients analyzed are still getting therapy and their pain status may change. Some opioids are underrepresented in the analyzed cohort. Finally, this study lacks in-depth stratification by type of pain, age, gender, and duration of opioid use. Conclusion: Chronic pain clinics can play a pivotal role in reducing opioid usage while improving pain and function in patients on chronic opioids. We wish to emphasize the importance of allocating resources toward nonopioid treatments that may improve the function and well-being of patients. Key words: Pain clinic, pain management, multimodal pain management, chronic pain, opioid reduction, improved pain, improved functional capacity

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