Pulmonary Cement Emboli After Kyphoplasty: A Case Of Bilateral Pulmonary Emboli And Exacerbation Of Interstitial Lung Disease

Introduction/Objective Osteoporosis often complicates the management of vertebral conditions, including spinal stenosis and vertebral fractures in the geriatric population. In addition to pharmacologic pain management; surgical interventions are employed if the pain is not adequately managed. The surgical interventions include vertebroplasty and kyphoplasty. These procedures involve the introduction of a cement polymer, Polymethylmethacrylate (PMMA), into the vertebral body. Cement leakage is a reported complication more commonly seen in vertebroplasty (30-75%) compared to kyphoplasty (8-33%). This occurs due to distant leakage of cement into the venous plexus or retrograde migration into the aorta which leads to pulmonary cement emboli (PCE). PCE are usually asymptomatic; few patients are symptomatic; seen in 0.9% for vertebroplasty and 0.4% for kyphoplasty. PMMA has a prothrombotic effect, contributing to the thrombosis of the pulmonary vessels. Symptoms typically arise weeks to months after the procedure. In addition, it has been reported that rarely PCE can present with ARDS especially in patients with interstitial lung abnormalities. Methods We present a case of an 80-year-old female with a history of hypertension, diabetes mellitus and osteoporosis who underwent a kyphoplasty procedure with use of PMMA for spinal stenosis. Her post-operative course was complicated by multiple surgical revisions. She was noted to have pulmonary cement emboli five months post kyphoplasty and developed significant shortness of breath eight months post procedure. She ultimately developed cardio-pulmonary failure and was found to have bilateral pulmonary emboli and cement emboli at autopsy. Microscopic examination of the cement emboli documented round to oval vacuole-like cavities within and around blood vessels consistent with PMMA. Conclusion The histo-pathologic findings of cement emboli are not well documented in human beings compared to animal models. We attempt to highlight the gross and microscopic findings of PMMA cement emboli which is essential in the clinical-histo-pathologic correlation and characterization of pulmonary emboli at autopsy.

Benefits of Aquatic Therapy in Pediatric Patients with Sickle Cell Disease

Introduction: Individuals with sickle cell disease (SCD) experience both acute vaso-occlusive pain (VOC) and chronic pain, both primarily treated with opioids. However, opioids only address the sensory dimension of pain and repeated use of opioids can cause short and long-term side effects such as respiratory system depression, increased risk of cardiovascular events, and hyperalgesia. Non-pharmacologic approaches to the management of acute and chronic SCD pain, such as cognitive behavioral therapy, biofeedback, acupuncture, hypnosis, and megavitamins, have shown positive effects for pain management and may reduce opioid use. Among non-pharmacologic pain management methods, aquatic therapy has been underutilized and understudied in patients with SCD, despite showing benefits for pain management and quality of life in adults with musculoskeletal conditions. At Vidant Medical Center, aquatic therapy has been introduced for patients with SCD in 2015 and has been increasingly used since then. To describe the use of aquatic therapy and outcomes in pediatric patients with SCD, we retrospectively evaluated the use of this therapy at Vidant Medical Center among children hospitalized for acute VOC pain. Methods: The study was approved by the Institutional Review Board at East Carolina University. Children with SCD between 7-18 years of age at the time of admission for acute VOC pain between the years 2015-2018 were included in the analysis. During the review period, orders for aquatic therapy were placed at the provider's discretion. Our primary outcome was utilization of aquatic therapy during a given hospitalization, determined by retrospective query of the electronic medical record (EMR). Secondary outcomes include length of stay and time to readmission for VOC. Covariates were assessed at the time of the index admission included age, sex, and insurance coverage. Mixed-effects logistic or Poisson regression models were fitted to account for multiple hospitalizations per patient. Results: The analysis included 316 hospitalizations of 87 patients (48% female; median age at the earliest hospitalization, 11 years). The median duration of hospital admissions was 4 days (interquartile range [IQR]: 3, 7). Aquatic therapy was used in 38% of admissions, with a trend of increasing use during the study period (Figure 1). On multivariable logistic regression analysis of aquatic use during a given admission, characteristics associated with greater likelihood of aquatic therapy use included older age and more recent year of admission. Aquatic therapy was associated with 69% longer hospital stays, although this may be related to availability of aquatic therapy services. Among 52 patients with multiple admissions, use of aquatic therapy during a given admission was associated with 26% more days between hospitalizations (incidence rate ratio = 1.26; 95% CI: 1.21, 1.31; p=<0.001). Conclusion: Research into the use of non-pharmacologic pain management strategies for sickle cell disease has recently increased in order to better address the multidimensional aspects of pain. Of these management strategies, aquatic therapy has been very underutilized and under researched. Analysis of the utilization of aquatic therapy in our institution showed improved use over the last 3 years as well as increased duration between hospitalizations after the use of aquatic therapy. These positive results point towards the need for more research into other outcome measures derived from the use of aquatic therapy in pain management of pediatric SCD patients. Figure 1 Disclosures No relevant conflicts of interest to declare.

A qualitative study of health professionals’ views on using iPads to facilitate distraction during paediatric burn dressing changes

Introduction: Distraction is a non-pharmacologic pain management technique commonly used to avert a person’s attention from procedural pain and distress during stressful procedures such as treatment after a burn injury. In recent years, computer tablets (such as iPads) have been used within paediatric burns services to facilitate distraction by way of apps, games, cartoons and videos during dressing changes. However, we know very little about health professionals’ experiences of using them in this context. Methods: The current study explored health professionals’ experiences of using iPads to facilitate distraction during paediatric burn dressing changes. Fifteen health professionals from a single paediatric burns unit were interviewed. Thematic analysis revealed two key themes: (1) the iPad is a universal panacea for distraction; and (2) trials and tribulations. Discussion: Participants considered iPads to be potentially useful and effective distraction tools, suitable for use with a wide range of patients with burn injuries including young children, adolescents and young adults. However, issues including health professionals’ understandings of one another’s roles, the challenge of working in a busy burns service, and lack of experience and confidence were identified as possible barriers to their use within routine burn care. Training for staff on the use of iPads as a means of facilitating distraction, development of guidelines and a review of how they are incorporated into routine burn care are recommended.