BACKGROUND:Intrathecal drug delivery systems (IDDS) have long been recommended to relieve intractable cancer pain. Intrathecal treatment administered by continuous flow rate can result in suboptimal analgesia, despite daily dosage escalation. The distribution of drugs in the cerebrospinal fluid remains limited during intrathecal infusion.Thus, despite catheter localization close to the target level in the intrathecal space, it is challenging to maintain effective therapy despite a considerable increase in continuous pump flow rate. This led to the consideration of how to cover more dermatomes with an already implanted IDDS. Literature suggests that using large boluses, in addition to conventional continuous infusion, may help intrathecal drug spread. An innovative infusion mode, defined as the sequential flex mode, using a basal flow rate with large boluses, could provide better pain relief than the usual continuous flow rate mode. METHODS:The sequential flex mode was used only for patients suffering despite a high continuous flow rate and a high daily drug dosage. The main objective of this retrospective monocentric study was to determine if patients achieved better pain relief with the sequential flex mode than the continuous flow rate mode. RESULTS:53 patients were included. 71.7%±6.43% of the patients achieved at least 30% Numerical Rating Scale (NRS) pain reduction with the sequential flex mode, and in 52.5%±7.12% of the switches, the pain relief achieved was even greater than 50% NRS reduction. The median NRS evaluation showed a significant pain reduction after the switch from 6.4 (SD 2.0) to 3.3 (SD 2.2) (p<0.0001). Intrathecal morphine and ropivacaine daily doses remained stable in the switch success group around the switch. Adverse effects occurred in 12 switches out of 59 (20.3%±6.06%), and were non-serious in nature, most commonly increased anxiety. CONCLUSION:The sequential flex intrathecal infusion mode may provide better pain relief when the continuous mode loses efficacy, as well as help to reduce daily dosage escalation.
Intrathecal drug delivery (IDD) is an established therapy for patients with refractory pain across cancer and non-cancer populations. By enabling targeted spinal drug delivery, IDD can provide durable symptom control at substantially lower doses than systemic therapy, often reducing systemic medication burden and treatment-limiting adverse effects. Despite decades of clinical experience and supportive evidence, IDD remains underutilized and largely concentrated in high-volume centers, reflecting persistent uncertainty related to patient selection, trialing, device planning, long-term management, limited evidence, and complication mitigation. This practical guide synthesizes current evidence, consensus recommendations, and collective international clinical experience to provide a structured approach to short-term and long-term management of implantable IDD systems. Shared principles applicable across indications are emphasized, while cancer-specific considerations are addressed separately, including prognosis, coordination with oncologic therapies, evolving spinal anatomy, and compressed treatment horizons. Key topics include preimplant evaluation and risk mitigation, trialing strategies and their limitations, pump and catheter selection, perioperative management, early post-implant troubleshooting, long-term maintenance, and surveillance for device-related, biological, and operational complications. Intrathecal pharmacologic strategies for pain are examined, including opioids, local anesthetics, ziconotide, clonidine, and baclofen, with attention to indication-specific dosing, titration, and safety considerations. Clinical outcomes are framed beyond pain intensity alone, emphasizing functional improvement, quality of life, and reduction in systemic medication use as clinically meaningful endpoints. Differences in therapeutic goals, time horizons, and risk tolerance between cancer and non-cancer populations are integrated into a practical decision framework aligned with real-world pain practice. International and regional practice variations are also discussed to contextualize differences in drug availability, compounding practices, and reimbursement. By consolidating pragmatic guidance across the full lifecycle of intrathecal therapy, this guide aims to support consistent, safe, and effective use of IDD for complex pain management in contemporary practice.
Background Intrathecal analgesia is recommended for the management of refractory cancer pain. Bupivacaine is the most commonly used local anesthetic in combination intrathecal therapies and is often administered at high doses. However, data on its systemic toxicity in this context remain limited. While the pharmacokinetics of bupivacaine have been described in epidural and spinal anesthesia, those studies involved substantially lower doses and minimal systemic absorption. A maximum serum concentration of 2 µg/mL (2000 µg/L) is generally considered the upper safety limit to prevent systemic toxicity, yet systemic exposure during chronic intrathecal infusion via an intrathecal drug delivery system has not been well characterized. Methods This single-center retrospective study aimed to quantify serum bupivacaine concentrations during intrathecal infusion and evaluate factors associated with systemic absorption. Serial bupivacaine plasma concentrations were measured with an in-house analytical assay on blood samples collected before each pump refill. Results Thirty-one patients were included, with a total of 162 blood samples analyzed. The mean daily intrathecal bupivacaine dose was 39.5 mg/day (SD 31.4 mg/day), resulting in a mean serum concentration of 167.7 µg/L (SD 266.2 µg/L). Serum bupivacaine levels were positively correlated with the daily dose and were also influenced by body mass index. After adjustment for daily dose, higher infusion flow rates remained independently associated with increased serum concentrations. Conclusion Chronic intrathecal infusion of bupivacaine for cancer pain management results in systemic exposure well below the established toxicity threshold.
In the present commentary, we consider the historical trajectory that reflects the evolution of neuraxial therapeutics that has transpired over the last 50 or so years, with a particular emphasis on its application to pain and its management. The review addresses the advances that led to where we are now in the 21st century with neuraxially targeted therapeutics and consideration of where this thread leads.
Intrathecal drug delivery systems (IDDS) have been used successfully for a number of refractory chronic pain conditions. The most common pain indications for the use of IDDS include cancer-related pain and postlaminectomy syndrome. IDDS can also be used to treat a variety of other less common refractory pain conditions, including central neuropathic pain, peripheral neuropathic pain and craniofacial pain. The aim of this article was to review the existing literature on the efficacy and clinical utility of IDDS for the management of uncommon pain indications, including spinal cord injury-related pain, transverse myelitis, diabetic painful neuropathy, postherpetic neuralgia and craniofacial pain to inform clinicians on the state of the current evidence of IDDS use in these challenging pain conditions. PubMed, Embase, Web of Science, CINAHL and Cochrane databases were searched with keywords. Additionally, reference lists of retrieved articles and relevant reviews were manually screened to identify additional publications. Articles were screened for relevance using Covidence by three reviewers. Eligible studies included the use of IDDS for refractory uncommon pain conditions. Exclusion criteria included non-English studies, animal studies, studies that focused on non-pain indications and abstracts without accompanied full text. Given heterogeneity and largely descriptive data, findings were analyzed narratively by descriptive categories. The use of IDDS for refractory pain in patients with select pain conditions is supported primarily by observational studies and small clinical trials. Current evidence suggests that the IDDS may provide meaningful analgesia in carefully selected patients with central and peripheral pain, and facial neuropathic pain; however, the magnitude of pain relief and durability of response is variable. These findings are likely reflective of the limited evidence as a result of selective utilization of this therapy in clinical practice. Based on limited evidence, IDDS may provide meaningful clinical benefit in patients with refractory uncommon pain syndromes. Future research can help to define the use of IDDS in this challenging patient population.
Economic evaluations, which systematically compare the costs and health-related outcomes of health interventions, are essential for informing resource allocation decisions, particularly in the context of financial constraints and limited healthcare budgets. Intrathecal drug delivery (ITDD) systems are widely used for the management of cancer pain, chronic non-cancer pain, and spasticity. However, ITDD involves substantial upfront costs, ongoing maintenance expenses, and potential complications. This article provides an overview of health-related economic evaluation principles and of the evidence on the cost-effectiveness of ITDD systems across cancer pain, chronic non-cancer pain, and spasticity. Published studies include both full and partial economic evaluations, conducted from varying perspectives and in diverse healthcare settings. Most analyses suggest that ITDD is cost-effective compared with conventional management strategies, particularly for cancer-related pain and spasticity. However, the robustness of these findings is limited by methodological heterogeneity and reliance on effectiveness data that are often derived from small or uncontrolled studies. Evidence for chronic non-cancer pain is especially sparse and inconsistent, highlighting the need for further research using rigorous designs and comprehensive cost data. Given the high costs and complexity of ITDD systems, strengthening the evidence base on their clinical and economic value is critical to support informed decision-making by health technology assessment bodies and payers. Future studies should prioritize comparative effectiveness research and long-term economic modeling to address current gaps and uncertainties.
BACKGROUND/IMPORTANCE:Intrathecal drug delivery (ITDD) is an established intervention for chronic non-cancer pain, cancer pain, and spasticity. However, ITDD is not routinely commissioned for non-cancer pain in some countries, including England. A comprehensive synthesis of its clinical impact and safety profile in this population is lacking. OBJECTIVE:To investigate the clinical outcomes and adverse events (AEs) associated with ITDD in adults with chronic non-cancer pain. EVIDENCE REVIEW:A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a registered protocol (CRD42024581505). Searches across MEDLINE, EMBASE, CENTRAL, and WikiStim until September 2024 were performed to identify studies reporting pain intensity, function, health-related quality of life (HRQoL), and AEs in ITDD recipients with non-cancer pain. Risk of bias was assessed using National Institutes of Health and Cochrane tools. A random-effects meta-analysis was performed on the pain intensity outcome (0-10 scale equivalent) at the 12-month time point. FINDINGS:39 studies (n=2652) were included; 20 single-arm comparisons contributed to meta-analysis. The pooled mean reduction in pain from baseline was 2.64 (95% CI 2.19 to 3.08). Accounting for between-study heterogeneity in effect size, the 95% prediction interval is 0.734 to 4.54 units. The probability that the change from baseline in a new, similar study would be greater than the minimum clinically important difference of 2 units is 75% (95% CI 68% to 83%). All studies reported improvements from baseline in function and HRQoL. Reporting of AEs or discontinuation of ITDD due to AEs was inconsistent. Risk of bias was moderate or high for cohort studies and pre-post studies, low for two crossover randomized trials and one parallel-arm randomized trial, and high for one parallel-arm randomized trial. CONCLUSIONS:ITDD is associated with meaningful reductions in pain from baseline, and functional and HRQoL improvement in patients with chronic non-cancer pain. However, the certainty of evidence is low for pain and very low for other outcomes due to study limitations. Improved reporting and controlled trials are needed to strengthen the evidence base, with careful consideration of a control intervention that maintains clinical equipoise.
INTRODUCTION:Bupivacaine is an established agent in intrathecal drug delivery (IDD), often used in combination with opioids. The efficacy of intrathecal bupivacaine monotherapy has not been reported. METHODS:A retrospective case series review was undertaken examining patients with chronic pain who underwent device implants and were receiving intrathecal bupivacaine monotherapy. Data collection included patient demographics as well as pain and IDD characteristics. RESULTS:Five patients receiving intrathecal bupivacaine monotherapy were identified. All patients had regionally localized pain. Duration of IDD ranged from >2 to >12 years. Two of the patients had initially received a combination of an opioid with bupivacaine but were later transitioned to intrathecal bupivacaine monotherapy. Three of the patients were on systemic opioids prior to IDD. All patients experienced ≥50% pain relief and discontinued systemic opioids. CONCLUSION:IDD with bupivacaine monotherapy may be effective in patients with localized pain. However, more studies are needed to establish the safety and efficacy of intrathecal bupivacaine monotherapy.
BACKGROUND:Cancer-related pain is common and difficult to manage, and many patients require opioid therapy with dose-limiting toxicity. As pain progresses, opioid escalation may result in adverse effects and suboptimal analgesia. Intrathecal drug delivery (IDD) provides targeted analgesia and may reduce systemic toxicity. This study evaluated temporal trends in pain and symptom burden before and after IDD initiation. METHODS:Retrospective analysis of longitudinal Brief Pain Inventory (BPI) and Condensed Memorial Symptom Assessment Scale (CMSAS) scores in 435 patients with cancer pain treated with IDD at an academic cancer center between 2013 and 2023. Inclusion required ≥1 symptom assessment within 30 days prior to implantation and survival >10 days postimplant. Primary outcomes were changes in BPI-Severity (BPI-SEV), BPI-Interference (BPI-INT) and CMSAS-Physical (CMSAS-PHYS) after IDD, estimated using joint longitudinal-survival models to account for informative dropout due to death over 1 year. Pre-IDD symptom trajectories were modeled separately. Secondary outcomes included remaining BPI and CMSAS domains assessed at prespecified time points up to 1 year, analyzed descriptively. RESULTS:222 patients met inclusion criteria. During follow-up, 91% discontinued systemic opioids. In joint models over the first 90 days after implantation, BPI-SEV decreased by 0.014 units/day (n=219; 95% CI -0.020 to -0.009; p<0.001), BPI-INT decreased by 0.020 units/day (n=209; 95% CI -0.029 to -0.011; p<0.001) and CMSAS-PHYS improved by 0.004 units per day (n=195; 95% CI -0.006 to -0.001; p=0.002). Symptom trajectories worsened prior to implantation and improved following IDD initiation. Mean composite scores improved significantly across all time points for BPI-SEV, BPI-INT and CMSAS-PHYS. CONCLUSIONS:Among patients with advanced cancer, pain and symptom burden worsened prior to IDD but improved within 90 days after implantation, with sustained benefits observed up to 1 year.
Introduction Intrathecal drug delivery (IDD) is often used in the management of refractory chronic non-cancer pain, particularly persistent chronic low back pain in the setting of previous lumbar spine surgery (persistent spinal pain syndrome type 2 (PSPS2)). Complications of IDD leading to device explant in patients with chronic non-cancer pain have not been well characterized. This study evaluated complications leading to device explants in a large cohort of patients with chronic non-cancer pain treated with IDD. Methods A retrospective study was undertaken on patients with chronic non-cancer pain who underwent device implants by Pain Medicine physicians between June 2009 and December 2022 at a large tertiary center academic practice. Data collection included demographic and comorbidity data as well as the various indications for device explant. Results Data were collected from 215 patients with chronic non-cancer pain who underwent device implant and were followed for a mean duration of 80±48.8 months. The average age at the time of implant was 63.24±12.05 years, and the majority (184 patients) suffered from PSPS2. The explant rate was 26.1%, and device-related infection was the leading cause of explants occurring in 9.3% of patients and 5.9% of device surgeries. Loss of analgesic efficacy leading to device explant occurred in 5.6% of patients, but this was significantly less than the explant rate due to habituation noted with spinal cord stimulation (SCS) in a similar patient population. compared with other complications leading to device explants, infections had a much earlier time interval from device implant to explant. No demographic or comorbidity factors correlated with device explants. Conclusion Device-related infections are the leading cause for explants in IDD for chronic non-cancer pain. Explants due to loss of analgesic efficacy occurred at a lesser frequency with IDD compared with SCS explants in a similar patient population.
INTRODUCTION:Intrathecal drug delivery systems offer a potent modality for managing cancer-related pain that is resistant to conservative measures. However, catheter-related complications, particularly migration, remain a concern. This study assessed the prevalence, risk factors, and implications of catheter migration rates in patients with intrathecal pumps (ITP) for cancer-related pain. MATERIALS AND METHODS:A retrospective database and chart review of 441 patients with cancer with an ITP at the Huntsman Cancer Institute from May 2014 to December 2023 was performed to identify patients who had two chest CT scans after implant separation by at least 30 days. Catheter migration was defined as movement of the catheter by one or more vertebral levels when comparing the two imaging studies. Demographics were analyzed to identify factors associated with migration. To identify subjects with catheter complications missed by the initial approach, an additional chart review was performed to identify operative procedures linked to catheter revision. RESULTS:117 patients were suitable for analysis, and 15.4% (n=18) had catheter migration between the two CT scans. These were all limited to a single vertebral level. Across the full cohort of 441 patients, radiographically significant migration requiring revision occurred in only two patients (0.45%). No demographic or clinical factors were significantly associated with migration. CONCLUSIONS:Minor catheter migration is relatively common following ITP implantation, but clinically significant migration is rare with the anchoring and closure techniques described.
Background/importance Patients with implanted intrathecal drug delivery systems (IDDS) present unique challenges for anesthesiologists in the perioperative, peripartum, and intensive care settings. A comprehensive and practical review on this topic is needed. Objective This narrative review highlights essential knowledge required for safe management of this patient population, including familiarity with: (1) IDDS technology and therapeutics; (2) the appropriateness of neuraxial procedures in IDDS patients; and (3) IDDS-related complications in the operating room and intensive care unit. Evidence reviewed A literature search was conducted using PubMed/MEDLINE and Google Scholar with the following keywords: intrathecal pump, intrathecal drug delivery, intrathecal morphine, perioperative medicine, labor anesthesia, regional anesthesia, and intrathecal baclofen. Reference lists of relevant articles were manually screened to identify additional pertinent studies, case series, and case reports. Intrathecal pump device manuals were also reviewed to obtain technical details. Findings Based on the available evidence, we provide background medical knowledge and guidance regarding IDDS across five main sections: intrathecal pharmacology, considerations related to IDDS implantation, perioperative care of patients with IDDS, neuraxial anesthesia, and device-related safety concerns. In each section, we summarize available literature and provide contextual interpretation informed by expert opinion when evidence is limited. Conclusions This review provides a comprehensive overview of current best practices for the perioperative management of patients with IDDS, emphasizing evidence-based approaches to optimize clinical outcomes and ensure patient safety. Key topics covered include intrathecal medications, their performance under MRI, and precautions prior to attempting any neuraxial access in patients with IDDS.
Background Hypersensitivity reactions to implanted neuromodulation devices often mimic infection and result in device explants. Among device components, titanium is an infrequent immune irritant that can lead to implant rejection. Case presentation This case report describes a patient with a history of prior lumbar spine surgery and refractory low back pain who had two intrathecal pump explants for suspicion of infection and who was ultimately diagnosed to have a type IV titanium hypersensitivity. An intrathecal drug delivery system was successfully reimplanted without rejection by encasing the pump with a pouch of expanded polytetrafluoroethylene (ePTFE) fabric. Conclusions Hypersensitivity to device components should be considered in patients with recurrent or unexplained pump site complications. The use of an ePTFE pouch may allow device reimplantation in patients with type IV hypersensitivity reactions to implanted neuromodulation devices.
BACKGROUND:Local anesthetics are effective for regional anesthesia but have a relatively short duration of action. This motivates the development of sustained-release delivery systems. The aim of this study was to evaluate whether an in situ-forming hydrogel composed of poloxamers and alginate could prolong the duration of ropivacaine-induced sensory and motor blockade. METHODS:In this randomized and blinded two-period cross-over study, 10 female sheep received ultrasound-guided sciatic nerve injections of either 200 mg ropivacaine poloxamer-alginate hydrogel (Rop-HG) or 200 mg, as a control, plain ropivacaine solution (Rop-C). Sensory and motor functions were assessed repeatedly using a standardized clinical scoring system. Plasma ropivacaine concentrations were measured over time, and postmortem histopathological evaluation of the sciatic nerve and surrounding tissues was performed. RESULTS:Rop-HG markedly prolonged block duration compared with Rop-C, increasing the median (IQR) sensory block from 24 hours (IQR 16-36) to 60 hours (IQR 60-72) and the median motor block from 16 hours (IQR 16-18) to 60 hours (IQR 36-72). Pharmacokinetic analysis showed a sharp early peak for Rop-C (median Cmax 5101 nmol/L and median Tmax 0.33 hours), whereas Rop-HG produced a lower and delayed profile (median Cmax 558 nmol/L and median Tmax 8 hours). Histopathology revealed more pronounced and persistent local tissue reactions in Rop-HG-treated limbs, characterized by degeneration, necrosis, and inflammation. CONCLUSION:Ultrasound-guided perineural injections of 200 mg Rop-HG substantially prolonged the clinical duration of sciatic nerve block and reduced early systemic exposure compared with a 200 mg plain ropivacaine solution. However, the formulation was associated with severe local tissue degeneration, necrosis, and inflammation. Consequently, it remains unclear whether the prolonged clinical effect resulted from a sustained pharmacological release of ropivacaine or from the local tissue toxicity. Further optimization of the formulation is required before clinical translation.
BACKGROUND AND OBJECTIVES:Perioperative intravenous lidocaine infusion has been proposed as an opioid-sparing analgesic adjunct in spine surgery, but previous meta-analyses pooled heterogeneous procedures and may have obscured procedure-specific treatment effects. We evaluated the analgesic and opioid-sparing effects of perioperative intravenous lidocaine in adult spine surgery and whether efficacy differs by procedure type. METHODS:We searched PubMed, Embase, Web of Science, and the Cochrane Library from inception through June 2026 for randomized controlled trials comparing perioperative intravenous lidocaine infusion with placebo or standard care in adults undergoing spine surgery. The primary outcome was postoperative pain intensity at 24 hours. Secondary outcomes were opioid consumption, postoperative nausea and vomiting (PONV), and hospital length of stay (LOS). Random-effects meta-analyses, a post hoc subgroup analysis by procedure type, and meta-regression were performed. RESULTS:10 randomized trials were included. Intravenous lidocaine reduced postoperative pain at 24 hours (9 trials, 655 patients; mean difference (MD), -0.83; 95% CI -1.36 to -0.30; p=0.002; I²=89%, 95% CI 81% to 93%; prediction interval, -2.69 to 1.02; moderate certainty) and opioid consumption (9 trials; MD, -11.64 mg intravenous morphine equivalents; 95% CI -16.14 to -7.14; p<0.001). In a post hoc exploratory analysis, the analgesic effect differed by procedure type (test for subgroup differences, p=0.005): the reduction was clinically meaningful after instrumented fusion or complex spine surgery (MD, -1.23; 95% CI -1.81 to -0.64), exceeding the minimal clinically important difference of 1.0 point, but minimal after decompression (MD, -0.20; 95% CI -0.61 to 0.21). Baseline pain severity explained approximately 53% of between-study heterogeneity, whereas lidocaine infusion rate did not modify the treatment effect (p=0.97). No significant effects were observed for PONV or LOS. CONCLUSIONS:There is moderate-certainty evidence that perioperative intravenous lidocaine reduces postoperative pain and opioid consumption after adult spine surgery. Its analgesic benefit appeared procedure-specific, with the greatest benefit after instrumented fusion and complex procedures; this difference emerged from a post hoc, exploratory analysis and should be regarded as hypothesis-generating.
Gastric point-of-care ultrasound (POCUS) is increasingly used to assess aspiration risk, but studies differ in whether ultrasound is used to validate the technique, characterize gastric contents in populations, or guide bedside clinical decisions. We performed a focused secondary analysis of 65 studies from the study-level extraction associated with a previously published ASRA Pain Medicine narrative review to determine how often gastric POCUS studies evaluated or reported changes in management. Studies were categorized by primary study purpose as foundational/validation/diagnostic-performance/reliability, clinical POCUS/decision-impact, or population/intervention research. Of 65 studies, 2 were clinical POCUS/decision-impact studies, 9 were foundational/validation studies, and 54 were population/intervention studies. Management-change status was reported or extractable in 8 studies and prespecified in 3; all 8 reported at least one actual management change, with rates ranging from 0.4% to 46%. Both clinical POCUS studies prespecified a management change, with reported change rates of 5.0% and 18.9%, respectively. Reported changes included rapid sequence induction, airway modification, postponement or cancellation, conversion to local/regional anesthesia, and more liberal or conservative aspiration-risk management. No study clearly linked management change to patient-centered outcomes. Future clinical gastric POCUS studies should prospectively define the indication, pre-scan plan, scan findings and decision thresholds, post-scan decision, and reason for change or non-change, while evaluating downstream patient-centered outcomes, resource utilization, and potential harms.
BACKGROUND:Phantom limb syndrome (PLS) is a common complication following below-knee amputations (BKA) causing painful and/or nonpainful sensations in the absent limb. Peripheral nerve blocks (PNBs) are used for perioperative analgesia, but their association with PLS risk remains unclear. This study sought to evaluate potential associations regarding PLS incidence after BKA with and without PNBs. METHODS:This retrospective cohort study was conducted using Epic Cosmos data from 2016 to 2025. Adults undergoing elective BKA were identified using Current Procedural Terminology codes 27880-27889 and categorized by PNBs versus none. The primary outcome was PLS diagnosis within 12 months of surgery using International Classification of Diseases, 10th Revision, Clinical Modification codes (G54.6, G54.7). Relative risks (RRs) were estimated using Mantel-Haenszel stratification adjusted for age, sex, and race only, with subgroup analysis by comorbidity burden. Secondary outcomes included length of stay (LOS). RESULTS:Among 38 433 patients, 7430 (19.3%) received perioperative PNBs and 31 003 (80.7%) did not. PLS diagnosis coding occurred in 18.8% of the PNB group versus 15.1% of the non-block group (absolute difference 3.7%). Analysis adjusted for age, sex, and race only did not change the association (Mantel-Haenszel RR 1.24, 95% CI 1.20 to 1.28). PNBs were associated with a shorter LOS. All estimates should be considered exploratory associations. CONCLUSIONS:In this multicenter electronic health record-based cohort, exploratory analysis showed that perioperative PNB use was associated with increased rates of documented PLS coding across subgroups. However, the overall RR increase is modest. The observed association may reflect residual confounding by indication and differential surveillance rather than a causal effect. PNBs still remain appropriate for improving acute pain and reducing LOS. Prospective studies are needed to clarify causality and inform prevention strategies.
BACKGROUND:Do-not-resuscitate orders are intended to prioritize patient comfort, but do-not-resuscitate patients may receive fewer procedural interventions. Regional analgesia is recommended for rib and hip fractures and may provide superior pain control to systemic analgesics. However, utilization remains low. Whether do-not-resuscitate status is associated with the utilization of comfort-enhancing regional analgesia has not been studied. METHODS:This was a cross-sectional study using the National Inpatient Sample of adult (≥18 years) hospitalizations for rib and hip fractures identified using International Classification of Diseases, 10th Revision codes from January 1, 2016, through December 31, 2022. The primary exposure was do-not-resuscitate status. The primary outcome was receipt of regional analgesia. RESULTS:298,343 rib fracture and 462,796 hip fracture hospitalizations met inclusion criteria, of which 8,568 (2.9%) and 13,730 (3.0%) received regional analgesia, respectively. Do-not-resuscitate status was present in 31,882 (10.7%) of rib fracture and 77,255 (16.7%) hip fracture hospitalizations.In adjusted analyses, do-not-resuscitate status was associated with lower odds of regional analgesia for rib fractures (OR 0.76; 95% CI 0.69 to 0.83), but not hip fractures (OR 1.00; 95% CI 0.94 to 1.06). In frailty-stratified analyses, the association between do-not-resuscitate status and lower rates of regional analgesia utilization was strongest among the least frail rib fracture hospitalizations (OR 0.34; 95% CI 0.25 to 0.48). CONCLUSIONS:Do-not-resuscitate status is associated with lower regional analgesia utilization for rib fractures but not hip fractures. Prospective studies are needed to confirm these findings.
