The aim of this study was to characterize patients requiring hospitalization for severe chronic venous insufficiency (CVI) at the local and national levels and to analyze factors related to primary amputation. An administrative database (Nationwide Inpatient Sample, 1988-2000) and a single institution (1992-2000) were reviewed using the International Classification of Diseases, 9th ed., Clinical Modification, codes for CVI, excluding phlegmasia and concomitant peripheral vascular occlusive disease codes. Demographics, clinical course, and outcomes were assessed. Descriptive, univariate, and multivariate statistical analyses were used; p < 0.05 was considered significant. Nationally, CVI occurred with a mean incidence of 92/100,000 admissions, of which 55% were women, having a mean age of 65 years and a median length of stay of 7 days. Mean hospital charges were $13,900 and did not change significantly over time. Acute deep vein thrombosis affected 1.3%, amputation was performed in 1.2%, and in-hospital mortality was 1.6% The local cohort included 67 patients with a mean age of 51 years; a majority were men (60%), and 85% were C6 (of Clinical-Etiologic-Anatomic-Pathophysiology [CEAP]). Patients averaged 23 clinic visits and a median of one hospitalization for CVI care over a 44-month follow-up. Twelve patients (18%) underwent a CVI-related amputation (one transmetatarsal amputation, nine below-knee amputations, and two above-knee amputations). They had fourfold more CVI-related hospitalizations, greater preoperative chronic narcotic use than nonamputee patients (85% vs. 58%), but less ongoing wound care needs (25% vs. 89%) (all p values < 0.05). However, no significant difference in long-term mortality, number of clinic visits, duration of symptoms, antibiotic courses, or prior venous-related surgeries was found. In those with amputation, ambulatory status was maintained in 75% at 15-month follow-up. The physiological and economic costs of severe CVI are significant and have not decreased over more than a decade. Amputation for CVI-related nonhealing wounds has a reasonable outcome. Future therapy must focus on prevention of CVI sequelae.

To the Editor:-One always needs to be careful about stating that anything is "new," and I wonder if I might suggest to Ueda et al. 1 that they were incautious in their claim in regard to the use of regular intermittent bolus administration of epidural local anesthetic. This technique was studied in Edinburgh, many years ago, in both open 2 and randomized double-blind 3 studies in gynecologic patients. I am delighted that others are now studying this method of administration, but priority in this regard belongs properly to

Buprenorphine is a partial agonist/antagonist used for the outpatient management of pain and addiction. It avidly binds to the opioid receptors and has a long and varied half-life. Its effects can impair the efficacy of opioids used for postoperative pain. The authors present a case of a patient managed with buprenorphine as an outpatient who presented for revision spine surgery and had significant postoperative pain that was successfully treated with hydromorphone and dexmedetomidine. This is the first reported use of dexmedetomidine for postoperative pain in a patient treated with buprenorphine.

Respiratory failure requiring intubation has traditionally been a relative contraindication to lung transplantation due to increased morbidity and mortality. Advances in extracorporeal membranous oxygenation (ECMO) have made it possible to extubate patients and provide physical therapy with minimal native lung function. By "bridging" patients to lung transplant using ECMO, they are able to undergo rehabilitation and withstand the demands of surgery. However, providing anesthesia for these cases requires an understanding of ECMO physiology and the pharmacology associated with ECMO. We describe the anesthetic for four patients who were bridged to lung transplant and the complexities of their perioperative management.

Background. Elevated lactate levels may be caused by increased production suggestive of tissue ischemia; however, they may also occur without evidence of ischemia, by catecholamine activation of beta receptors. The purpose of this study was to determine the factors associated with increased lactate levels during and after lung transplantation and to evaluate whether lactate levels were associated with increased time to extubation and postoperative complications.Methods. This was a retrospective study of patients who underwent lung transplantation between January 2015 and May 2017 at the University of Michigan, Ann Arbor, MI. Multivariable linear regression was used to determine the factors associated with peak lactate levels and to find the associations between lactate levels and outcomes of nitric oxide time, intubation time, length of stay, and creatinine level. Logistic regression was used to determine the associations between lactate levels and acute kidney injury and atrial fibrillation.Results. A total of 86 patients underwent singlelung transplantation (n [ 17; 20%