- Email: [email protected]
Acute pain management
Correspondence
guidelines4 have suggested that recommendations for performing these blocks should be similar to those for neuraxial blocks. Performing a central neuraxial block on patients receiving antithrombotic medication is usually a risk benefit analysis and commonly the population receiving such agents are often the ones that benefit most from a neuraxial or regional technique. The incidence of epidural haematomas is rare and is based on retrospective analysis and case reports but the neurological outcome can be devastating for the patients. By reporting such cases we hope to increase awareness of this complication and vigilance in all patients receiving central neuraxial anaesthesia.
1 Tam NL, Pac-Soo C, Pretorius PM. Epidural haematoma after a combined spinal-epidural anaesthetic in a patient treated with clopidogrel and dalteparin. Br J Anaesth 2006; 96: 262–5 2 Victorian Consultative Council on Anaesthetic Mortality and Morbidity. Available from http://www.health.vic.gov.au/vccamm/ index.htm 3 Victorian Consultative Council on Anaesthetic Mortality and Morbidity. Neurological complications of regional anaesthesia— early consultation with the anaesthetist 2005. Available from http://www.health.vic.gov.au/vccamm/articles/neuro.pdf 4 Horlocker TT, Benzon H, Brown DL, et al. Regional anaesthesia in the anticoagulated patient: defining the risks (the Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28: 172–97 5 Craft RM, Chavez JJ, Bresee SJ, et al. A novel modification of the thromboelastograph assay, isolating platelet function, correlates with optical platelet aggregation. J Lab Clin Med 2004; 143: 301–9 6 Mentegazzi F, Danelli G, Ghisi D, et al. Locoregional anesthesia and coagulation. Minerva Anesthesiol 2005; 71: 497–9 doi:10.1093/bja/ael164
Acute pain management Editor—Macintyre and colleagues1 highlighted the increasing role of the acute pain service across the spectrum of inpatient pain problems. We have conducted an audit at the James Cook University Hospital to find out the contribution of the inpatient pain service to the management of non-postoperative pain. This audit was conducted over a 3 month period from November 2005 to January 2006. During this period, 563 patients were seen by the acute pain service of which 114 (20%) were not postoperative patients (Table 1). About half of the patients (59) required a single visit, 26 required 2 visits, 14 needed 3 visits, 9 patients were visited
Specialty
No. of cases
Orthopaedics and trauma Neurology and neurosurgery Vascular Medicine Surgery Renal Cardiology and cardiovascular surgery Dermatology Others
19 18 15 15 15 5 5 5 17
4 times, and 5 patients had to be seen 5 times or more. On average each visit took 12 min though 7 visits lasted more than 30 min. This meant that the inpatient pain service made 216 visits over the 3 month audit, which equates to 3–4 h work per week for the non-postoperative patients. If this time is not taken into account when allocating resources to the inpatient pain service there is a danger that the core duties of the service that is maintaining high standards of acute pain management and the teaching of medical and nursing staff may be compromised. Another observation made during this audit was that more than half these patients needed only a single visit from the inpatient pain service. This was principally to support and advise the ward staff on an appropriate management plan. Based on this audit it is possible to identify the common conditions requiring input from the inpatient pain service. The pain team can then disseminate the evidence-based guidelines among the referring units and the ward staff to give them more confidence in managing the common pain problems. The inpatient pain service is closely aligned to the chronic pain (outpatient) service. Several patients seen by the inpatients pain service are offered follow-up in the chronic pain clinic following discharge. We need to evaluate further whether the input from the inpatient pain service facilitates earlier discharge from hospital and improves outcomes. A. Date J. Hughes K. Milligan Middlesbrough, UK E-mail: [email protected] 1 Macintyre PE, Walker S, Power I, Schug SA. Acute pain management: scientific evidence revisited. Br J Anaesth 2006; 96: 1–4 doi:10.1093/bja/ael165
Single-use LMAs—a cautionary tale Editor—We read with interest the editorial by Cook1 regarding the recent introduction of single-use, supraglottic airway devices. In response, we would like to describe our local experience of their introduction into clinical
265
Downloaded from http://bja.oxfordjournals.org/ at University of Pennsylvania Library on June 25, 2015
N. L. Tam* C. Pac-Soo P. M. Pretorius High Wycombe, UK *E-mail: [email protected]
Table 1 The distribution, by speciality, of the non-postoperative patients seen by the inpatient pain service during the audit period
guidelines4 have suggested that recommendations for performing these blocks should be similar to those for neuraxial blocks. Performing a central neuraxial block on patients receiving antithrombotic medication is usually a risk benefit analysis and commonly the population receiving such agents are often the ones that benefit most from a neuraxial or regional technique. The incidence of epidural haematomas is rare and is based on retrospective analysis and case reports but the neurological outcome can be devastating for the patients. By reporting such cases we hope to increase awareness of this complication and vigilance in all patients receiving central neuraxial anaesthesia.
1 Tam NL, Pac-Soo C, Pretorius PM. Epidural haematoma after a combined spinal-epidural anaesthetic in a patient treated with clopidogrel and dalteparin. Br J Anaesth 2006; 96: 262–5 2 Victorian Consultative Council on Anaesthetic Mortality and Morbidity. Available from http://www.health.vic.gov.au/vccamm/ index.htm 3 Victorian Consultative Council on Anaesthetic Mortality and Morbidity. Neurological complications of regional anaesthesia— early consultation with the anaesthetist 2005. Available from http://www.health.vic.gov.au/vccamm/articles/neuro.pdf 4 Horlocker TT, Benzon H, Brown DL, et al. Regional anaesthesia in the anticoagulated patient: defining the risks (the Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28: 172–97 5 Craft RM, Chavez JJ, Bresee SJ, et al. A novel modification of the thromboelastograph assay, isolating platelet function, correlates with optical platelet aggregation. J Lab Clin Med 2004; 143: 301–9 6 Mentegazzi F, Danelli G, Ghisi D, et al. Locoregional anesthesia and coagulation. Minerva Anesthesiol 2005; 71: 497–9 doi:10.1093/bja/ael164
Acute pain management Editor—Macintyre and colleagues1 highlighted the increasing role of the acute pain service across the spectrum of inpatient pain problems. We have conducted an audit at the James Cook University Hospital to find out the contribution of the inpatient pain service to the management of non-postoperative pain. This audit was conducted over a 3 month period from November 2005 to January 2006. During this period, 563 patients were seen by the acute pain service of which 114 (20%) were not postoperative patients (Table 1). About half of the patients (59) required a single visit, 26 required 2 visits, 14 needed 3 visits, 9 patients were visited
Specialty
No. of cases
Orthopaedics and trauma Neurology and neurosurgery Vascular Medicine Surgery Renal Cardiology and cardiovascular surgery Dermatology Others
19 18 15 15 15 5 5 5 17
4 times, and 5 patients had to be seen 5 times or more. On average each visit took 12 min though 7 visits lasted more than 30 min. This meant that the inpatient pain service made 216 visits over the 3 month audit, which equates to 3–4 h work per week for the non-postoperative patients. If this time is not taken into account when allocating resources to the inpatient pain service there is a danger that the core duties of the service that is maintaining high standards of acute pain management and the teaching of medical and nursing staff may be compromised. Another observation made during this audit was that more than half these patients needed only a single visit from the inpatient pain service. This was principally to support and advise the ward staff on an appropriate management plan. Based on this audit it is possible to identify the common conditions requiring input from the inpatient pain service. The pain team can then disseminate the evidence-based guidelines among the referring units and the ward staff to give them more confidence in managing the common pain problems. The inpatient pain service is closely aligned to the chronic pain (outpatient) service. Several patients seen by the inpatients pain service are offered follow-up in the chronic pain clinic following discharge. We need to evaluate further whether the input from the inpatient pain service facilitates earlier discharge from hospital and improves outcomes. A. Date J. Hughes K. Milligan Middlesbrough, UK E-mail: [email protected] 1 Macintyre PE, Walker S, Power I, Schug SA. Acute pain management: scientific evidence revisited. Br J Anaesth 2006; 96: 1–4 doi:10.1093/bja/ael165
Single-use LMAs—a cautionary tale Editor—We read with interest the editorial by Cook1 regarding the recent introduction of single-use, supraglottic airway devices. In response, we would like to describe our local experience of their introduction into clinical
265
Downloaded from http://bja.oxfordjournals.org/ at University of Pennsylvania Library on June 25, 2015
N. L. Tam* C. Pac-Soo P. M. Pretorius High Wycombe, UK *E-mail: [email protected]
Table 1 The distribution, by speciality, of the non-postoperative patients seen by the inpatient pain service during the audit period