Jonathan Bannister

Postoperative pain relief using thoracic epidural analgesia : outstanding success and disappointing failures

Six hundred and forty patients received epidural analgesia for postoperative pain relief following major surgery in the 6‐year period 1993–1998. Although satisfactory pain relief was achieved in over two‐thirds of patients for a median duration of 44 h after surgery, one‐fifth of patients (133 individuals) still experienced poor pain relief. Almost one out of three patients (194 individuals) had a problem with their epidural. Eighty‐three patients (13%) suffered a technical failure and 84 (13%) patients had their epidurals removed at night time when pain‐free because of pressure on beds. Seven patients had their epidural replaced and subsequently experienced excellent pain relief for a median of 77 h. Lack of resources prevented a further 480 patients from receiving the potential benefits of epidural analgesia. These results would suggest that the practical problems of delivering an epidural service far outweigh any differences in drug regimens or modes of delivery of epidural solutions.

Spinal anesthesia with 0.5% S(-)-bupivacaine for elective lower limb surgery.

BACKGROUND AND OBJECTIVES This study examines the clinical effects of the subarachnoid administration of levobupivacaine, the S(-)-enantiomer of racemic bupivacaine. METHODS An open, noncomparative study was performed on 20 patients undergoing elective lower limb surgery. Three milliliters of a plain solution of 0.5% S(-)-bupivacaine ( 15 mg) was administered via the L2 or L3 interspace with the patient in the sitting position. Following injection, the patients were immediately placed supine. Spread of sensory analgesia, degree of motor block, and hemodynamic parameters were recorded. RESULTS Satisfactory surgical anesthesia was achieved in 18 patients. The median time to onset of analgesia was 2 minutes (ranging 2-10 minutes) and the median duration of analgesia was 388 minutes (range, 295-478 minutes). This group of patients achieved complete motor block, with a median onset time of 5 minutes (2-10 minutes) and duration of 266 minutes (range, 170-415 minutes). Sensory block height was inadequate for surgery in 2 patients, who received supplemental anesthesia. CONCLUSIONS The results suggest that S(-)-bupivacaine can provide satisfactory surgical anesthesia, but the spread of the plain solution is unpredictable.

Skin blood flow changes in response to intradermal injection of bupivacaine and levobupivacaine, assessed by laser Doppler imaging.

Background and Objectives The vascular effects of local anesthetics are important determinants of their therapeutic activity. Drugs that vasoconstrict have the potential clinical advantages of limited systemic uptake and prolonged duration of effect. The aim of this study was to assess quantitatively the cutaneous vasoactivity of racemic bupivacaine and one of its enantiomers, levobupivacaine. Methods Four concentrations of each drug (0.1 mL each of 0.125%, 0.25%, 0.5%, and 0.75%), as well as normal saline, were injected intradermally into randomly assigned sites on the forearms of 10 volunteers. We measured skin blood perfusion using laser Doppler imaging before injection and at 2.5, 10, 20, 40, 60, and 90 minutes thereafter. Results Both drugs produced a rapid, dose-dependent increase in skin perfusion (P < .001). Saline also caused an increase in perfusion, although less sustained. By 40 minutes, most responses had returned to baseline levels. However, after this time, perfusion continued to decrease, below baseline, for both bupivacaine and levobupivacaine. The exception to this was 0.75% bupivacaine, the response to which was significantly higher than the same concentration of levobupivacaine over this later period (P < .05). Conclusions Bupivacaine and levobupivacaine both have a biphasic effect on skin microvessels. The vasoconstriction observed after 40 minutes may occur when the quantity of drug remaining at the administration site has decreased to a lower level. The continued vasodilatation caused by bupivacaine is more difficult to interpret. The results suggest that these local anesthetics cause vasodilatation at high doses and vasoconstriction at lower, subclinical doses. This hypothesis and the clinical relevance of these effects warrant further investigation.

Substance misuse of gabapentin.

Neuropathic pain affects up to 8% of the population,1 causing significant distress and morbidity. Good evidence-based treatment is available,2 so early diagnosis is important. Recent publicity and guidelines, and increasing prevalences of age-related causes of neuropathic pain (including postherpetic neuralgia and diabetic neuropathy), have led to increasing rates of diagnosis and treatment in primary care. Gabapentin is one of the recommended mainstays of evidence-based treatment.3 Unfortunately, our clinical experience suggests that gabapentin is now prevalent as a drug of abuse. The drug’s effects vary with the user, dosage, …

Challenge of improving postoperative pain management: case studies of three acute pain services in the UK National Health Service

BACKGROUND Previous national survey research has shown significant deficits in routine postoperative pain management in the UK. This study used an organizational change perspective to explore in detail the organizational challenges faced by three acute pain services in improving postoperative pain management. METHODS Case studies were conducted comprising documentary review and semi-structured interviews (71) with anaesthetists, surgeons, nurses, other health professionals, and managers working in and around three broadly typical acute pain services. RESULTS Although the precise details differed to some degree, the three acute pain services all faced the same broad range of inter-related challenges identified in the organizational change literature (i.e. structural, political, cultural, educational, emotional, and physical/technological challenges). The services were largely isolated from wider organizational objectives and activities and struggled to engage other health professionals in improving postoperative pain management against a background of limited resources, turbulent organizational change, and inter- and intra-professional politics. Despite considerable efforts they struggled to address these challenges effectively. CONCLUSIONS The literature on organizational change and quality improvement in health care suggests that it is only by addressing the multiple challenges in a comprehensive way across all levels of the organization and health-care system that sustained improvements in patient care can be secured. This helps to explain why the hard work and commitment of acute pain services over the years have not always resulted in significant improvements in routine postoperative pain management for all surgical patients. Using this literature and adopting a whole-organization quality improvement approach tailored to local circumstances may produce a step-change in the quality of routine postoperative pain management.

Understanding the challenges of service change – learning from acute pain services in the UK

Summary Objectives To explore organizational difficulties faced when implementing national policy recommendations in local contexts. Design Qualitative case study involving semi-structured interviews with health professionals and managers working in and around acute pain services. Setting Three UK acute hospital organizations. Main outcome measures Identification of the content, context and process factors impacting on the implementation of the national policy recommendations on acute pain services; insights into and deeper understanding of the generic obstacles to change facing service improvements. Results The process of implementing policy recommendations and improving services in each of the three organizations was undermined by multiple factors relating to: doubts and disagreements about the nature of the change; challenging local organizational contexts; and the beliefs, attitudes and responses of health professionals and managers. The impact of these factors was compounded by the interaction between them. Conclusions Local implementation of national policies aimed at service improvement can be undermined by multiple interacting factors. Particularly important are the pre-existing local organizational contexts and histories, and the deeply-ingrained attitudes, beliefs and assumptions of diverse staff groups. Without close attention to all of these underlying issues and how they interact in individual organizations against the background of local and national contexts, more resources or further structural change are unlikely to deliver the intended improvements in patient care.

Continuous epidural infusion of ropivacaine for the prevention of postoperative pain after major orthopaedic surgery: A dose-finding study

Abstract The present study investigated the dose relationship of ropivacaine with regard to analgesia and motor block when administered as a continuous 21 hour epidural infusion following major orthopaedic surgery. Forty six patients scheduled for elective total knee or hip arthroplasty were compared in this double-blind study. Patients were randomly assigned to one of four treatment groups: saline ( n =12); ropivacaine 0.1% ( n =11); ropivacaine 0.2% ( n =12); ropivacaine 0.3% ( n =11). Initial epidural analgesia was established with 0.5% ropivacaine and general anaesthesia was then induced for surgery. Within 30 minutes of the end of surgery, epidural infusions were commenced at a rate of 10 ml/hour for 21 hours. All patients had access to PCA morphine. Morphine consumption, VAS pain scores at rest, sensory and motor block and overall quality of treatment were assessed at regular intervals. The morphine consumption and VAS scores were lower overall in the ropivacaine groups than in the group receiving only PCA morphine. The difference was more evident during the first 8 hours of postoperative infusion, when significant differences between the ropivacaine 0.2% and 0.3% groups and the saline group were found. The incidence and degree of motor block were dose dependent. There was significantly higher patient satisfaction in all ropivacaine groups compared to the saline control group. In conclusion, 21 hour epidural infusion of ropivacaine, combined with PCA morphine, provides effective pain relief following major joint surgery and without significant adverse events. Morphine consumption and pain scores were lowest in the 0.3% ropivacaine group but this group had a higher degree of motor block. Pain relief with the combination of ropivacaine and PCA morphine is superior to that of PCA morphine alone.