W.A. Macrae

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.

Pain in traumatic upper limb amputees in Sierra Leone.

&NA; Data on 40 upper limb amputees (11 bilateral) with regard to stump pain, phantom sensation and phantom pain is presented. All the patients lost their limbs as a result of violent injuries intended to terrorise the population and were assessed 10–48 months after the injury. All amputees reported stump pain in the month prior to interview and ten of the 11 bilateral amputees had bilateral pain. Phantom sensation was common (92.5%), but phantom pain was only present in 32.5% of amputees. Problems in translation and explanation may have influenced the low incidence of phantom pain and high incidence of stump pain. In the bilateral amputees phantom sensation, phantom pain and telescoping all showed bilateral concordance, whereas stump pain and neuromas did not show concordance. About half the subjects (56%) had lost their limb at the time of injury (primary) while the remainder had an injury, then a subsequent amputation in hospital (secondary). There was no association between the incidence of phantom pain and amputation irrespective of being primary or secondary.

Consensus and contention in the treatment of chronic nerve-damage pain

&NA; A postal questionnaire survey was carried out to investigate beliefs in the efficacy of specific treatments held by consultants involved in the treatment of chronic nerve‐damage pain. One hundred eighty‐eight consultants experienced in the treatment of chronic pain were identified by local Pain Clinic consultants in 5 centres. The specialties represented were neurology, neurosurgery, orthopaedic surgery, oncology/radiotherapy, plastic surgery and anaesthesia. Replies were received from 181 consultants (96%). Over one fifth of the consultants expressed no opinion about half of the treatments assessed. Widely divergent views were held by those who did give an opinion. Many clinicians assessed some treatments as ‘poor’ while other clinicians assessed the same treatments as ‘excellent’ (neurolytic nerve block, somatic nerve block, cortodomy and opioids). For some treatments divergence of opinion can be explained in part by differences between specialties. For other treatments marked diversity was seen within as well as between specialties. There is a clear need for education in the use of particular treatments, even amongst those clinicians who regularly see this type of patient.

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.

Polarised views on treating neurogenic pain

&NA; This study aimed to identify areas of disagreement in the management of neurogenic pain. A short questionnaire was mailed to 179 consultants with an interest in chronic pain (response rate 89%). The questionnaire listed 11 specific conditions involving nerve pain (e.g., post‐herpetic neuralgia, causalgia) together with 11 treatments (e.g., antidepressants, neurectomy). Consultants were asked to rate the use of each treatment for each condition as ‘appropriate’, ’no value or positively harmful’ or ‘no opinion’. Much disagreement emerged about the value of each therapy for each condition: in almost every instance at least some consultants disagreed with the majority view. The dissenting minority was greater than 20% of those who gave an opinion for 48 of the 121 applications of therapy asked about. The appropriateness of treatments for trigeminal neuralgia, amputation stump pain and phantom pain was most often in dispute and there was little consensus on the value of nerve blocks. There were a few areas of near agreement. Antidepressants and anticonvulsants were mostly identified as appropriate for all the conditions listed and there was some agreement that strong opioids and the neuroablative techniques were appropriate for cancer pressure or infiltration of nerves but, with a few exceptions, of no value for all other neurogenic pain conditions. Divergence of views about treatments may indicate a lack of credible evidence on the value of therapies or a lack of professional knowledge. Where published evidence is clear, the consequences for patients may be under‐use of useful therapies or potential iatrogenic harm.

Continuous subcutaneous infusion of morphine for postoperative pain relief

A double‐blind randomised study of 48 patients in whom continuous subcutaneous infusion and regular intramuscular injection of morphine were compared as analgesic regimens after upper abdominal surgery, is described. Over a 48‐hour period, no difference in pain intensity between the two groups was found by comparing linear analogue scores, assessments on a four‐point rank scale, peak expiratory flow rates or requirement for additional analgesia. Nausea and sedation were assessed using a four‐point rank scale. These side effects were less frequent with subcutaneous infusion (p<0.05). Two patients from each group were judged to have received an overdose. The infusion apparatus was simple and convenient to use. Continuous subcutaneous infusion of morphine is a practical and effective means of achieving postoperative analgesia but, as with other mandatory dosing regimens, relative overdosage may occur.

Why use a pain clinic? Management of neurogenic pain before and after referral.

Pain arising from damage or malfunction of the nervous system (for example postherpetic neuralgia, peripheral nerve injuries and the neuropathies) is often severe and resistant to standard analgesics. These patients are commonly seen in pain clinics where they receive a variety of treatments including psychotropic drugs (such as antidepressants and anticonvulsants), nerve blocks and stimulation. There is concern that the management of these difficult patients may be less than optimal where they are not seen by pain specialists. We examined a cohort of 703 patients with long-established nerve-damage pain seen in ten outpatient pain clinics. We compared their use of treatments prior to referral with the management given in the pain clinic. The majority of patients (79%) had had their pain for over 1 year before being seen in the pain clinic, yet many had not tried simple and effective treatments prior to referral. Less than a quarter had received an adequate trial of antidepressants; only one in seven had been appropriately treated with anticonvulsants; and only one in 10 had tried a nerve stimulator. All these treatments were frequently provided in the pain clinic. Referral of patients with nerve-damage pain to a pain clinic may greatly increase their access to therapies of proven value.

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.

Post Surgical Pain- The Transition from Acute to Chronic Pain

• Chronic pain after surgery is common. • Surgery is widely performed therefore the at risk population is large. • The mechanisms of chronic pain after surgery are complex. • There are many risk factors associated with onset of chronic post-surgical pain: demographic, genetic and medical. • Unnecessary and inappropriate surgery should be avoided.

Let them eat asparagus

Editor—Through the letterboxes of residents of East Fife recently dropped a booklet entitled Eating for Health published by the Health Education Board for Scotland.1 Tucked into the booklet was a letter from Lord James Douglas-Hamilton, minister of state at the Scottish Office, exhorting us all to read and digest the contents. The booklet gives advice about healthy eating—we should all eat more bread, cereals, fruit, and …