Management of pain following craniotomy.

Pain following craniotomy is common, however, achieving effective analgesia can be difficult. The assessment of pain postoperatively can be a challenge in patients who are obtunded (not fully alert) and the severity of pain has historically been underestimated. There are also concerns about side-effects from drugs, particularly with opioids, which may lead to reluctance to administer effective doses. Paracetamol is generally safe and, if given intravenously, provides rapid analgesia, although there are risks associated with overdose and care must be taken to ensure that the safe daily limit is not exceeded. Opioids are effective but side effects of pupillary constriction and respiratory depression may be problematic in the neurosurgical patient. The total use of systemic analgesia can be minimised with the use of regional techniques, such as local anaesthetic nerve blocks. A multimodal technique, using different agents, is most likely to be effective.

Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit.

AIM: To investigate the effect of a powered toothbrush on colonization of dental plaque by ventilator-associated pneumonia (VAP)-associated organisms and dental plaque removal. MATERIALS AND METHODS: Parallel-arm, single-centre, examiner- and analyst-masked randomized controlled trial. Forty-six adults were recruited within 48 h of admission. Test intervention: powered toothbrush, control intervention: sponge toothette, both used four times per day for 2 min. Groups received 20 ml, 0.2% chlorhexidine mouthwash at each time point. RESULTS: The results showed a low prevalence of respiratory pathogens throughout with no statistically significant differences between groups. A highly statistically significantly greater reduction in dental plaque was produced by the powered toothbrush compared with the control treatment; mean plaque index at day 5, powered toothbrush 0.75 [95% confidence interval (CI) 0.53, 1.00], sponge toothette 1.35 (95% CI 0.95, 1.74), p=0.006. Total bacterial viable count was also highly statistically significantly lower in the test group at day 5; Log(10) mean total bacterial counts: powered toothbrush 5.12 (95% CI 4.60, 5.63), sponge toothette 6.61 (95% CI 5.93, 7.28), p=0.002. CONCLUSIONS: Powered toothbrushes are highly effective for plaque removal in intubated patients in a critical unit and should be tested for their potential to reduce VAP incidence and health complications.