PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations.

Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50-100 µg or diamorphine 300 µg administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery.

BACKGROUND: Open inguinal hernia repair is associated with moderate postoperative pain, but optimal analgesia remains controversial. The aim of this systematic review was to evaluate the available literature on the management of pain after open hernia surgery. METHODS: Randomized studies, in English, published between January 1966 and March 2009, assessing analgesic and anaesthetic interventions in adult open hernia surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. In addition to published evidence, clinical practice was taken into account to ensure that the recommendations had clinical validity. RESULTS: Of the 334 randomized studies identified, 79 were included. Quantitative analysis suggested that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain. Spinal anaesthesia was associated with a higher incidence of urinary retention and increased time to home-readiness compared with regional anaesthesia. CONCLUSION: Field block with, or without wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to general anaesthesia, is recommended to reduce postoperative pain. Continuous local anaesthetic infusion of a surgical wound provides a longer duration of analgesia. Conventional non-steroidal anti-inflammatory drugs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol, administered in time to provide sufficient analgesia in the early recovery phase, are optimal. In addition, weak opioids are recommended for moderate pain, and strong opioids for severe pain, on request.

Choose your menu wisely: cuisine-associated food-poisoning risks in restaurants in England and Wales.

The food service sector continues to be the most common setting for reported foodborne disease outbreaks in England and Wales. Using restaurant-associated foodborne outbreaks reported in England and Wales from 1992 to 2009, cuisine-specific risk factors were examined. Of 677 restaurant outbreaks, there were 11 795 people affected, 491 hospitalizations, and seven deaths; and Chinese, Indian, British and Italian cuisines were the most commonly implicated (26%, 16%, 13% and 10%, respectively). Salmonella spp. accounted for most outbreaks of all cuisine types, and particularly Chinese (76%, 133/175) and Italian (55%, 38/69). Poultry meat was the most frequently implicated food vehicle in outbreaks associated with Indian (30%), Chinese (21%), and British (18%) cuisines while for Italian cuisine, desserts and cakes were more frequently implicated (33%). Rice dishes were also a common outbreak food vehicle in those restaurants serving Chinese (22%) and Indian (16%) cuisine. Cross-contamination was the biggest contributory factor associated with Chinese (46%), British (33%) and Indian (30%) cuisines whereas inadequate cooking (38%) and use of raw shell eggs in lightly cooked or uncooked food (35%) were more often associated with Italian cuisine. Over the surveillance period, the proportion of Salmonella Enteritidis PT4 outbreaks in restaurants serving Chinese cuisine significantly decreased (P<0.0001) and this was mirrored by an increase in S. Enteritidis non-PT4 outbreaks (P<0.0001). Despite this change in proportion, contributory factors such as cross-contamination have continued to cause outbreaks throughout the 18 years. The results show that by stratifying the risks associated with restaurants by cuisine type, specific evidence of food control failures can be used to target foodborne illness reduction strategies.

A 17-year review of foodborne outbreaks: describing the continuing decline in England and Wales (1992-2008).

Systematic national surveillance of foodborne disease outbreaks effectively serves the development of public health policy on food safety. The Health Protection Agency has maintained a collaborative surveillance system for foodborne outbreaks in England and Wales since 1992. Up to 2008, 2429 foodborne outbreaks were identified, described and analysed for changes over time. Salmonella spp. accounted for half of the outbreaks, although the proportion of these decreased over the surveillance period. Similarly, the proportion of outbreaks caused by Clostridium perfringens decreased, while those attributed to Campylobacter spp. and Vero cytotoxin-producing Escherichia coli O157 increased. Although poultry meat was the most frequently implicated food vehicle in outbreaks followed by miscellaneous foods and red meats, the proportion of outbreaks attributed to meats in fact decreased over time but those linked to miscellaneous foods did not. Over the surveillance period, the proportion of outbreaks linked to eggs and S. Enteritidis non-phage-type 4, particularly in food service establishments, increased, highlighting the importance of this organism/setting/vehicle association. Contributory factors in most outbreaks were cross-contamination, inadequate heat treatment, and inappropriate food storage. This study describes the overall decline in foodborne outbreaks, providing evidence that the introduction and adherence to effective control measures provide the best means of minimizing the risk of foodborne infection.

Patients' assessment of 4-week recovery after ambulatory surgery.

BACKGROUND: patients' own assessment of recovery after ambulatory surgery has not been well studied. The aim was to study patients' self-assessed recovery, the occurrence and time course of post-operative problems in relation to the type of ambulatory surgery. METHODS: a questionnaire was filled in by 355 patients at five time points: pre-operative, first day at home, 1, 2 and 4 weeks post-operatively. Consecutive patients who underwent either inguinal hernia repair (IHR), arthroscopic procedures (AS) or cosmetic breast augmentation (CBA) were included. RESULTS: unplanned return to hospital was rare (3/355). Health care contacts were noted for 9% of the patients during the first week; a total of 70 contacts occurred during the entire period. Pain was the most frequently reported symptom; 40% of the patients reported pain or mobility problems at 1 week, 28% after 2 weeks and 20% after 4 weeks. Pre-operative pain was associated with an increased level of pain during the early post-operative course, in the recovery room and at 1 week post-operatively. IHR was associated with an overall rapid recovery, while AS patients experienced a slower restitution. All AS patients who reported pain after 4 weeks had reported pain problems already pre-operatively. Pain was not present pre-operatively in the CBA group, but was common at 1 and 2 post-operative weeks and was still reported by 11% at 4 weeks. CONCLUSION: self-assessed recovery was found to cover several weeks with procedure-specific recovery patterns. Pain and mobility impairment were still frequently reported 4 weeks post-operatively.

A recipe for disaster: outbreaks of campylobacteriosis associated with poultry liver pâté in England and Wales.

Despite the frequency of Campylobacter as the principal cause of bacterial gastroenteritis in the UK, outbreaks attributed to this pathogen are rare. One hundred and fourteen general foodborne outbreaks of campylobacteriosis were reported to the Health Protection Agency from 1992 to 2009 with most occurring in food service establishments (64%, 73/114). Poultry meat (38%, 43/114) was the most commonly reported vehicle of infection, of which poultry liver pâté, and undercooking, were strongly associated with this pathogen. Notably, the number of outbreaks of campylobacteriosis linked to consumption of poultry liver pâté in England and Wales increased significantly from 2007 (74% as opposed to 12%, P<0·00001) with a preponderance of these occurring in December. These outbreaks highlight the hazards associated with inappropriate culinary practices leading to undercooking of poultry liver pâté and suggest that improving catering practice is an important last line of defence in reducing exposure to Campylobacter-contaminated products.

Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi-center study.

BACKGROUND: The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery. METHODS: The 355 allocated patients were followed during recovery and the first day at home. RESULTS: Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS>3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes. CONCLUSION: We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment.

Patient assessed health profile: a six-month quality of life questionnaire survey after day surgery.

AIM: Patient assessed quality of life is one of the principal end-points after day surgery. The aim of the present study was to describe the natural course, differences and timing of final evaluation for three common day surgical procedures; inguinal hernia repair (IHR), arthroscopic procedures (AS); and cosmetic breast augmentation (CBA). METHOD: A total of 355 patients prospectively completed an extended eight-item EQ-5D questionnaire (pain, mobility, mood, self-care, activities, sleep, sex, need for analgesic), preoperatively and at one, three and six months postoperatively. RESULTS: Pain and mobility problems were frequently reported prior to surgery among IHR and AS patients, while CBA patients had less deviation from normal in the preoperative health profile. The proportions of patients reporting surgery-related deviations were 35%, 20% and 5% at one, three and six months respectively. After one month, 50% of AS patients still suffered subjective discomfort as compared to 13% and 20% of the IHR and CBA patients, respectively. Pain and ambulation problems were the most common symptoms in all groups. Six months after surgery, 94% of IHR, 89% of AS and 97% of CBA patients were fully recovered. CONCLUSIONS: No major morbidity or severe complications were observed and patients' satisfaction was high overall. We found procedure-specific changes in the postoperative health profile after day surgery. AS patients recovered more slowly compared with IHR and CBA patients. We conclude that time for final evaluation differs significantly between procedures.

Survey of Salmonella contamination of edible nut kernels on retail sale in the UK.

Consumption of nut kernels has shown an upward trend due to people's increasing tendency to eat healthy snacks. The purpose of this survey was to establish the microbiological safety of retail edible nut kernel samples of different varieties. Overall Salmonella spp. and Escherichia coli were detected from 0.1% and 0.8% of 2886 edible nut kernels, respectively. S. Senftenberg and S. Tennessee were detected from two pre-packed samples of Brazil nuts (0.4%) and S. Anatum from a pre-packed mixed nuts sample (0.9%; mix: almonds, Brazils, cashews, peanuts, walnuts) indicating a risk to health. The levels of Salmonella ranged from <0.01 to 0.23/g. E. coli at unsatisfactory levels (150/g) was present in another pre-packed Brazils nuts sample (0.2%). E. coli was additionally found at lower levels (range: 3.6-43/g) in Brazils (1.9%), macadamia (1.5%), pistachios (1.1%), walnuts (0.7%), peanuts (0.7%), hazels (0.5%), cashews (0.4%), and almonds (0.3%). Levels of E. coli did not correlate with the presence of Salmonella. The batches contaminated with Salmonella were recalled and Food Standards Agency food alerts were issued to advise against the consumption of the affected products. The presence of Salmonella is unacceptable in ready-to-eat foods and follows that the need for applying good agricultural and hygiene practices and effective decontamination procedures during the production of edible kernels cannot be overemphasized.

Clinical practice and routines for day surgery in Sweden: results from a nation-wide survey.

BACKGROUND: Day surgery has expanded considerably during the last decades. Routines and standards have developed but differ between and within countries. METHODS: We studied the practice of day surgery in Sweden by an extensive questionnaire survey sent to all 92 hospitals. RESULTS: The proportion of day surgery vs. in-hospital procedures was overall 43%, with 43% in adults and 46% in children. Orthopaedic (33%), general (29%) and gynaecological (17%) surgery were the most common ambulatory procedures. Most patients (>90%) underwent pre-operative assessment by an anaesthesiologist. Patient self-assessment questionnaires were common (86%). Risk stratification for post-operative nausea and vomiting was used by 70% of the departments. Anxiolytic pre-medication was uncommon. Most anaesthesiologists (95%) used pre-operative oral analgesics to initiate post-operative analgesia, the most common being paracetamol (95%), NSAIDs (73%) and coxibs (15%). A balanced general anaesthesia technique was preferred. Post-operatively, 93% of the units routinely assessed patients' pain. Analgesic combinations of paracetamol, NSAIDs and weak opioids were used by 94% of the units. Most hospitals (80%) had standardised discharge criteria based on clinical assessment, and many required a patient escort at home for 24 h post-operatively. Assessments of unplanned admission, re-admission and post-operative complications were not performed routinely. Follow-up telephone calls within 1-2 days were performed regularly in about 40% of the units, or in selected patients only (37%). Pain was the most frequent complaint on follow-up. CONCLUSIONS: In Sweden, a high degree of standardised regime for day surgical practice was found. Post-operative pain is the most common complaint after discharge.

Children in day surgery: clinical practice and routines. The results from a nation-wide survey.

BACKGROUND: Day surgery is common in paediatric surgical practice. Safe routines including parental and child information in order to optimise care and reduce anxiety are important. Most day surgery units are not specialised in paediatric care, which is why specific paediatric expertise is often lacking. METHODS: We studied the practice of paediatric day surgery in Sweden by a questionnaire survey sent to all hospitals, obtaining an 88% response rate. Three specific paediatric cases were enquired for in more detail. RESULTS: The proportion of paediatric day surgery vs. in-hospital procedures was 46%. Seventy-one out of 88 responding units performed paediatric day surgery. All units had anxiolytic pre-medication as a routine in 1-6-year-olds, and in 7-16-year-olds at 60% of the units. Most units performed circumcision and adenoidectomy, while 33% performed tonsillectomy. Anaesthesia induction was intravenous in older children, and also in 1-6-year-olds at 50% of the units. Parental presence at induction was mandatory. Post-operatively, 93% of units routinely assessed pain. Paracetamol and NSAIDs were the most common analgesics, as monotherapy or combined with rescue medication in the recovery as IV morphine. At 42% of units, take-home bags of analgesics were provided, covering 1-3 days of treatment. Pain was the most frequent complaint on follow-up. Micturition difficulties were common after circumcision, nausea after adenoidectomy and nutrition difficulties after tonsillectomy. CONCLUSIONS: In Sweden, most day surgery units perform paediatric surgery, most children receive pre-medication, anaesthesia is induced IV and take-home analgesics paracetamol and or NSAIDs are often provided. Still, pain is a common complaint after discharge.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty.

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).

Intrauterine insemination practice in the UK.

Intrauterine insemination (IUI) is a recognised treatment for infertility. The overall success rate of IUI remains controversial and depends on several factors. There is a wide variation in the practice of IUI across the country. A postal survey was conducted to determine the attitudes to the factors influencing IUI practice. A questionnaire containing 22 factors was sent to 150 reproductive medicine units in the UK. Practitioners were requested to rate each parameter on the scale of 1-10, where 1 was least important and 10 very important. A total of 101 practitioners replied. Over 50% of the corresponding practitioners were Consultants, 32% were Infertility Nurse Specialists and 12% were other clinicians. The factor with the highest rating was the number of the follicles on the day of human chorionic gonadotrophin (hCG) injection, followed by the size of the follicle and the total sperm count. The fourth critical factor voted was the need for a standardised protocol for all the unit staff. The wide variation in the approach to IUI probably explains the great variance in pregnancy rates. Further properly designed studies are needed to ascertain the role of the factors in determining the success of IUI and the most successful protocols.

Clinical practice and routines for day surgery in Sweden: implications for improvement in nursing interventions.

The purpose of this study was to examine nursing practice in day surgery settings in Sweden. A questionnaire focusing on the routines of the day surgery process of patients in Sweden was administered. Based on these findings, appropriate nursing interventions are outlined and discussed. Day surgery routines were in accordance with general worldwide practice. The study revealed that nursing involvement was rare in the preoperative routine. In addition, the major part of the recovery process, including assessments of discharge eligibility and information about pain management, was managed by PACU nurses. The nurse follow-up revealed a number of subjective queries and symptoms that, in a seemingly easy way, could have been prevented by further perianesthesia/perioperative patient education. There is an obvious place for nursing interventions when the decision for day surgery is taken. These interventions should focus on providing the patient with information before surgery, preoperative patient health screening, and information/education at discharge. Furthermore, nursing interventions should include quality assurance, such as follow-up calls for the evaluation of care, as well as providing information and coaching for the patient at home.