ABSTRACT
BACKGROUND: Epidural haematoma is a rare, but potentially disastrous complication of epidural analgesia. Favourable neurological outcome depends upon early recognition and surgical decompression; therefore, the management of epidural analgesia should include a systematic approach to recognition of the signs of epidural haematoma. METHODS: We conducted a national postal survey of the policies and protocols used by acute pain services for investigating clinical signs suggestive of epidural haematoma, and the availability of urgent MRI scans. This was a repeat of a survey that was carried out in 2001, but not published. RESULTS: The response rate was 84%. Of the acute pain services that responded, 99% have a written protocol for running epidural infusions, 91% include regular assessment of sensory and motor function, and 55% have a written protocol for the investigation of abnormal motor block. On-site 24 h access to MRI scanning facilities was available to 57%, 33% have arrangements with another hospital, and 10% do not have 24 h access to MRI. Thirty per cent of respondents knew of an epidural haematoma related to epidural analgesia in their hospital, one-third of which were not diagnosed and treated within 24 h. CONCLUSIONS: Improvements in monitoring have occurred over the last 5 yr, but observations of neurological function are not routine in all units, and are not continued after removal of the epidural catheter in the majority. The authors suggest that acute pain services should be responsible for protocols for the investigation and treatment of epidural haematomas.
Subject(s)
Analgesia, Epidural/adverse effects , Hematoma, Epidural, Spinal/diagnosis , Hematoma, Epidural, Spinal/etiology , Postoperative Complications/diagnosis , Clinical Protocols , Emergencies , Health Care Surveys , Hematoma, Epidural, Spinal/therapy , Humans , Magnetic Resonance Imaging/statistics & numerical data , Pain Clinics/organization & administration , Pain Clinics/statistics & numerical data , Pain, Postoperative/prevention & control , Postoperative Care/methods , Postoperative Complications/therapy , Professional Practice/statistics & numerical data , United KingdomABSTRACT
BACKGROUND: There is little published evidence of the analgesic efficacy of patient-controlled epidural analgesia (PCEA) for postoperative pain relief. The aim of this study was to compare the analgesic efficacy of epidural infusion of bupivacaine 0.125% and fentanyl 4 microg ml(-1) administered by either PCEA with a background infusion or nurse-administered continuous epidural infusion (CEI) after major intra-abdominal surgery. METHODS: In a double-blind, randomized clinical trial, 205 adult patients undergoing colonic resection by laparotomy received either PCEA or CEI. Pain scores were recorded via a four-point verbal rating scale at 1, 2, 3, 4, 8, 12, 24, 48, and 72 h after surgery. The administration of epidural top-ups and systemic analgesia over the same period was also recorded, and patient satisfaction questionnaires completed. RESULTS: The median area under the curve of pain against time was significantly lower in the PCEA group (2 vs 24, P<0.001) as were median summary pain scores on movement (0.67 vs 1.33, P<0.001). Significantly fewer patients in the PCEA group received one or more epidural top-ups (13 vs 36%, P = 0.0002) or any systemic analgesics (41 vs 63%, P = 0.0021). Patients in the PCEA group were significantly more likely to be very satisfied than in the CEI group (76 vs 43%, P<0.0001). CONCLUSIONS: PCEA provides greater analgesic efficacy than CEI for postoperative analgesia after major intra-abdominal surgery, and a decreased requirement for physician or nurse intervention.
Subject(s)
Analgesia, Epidural/methods , Analgesia, Patient-Controlled/methods , Colectomy , Pain, Postoperative/drug therapy , Adolescent , Adult , Aged , Aged, 80 and over , Analgesia, Epidural/nursing , Analgesics, Opioid/administration & dosage , Anesthetics, Local/administration & dosage , Bupivacaine/administration & dosage , Double-Blind Method , Female , Fentanyl/administration & dosage , Humans , Male , Middle Aged , Pain Measurement/methods , Pain, Postoperative/nursing , Patient Satisfaction , Treatment OutcomeABSTRACT
One hundred and thirty-two patients staying in hospital more than 24 h were visited pre- and postoperatively. Patients were asked a standard set of questions, and 39% could not remember accurately what they were asked. This has important medicolegal implications. In 15% of patients, information that significantly altered subsequent anaesthetic management was discovered, but in less than 3% would ignorance of the patient's condition have required postponement of the surgery. We conclude that the major reason for a pre-operative visit by an anaesthetist is that patients appreciate it, rather than it being medically necessary.
Subject(s)
Anesthesiology , Preoperative Care/psychology , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Mental Recall/physiology , Middle Aged , Physician-Patient RelationsABSTRACT
A prospective, double-blind study was conducted to compare postoperative recovery after either total i.v. anaesthesia (TIVA: propofol and alfentanil) or an inhalation technique (propofol and alfentanil followed by nitrous oxide and isoflurane) in 50 patients undergoing day-case gynaecological surgery. Psychomotor performance was assessed at 1 and 2 h after surgery using the Critical Flicker Fusion Threshold (CFFT), Simple Reaction Time (SRT) and Choice Reaction Time (CRT). Subjective recovery and side effects after discharge from hospital were assessed using a postal questionnaire. Recovery occurred significantly earlier in the TIVA group as assessed by CFFT and SRT (P less than 0.01); there were no significant differences (P greater than 0.05) between the two groups in CRT, subjective duration of recovery or side effects.
Subject(s)
Ambulatory Surgical Procedures , Anesthesia Recovery Period , Anesthesia, Inhalation , Anesthesia, Intravenous , Propofol , Adolescent , Adult , Alfentanil , Double-Blind Method , Female , Humans , Isoflurane , Middle Aged , Nitrous Oxide , Postoperative Complications/etiology , Propofol/pharmacology , Prospective Studies , Psychomotor Performance/drug effectsABSTRACT
Ninety-eight in-patients received halothane anaesthesia for dental surgery following intramuscular premedication with papavaretum and hyoscine. All anaesthetics involved tracheal intubation. Fifty patients breathed spontaneously and 48 were artifically ventilated. The incidence of ectopic dysrhythmias during surgery, both ventricular and supraventricular, was significantly higher in the spontaneously breathing group (34.0%) than in the artificially ventilated group (2.1%). Blood halothane concentrations and end-expiratory carbon dioxide tensions during surgery were both significantly higher in the spontaneously breathing group. However, regression analysis of the data failed to identify either factor as solely responsible for the different incidence of cardiac dysrhythmias. It is likely that at least one further factor is involved.
Subject(s)
Anesthesia, Dental , Anesthesia, Inhalation , Carbon Dioxide/analysis , Halothane/blood , Tachycardia/etiology , Adolescent , Adult , Clinical Trials as Topic , Female , Humans , Male , Middle Aged , Opium , Partial Pressure , Preanesthetic Medication , Random Allocation , Respiration, Artificial , Scopolamine , Tachycardia, Supraventricular/etiologyABSTRACT
A single-breath technique of inhalational induction of anaesthesia allows intravenous induction agents to be avoided. We have investigated recovery from anaesthesia in 40 daycase patients, using tests of psychomotor function. Patients anaesthetised with inhalational induction awaken earlier than those who receive thiopentone, but not significantly earlier. There were no significant differences in postoperative psychomotor function between patients who received thiopentone and those who had inhalational inductions. Single-breath halothane, nitrous-oxide, oxygen induction is an alternative to intravenous induction in cooperative adults, but does not confer significant benefits in terms of recovery.
Subject(s)
Ambulatory Surgical Procedures , Anesthesia Recovery Period , Anesthesia, Inhalation , Halothane , Postoperative Period , Anesthesia, General , Female , Halothane/pharmacology , Humans , Male , Middle Aged , Psychomotor Performance/drug effects , Thiopental/pharmacologyABSTRACT
One hundred patients who underwent day case surgery took part in a randomized double-blind comparison between midazolam 15 mg and temazepam 20 mg orally as premedicants. Postoperative recovery was studied using tests of psychomotor function. Midazolam produced a similar degree of anxiolysis to temazepam and a greater incidence of drowsiness. Recovery was similar after either premedicant and psychomotor function was still depressed 4 hours postoperatively (p less than 0.001). Nearly 90% of patients felt that they had benefitted from either premedicant. We conclude that midazolam is a suitable drug for premedication in day case surgery.
Subject(s)
Ambulatory Surgical Procedures , Anti-Anxiety Agents , Midazolam , Preanesthetic Medication , Temazepam , Adolescent , Adult , Aged , Anesthesia Recovery Period , Anti-Anxiety Agents/pharmacology , Anxiety/prevention & control , Flicker Fusion/drug effects , Humans , Midazolam/pharmacology , Middle Aged , Psychomotor Performance/drug effects , Temazepam/pharmacology , Time FactorsABSTRACT
Sixty patients scheduled for vaginal surgery under lumbar epidural block were randomly allocated into two groups, one of which received ethamsylate intravenously prior to induction of anaesthesia. Ethamsylate did not reduce the blood loss at operation in these patients. The possible factors underlying this observation are discussed.