Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists.

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.

Clinical and microbiological evaluation of epidural and regional anaesthesia catheters in injured UK military personnel.

INTRODUCTION: The adoption of regional and epidural analgesia in UK military personnel injured in action during Op HERRICK increased from 2008, in line with structural and environmental developments in the UK medical treatment facility. Historically, there have been concerns that invasive analgesic techniques could carry an increased risk of infection, due to the mechanism of injury and the environmental conditions in which the injuries were sustained. Consequently, the epidural and continuous peripheral nerve blockade (CPNB) catheters that were inserted in UK military personnel during a 33-month period of Op HERRICK were clinically and microbiologically examined, after subsequent admission to the University Hospitals Birmingham (UHB) NHS Trust. METHODS: Data on epidural and CPNB insertions were collected via the specialist pain service at UHB over the study period, including de novo and replacement insertions performed in both Afghanistan and the UK. Patients were regularly reviewed and relevant clinical concerns were documented in patients' case notes as necessary. The anatomical site, duration of placement and the results of microbiological culture of the epidural and CPNB catheter tips were all recorded. RESULTS: Overall, 236 catheters were assessed, of which 151 catheter tips (64%) were cultured (85 epidural, 66 CPNB). Of these, 48 grew bacteria (34% of cultured epidurals and 29% of cultured CPNB). There was no difference between the colonisation rates of epidurals inserted in Afghanistan and the UK. Only one infection related to a misplaced epidural catheter was confirmed. CONCLUSIONS: With the exception of the epidural (34%) and proximal sciatic (42%) catheters, these figures, in a military cohort characterised by significant injury scores, are consistent with those reported for civilian surgical patients. The results strongly support the expansion of regional analgesia during Op HERRICK from 2008 onwards. The outcomes suggest a possible translation into civilian major trauma practice.

Overview review: Comparative efficacy of oral ibuprofen and paracetamol (acetaminophen) across acute and chronic pain conditions.

BACKGROUND: Ibuprofen and paracetamol have long been used as analgesics in a range of acute, intermittent and chronic pain conditions. Paracetamol is often the first line analgesic recommended, without consensus about which is the better analgesic. METHODS: An overview review of systematic reviews and meta-analyses directly compares ibuprofen and paracetamol at standard doses in particular painful conditions, or uses indirect comparisons against placebo. Electronic searches for systematic reviews were sought published since 1995 using outcomes approximating to ≥50% pain intensity reduction. Painful conditions were acute post-operative pain, dysmenorrhoea, tension-type headache (TTH), migraine, osteoarthritis and rheumatoid arthritis, back pain, cancer and paediatric pain. There was no systematic assessment of harm. RESULTS: Sixteen systematic reviews and four individual patient data meta-analyses were included. Ibuprofen was consistently superior to paracetamol at conventional doses in a range of painful conditions. Two direct comparisons favoured ibuprofen (acute pain, osteoarthritis). Three of four indirect comparisons favoured ibuprofen (acute pain, migraine, osteoarthritis); one showed no difference (TTH), although there were methodological problems. In five pain conditions (dysmenorrhoea, paediatric pain, cancer pain, back pain and rheumatoid arthritis), there were limited data on paracetamol and ibuprofen. CONCLUSIONS: At standard doses in different painful conditions, ibuprofen was usually superior producing more patients with the degree of pain relief that patients feel worthwhile. Neither of the drugs will be effective for everyone, and both are needed. This overview questions the practice of routinely using paracetamol as a first line analgesic because there is no good evidence for efficacy of paracetamol in many pain conditions.

Know pain know gain: proposing a treatment approach for phantom limb pain.

Phantom limb pain affects between 50 and 80% of amputees. With an increasing number of battle casualties having had an amputation after combat trauma, it is inevitable that both primary and secondary care clinicians will come into contact with a patient with phantom limb pain (PLP). It is widely acknowledged that its complex aetiology means that this condition is often poorly understood and difficult to manage. A growing pathophysiological understanding is shedding new light on the mechanisms which underlie PLP. Knowledge of these mechanisms will inform treatment and enable clinicians to plan and implement solutions which make a difference to those individuals with this condition. This paper seeks to outline current research into this condition and proposes an approach to treatment. This approach has been formulated from an amalgamation of clinical experience working with battle casualties at the Defence Medical Rehabilitation Centre, Headley Court.

A survey of experience of parenteral analgesia at Role 1.

OBJECTIVES: To assess the confidence of deploying Role 1 Medical Officers (MOs) in the use of parenteral analgesia, to collate opinion as to whether analgesia training for Role 1 MOs is fit for purpose and to explore options for future analgesic approaches at Role 1. METHODS: A survey distributed to Role 1 doctors prior to deployment to Afghanistan. RESULTS: Areas of expressed concern included the use of ketamine and a lack of experience of intraosseous drug administration. Qualitative data collected included anecdotal experiences with analgesia administration which provides evidence to support a change in training. CONCLUSIONS: Doctors have the capability to provide good analgesic care but lack the confidence and experience to do it effectively. Improved analgesia training is required for deploying Role 1 MOs.

A proposed model for improving battlefield analgesia training: post-graduate medical officer pain management day.

In response to increasing awareness of the need to improve Post Graduate Medical Officers training in the use of analgesics when on Operations and exercises, a new "Pain Day" format has been realised and included in the Post Graduate Medical Officers Course. This article discusses the format of the Pain Day; gives evidence of the feedback received; explores areas where further training may be required and suggests mechanisms through which improved training could be provided throughout the armed forces medical community.

End-to-end military pain management.

The last three years have seen significant changes in the Defence Medical Services approach to trauma pain management. This article seeks to outline these changes that have occurred at every level of the casualty's journey along the chain of evacuation, from the point of injury to rehabilitation and either continued employment in the Services or to medical discharge. Particular attention is paid to the evidence for the interventions used for both acute pain and chronic pain management. Also highlighted are possible differences in pain management techniques between civilian and military casualties.

Pharmacological treatment of chronic pain - the need for CHANGE.

BACKGROUND: Although chronic pain affects around 20% of adults in Europe and the USA, there is substantial evidence that it is inadequately treated. In June 2009, an international group of pain specialists met in Brussels to identify the reasons for this and to achieve consensus on strategies for improving pain management. SCOPE: Literature on chronic pain management was reviewed, and information presented to and discussed by a panel of experts. FINDINGS: It was agreed that guidelines are not universally accepted by those involved in pain management, and pain treatment seems to be driven mainly by tradition and personal experience. Other factors include poor communication between patients and physicians, the side effects of analgesic drugs, and limited individualisation of therapy. Difficulty in maintaining the balance between adequate pain relief and acceptable tolerability, particularly with strong opioids, can lead to the establishment of a 'vicious circle' that alternates between lack of efficacy and unpleasant side effects, prompting discontinuation of treatment. The medical community's understanding of the physiological differences between nociceptive pain and neuropathic pain, which is often more severe and difficult to treat, could be improved. Increasing physicians' knowledge of the pharmacological options available to manage these different pain mechanisms offers the promise of better treatment decisions and more widespread adoption of a multi-mechanistic approach; this could involve loosely combining two substances from different drug classes, or administering an analgesic with two different mechanisms of action. In some circumstances, a single compound capable of addressing both nociceptive and neuropathic pain is desirable. CONCLUSIONS: To improve patient outcomes, a thorough understanding of pain mechanisms, sensitisation and multi-mechanistic management is required. Universal, user-friendly educational tools are therefore required to familiarise physicians with these topics, and also to improve communication between physicians and their pain patients, so that realistic expectations of treatment can be established.

Prehospital analgesia: systematic review of evidence.

The purpose of this systematic review is to investigate current evidence for analgesic use in the prehospital environment using expert military and civilian opinion to determine the important clinical questions. There was a high degree of agreement that pain should be no worse than mild, that pain relief be rapid (within 10 minutes), that patients should respond to verbal stimuli and not require ventilatory support, and that major adverse events should be avoided. Twenty-one studies provided information about 6212 patients; the majority reported most of the outcomes of interest. With opioids 60-70% of patients still had pain levels above 30/100 mm on a Visual Analogue Scale after 10 minutes, falling to about 30% by 30-40 minutes. Fascia iliaca blocks demonstrated some efficacy for femoral fractures. No patient on opioids required ventilatory support; two required naloxone; sedation was rare. Cardiovascular instability was uncommon. Main adverse events were dizziness or giddiness, and pruritus with opioids. There was little evidence regarding the prehospital use ofketamine.

Current epidural practice--results of a survey of military anaesthetists.

OBJECTIVES: As epidurals are now used for pain relief on deployment a survey was conducted to look at the current epidural practice of U.K. military anaesthetists. The aim was to identify any potential issues with regard to equipment and training to allow future development ofpre-deployment training. METHODS: An Internet based survey was carriedout. All military anaesthetistswere sent an e-mail containing a link to the survey and the results of those who responded were analysed. RESULTS: A total of 49 surveys were completed. 78% of respondents carried out epidurals more than once a month, in a wide range of specialities. There was considerable variation in methods of securing epidurals and in drug choice amongst respondents. CONCLUSIONS: The results of this survey show that whilst epidurals are commonly carried out amongst military anaesthetists during their U.K. practice, there is significant variation within the practice. Areas have been identified for development of educational courses, for example methods of securing epidurals, and these have already been acted upon.

Evolution of the role 4 U.K. military pain service.

The early development of the U.K. Role 4 pain service has already been described. This article will describe developments up to October 2010, and present the results of projects used in assessing the effect of this service.

Field hospital analgesia.

Acute pain is every health care worker's responsibility, a key area of clinical management and one of Surgeon General's four focus points for improving quality of life after battlefield injury. The evolving practice of acute pain management requires an informed multidisciplinary and multimodal therapeutic approach to minimise each individual patient's experience of pain. Whilst subject matter experts progress the policies, protocols and capabilities associated with pain management, it remains the duty of every clinician, nurse, health care support worker and all Professions Allied to medicine (PAMs) to keep updated and maintain capability in this key area of clinical management.