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Efficacy and safety of neuroaxial analgesia
- Esther M. Pogatzki-Zahn, Daniel Pöpping, Peter K. Zahn (2 March 2009)
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Post operative pain - a prospective audit
- Roopa Chatterjee, P.Joshi. Frimley Park Hospital (13 February 2009)
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Esther M. Pogatzki-Zahn , Daniel Pöpping, Peter K. Zahn
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Editor - We thank Dr. Chatterjee and Dr. Joshi for their interest in our publication. There is now ample evidence including our database analysis 1 demonstrating that peripheral and neuroaxial regional analgesia provide superior postoperative analgesia 2, 3. The observations by Dr. Chaterjee and Dr. Joshi that patients with regional anesthesia reported lower pain scores in the recovery room and were discharged earlier than patients without regional anesthesia are in agreement with these findings and emphasize some benefits associated with regional anesthesia. In order to perform a risk-benefit analysis for the use of central nerve blocks it is essential to increase our knowledge about the incidence of serious adverse effects including epidural hematoma, meningitis or severe neurological injuries. Because these adverse effects are rare but possibly disastrous neither a meta-analysis nor a randomized controlled analysis are appropriate methods to obtain the reliable incidence of these serious side effects or to define possible groups of patients with increased risk factors. Large single centre database analysis 1, 4, 5 or national audits 6 may help us to improve our knowledge about the safety of central nerve blocks. In the February issue of this journal, the third national audit project of the Royal college of anaesthetists reported about major complications of central neuroaxial blocks performed over 1 year in the UK National Health Service 7. The audit included 707.455 central neuroaxial blocks (CNB) and reported about 52 major complications included in this survey. The incidence of a permanent injury for more than 6 months due to CNB was between 2 and 4.2 per 100.000 cases indicating that CNB has a low incidence of major complications. Overall we emphasize that large database analysis and national audits performed on a regular base are necessary to ensure the safety and quality of CNB and benchmark postoperative pain treatment strategies. Daniel Pöpping Peter K. Zahn Esther Pogatzki-Zahn * Muenster, Germany *e-mail: pogatzki@anit.uni-muenster.de References: 1. Popping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth 2008; 101: 832-40 2. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Jr., Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; 290: 2455-63 3. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient- controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005; 103: 1079-88; quiz 109-10 4. Cameron CM, Scott DA, McDonald WM, Davies MJ. A review of neuraxial epidural morbidity: experience of more than 8,000 cases at a single teaching hospital. Anesthesiology 2007; 106: 997-1002 5. Christie IW, McCabe S. Major complications of epidural analgesia after surgery: results of a six-year survey. Anaesthesia 2007; 62: 335-41 6. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004; 101: 950-9 7. Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179-90 Conflict of Interest:None declared |
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Roopa Chatterjee Frimley Park Hospital, Surrey., P.Joshi. Frimley Park Hospital
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Editor - We read with interest the study on effectiveness and safety of post operative pain management by D.M Popping et al. We recently conducted an audit of postoperative pain in our trust. It was a prospective audit over one week, and we analyzed the pain scores, the measures taken to alleviate post operative pain and whether any of these resulted in a longer stay in recovery. We had two categories of surgery, major i.e. any body cavity surgery and joint operations resulting in substantial tissue damage and non-major. We had a 5 point pain score system 0 to 4, 0 being no pain and 4 being excruciating pain. Forty percent were major surgeries, and 59% of the major cases had pain score of 0 and no one required prolonged stay in recovery. 11.6% had a score of 1, of these 4% required prolonged recovery. Intra operatively 67% of these i.e patients with score 0 and 1 had central neuraxial blocks (single shot spinal or epidural catheters) or peripheral nerve blocks and 33% multimodal approach to pain relief i.e combination of paracetamol, NSAIDs and opiates. We found that 11.7% had pain score of 2, half of them had to stay longer. Those requiring prolonged recovery either recieved GA + opiates intra operatively or GA only Sixty percent of the total cases were non major surgery. 69% of these had a score 0 and 11.8% score of 1, of these 0.007% had to stay longer in recovery due to pain. Score of 2 0.096% almost half of these had to stay longer. We found that all those who came out with a pain score of 3 and 4 both minor and major stayed longer in recovery due to pain, range 45mins to 3hr30mins. These patients either had failed peripheral nerve blocks, epidurals or received only opiates intra-operatively. Our audit demonstrated the usefulness of even single shot technique and its impact on immediate post op analgesia and recovery. Also we didn’t look into the pain scores and requirement of analgesia once the patients were discharged from recovery. Nevertheless our findings consolidate those of Popping et al that appropriate use of central and peripheral neuraxail blockade results in lower VAT score and shorter recovery time, even though they used continuous neuraxial blocks and had a longer follow up. Conflict of Interest:None declared |
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