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POSSI - Authors' response
- Kim E Russon, Nicholas M Denny (4 January 2007)
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POSSI; initiative or whim?
- Bruce Patrick Powell (15 December 2006)
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Kim E Russon , Nicholas M Denny
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Dear Dr Powell, We thank you for your letter and comments about our study. We do agree with your comments that the patients seem to have a lower Body Mass Index (BMI) than one might have expected, but this seems to reflect the practice in King's Lynn. There was no bias in selection and so it appears that most of our patients here having shoulder surgery tend not to have a high BMI. In an audit(1) of 400 patients undergoing day case surgery in King’s Lynn the mean age was 61 years old. This fits with our data for Phase 1 but we agree the mean age in Phase 2 was lower than average. We would agree with your comment that it would be reasonable to send patients home having had a single injection interscalene block as day cases fter "arthroscopic surgery" (our comment), which is indeed our practice, and audits and other studies(2,3) have shown this to be highly acceptable to the patients and provides them with good postoperative pain relief. However after open shoulder surgery, on which this study was based, our own experience and that of several published studies(as outlined in our paper(4)), have shown that single injection interscalene brachial plexus blocks provide too short a period of analgesia to cover the postoperative period. When the block wears off the patients require systemic opiates which can only really be used in the hospital setting. This has been our experience and the one patient in the study who had a catheter failure demonstrates this well. He had to be readmitted to control his severe pain. The Healthcare Commission report on Day Surgery 2005(5) suggested there are many benefits for the patients and financially for the hospital. We are convinced of the potential cost benefits of our initiative and that the patients prefer to be treated as day cases. References 1 Watson B, Allen JG. Spinal anaesthesia in day surgery – an audit of the first 400 cases. Journal of One Day Surgery 2003 Spring:1-4 2 Conroy BP, Fischer RB, Kenter K, et al. Interscalene block for elective shoulder surgery. Orthopaedics 2003; 26: 501-3 3. Singelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Anesth Analg 2004;99:589-592 4 Russon K, Sardesai A, Denny NM et al. Postoperative shoulder surgery initiative (POSSI). A new service using continuous interscalene brachial plexus blockade at home to enable major shoulder surgery to be managed as a day case - an interim report. Br J Anaesth 2006;97:6:869-973 5 Healthcare commission. Acute hospital portfolio review: Day surgery July 2005 http://www.healthcarecommission.org.uk Conflict of Interest:None declared |
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Bruce Patrick Powell, Anaesthetist Fremantle Hospital, Western Australia
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*B P Powell Fremantle, Western Australia *E-mail; brucep@blueyonder.co.uk Editor - I read with great interest the article by Russon and colleagues1 entitled "Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure". Interest in broadening the scope of day surgery procedures and reduction in patient discomfort and days in hospital is clinically commendable and financially attractive. Given the well-documented challenges facing the pain team post-shoulder surgery, Dr Russon and her team have clearly devoted an enormous amount of time and resources towards achieving a successful pilot study utilising a continuous interscalene brachial plexus blockade (CIBPB) technique. There are however problems with such pilot studies in extending them and reproducing their results on a clinically significant scale. The study’s pilot 1 group of 5 had a mean body mass index (BMI) of only 25.8 and an average age of 60 years. The second group had a mean BMI of 29.6 and an average age of only 48. These groups seem unlikely to be representative of the usual shoulder surgery patient encountered in Cambridge or elsewhere. The authors inclusion criteria included all those with a BMI under 38 and yet only one of the patients even had a BMI greater than 30. A less expensive and labour intensive study would have been simply to discharge this highly selected group of patients with an intra-operative interscalene block and conventional oral analgesia. Subsequent follow-up in the community by the district nurse could easily be arranged without any specific additional training or resources. Presenting satisfaction surveys in a highly selected group who would be expected to cope best with any surgical procedure is not necessarily indicative of success, but more likely a reflection of the patient group and the resources committed to them. As a model of how to construct and design a day-case surgical programme this paper is very useful. I do not believe, however that it provides a convincing argument for CIBPB in shoulder surgery either on financial or patient grounds. The logical next step would be to compare this technique with a matched group treated conventionally before any assertions about its success or applicability could be made. Yours Sincerely, B Powell References 1. K. Russon, A. M. Sardesai, S. Ridgway, et al. Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. Br. J. Anaesth. 2006; 97: 869-873 Conflict of Interest:None declared |
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