Improvement of burn pain management through routine pain monitoring and pain management protocol

Introduction

Pain management is an important aspect of burn management. We developed a routine pain monitoring system and pain management protocol for burn patients. The purpose of this study is to evaluate the effectiveness of our new pain management system.

Methods

From May 2011 to November 2011, the prospective study was performed with 107 burn patients. We performed control group (n = 58) data analysis and then developed the pain management protocol and monitoring system. Next, we applied our protocol to patients and performed protocol group (n = 49) data analysis, and compared this to control group data. Data analysis was performed using the Numeric Rating Scale (NRS) of background pain and procedural pain, Clinician-Administered PTSD Scale (CAPS), Hamilton Depression Rating Scale (HDRS), State-Trait Anxiety Inventory Scale (STAIS), and Holmes and Rahe Stress Scale (HRSS).

Results

The NRS of background pain for the protocol group was significantly decreased compared to the control group (2.8 ± 2.0 versus 3.9 ± 1.9), and the NRS of procedural pain of the protocol group was significantly decreased compared to the control group (4.8 ± 2.8 versus 3.7 ± 2.5). CAPS and HDRS were decreased in the protocol group, but did not have statistical significance. STAIS and HRSS were decreased in the protocol group, but only the STAIS had statistical significance.

Conclusion

Our new pain management system was effective in burn pain management. However, adequate pain management can only be accomplished by a continuous and thorough effort. Therefore, pain control protocol and pain monitoring systems need to be under constant revision and improvement using creative ideas and approaches.     

Impact of a pain protocol including hypnosis in major burns

Background

Pain is a major issue after burns even when large doses of opioids are prescribed. The study focused on the impact of a pain protocol using hypnosis on pain intensity, anxiety, clinical course, and costs.

Methods

All patients admitted to the ICU, aged >18 years, with an ICU stay >24 h, accepting to try hypnosis, and treated according to standardized pain protocol were included. Pain was scaled on the Visual Analog Scale (VAS) (mean of daily multiple recordings), and basal and procedural opioid doses were recorded. Clinical outcome and economical data were retrieved from hospital charts and information system, respectively. Treated patients were matched with controls for sex, age, and the burned surface area.

Findings

Forty patients were admitted from 2006 to 2007: 17 met exclusion criteria, leaving 23 patients, who were matched with 23 historical controls. Altogether patients were 36 ± 14 years old and burned 27 ± 15%BSA. The first hypnosis session was performed after a median of 9 days. The protocol resulted in the early delivery of higher opioid doses/24 h (p < 0.0001) followed by a later reduction with lower pain scores (p < 0.0001), less procedural related anxiety, less procedures under anaesthesia, reduced total grafting requirements (p = 0.014), and lower hospital costs per patient.

Conclusion

A pain protocol including hypnosis reduced pain intensity, improved opioid efficiency, reduced anxiety, improved wound outcome while reducing costs. The protocol guided use of opioids improved patient care without side effects, while hypnosis had significant psychological benefits.     

Clinical outcomes following bowel resection versus reduction of intussusception

Background

Intussusception is most commonly managed with air-contrast reduction. However, when this fails, emergent operation with resection or manual reduction is indicated. It is not known if there are advantages to resection compared with manual reduction.

Methods

A retrospective review of all patients receiving operative care for intussusception from February 2000 to December 2011. Patients undergoing intestinal resection were compared with those treated with manual reduction alone.

Results

Of 111 patients, 49 underwent resection and 62 underwent manual reduction. Mean (±SD) time to oral intake favored manual reduction (2.1 ± 1.2 versus 2.6 ± 1.2 d, respectively, P = 0.05). Manual reduction was associated with a greater need for repeat imaging (47% versus 18%, P = 0.002) and the only recurrences were with manual reduction (8% versus 0%, P = 0.1). Mean duration of stay was no different (P = 0.36), nor was the need for reoperation (P = 0.9).

Conclusions

Patients undergoing manual reduction have an increased number of radiographic imaging procedures. The surgeon should have a low threshold for resection for intussusceptions requiring operative management.     

Effet d’une dose unique intramusculaire de déxaméthasone sur la douleur après circoncision. Étude randomisée contrôlée

Objective

To assess the effect of a preoperative single dose of dexamethasone associated with penile block on pain after circumcision.

Study design

Prospective randomized controlled study.

Patients and methods

Forty male children aged 2 to 5 years, scheduled for circumcision under general anaesthesia, combined with penile block, were randomized into two groups. The dexamethasone group received dexamethasone 0.4 mg/kg preoperatively. The control group received the same volume of normal saline. Data compared between two groups were: postoperative pain assessed by the Objective Pain Scale collected in the recovery room, at 8 and 24 hours postoperatively (h0, h8 and h24), time to first analgesic request and the quality of sleep on the first postoperative night.

Results

Pain scores at h0 were similar between the two groups. The dexamethasone group showed significantly lower pain scores at h8 [0 (0–1) vs. 2 (0–3); P = 0.04] and h24 [0 (0–0) vs. 0 (0–1); P = 0.02]. The time to first analgesic administration was also significantly delayed in the dexamethasone group compared to the control group (240 vs 180 min; P = 0.035). The quality of sleep was also better in children in the dexamethasone group (P = 0.018).

Conclusion

This study showed that the combination of a preoperative single dose of dexamethasone 0.4 mg/kg with penile block significantly improves the quality of analgesia after circumcision.     

Radiological outcome and intraoperative evaluation of a computer-navigation system for femoral nailing: A retrospective cohort study

Aim

Intraoperative determinations of femoral antetorsion and leg length during fixation of femoral shaft fractures present a challenge. In femoral shaft fracture fixations, a computer-navigation system has shown promise in determining antetorsion and leg length discrepancies. This retrospective cohort study aimed to determine whether the use of computer navigation during femoral nailing procedures reduced postoperative femoral malrotation and leg length discrepancy, as well as the number of revision cases. We also sought to determine whether radiation exposure time was reduced when computer navigation was used.

Materials and methods

Of 246 patients treated for femoral shaft fractures between 2004 and 2012, we selected those that received postoperative computed tomography for rotation and leg length control. We included 24 patients who received navigation-assisted treatments and 48 who received unassisted treatments, matched for age, sex, and fracture type. All patients were treated by femoral nailing.

Results

The groups showed significant differences in the mean (standard deviation (SD) delay before surgery (navigation-assisted vs. unassisted groups: 8.5 ± 3.2 vs. 5.2 ± 5.8 days; P < 0.05) and surgery times (163.7 ± 43.94 vs. 98.3 ± 28.13 min; P < 0.001). The groups were significantly different in the mean (SD) radiation exposure time (4.43 ± 1.35 vs. 3.73 ± 1.5 min; P = 0.042), and were not significantly different in the postoperative femoral antetorsion difference (8.83 ± 5.52° vs. 12.4 ± 9.2°; P = 0.056), or in the postoperative length discrepancy (0.92 ± 0.75 vs. 0.95 ± 0.94 cm; P = 0.453). Four (16.7%) navigation-assisted and 15 (31.25%) unassisted surgeries got revision for torsion and/or length corrections.

Conclusion

Our results showed that, compared to unassisted femoral surgery, the computer-navigation system did not improve postoperative results or reduce radiation exposure. In the future, improvements in handling and application could facilitate the workflow and may provide better postoperative results. Currently, computer navigation may provide advantages for complicated or sophisticated cases, such as complex three-dimensional deformity corrections.

Level of evidence

Level III.     

Th17 lymphocyte levels are higher in patients with ruptured than non-ruptured lumbar discs,and are correlated with pain intensity

Background

Th17 lymphocytes have important roles in inflammation and autoimmune disease. Research on relationship between Th17 lymphocytes and pain associated with lumbar disc herniation (LDH) is limited. The purpose of this study was to examine the association of pain and Th17 lymphocyte and interleukin (IL)-17 levels in patients with herniated and non-herniated lumbar discs.

Methods

Thirty-four patients with single lumbar intervertebral disc herniation (median age, 44 years), and 17 healthy adults (median age, 37 years) were enrolled. Patients were divided into 2 groups depending on their magnetic resonance imaging (MRI) results and visual observations during surgery (group P, non-ruptured disc, n = 15; group E, ruptured disc, n = 19). Patients received posterior or transforaminal lumbar interbody fusion. Preoperative pain intensity was recorded using a visual analogue scale (VAS) score. The percentage of Th17 lymphocytes and IL-17 and prostaglandin E2 (PGE2) levels in peripheral blood were determined. Disc tissue was examined by immunohistochemistry for Th17 and IL-17 expression.

Results

Preoperative VAS pain scores were significantly higher in group E than group P (8.32 ± 1.04 vs. 6.33 ± 2.68, respectively, p = 0.009). Similarly, PGE2 level was greater in group E than group P (3.75 ± 1.41 pg/ml vs. 2.63 ± 0.89 pg/ml, respectively, p = 0.011). Compared to healthy controls (1.05 ± 0.19%), the percentage of Th17 cells was significantly greater in group P (1.52 ± 0.62%, p = 0.031), and the percentage in group E (2.99 ± 1.09%, p < 0.001) was significantly greater than in group P. The IL-17 expressions were similar. VAS pain score was positively correlated with Th17 proportion (r = 0.489, p = 0.003), and IL-17 concentration (r = 0.458, p = 0.007). PGE2 was also positively correlated with Th17 proportion (r = 0.539, p = 0.001), and IL-17 concentration (r = 0.500, p = 0.003). The expression of IL-17 was higher in the cells of group E and group P compared with normal tissue (p < 0.001).

Conclusions

Immune system activation is responsible, at least in part, for the pain experienced by patients with LDH, and increased levels of Th17 lymphocytes and IL-17 contribute to the pain.     

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Objectives

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

Design

Retrospective review.

Setting

Two level one trauma centres.

Patients

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

Intervention

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

Main outcome measurements

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p < 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333).

Conclusions

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

Level of evidence

Level III.     

Lower limb peripheral NIRS parameters during a vascular occlusion test: An experimental study in healthy volunteers

Objectives

The aim of the study was to compare NIRS parameters in combination with a vascular occlusion test (VOT) at a proximal (leg) and a distal (foot) site in male and female.

Study design

A prospective experimental study in healthy subjects.

Patients and methods

Twenty volunteers (10 male, 10 female, 28 ± 4 years) were investigated during 4 experimental steps: baseline, ischemia, reperfusion, and baseline. For each volunteer, 3 NIRS optodes were placed on right and left calves and the left arch of the foot. Blood pressure, heart rate and peripheral pulse oxymetry were monitored.

Results

Significant differences were observed at baseline between regional oxygen saturation (rSO₂) values according to the site of measurement (proximal rSO₂ 81 ± 9% vs distal rSO₂ 60 ± 5%, P < 0.001) but not according to gender. Both decreases in proximal and distal rSO₂ during ischemia and increases over baseline values during reperfusion depended on group membership (male or female). NIRS parameters during the VOT were significantly higher in male when compared with female at the proximal site: desaturation rate 5.6% (IQR: 5.5) vs 2.5% (IQR: 0.8), P = 0.001; resaturation rate 40.7% (IQR: 6.6) vs 21.7% (IQR: 5.4), P = 0.003; and ΔrSO₂ 10.0% (IQR: 7.0) vs 5.5% (IQR: 6.0), P = 0.041.

Conclusions

Values of rSO₂ at the lower limb varied according to the anatomical site of measurement. A VOT induced major changes in rSO₂ that differed between male and female. These results should be taken into account in further clinical studies.     

Risk factors for persistent pain after urological surgery

Objective

Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to identify risk factors following urology surgery.

Design

Retrospective observational study.

Patients

Two hundred and twenty-eight patients scheduled for urology surgery. Reasons for non-inclusions: patients who underwent a procedure not defined as being associated with PPSP.

Methods

Surgical urologic procedures potentially associated with PPSP were defined. All patients who had one of these procedures during the study period received a questionnaire by mail at least 3 months after the surgery. The files of these patients were retrospectively studied.

Results

Eight percent of the patients had preoperative pain. PPSP, assessed approximately 6 months after the surgery, was reported by 24% of the patients. Twenty-five (36%) of them reported neuropathic pain. Patients with PPSP had significantly more preoperative pain and an increased postoperative morphine consumption. Postoperative NSAID administration led to less persistent pain. Multivariate logistic regression analysis identified two independent risk factors of developing persistent pain: preoperative pain (OR = 21.6, 95% CI 6.7–69.5, P < 0.0001), morphine consumption 48 hours after surgery higher than 6 mg (OR = 2.3, 95% CI 1.2–4.3, P = 0.0118).

Conclusion

These findings confirm the role of preoperative pain and morphine consumption in the genesis of PPSP and call for establishing clinical perioperative pathways tailored to the patient.     

The effects of relaxation breathing on procedural pain and anxiety during burn care

Introduction

Burn patients experience high levels of pain and anxiety during dressing changes. Relaxation breathing is a simple behavioral intervention to manage pain and anxiety. However, the information about the effects of relaxation breathing on pain and anxiety levels for burn patients during dressing changes is limited.

Methods

This study followed a quasi-experimental, pretest-posttest comparison group design without random assignment to groups. A total of 64 burn patients from Daejeon, South Korea were recruited by a convenience sequential sampling approach. With institutional approval and written consent, the experimental group practiced relaxation breathing during dressing change procedures. Data were collected from June to September 2011 using a VAS for pain and a VAS-A for anxiety.

Results

The homogeneity test was used to detect any significant group differences in the demographic data and pretest measures. The pain scores significantly differed between the 2 groups after intervention (RB group vs. control group, P = .01) and over time (pretest vs. posttest, P = .001). The anxiety scores significantly differed between the 2 groups (P = .01) and over time (P = .02).

Conclusion

Relaxation breathing is a simple and inexpensive technique nurses can use to help burn patients manage pain and anxiety during dressing changes.     

Play and heal: Randomized controlled trial of Ditto™ intervention efficacy on improving re-epithelialization in pediatric burns

Background

The relationships between pain, stress and anxiety, and their effect on burn wound re-epithelialization have not been well explored to-date. The aim of this study was to investigate the effect of the Ditto™ (a hand-held electronic medical device providing procedural preparation and distraction) intervention on re-epithelialization rates in acute pediatric burns.

Methods/Design

From August 2011 to August 2012, children (4–12 years) with an acute burn presenting to the Royal Children's Hospital, Brisbane, Australia fulfilled the study requirements and were randomized to [1] Ditto™ intervention or [2] standard practice. Burn re-epithelialization, pain intensity, anxiety and stress measures were obtained at every dressing change until complete wound re-epithelialization.

Results

One hundred and seventeen children were randomized and 75 children were analyzed (n = 40 standard group; n = 35 Ditto™ group). Inability to predict wound management resulted in 42 participants no longer meeting the eligibility criteria. Wounds in the Ditto™ intervention group re-epithelialized faster than the standard practice group (−2.14 days (CI: −4.38 to 0.10), p-value = 0.061), and significantly faster when analyses were adjusted for mean burn depth (−2.26 days (CI: −4.48 to −0.04), p-value = 0.046). Following procedural preparation at the first change of dressing, the Ditto™ group reported lower pain intensity scores (−0.64 (CI: −1.28, 0.01) p = 0.052) and lower anxiety ratings (−1.79 (CI: −3.59, 0.01) p = 0.051). At the second and third dressing removals average pain (FPS-R and FLACC) and anxiety scores (VAS-A) were at least one point lower when Ditto™ intervention was received.

Conclusions

The Ditto™ procedural preparation and distraction device is a useful tool alongside pharmacological intervention to improve the rate of burn re-epithelialization and manage pain and anxiety during burn wound care procedures.     

Eficacia e impacto económico del bisturí armónico Focus frente al dispositivo ACS-14C en la tiroidectomía total por bocio multinodular. Estudio prospectivo aleatorizado

Objective

To analyse the potential advantages and outcomes of the new Harmonic Focus™ (Focus) device compared to the Harmonic Scalpel™ ACS-14C in benign thyroid surgery.

Methods

A controlled randomised study was conducted in which the Focus was compared to former ACS-14C device in patients undergoing total thyroidectomy for multinodular goitre. The primary endpoint was time of surgery. The secondary endpoints were time of use of the device, number of ligatures, blood loss, hypocalcaemia, laryngeal nerve impairment, postoperative pain and quality of life.

Results

Two groups of patients were included, 26 patients in group i (ACS-14C) and 28 in group ii (Focus). There was a 16% reduction in surgical time (78.7 ± 22.01 vs. 66 ± 17.0 min; P<.05) between group i and ii respectively. The Focus was used longer than ACE-14S, both in absolute time (26.0 ± 7.7 vs. 10.0 ± 3.5 minutes; P<.05), as well as in relative time (40.7 ± 11.8% vs. 13.1 ± 4.1%; P<.05), respectively.A significant reduction in number of ligatures in Focus patients was also observed (0,3 ± 0,8 vs. 2.9 ± 3.6; P<.05).Budget impact analysis showed an additional average savings per procedure of 179.74 €.

Conclusions

Focus ergonomics significantly improved the operation time in thyroidectomy causing a positive impact on the budget.Focus also adds further benefits to those previously achieved by Harmonic technology, and it is by itself more cost-effective in total thyroidectomy than ACS-14C.     

An electrophysiologic evaluation of whether open and laparoscopic techniques used in pediatric inguinal hernia repairs affect the genitofemoral nerve

Background

A prospective study was performed to evaluate the effect of inguinal hernia repairs on the genitofemoral nerve (GFN), and to compare postoperative electrophysiologic changes in the GFN of patients who had undergone either open or laparoscopic surgery.

Methods

Seventy patients with a mean age of 6.48 ± 3.49 were enrolled in the study. Either open or laparoscopic techniques were used to operate on the patients' inguinal hernias. In all cases, bilateral GFN motor responses were investigated electrophysiologically using surface electrodes on three occasions: preoperatively, in the first month, and third month postoperatively. t-Tests were used to compare changes in the GFN.

Results

Preoperative mean latency of the GFN in all groups was found to be significantly prolonged on the hernia side, compared with the non-hernia side (P = 0.01). Although no difference was observed in the latency levels of the GFN on the operated side at the preoperative and early postoperative stages, GFN latency levels decreased significantly in the late postoperative period in the laparoscopic group (P < 0.05). In the late postoperative period, amplitudes of GFN motor responses were significantly higher in the laparoscopic group than the open repair group (0.91 ± 0.11 mV and 0.57 ± 0.053 mV, respectively; P < 0.05).

Conclusion

Preoperative prolonged latency of GFN on the hernia side is likely to occur due to the pressure on the nerve caused by the hernia mass. By surgically removing the hernia mass, this buildup of pressure is prevented, decreasing the latency of the GFN. The significantly higher motor response amplitudes and decreased latency in the late postoperative stage for the laparoscopic group may be due to the fact that this technique is less invasive.     

Determinants of Laparoscopic Donor Nephrectomy Outcomes

Background

Pure laparoscopic donor nephrectomy (LDN) is a unique intervention because it carries known risks and complications, yet carries no direct benefit to the donor. Therefore, it is critical to continually examine and improve quality of care.

Objective

To identify factors affecting LDN outcomes and complications.

Design, setting, and participants

A retrospective analysis of prospectively collected data for 1204 consecutive LDNs performed from March 2000 through August 2012.

Intervention

LDN performed at an academic training center.

Outcome measurements and statistical analysis

Using multivariable regression, we assessed the effect of age, sex, body mass index (BMI), laterality, and vascular variation on operative time, estimated blood loss (EBL), complications, and length of stay.

Results and limitations

The following variables were associated with longer operative time (data given as parameter estimate plus or minus the standard error): female sex (9.09 ± 2.43; p < 0.001), higher BMI (1.03 ± 0.32; p = 0.001), two (7.87 ± 2.70; p = 0.004) and three or more (22.45 ± 7.13; p = 0.002) versus one renal artery, and early renal arterial branching (5.67 ± 2.82; p = 0.045), while early renal arterial branching (7.81 ± 3.85; p = 0.043) was associated with higher EBL. Overall, 8.2% of LDNs experienced complications, and by modified Clavien classification, 74 (5.9%) were grade 1, 13 (1.1%) were grade 2a, 10 (0.8%) were grade 2b, and 2 (0.2%) were grade 2c. There were no grade 3 or 4 complications. Three or more renal arteries (odds ratio [OR]: 2.74; 95% CI, 1.05–7.16; p = 0.04) and late renal vein confluence (OR: 2.42; 95% CI, 1.50–3.91; p = 0.0003) were associated with more complications. Finally, we did not find an association of the independent variables with length of stay. A limitation is that warm ischemia time was not assessed.

Conclusions

In our series, renal vascular variation prolonged operative time and was associated with more complications. While complicated donor anatomy is not a contraindication of LDN, surgical decision-making should take into consideration these results.     

Differences in patients with systemic sclerosis recruited from associations and tertiary care settings

Objective

To compare patients with systemic sclerosis (SSc) recruited from a patient association or a tertiary care setting.

Methods

We evaluated 248 SSc patients attending 4 annual meetings of a patient association between 2004 and 2007 (177) or during hospitalization (71). health-related quality of life (HRQoL) was assessed by the SF-36, global disability by the health assessment questionnaire (HAQ), hand disability by the Cochin Hand Function Scale (CHFS), mouth disability by the Mouth Handicap in Systemic Sclerosis (MHISS) scale, global hand and wrist mobility by the Kapandji index.

Results

As compared with hospitalized patients, those from the patient association were significantly older (mean age 58.73 ± 12.04 vs 53.818 ± 13.1; p = 0.001) and had a longer disease duration (10.98 ± 8.7 vs 7.13 ± 6.723 p = 0.0001). Association patients had significantly increased disability of the hand (CHFS 21.8 ± 19.8 vs 9.8 ± 14.1; p = 0.0001) and mouth (MHISS 20.65 ± 10.8 vs 13.25 ± 9.3; p = 0.0001) and impaired hand and wrist mobility (Kapandji score 38.05 ± 10.26 vs 43.90 ± 8.26, p = 0.001). The 2 groups did not differ in global disability or physical and mental scores of the SF36.

Conclusion

Patients recruited from a patient association have more severe SSc than do hospitalized patients. This finding must be taken into account in the design of surveys and clinical trials.     

Évaluation des pratiques professionnelles de la prise en charge de la douleur postopératoire à court,moyen et long terme

Objectives

To evaluate the short medium and long-term impact of a quality-improvement program (QIP) in a university hospital using a validated reference tool.

Methods

Seven surgical departments were audited before and after implementation of a QIP in postoperative pain management. Audits were conducted in 2005, 2007, 2009 and 2012. In each audit, 10 medical charts from each surgical department were analyzed for 9 quality criteria. A surgical department score (SDS) was calculated for each department (maximum score = 90). The surgical departments with a SDS < 45 received targeted training sessions.

Results

In 2005, three surgical departments had a SDS < 45. After the first audit, a targeted training sessions was conducted in the three surgical departments, all seven departments improved their scores with a SDS > 45 in 2007. Between 2007 and 2009, all seven departments improved their scores. Conversely, between 2009 and 2012, the SDS diminished in six of the seven surgical departments and four of the nine evaluated quality criteria decreased significantly: right detailed order for postoperative pain analgesia (prescriber identifier, agent used, unit doses, mode of administration; 100% versus 53; P = 0.027), appropriate dosing of steps I and II analgesics (96% versus 80%; P = 0.041), morphine (90% versus 76%; P = 0.039), based on corresponding physician orders and monitor morphine side effects (87% versus 29; P = 0.027).

Conclusion

Audits should be performed regularly (at least every two years) for detecting postoperative pain management degradation. Lack of targeted training sessions can explain partially this degradation.     

Préremplissage par HEA 130/0,4 versus sérum salé isotonique dans la prévention de l’hypotension au cours de la rachianesthésie pour césarienne programmée

Objective

To evaluate the efficacy of HES 130/0.4 preload compared to normal saline solution for prevention of hypotension during spinal anaesthesia for elective caesarean section.

Study design

Prospective, randomized.

Patients and methods

Sixty ASA I patients scheduled for elective caesarean section were randomized to receive either 1000 mL of normal saline solution preload (Group C) or 500 mL of HES 130/0.4 preload (Group V) within 15 minutes prior to spinal anaesthesia. Spinal anaesthesia techniques and ephedrine administration was standardized in both groups. The primary endpoint was the incidence of maternal hypotension before fetal extraction.

Results

The incidence of hypotension before fetal extraction was significantly lower in group V compared to group C (40% vs 66%, P = 0.03). Ephedrine consumption was significantly lower in group V (7.6 ± 13 mg vs 16.4 ± 15 mg). Lowest systolic blood pressure was significantly higher in group V (96 ± 14 vs 85 ± 14 mmHg, P = 0.005). Incidence of adverse maternal effects and neonatal consequences were similar in both groups.

Conclusion

HES 130/0.4 preload reduced the incidence of hypotension, the duration of longest hypotension, and the need for ephedrine during spinal anaesthesia for elective caesarean section. However, the efficacy of HES 130/0.4 alone in prevention of maternal hypotension during spinal anaesthesia for caesarean section is still insufficient.     

Effectiveness of a topical local anaesthetic spray as analgesia for dressing changes: A double-blinded randomised pilot trial comparing an emulsion with an aqueous lidocaine formulation

Background

Partial thickness skin graft wounds are painful. Topically applied lidocaine has been used for analgesia in several clinical trials. This study compared the effectiveness of two different formulations of topical local anaesthetic for dressing changes of partial thickness skin graft donor sites.

Methods

A double-blind randomised controlled, pilot trial was conducted in 29 patients undergoing split thickness skin graft surgery. Subjects were randomised to either a 3% lidocaine emulsion formulation “Treatment E” (NOPAYNE™) or a 4% aqueous solution “Treatment A” (Xylocaine™). Subjects received one spray per 3 cm² of donor site area followed by up to two further spays as required. Endpoints included pain intensity measured by the numerical rating scale (NRS) up to 1 h after dressing change commencement, sting sensation, overall satisfaction and lidocaine plasma concentration.

Results

The 60 min pain scores for E and A were 1.3 ± 0.3 (mean ± SEM) and 1.8 ± 0.4 (p = 0.98) respectively. Nearly 90% of patients were very satisfied with their treatment. The mean plasma concentrations of lidocaine for A and E were 0.132 mg/l and 0.040 mg/l respectively (p = 0.069).

Conclusion

The topical local anaesthetic formulations achieved low pain scores during dressing changes. The safety profile was potentially improved with the emulsion formulation of lidocaine.     

Staphylococcus aureus bacteremia after thermal injury: The clinical impact of methicillin resistance

Objective

To evaluate the impact of methicillin resistance in Staphylococcus aureus bacteremia (SAB) on mortality and length of stay in burn patients.

Design

Retrospective cohort study.

Setting

A 750-bed tertiary care university hospital in Cologne, Germany.

Patients

Patients registered in the database of the burn intensive care unit (BICU) between 1989 and 2009 with complete data sets (n = 1688).

Results

Over the 21-year study period, 74 patients with SAB were identified; 33 patients had methicillin-resistant S. aureus (MRSA) and 41 methicillin-susceptible S. aureus (MSSA). Comparing the MRSA with the MSSA population the following parameters were significantly different in the univariate analysis: BMI (27.2 kg/m² vs. 23.6 kg/m²; P = 0.05), extent of deep partial thickness burns (17.8% vs. 9.0% of total body surface area; P = 0.007), antibiotic requirement on admission (45.5% vs. 22.0%; P = 0.046), median length of hospitalization prior SAB (24 days vs. 7 days; P < 0.001), packed red blood cells administration (47.6 units vs. 26.1 units; P = 0.003), intubation requirement (100% vs. 80.5%; P = 0.007), intubation period (43.5 days vs. 26.8 days; P = 0.008), catecholamine requirement (90.9% vs. 61.0%; P = 0.004), sepsis (60.6% vs. 34.1%; P = 0.035) and organ failures (81.8% vs. 39.0%; P < 0.001). Regarding outcome parameters, methicillin resistance was not significantly related with mortality (adjusted OR 1.55, 95% CI 0.56–4.28; P = 0.40) and length of BICU stay after SAB (Kaplan–Meier analysis log-rank test P = 0.32; Cox's proportional hazards regression HR 1.22, 95% CI 0.65–2.27, P = 0.535) in the univariate and multivariate analyses.

Conclusion

Our data suggest that methicillin resistance is not associated with significant increases in mortality and length of BICU stay among burn patients with SAB.     

Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l’arrivée aux urgences

Objectives

To find out prehospital factors linked with low pain on arrival into a traumatic emergency unit.

Methods

A 4-month monocentric prospective study, including patients recruited at their arrival into a traumatic emergency unit. Pain (with a numerical rating scale [NRS]), anxiety, prehospital care including the type of transportation (Physician staffed ambulances Smur, emergency medical technicians or firemen ambulances), immobilization and analgesics used were evaluated. These data were collected on arrival at the hospital by the ED orientation nurse. Uni- and multivariate analysis were performed to identify low pain's predictive factors (e.g. with a NRS ≤ 3).

Results

Three hundred and four patients were recruited, mean age = 51 ± 25, sex ratio = 1.8, mean pain/10 = 5.8 ± 2.9, 64% with a moderate or severe pain on arrival (NRS > 3). For one third of patients, immobilizations hadn’t been performed during the prehospital phase. Medical management by Smur is a low pain predictive factor (OR = 5.8; CI 95% = 1.4–24.16), anxiety is a pejorative factor (OR = 0.53 CI 95% = 0.38–0.75).

Conclusion

Our study highlights the physician staffed ambulances’ effectiveness in prehospital trauma victim's management and raises the question of anxiolysis as an adjuvant for traumatic pain management.