Labour pain: the hidden influences of anxiety and social deprivation

No abstract available

Tales from the vault

An anthology of short stories by Timothy Peter Kinsella

Physical outcome measure for critical care patients following intensive care discharge

Introduction: The aim of this study was to evaluate the most suitable physical outcome measures to be used with critical care patients following discharge. ICU survivors experience physical problems such as reduced exercise capacity and intensive care acquired weakness. NICE guideline ‘Rehabilitation after critical illness’ (1) recommends the use of outcome measures however does not provide any specific guidance. A recent Cochrane review noted wide variability in measures used following ICU discharge (2). Methods: Discharged ICU patients attended a five week multidisciplinary programme. Patients’ physical function was assessed during the programme, at 6 months and 12 months post discharge. Three outcome measures were included in the initial two cohorts. The Six Minute Walk Test (6MWT) and the Incremental Shuttle Walk test (ISWT) were chosen as they have been used within the critical care follow up setting (2). The Chester Step Test (CST) is widely thought to be a good indicator of ability to return to work (one of the programmes primary aims). Ethics approval was waived as the programme was part of a quality improvement initiative. Results: Data was collected for the initial patients attending the programme (n = 13), median age was 52 (IQR = 38-72), median ICU LOS was 19 days (IQR = 4-91), median APACHE II was 23 (IQR = 19-41) and 11 were men. One patient was so physically debilitated that the CST or ISWT could not be completed however a score was achieved using the 6MWT. Another patient almost failed to achieve level 1 of the ISWT. Subsequent patients for this project (total n = 47) have all therefore been tested using the 6MWT. Good inter-rater and intrarater reliability and validity have been reported for the 6MWT (3). Conclusions: Exercise capacity measurement is not achievable for some patients with either the ISWT or the CST due to the severity of their physical debilitation. Anxiety, post-traumatic stress disorder and depression are common psychological problems post discharge (4), therefore using a test with a bleep is not appropriate. Therefore, the 6MWT is the most appropriate physical outcome measure to be used with critical care patients post discharge

Classification of pain and its treatment at an intensive care rehabilitation clinic

Introduction Treatment in an Intensive Care Unit (ICU) often necessitates uncomfortable and painful procedures for patients throughout their admission. There is growing evidence to suggest that chronic pain is becoming increasingly recognised as a long term problem for patients following an ICU admission [1]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU discharge at Glasgow Royal Infirmary. This study investigated the incidence and location of chronic pain in patients discharged from ICU and classified the analgesics prescribed according to the World Health Organization analgesic Methods The InS:PIRE programme involved individual sessions for patients and their caregivers with a physiotherapist and a pharmacist along with interventions from medical, nursing, psychology and community services. The physiotherapist documented the incidence and pain location during the assessment. The pharmacist recorded all analgesic medications prescribed prior to admission and at their clinic visit. The patient’s analgesic medication was classified according to the WHO pain ladder from zero to three, zero being no pain medication and three being treatment with a strong opioid. Data collected was part of an evaluation of a quality improvement initiative, therefore ethics approval was waived. Results Data was collected from 47 of the 48 patients who attended the rehabilitation clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67 %)). Prior to admission to ICU 43 % of patients were taking analgesics and this increased to 81 % at the time of their clinic visit. The number of patients at step two and above on the WHO pain ladder also increased from 34 % to 56 %. Conclusions Of the patients seen at the InS:PIRE clinic two-thirds stated that they had new pain since their ICU admission. Despite the increase in the number and strength of analgesics prescribed, almost a quarter of patients still complained of pain at their clinic visit. These results confirm that pain continues to be a significant problem in this patient group. Raising awareness in primary care of the incidence of chronic pain and improving its management is essential to the recovery process following an ICU admission

Pharmacy intervention at an intensive care rehabilitation clinic

Introduction: During an intensive care stay, patients often have their chronic medications withheld for a variety of reasons and new drugs commenced [1]. As patients are often under the care of a number of different medical teams during their admission there is potential for these changes to be inadvertently continued [2]. Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) is a five week rehabilitation programme for patients and their caregivers after ICU (Intensive Care Unit) discharge at Glasgow Royal Infirmary. Within this programme a medication review by the critical care pharmacist provided an opportunity to identify and resolve any pharmaceutical care issues and also an opportunity to educate patients and their caregivers about changes to their medication. Methods: During the medication review we identified ongoing pharmaceutical care issues which were communicated to the patient’s primary care physician (GP) by letter or a telephone call. The patients were also encouraged to discuss any issues raised with their GP. The significance of the interventions was classified from those not likely to be of clinical benefit to the patient, to those which prevented serious therapeutic failure. Results: Data was collected from 47 of the 48 patients who attended the clinic (median age was 52 (IQR, 44-57) median ICU LOS was 15 (IQR 9-25), median APACHE II was 23 (IQR 18-27) and 32 of the patients were men (67%). The pharmacist made 69 recommendations; including 20 relating to drugs which had been withheld and not restarted, dose adjustments were suggested on 13 occasions and new drug recommendations were made for 10 patients. Duration of treatment for new medications started during hospital admission was clarified on 12 occasions. Lastly adverse drug effects were reported on 4 occasions and the incorrect drug was prescribed on 2 occasions. Of the interventions made 58% were considered to be of moderate to high impact. Conclusions: The pharmacist identified pharmaceutical care issues with 18.6% of the prescribed medications. Just over half of the patients reported that they were not made aware of any alterations to their prescribed medication on discharge. Therefore a pharmacy intervention is an essential part of an intensive care rehabilitation programme to address any medication related problems, provide education and to ensure patients gain optimal benefit from their medication

Critical care provision after colorectal cancer surgery

Background: Colorectal cancer (CRC) is the 2nd largest cause of cancer related mortality in the UK with 40 000 new patients being diagnosed each year. Complications of CRC surgery can occur in the perioperative period that leads to the requirement of organ support. The aim of this study was to identify pre-operative risk factors that increased the likelihood of this occurring. Methods: This is a retrospective observational study of all 6441 patients who underwent colorectal cancer surgery within the West of Scotland Region between 2005 and 2011. Logistic regression was employed to determine factors associated with receiving postoperative organ support. Results: A total of 610 (9 %) patients received organ support. Multivariate analysis identified age ≥65, male gender, emergency surgery, social deprivation, heart failure and type II diabetes as being independently associated with organ support postoperatively. After adjusting for demographic and clinical factors, patients with metastatic disease appeared less likely to receive organ support (p = 0.012). Conclusions: Nearly one in ten patients undergoing CRC surgery receive organ support in the post operative period. We identified several risk factors which increase the likelihood of receiving organ support post operatively. This is relevant when consenting patients about the risks of CRC surgery

Organ failure, outcomes and deprivation status among critically ill cirrhosis patients — a one-year cohort study

No abstract available

A randomised, controlled, double blind, non-inferiority trial of ultrasound-guided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty

We performed a single centre, double blind, randomised, controlled, non-inferiority study comparing ultrasound-guided fascia iliaca block with spinal morphine for the primary outcome of 24-h postoperative morphine consumption in patients undergoing primary total hip arthroplasty under spinal anaesthesia with levobupivacaine. One hundred and eight patients were randomly allocated to receive either ultrasound-guided fascia iliaca block with 2 mg.kg−1 levobupivacaine (fascia iliaca group) or spinal morphine 100 μg plus a sham ultrasound-guided fascia iliaca block using saline (spinal morphine group). The pre-defined non-inferiority margin was a median difference between the groups of 10 mg in cumulative intravenous morphine use in the first 24 h postoperatively. Patients in the fascia iliaca group received 25 mg more intravenous morphine than patients in the spinal morphine group (95% CI 9.0–30.5 mg, p < 0.001). Ultrasound-guided fascia iliaca block was significantly worse than spinal morphine in the provision of analgesia in the first 24 h after total hip arthroplasty. No increase in side-effects was noted in the spinal morphine group but the study was not powered to investigate all secondary outcomes