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Macintyre, P.

Russell, W.

Anaesthesia and Intensive Care

Adelaide Research & Scholarship

megaly with a spleen extending 12 cm beyond thecostal margin. A combination of NYHA class 2 short-ness of breath and signs of right heart failure withsevere tricuspid regurgitation led to the decision forintraoperative monitoring with TOE.There being no contraindications and with in-formed consent obtained, an ATL multiplane TOEprobe was inserted uneventfully after induction ofanaesthesia. A problem was noted when obtainingtransgastric views. Added traction through the gastro-splenic ligament to an already stressed splenic vas-cular pedicle caused the surgeon difficulty withhaemostasis whilst ligating these vessels. Because ofthis the probe was withdrawn, relieving the problemand allowing the surgeon to achieve haemostasis andcomplete the procedure successfully.A literature search using Medline revealed noreports of splenomegaly associated with potentialproblems during use of TOE.One should bear in mind the close anatomical re-lationship of the gastrosplenic ligament and thesplenic vessels lying within the lienorenal ligament2when performing TOE during splenectomy forsplenomegaly.G. G. PATTULLODepartment of Anaesthesia and PainManagement,Royal North Shore Hospital, Sydney, N.S.W.References1. Practice guidelines for perioperative transesophageal echo-cardiography. Anesthesiology 1996; 84:986-1006.2. The Peritoneum. In: Williams PL, Warwick R, Dyson M,Bannister L, eds. Gray’s Anatomy, 37th Ed. ChurchillLivingstone, Edinburgh, United Kingdom, 1989; 1336-1347.Pain scores in the early postoperative periodDr Pfizner and Professor Moyes raise some impor-tant issues with respect to management of pain usingopioids in the immediate postoperative period1.We agree that it is unrealistic to expect thatpatients will not feel pain after surgery. However,“pain” or “comfort” scores are a valuable tool intracking a patient’s response to treatment. The aimshould be patient comfort, both at rest and withmovement. This can be explained to patients at thetime they are seen before surgery. If patients areinformed about the way in which their pain will beassessed and managed at this time, we do not believethat the use of “pain” rather than “comfort” scoresmakes a patient focus on the pain more. However, the authors highlight an important pointin the use of pain scores and “associated use ofreputable ‘Pain Protocol’ regimens” when they sug-gest that “conscientious persistence” in the use ofboth may result in some patients receiving excessiveopioid doses. The aim of treatment should be patientcomfort in the absence of clinical signs of excessiveopioid dose. All nursing staff administering the “PainProtocol” regimens (small doses of intermittent intra-venous opioids) must be aware of the importance of sedation and understand both its significance(increasing sedation being a more reliable clinicalindicator of respiratory depression than a decrease inrespiratory rate) and how to monitor it properly. Itmay not be possible to get patient comfort withoutexcessive sedation and at this stage an anaesthetistshould be consulted for advice. Our “Pain Protocol”specifically states that administration of opioidsshould “cease when the patient is comfortable” (theywill not necessarily be pain-free) and that no furtheropioids can be given by the nurses unless the patienthas a sedation score of less than 2. With our system a sedation score of 2 means that the patient ismoderately drowsy, i.e. they wake easily but cannotstay awake. Administration of any sedative, even for an “overly anxious” patient with inadequateanalgesia, is inappropriate.As with any drug where titration is required,clinical endpoints that can identify both inadequateand excessive dosing are needed. If these are usedwhen opioids are administered, regardless of drug orroute, patients who become “over-narcotized” in therecovery ward should be very rare.P. E. MACINTYREW. J. RUSSELLDepartment of Anaesthesia and Intensive Care,Royal Adelaide Hospital and University of Adelaide,Adelaide, South AustraliaReference1. Pfitzner J, Moyes DG. Pain scores in the early postoperativeperiod. Anaesth Intensive Care 2003; 31:233.Pain scores in the early postoperative period—ReplyWe are grateful for the opportunity to comment onthe letter from Dr Macintyre and Professor Russell.Their letter, like ours, highlights the need for “com-fort” scores rather than “pain” scores in the manage-ment of pain following surgery. We do believe alsothat the use of “comfort” scores will lessen the risk of595CORRESPONDENCEAnaesthesia and Intensive Care, Vol. 31, No. 5, October 2003

Pain scores in the early postoperative period

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Pain scores in the early postoperative period

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