Summer 2010 - The British Pain Society

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Papers appraised by Dr Aileen Clyde Pain Fellow Glasgow PAIN SHORTCUTS Incidence and Root Cause Analysis of Wrong-site Pain Management Procedures Anesthesiology 2010;112:711-8 The objectives of this study were to estimate the incidence of wrong site pain management procedures, to perform an analysis to identify the cause of these mistakes and to publicise the issue of wrong site surgery and its causes to prevent further occurrences. Quality improvement records were reviewed from pain clinics at 10 institutions in the USA ( 4 academic teaching hospitals, 2 military teaching hospitals, 1 non-academic treatment facility and 3 private practices) during a 2 year period from 2007-2009 to identify wrong site procedure events. All physicians involved in pain management at each facility were questioned to identify wrong site procedures that may not have been reported. Billing records from the non-military institutions were examined and procedure codes and scheduling records from the military institutions examine to identify the total number of pain procedures carried out in this 2 year period. When multiple distinct procedures were performed during a single visit, these were counted separately. For related or multilevel procedures that did not constitute an additional risk of wrong site surgery, then only the primary procedure was tabulated. Individual procedure reports were examined during a 6 month period to determine the number of unilateral procedures or spinal procedures in which correctly identifying the pathological level was deemed to be critically important. These procedures were called ‘at risk’ procedures. Causation was determined by referring to quality improvement records and by ‘debriefings’ with personnel involved in the event. The review found that 48,941 unrelated procedures were completed at the 10 institutions during the 2 year time frame. The review of 500 billing records along with daily schedules and electronic record review indicated 6 duplicate procedures or procedures that were not reflected in the billing records. This gives an estimated error rate of 1.2%. 13 wrong site procedures were identified (0.027%; CI 0.01- 0.05%). 12 were from quality improvement records and 1 from staff questioning. The proportion of ‘at risk’ procedures from each institution ranged from 39-65%, the weighted average was 52.4%. Therefore, the incidence of wrong site procedures was estimated to be 2.7 per 10,000 pain management procedures and 5.1 per 10,000 high risk pain management procedures. Of the 13 wrong site procedures, 5 were wrong side transforaminal epidural steroid injections. There was 1 wrong side facet radiofrequency denervation, 1 wrong side intercostal nerve radio frequency ablation, 1 wrong side intercostal nerve block, 2 wrong level spinal procedures, 1 wrong side lumbar sympathectomy, 1 wrong side suprascapular nerve block and 1 wrong side lumbar facet injection. In 5 cases either the side or level was not noted on the consent form. In four of the 8 cases where the consent form was correct, it was signed by a different person to that carrying out the procedure. In one patient the consent form was not sent with the patient to the procedure area. A ‘time out’ was performed in only 6 of the 13 cases and the side was marked in only 2 cases. The authors identified some causative factors which appear to increase the chances of wrong site surgery. There appeared to be an increased risk of wrong site procedures when the responsibility for safe performance is shifted between providers, steps in the ‘universal protocol’ are missed, the site is not marked, bilateral pathology is present or if a different practitioner from the one carrying out the procedure is involved in obtaining consent. Strangely in 8 of the 13 cases the patients knew that the wrong side Anesthesiology 111(2), August 2009 pp416-431 Intravenous analgesic infusion tests have been used for some time to facilitate the management of patients with chronic pain. The rational behind their use is that they can quickly predict who will respond to a subsequent course of oral medication, eliminating the time and expense of an oral medication trial and reducing the risks of adverse effects associated with ineffective drug treatment. This is the first attempt to review systematically the literature on intravenous analgesic infusion tests. The aim of the systematic review was to discern the value of these analgesic drug infusions tests as prognostic tools in guiding future drug therapy. was being targeted. 6 of the 13 patients received sedation for the procedure. No legal, professional or procedural consequence resulted from the errors although 2 practices determined that the mistake might lead to future litigation. No studies like this have been conducted to determine the incidence of wrong site pain procedures in the UK. The WHO surgical safety checklist, which has recently been implemented in many UK hospitals may help to reduce the problem of wrong site procedures. It is interesting to note that in many of the wrong site pain procedures mentioned in this study, there was a breach of universal protocol (U.S. version of surgical safety checklist) PAIN SHORTCUTS Intravenous Infusions for Chronic Pain- a systematic review The authors performed a MEDLINE, EMBASE and OVID search using appropriate key words. The search identified 111 published articles on the subject. Of these 22 articles were suitable for analysis. 10 studies looked at the predictive value of lignocaine infusion tests for treatment with oral sodium channel blocker mexiletine. Although these studies are small the data suggests that a brief lignocaine infusion test is predictive of subsequent response to oral mexiletine for patients with neuropathic pain. There is only weak evidence that the response to intravenous lignocaine can predict response to mexiletine in nociceptive pain. The authors point out that the long term effectiveness of mexiletine therapy remains in question as a result of its significant side effect profile, mainly nausea and sedation. 6 0 PAI N N E W S S U M M E R 2010
3 studies ( n=25,34,56) looked at the use of intravenous ketamine infusion to predict the response to the oral NMDA receptor antagonist dextromethorphan. One study (n=8) evaluated the efficacy of oral ketamine in subjects who responded positively to an infusion of ketamine. The authors emphasise the flaws associated with these studies namely short follow up period, use of single dose ketamine (0.1mg/kg) and the absence of any control treatment group. The review concludes that the studies included provide weak evidence supporting the use of a ketamine infusion test to predict short term treatment response to oral NMDA receptor antagonist therapy for both neuropathic and nociceptive pain. There were 4 studies (n=48,12,16,26) that looked at the use of opioid infusions to predict response to either oral or transdermal opioid. These yielded mixed results. 2 studies showed very poor correlation between the predictive results of an opioid infusion test and response to oral opioids while two studies showed that there was a correlation between the responses but only a small percentage of patients reported sustained benefit from oral opioids lasting at least 6 months. There were 3 studies (n=104,6,41) and one case report looking at the predictive effects of IV phentolamine. There are a number of significant flaws with these studies. The authors of the systematic review concluded that there was no credible evidence that the use of intravenous phentolamine infusion reliably predicts response to pharmacological sympathetic blockade (transdermal or oral clonidine used in these studies), and only weak evidence supporting the use of intravenous phentolamine before intravenous regional guanethidine. Despite having very liberal inclusion criteria in this review, there is little data on the predictive value of intravenous analgesic infusion tests. It is surprising that there is a paucity of literature available to support a commonly used test in pain management. Further, randomised, double blind studies are obviously required to determine the predictive nature of these tests. PAIN SHORTCUTS Group cognitive behavioural treatment for low back pain in primary care cognitive behavioural intervention. Subjects in the Control, advice only, group received a copy of the ‘back book’ and a 15 minute session on active management advice delivered by a nurse or physiotherapist. The intervention group subjects attended the Back skills training programme, which comprises an individual assessment and 6 sessions of group cognitive behavioural therapy. This cognitive behavioural therapy targets behaviours and beliefs about physical activity and avoidance of activity. Subjects were deemed to be compliant with the cognitive behavioural intervention if they attended the initial assessment and at least 3 of the subsequent sessions. Outcomes were assessed at 3, 6 and 12 months after randomisation by postal questionnaire. Subjects were asked to fill in the Roland Morris disability questionnaire and the modified Von Korff scale, mental and physical health related quality of life survey, fear avoidance beliefs questionnaire, pain self-efficacy scale and a questionnaire relating to selfrated benefit from and satisfaction with treatment. The authors estimated the costs of delivering both interventions and health care costs associated with lower back pain over 12 months by use of a within trial analysis. Quality Adjusted Life Years (QALY) were used to estimate cost utility. 701 subjects were randomised. There was 233 in the control group and 468 in the CBT group (1:2 ratio control:test). Followup was 85% in both groups at 12 months. The Roland Morris questionnaire score changed by 1.1 points (95% CI 0.39- 1.72) from baseline to 12 months in the control group and by 2.4 points (1.89-2.84) in the CBT group(1.3 points difference between gps, 0.56- 2.06; p=0.0008). The modified Von Korff pain score changed by 6.4% in the control group and by 13.4% in the CBT group (7% diff between groups,3.12-10.81; p
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