SummaryTo describe facilities for postoperative epidurals in UK National Health Service Hospitals, a questionnaire was sent to each hospital performing surgery below the head and neck. Of 271 hospitals, 256 replied (95%). While almost all offer postoperative epidurals, only 78 (30%) offer them to all surgical disciplines. Most hospitals rely on acute pain nurses for troubleshooting during the day, and on trainee anaesthetists after hours. Administration is most commonly by continuous infusion. There was no restriction on the use of epidural opioids in 67% of hospitals. Most (96%) hospitals have a protocol for epidural care, although the specified level of monitoring varies widely. There is no consensus of practice on removal of epidural catheters relative to anticoagulation. Levels of training in epidural care also vary widely. Two hundred and thirty-six hospitals (92%) have an acute pain team. Despite the expansion in acute pain services, facilities for postoperative epidurals are deficient in many NHS hospitals.Keywords Postoperative care. Analgesic technique: epidural. Correspondence to: Dr J. Austin E-mail: drjamesaustin@hotmail.com Accepted: 13 February 2002 Epidural analgesia offers several advantages for the relief of postoperative pain below the level of the axillae. A recent metanalysis [1] points to a significant reduction in mortality and major morbidity across a wide range of surgical groups when neuraxial blockade is used. The quality of analgesia is typically as good as or better than, that provided by other analgesic regimes and the sideeffect profile is different.Despite these apparent advantages, anecdotal evidence suggests that not all patients in NHS hospitals who may benefit from epidural analgesia receive it [2][3][4][5]. While major complications are rare, they are also potentially lethal, leading to the perception that a greater level of monitoring is required for postoperative epidural analgesia [6, 7]. Current constraints on nursing resources may therefore limit their use although the development of acute pain teams may go some way to alleviate this.This study sought to identify how widely postoperative epidurals are available in the NHS, and what facilities and protocols govern their use, with particular reference to workload and staffing implications. MethodsA questionnaire and stamped addressed reply envelope were sent to the clinical directors of 273 departments of anaesthetics in NHS hospitals. These were identified through the Royal College of Anaesthetists' database of tutors ' addresses [8], and by perusal of The Hospital Address Book [9]. Dedicated ophthalmic, ENT and neurosurgical hospitals were excluded. The questionnaire was designed to be completed quickly and easily. A covering letter explained the purpose of the questionnaire, and offered a small incentive towards completioncompleted returns would be entered into a prize draw for a £100 token towards acute pain expenses. Anonymous returns were possible, but hospitals were encouraged to put their names to their returns....
The prevalence of tetanus reflects a failure of immunization. Prompt diagnosis and prediction of severity are crucial for the prevention of early life threatening complications and the institution of appropriate management. The current symptomatic treatment of heavy sedation, paralysis and artificial ventilation for 3-5 weeks for moderate and severe tetanus, is, even in the best centers, still associated with unacceptably high mortality, due to the disease and complications of the therapy itself. It is especially inappropriate for the developing world where intensive care resources are minimal. New options reported to avoid artificial ventilation and sedation are dantrolene (Dantrium, Procter and Gamble Pharmaceuticals), baclofen (Lioresal, Novartis) and magnesium. Magnesium therapy has the advantages of controlling spasms and sympathetic over activity without sedation. This simplifies nursing care and minimizes the need for ventilatory support except in the very severe disease and the elderly. Magnesium is recommended as the first-line therapy in tetanus.
SummaryA prospective pilot study was undertaken to investigate the ability of magnesium sulphate to control the spasms of severe tetanus without the need for sedation and artificial ventilation. All eight patients admitted with severe tetanus to our intensive care unit within the last year were given magnesium sulphate intravenously as a 5-g loading dose followed by an infusion of 2-3 g h ¹1 . The infusion rate was increased to control spasms while retaining the patella tendon reflex, which proved a valid guide to avoid overdose. Spasms were effectively controlled and serum magnesium concentrations were maintained within the therapeutic range. Spontaneous ventilation was adequate, ventilatory support being required only for the management of lung pathology. There was no evidence of cardiovascular instability due to sympathetic over activity. No supplementary sedation was required for the control of spasms or autonomic dysfunction during magnesium therapy. We conclude that magnesium sulphate can be used as the sole agent for the control of spasms in tetanus without the need for sedation and artificial ventilation.
The value of Mg therapy for patients with tetanus, which minimizes heavy sedation and paralysis in keeping with the goals of modern intensive care, is discussed.
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