SummarySubcostal transversus abdominis plane (TAP) catheters have been reported to be an effective method of providing analgesia after upper abdominal surgery. We compared their analgesic efficacy with that of epidural analgesia after major upper abdominal surgery in a randomised controlled trial. Adult patients undergoing elective open hepatobiliary or renal surgery were randomly allocated to receive subcostal TAP catheters (n = 29) or epidural analgesia (n = 33), in addition to a standard postoperative analgesic regimen comprising of regular paracetamol and tramadol as required. The TAP group patients received bilateral subcostal TAP catheters and 1 mg.kg−1 bupivacaine 0.375% bilaterally every 8 h. The epidural group patients received an infusion of bupivacaine 0.125% with fentanyl 2 μg.ml−1. The primary outcome measure was visual analogue pain scores during coughing at 8, 24, 48 and 72 h after surgery. We found no significant differences in median (IQR [range]) visual analogue scores during coughing at 8 h between the TAP group (4.0 (2.3–6.0 [0–7.5])) and epidural group (4.0 (2.5–5.3) [0–8.5])) and at 72 h (2.0 (0.8–4.0 [0–5]) and 2.5 (1.0–5.0 [0–6]), respectively). Tramadol consumption was significantly greater in the TAP group (p = 0.002). Subcostal TAP catheter boluses may be an effective alternative to epidural infusions for providing postoperative analgesia after upper abdominal surgery.

In a double-blind, randomized, controlled study, 61 patients who received a standardized anaesthetic for day case arthroscopic knee surgery were studied. Group T (n = 31) received tramadol 1.5 mg kg-1, and group F (n = 30) received fentanyl 1.5 micrograms kg-1 at the induction of anaesthesia. All patients also received 20 mL of intra-articular bupivacaine 0.5% at the end of surgery. Assessments were made of pain at rest and on movement, analgesic requirements and side-effects at hourly intervals up to 6 h and by means of a postal questionnaire at 24 h and 48 h post-operatively. Group F had higher pain scores than group T at 4 h only [VAS 3.3 (1.6-5.5) vs. 2.4 (1-4), P = 0.039, respectively; median (interquartile range)]. There were no other significant differences between the groups in terms of pain scores, supplemental analgesic requirements or incidence of side-effects. We conclude that tramadol offers little benefit clinically compared with fentanyl when used at induction of anaesthesia for day case arthroscopic knee surgery. Further studies are indicated in patients with more severe pain to determine the role of tramadol in post-operative analgesia.

A short cut review was carried out to establish whether intra-articular injection of local anaesthetic is an effective alternative to intravenous analgesia with or without sedation to facilitate reduction of acute shoulder dislocations. Eleven studies were considered relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these studies are tabulated. The clinical bottom line is that intra-articular injection of local anaesthetic is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations.

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Background Methoxyflurane is an inhaled analgesic agent licensed in the United Kingdom for the relief of moderate to severe pain in conscious patients with trauma. Methoxyflurane has been widely used by Australian ambulance services since the 1970s. Aims Primary aim: To assess the efficacy of methoxyflurane for procedural analgesia in the emergency department and pre-hospital environment. Secondary aims: to assess the efficacy of methoxyflurane for analgesia in the emergency department and pre-hospital environment; to assess the safety of methoxyflurane as an analgesic. Method A literature search of Medline, EMBASE, CINAHL and Cochrane databases was performed. A total of 59 articles were reviewed. Results One study using methoxyflurane for procedural analgesia in the emergency department was found. Multiple studies demonstrate the use of methoxyflurane for procedural analgesia for painful procedures outside the emergency department. Compared to other analgesics, methoxyflurane provides adequate analgesia. Overall, methoxyflurane is inferior to fentanyl or morphine, but it provides quicker onset analgesia compared to fentanyl and tramadol. It provides similar analgesia to nitrous oxide. Nephrotoxicity is dose dependent. Used in the analgesic doses, the risk of clinically significant kidney injury is negligible. Rare cases of unpredictable, severe hepatitis are reported. Discussion The efficacy of methoxyflurane and its acceptability to patients and clinicians has been shown in a number of studies. As would be expected in any procedural analgesic choice, patient and clinician factors and the procedure planned are all important considerations. Compared to other analgesic agents, methoxyflurane performs favourably with a low chance of adverse events. Conclusion Methoxyflurane is an efficacious analgesic agent in the emergency department and pre-hospital environment. It is easily portable and has a rapid onset. Methoxyflurane is suitable for use in procedural analgesia and as a bridging analgesic agent. Risks to the patient from renal or hepatic injury, cardiorespiratory depression or malignant hyperthermia are low.

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A review was carried out to see whether hands-on defibrillation could be performed safely. 6 papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that hands-on defibrillation has the potential to be performed safely if the rescuer uses appropriate electrical insulating barriers such as polyethylene gloves or class 1 electrical insulating gloves. The safety profile of nitrile gloves is unclear. Since detection of shock was used as a proxy for safety, additional investigation is warranted before hands-on defibrillation becomes common practice.

A short cut review was carried out to whether the FAST screening tool is more accurate than the ROSIER tool at correctly identifying those with stroke in the prehospital setting. 9 papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that FAST and ROSIER have similar sensitivities in the recognition of stroke, with ROSIER demonstrating a higher specificity in the prehospital setting.