High‐dose intrathecal diamorphine for analgesia after Caesarean section

Abstract

SummaryAcute Physiology and Chronic Health Evaluation (APACHE) II scoring is widely used as an index of illness severity, for outcome prediction, in research protocols and to assess intensive care unit performance and quality of care. Despite its widespread use, little is known about the reliability and validity of APACHE II scores generated in everyday clinical practice. We retrospectively re-assessed APACHE II scores from the charts of 186 randomly selected patients admitted to our medical and surgical intensive care units. These`new' scores were compared with the original scores calculated by the attending physician. We found that most scores calculated retrospectively were lower than the original scores; 51% of our patients would have received a lower score, 26% a higher score and only 23% would have remained unchanged. Overall, the original scores changed by an average of 6.4 points. We identified various sources of error and concluded that wide variability exists in APACHE II scoring in everyday clinical practice, with the score being generally overestimated. Accurate use of the APACHE II scoring system requires adherence to strict guidelines and regular training of medical staff using the system. [4] are used widely in most intensive care units (ICUs). They are used not only as an index of illness severity and outcome prediction, but also to assess clinical performance and quality of care [5, 6]. The APACHE II score is the most frequently used scoring system and has become an important tool in efforts to improve effective use of intensive care [7±11]. In addition, it is often used in research protocols to ascertain that different treatment groups are comparable.Despite its widespread use in ICUs, little is known about the reliability and validity of the APACHE II scoring system in everyday medical practice. We reported that there was wide interobserver variation in the application of the APACHE II score when a group of doctors (residents and intensivists) assessed the same patient [12]. Chen et al.[13] studied interobserver variability and variability in data collection in a number of community and teaching hospitals; they reported that revised mortality predictions were similar to the original [13]. However, their study did not discuss in detail the specific sources of error and problems in APACHE II scoring.This study was designed to: (i) assess the accuracy of APACHE II scoring in a medical and surgical ICU; (ii) assess the influence of the method of data collection, manual or via a patient data management system (PDMS), on accuracy and overall variability in scoring; (iii) specifically identify and discuss sources of error and q 2001 Blackwell Science Ltd 47 confusion; and (iv) provide suggestions on how to decrease variability. MethodsThe charts of 64 patients admitted to the medical ICU and 122 patients admitted to the surgical ICU over a 6-month period were randomly selected. APACHE II scores are assessed routinely in all patients admitted to the ICU within 2 days of admission. In the medical ICU...

Obstetric anaesthesia outcome in obese and non-obese parturients undergoing caesarean delivery: an observational study

“…Despite some minor patient dissatisfaction with spinal block, overall patient satisfaction was good in our study population. More than 70% of our patients had neuraxial anaesthesia, which included diamorphine to provide postoperative analgesia for up to 24 h. 18 Although patient satisfaction surveys can be useful, they may be subjective and depend on maternal recall. However, these elements in our survey were minimal, as our standardized report was promptly collected directly by an anaesthetist, but usually not the one who performed the anaesthesia; in order to further encourage truthful responses.…”

Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard

“…We used postoperative opioid requirement as the primary outcome in keeping with previous dose-response studies. [5][6][7] It was anticipated that a single analysis of variance across all groups would be used to see whether any differences were present. Audit data from our unit indicated mean (SD) postoperative subcutaneous diamorphine requirements for the different doses of intrathecal diamorphine of 14.1 (7.3) mg for placebo, 12.5 (9.46) mg for 100 lg, 10.7 (8.7) mg for 200 lg and 8.7 (8.2) mg for 300 lg.…”

“…High-dose diclofenac (200 mg in 24 h) is opioid-sparing but without an increased incidence of side effects. 2,3 Intrathecal diamorphine is known to improve postoperative analgesia in this group of patients [4][5][6][7] and previous studies had indicated that approximately 300 lg was the optimal dose. Spinal opioids also have dose-dependent side effects of nausea, itching and respiratory depression.…”

“…Spinal opioids also have dose-dependent side effects of nausea, itching and respiratory depression. [4][5][6][7][8] The RCA audit guidance represents an accepted standard of analgesia in this group of patients. We believed that it might be possible to meet this audit standard using a relatively low dose of intrathecal diamorphine if used in combination with high-dose diclofenac.…”

The Unique Role of Diamorphine in British Medical Practice: A Survey of General Practitioners and Hospital Doctors

“…In a doubleblind study of primigravidae, epidural diamorphine has been found to effective for pain relief in labour [29]. Diamorphine has been used after Caesarean section for analgesia [30], and has been found to be safe in a double-blind study of patients undergoing Caesarean section with pain scores and other adverse effects reduced in a dose-dependent manner by intrathecal diamorphine [31]. It is an indication of the relaxed attitude of British physicians to diamorphine that it is also used with newborn infants and with children.…”