Anaesthesia & intensive care medicine - Current Issue

How we measure pain and patients’ responses to pain is key in developing both our understanding and treatment of it. This article outlines the application of tools for the measurement of clinical outcomes used in acute and chronic pain medicine; what makes a good outcome measurement and how this can be utilized in clinical and research practice is discussed. Various tools for outcome measurement are described including those which may be utilized in various patient groups.

This article considers why enhanced communication techniques are particularly important in pain management consultations. Background is provided from evidence in both primary and palliative care research. The techniques are introduced and explained and include generic communication skills appropriate for all consultations and more advanced techniques. The generic skills described are empathy, allaying anxiety, breaking bad news and shared decision-making. Advanced techniques are aimed at facilitating changes in behaviour and include coaching, mentoring and motivational interviewing.

Regional anaesthetic techniques are the commonest type of anaesthetic for caesarean birth primarily due to their safety profile compared to general anaesthesia in pregnant women. The selection of a regional technique is influenced by both patient and surgical factors. Caution is essential regarding the timing of regional anaesthesia in patients who are receiving anticoagulation or have clotting abnormalities. Information on the risks and benefits of regional anaesthesia should be provided to facilitate informed decision-making.

Central neuraxial blocks represent the most executed procedures in the field of obstetric anaesthesia. Most neurological complications observed in the post-partum period arise from obstetric palsies associated with the natural process of labour. It is crucial for anaesthetists to adopt a systematic methodology when evaluating neurological injuries to differentiate between causes related to anaesthesia and those that are not. Additionally, it is vital to promptly recognize circumstances that necessitate urgent investigation and intervention to avert lasting damage.

Postdural puncture headache (PDPH) is a complication of dural puncture resulting from cerebrospinal fluid leak associated with performance of neuraxial analgesia, neuraxial anaesthesia or a lumbar puncture. Given that neuraxial techniques are frequently employed during childbirth, PDPH is more particularly prevalent among women in the postpartum period. PDPH typically presents within 5 days post-procedure with a fronto-occipital headache, often postural in nature, accompanied by symptoms such as neck stiffness, visual and/or auditory disturbances.

Human factors and ergonomics play a crucial role in improving patient safety, team performance and clinical outcomes. The dynamic, high-risk situations encountered in obstetrics require a rapid, well-coordinated response from a highly functioning team. An understanding of the interaction of healthcare professionals with members of their team and their environment is essential. Lack of situational awareness, poor communication and inadequate leadership compounded by unfamiliar teams in a rapidly deteriorating clinical situation put obstetric patients at particular risk.

Medical consent, the process of agreeing the benefits and risks of a treatment or procedure, has specific challenges in pregnancy and labour. Consent should take the form of a discussion about risk and include the alternatives. It should be an ongoing process with the right to withdraw consent or seek further information if the person chooses. Ideally all risks to which the patient might attach significance should be discussed. To consent, a person must have capacity. It is accepted that while labour can involve stress, pain, and fatigue, and will not infrequently be in a time-critical situation, women will normally retain the capacity to consent.

Cardiovascular disease remains one of the leading causes of pregnancy-related mortality in the developed world. Preconception counselling is essential to highlight individualized maternal, fetal, and cardiac risks. Pregnant individuals with a high-risk cardiac condition should be managed by a multidisciplinary cardio-obstetrics team comprising a high-risk obstetrician, cardiologist, neonatologist, and an anaesthetist in a tertiary centre. Anaesthetists as peripartum physicians need to comprehend the haemodynamic changes occurring during pregnancy, labour and postpartum period which can exacerbate pre-existing cardiac conditions resulting in haemodynamic compromise.

Pain is a complex condition and warrants a multidisciplinary approach based on a bio-psycho-social model. Whilst often successful in acute pain, pharmacological treatment is rarely successful on its own in the management of chronic pain due to the high number of patients needed to treat to achieve a clinically meaningful improvement in function, quality of life and pain scores. There are also significant side effects in the short and long term. Recent re-analysis of clinic trial data focused on individual responder rates, showed that there is a cohort of patients who achieve 50% pain relief with subsequent improvement in physical function.

Which of the following are true regarding the pharmacological effects and mechanism of actions of non-opioid analgesics?

Fibromyalgia is a complex condition which can provide a challenge to healthcare professionals. Sufferers experience widespread body pain and debilitating fatigue in addition to cognitive difficulties and sleep disturbance. Group pain management programmes are an evidenced-based approach to providing pain management for people living with chronic pain. Occupational therapists are uniquely placed to provide a holistic approach to patients with chronic pain and a group programme specifically targeted at patients with fibromyalgia has been found to provide an additional benefit of meeting the wide range of challenges they experience.

Physiotherapy is one of the lesser understood but an integral part of chronic pain (CP) management. The complex nature of CP warrants a multidisciplinary approach, addressing the biopsychosocial (BPS) aspects of well-being. This often requires a team of several specialists to assess the burden of individual BPS domains and devise a tailored management programme. Physiotherapy management is based on 3Es – Educate, Empower and Exercise/Movement Interventions. Fear of causing further harm, disability and anxious/low mood associated with it are a common presentation among those living with CP.

During pregnancy, maternal physiology undergoes continual adaptation. These often-interlinked changes occur in all body systems and are affected by the hormonal influences of the placenta and the mechanical adaptations required to accommodate the developing fetus. These important physiological changes can potentially lead to decompensation in parturients with pre-existing comorbidities. They may also unmask asymptomatic pre-pregnancy disease. A sound knowledge of the expected maternal changes is essential to enable accurate interpretation of physiological and laboratory parameters.

Trauma is a significant cause of hospital presentations and admissions in the UK, comprising a diverse selection of patients with differing analgesic needs and levels of comorbidity. Pain from the initial injury and subsequent treatments such as closed reductions and surgery is often severe and can lead to discomfort, difficulty in nursing care physiotherapy, and unwanted admissions. Regional anaesthesia is perfectly placed to provide an individualized analgesic strategy for each trauma patient that gives significant pain relief, and reduces reliance on opiate medications which have a significant side-effect profile especially in the increasingly elderly population presenting to hospitals with trauma.

This article explores mechanisms that generate pain as a multidimensional and embodied construct rather than a simple sensory state. The shortcomings of existing models of pain will be considered alongside contemporary cognitive neuroscience theories of predictive processing, to provide a potential explanation of chronic pain states. The focus is an exploration of integrated corticothalamic-limbic processing as opposed to peripheral nociceptive mechanisms.

Opioids represent an important class of analgesic medication and are effective in moderate to severe acute and cancer pain management. Opioids bind to G protein coupled receptors leading to a variety of physiological effects, including analgesia. Choosing the most appropriate opioid for each individual patient will depend upon the opioids individual pharmacokinetics and pharmacodynamics, their actions across different physiological systems, side effect profiles, available routes of administration and patient factors that impact on drug efficacy.

Which of the following are true about the anatomy and nerve supply of uterus?

Oxygen transport from the atmosphere to the fetus is dependent on maternal, placental and fetal factors. If any of these are disturbed, progressive fetal hypoxia and acidosis occur. Electronic fetal heart rate (FHR) monitoring is considered the primary method to assess fetal condition. Fetal distress refers to the presence of a non-reassurance heart trace, irrespective of the presence or absence of fetal acidosis. Intrauterine fetal resuscitation (IUFR) is a practice designed to enhance oxygen delivery to the placenta and maintain umbilical blood flow to counteract fetal hypoxia and acidosis, enabling safe delivery.