Australasian Anaesthesia 2011 Australasian Anaesthesia 2011
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AUSTRALASIAN ANAESTHESIA 2011 AUSTRALASIAN ANAESTHESIA 2011 Invited papers and selected continuing education lectures Editor: Richard Riley Department of Anaesthesia and Pain Medicine Royal Perth Hospital Pharmacology and Anaesthesiology Unit, School of Medicine and Pharmacology University of Western Australia Published in 2012 by: Australian and New Zealand College of Anaesthetists 630 St Kilda Road Melbourne VIC 3004 ISBN 978-0-9775174-7-3 ISSN 1032-2515 Requests to reproduce original material should be addressed to the Publisher. Printed by: Snap West Melbourne 673 Spencer Street, West Melbourne, VIC, 3003 Contents Complex regional pain syndrome (CRPS), a brief review 1 Will Howard The flimsy framework of methodology in the acute pain literature – shaky structure in need of repair? 7 Mark Reeves Management of opioid side effects – a personal view 11 Paul de Souza Pethidine: the case for its withdrawal 17 Gavin Pattullo and Ross MacPherson Neuraxial Block and Septicaemia 27 Girish Palnitkar and Thomas Bruessel The disappointing spinal – A review of the potential aetiologies for failure of spinal anaesthesia 33 Steven Koh Anaesthetic Management of Acute Spinal Cord Injury 43 Neil Dooney and Armagan Dagal Anaesthesia for instrumented spinal surgery 49 Lars P. Wang and Andrew Nicolas Miles Reappraisal of Adult Airway Management 57 Keith B. Greenland Cricoid Pressure: Is there any evidence? 67 Christopher Acott Trends in Paediatric Tracheal Tubes 73 Martyn Lethbridge Jet Ventilation and Anaesthesia – A practical guide to understanding jet ventilation and its 79 current applications in clinical anaesthetic practice Sasanka S Dhara Care of the potential lung transplant donor – optimisation, prevention of decline and future prospects 93 Ian James Smith The Last Frontier: Donation after Cardiac Death (DCD) reaches Western Australia 103 David Simes Smoking and surgery: time to clear the air 115 Ashley Webb The Management of Adult Jehovah’s Witnesses in Anaesthesia and Critical Care 125 Anne-Marie Welsh Intravenous Iron in Surgery and Obstetrics 135 Roger Browning Sickle Cell Disease in Australia – a phantom menace? 145 Carmen P Owusu-Ansah and Peter L Mulrooney Oxytocin: A guide for Anaesthetists 157 Celine Andrea Baber Heart Disease in Pregnancy and Labour 163 James B Sartain Perioperative Transthoracic Echocardiography in Australasia: Current Position and Future Directions 171 John Faris and Colin Royse Cardiac output monitoring in non-cardiac surgery: how and why? 179 Philip Peyton Teamwork: hard facts, soft skills. 189 Jennifer Weller Innovations in continuing medical education in the age of Net 2.0 197 M. Jim Yen, Mel Herbert and Stuart P. Swadron What next for anaesthesia in Australia? 203 Richard Halliwell Leadership in Anaesthetic Departments: A Surgeon’s View 209 Mohamed Khadra Faculty and Regional Sub-Editors Dr Robyn Campbell Modbury Hospital, Adelaide Dr Robyn Campbell Faculty of Pain Medicine, Modbury Hospital, Adelaide Professor Thomas Bruessel Australian Capital Territory, Canberra Hospital, Canberra Dr Doug Campbell New Zealand, Auckland Hospital, Auckland Dr Simon Morphett Tasmania, Royal Hobart Hospital, Hobart Dr Richard Riley Western Australia, Royal Perth Hospital, Perth Dr Sean McManus Queensland, Cairns Base Hospital, Cairns Dr Gerald Toh South Australia, Royal Adelaide Hospital, Adelaide Professor David Story Victoria, Austin Health, Melbourne Dr Sharon Tivey New South Wales, St George Hospital, Sydney AUSTRALASIAN ANAESTHESIA 2011 Preface Welcome to the 2011 edition of Australasian Anaesthesia. This marks the first edition wherein our Intensive Care colleagues have officially departed and we are sad to see them go. However, this does not mean the end of articles with a focus on Intensive Care and this issue of Australasian Anaesthesia has two authors who are Intensive Care Physicians. Indeed, it will be our pleasure to continue to provide a vehicle for topics of mutual interest. Perhaps I should mention again that articles from this book are published on the website of ANZCA and that there is often some bonus material located there; such as video files or brochures. The authors have generously allowed their articles to be distributed in this way to maximise the educational impact of their work. Finally, this issue of the Blue Book once again provides a diverse range of topics for your interest. I thank the authors, the regional editors and Katherine Goodwin for their work and support. It always surprises me that our countries produce outstanding clinicians who are willing to share their experiences, knowledge and perspectives with us. I hope you have the opportunity to thank those authors personally when you can and also consider writing yourself for a future edition. Richard Riley Complex regional pain syndrome (CRPS), a brief review 1 Complex regional pain syndrome (CRPS), a brief review DR WILL HOWARD FFPMANZCA, FFANZCA, DIP MED (PAIN MANAGEMENT) Dr Howard became a fellow of ANZCA in 1987 and a fellow of the Faculty of Pain Medicine (ANZCA) in 2000. He has worked in the chronic pain service at Austin Health, Victoria, since 1992 and his interest in complex regional pain syndrome dates from then. He is the Director of the Chronic Pain Service at Austin Hospital. INTRODUCTION I was surprised when a colleague, with a well deserved reputation for his erudition, expressed his ignorance of the term CRPS. I should have masked my surprise better as that event transmogrified into a request to write this article. The term complex regional pain syndrome was adopted by the International Association of the Study of Pain (IASP) in 1994.1 The rationale of its adoption was that other terms (see table 1) implied a pathophysiology which was not necessarily occurring. For example, reflex sympathetic dystrophy (RSD) was widely used but the condition is not a reflex and the role of the sympathetic nervous system is contentious (see later – pathophysiology); another example is Sudeck’s atrophy which describes the abnormalities on plain X-ray which occur only in some patients. Commentators have made the point that when a condition has many names, the profusion of terms reflects the confusion surrounding the condition. CRPS is intended to be a neutral term which states what we know about the condition: that it is complex pathology, affecting a region, and pain is (usually) a feature. The IASP proposed two types: CRPS II where the condition followed traumatic damage to a peripheral nerve and CRPS I where it did not. The rationale for this distinction was that intense burning pain was a feature of the condition after nerve trauma; previously it had been called causalgia – derived from the Greek words for burning and pain. Patients with causalgia due to traumatic nerve injuries sustained in the American Civil War were the source of the original description by Silas Mitchell, an American surgeon. Pain very much occurs in CRPS I and it may be burning; however common alternative descriptors include cold and deep aching. CRPS is often an enduring and wretched condition which blights the lives of those affected.1-8 The pain can be spontaneous, or evoked by everyday activities such as a change in temperature when opening a refrigerator door or having a shower, light touch such as the brushing of clothes over skin, or the most minor motor activity such as using a keyboard or standing. Anyone can be affected. In the past decade I have treated three anaesthetists with CRPS all of whom have had to cease ‘hands on’ anaesthesia practice. Anaesthetists may encounter a patient with CRPS either where the diagnosis is established and the patient is presenting for surgery, or in the context of postoperative pain management when a patient has unexpectedly severe pain. EPIDEMIOLOGY AND ONSET CRPS is more prevalent in Caucasians. It can occur at any age but its incidence seems highest between 20 and 50 years. In adults, females are more frequently affected than males. Studies are occurring to identify the genetic causes of CRPS but at this time there is insufficient data to draw wide conclusions. Based on studies of the incidence of CRPS in Europe and the USA, in Australia one would expect 1,000 to 5,000 new cases each year. The onset of CRPS is usually associated with an event of tissue damage, commonly of musculo-skeletal tissue but sometimes visceral, e.g. after stroke; occasionally no event can be identified. Frequently the event is minor e.g. a sprain, surgery for carpal tunnel release; it can even follow a venepuncture or a bee sting. Colles fracture is a well-recognised preceding event. CRPS usually occurs in the extremities; in adults the upper limb is much more commonly affected than the lower limb; in children the lower limb is more frequently affected. In the past there was a view that CRPS was a psychological disease: this view has no credence these days. It has been replaced by recognition that those affected by persisting manifestations of this unpleasant disease would be expected to show psychological sequelae due to ongoing pain and loss of function. DIAGNOSIS CRPS is a syndrome comprising pain, oedema, abnormalities of the vasomotor, sudomotor (sweating), and motor systems, and trophic changes. The severity of each of these manifestations varies from one patient to another. Generally diagnosis is clinical. Investigations may be supportive of the diagnosis: for example bone scan may show characteristic abnormalities of blood flow; plain X-ray, CT or MRI may show abnormalities of bone mineralisation or oedema; however such changes are usually where the condition has been or could have been diagnosed clinically. In 2006 a consensus group of Dutch experts concluded that “ ... additional tests were not required” (my emphasis).1 There is not a widely available test to support the diagnosis where the situation is unclear. This lack of certainty can result in contention when considering clinical management, when interpreting trials, and in reaching medicolegal outcomes. A number of proposals have been made regarding what variables must be satisfied to satisfy diagnostic criteria; it has been proposed that criteria for research are more stringent than those for clinical use.