EP.WE.859Pain management in critical limb ischaemia patients: a clinical audit

Abstract Aims Critical Limb Ischaemia (CLI) patients often present with ischaemic rest pain and uncontrolled pain can impact on quality of life. To improve pain control, a set a of trust-wide guidelines were developed to standardise pain management for CLI patients. Methods This was a prospective cross-sectional audit, which initially involved 30 patients admitted under vascular surgery at a tertiary centre with CLI between May and June 2020. The improvements implemented included an analgesia education session for junior doctors, inclusion of an analgesia dosing table in the vascular clerking proforma and a simplified analgesia table as a poster. The re-audit included 22 patients with CLI between September and October 2020. Data was collected from drug charts and Fisher’s exact test was used for the statistical analysis. Results Baseline data suggested poor compliance with guidelines with only 3% of patients prescribed the guideline recommended PRN opiate doses. This improved post-intervention to 52% (p < 0.05). Following the interventions, naloxone prescribing significantly improved from 37% to 91% (p < 0.05). Standard dosing of opiates was seen irrespective of age or renal function. 14% of patients with renal impairment were prescribed opiate analgesia above the initial ranges indicated by the guidelines; compared to 33% in the first cycle (p = 0.58). Conclusion This audit has demonstrated the successful implementation of targeted changes to improve compliance with trust pain management guidelines for patients with CLI. The challenge remains of overcoming the unknown eGFR at time of prescription and unknown background analgesia that can lead to over and under prescribing.

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Antiplatelet therapy for tibial balloon angioplasty: A clinical perspective

SAGE Open Medicine ◽

10.1177/2050312119854579 ◽

2019 ◽

Vol 7 ◽

pp. 205031211985457

Author(s):

Costin N Ionescu ◽

Sophia E Altin ◽

Carlos Mena-Hurtado

Keyword(s):

Antiplatelet Therapy ◽

Balloon Angioplasty ◽

Therapeutic Approach ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Clinical Perspective ◽

Post Intervention ◽

Risk Of Bleeding ◽

Number Of Patients ◽

Percutaneous Transluminal

Percutaneous transluminal tibial balloon angioplasty has an important role in the therapeutic approach of critical limb ischaemia. Despite a growing number of patients with critical limb ischaemia, there are no trials to guide the pharmacologic approach post intervention. Guidelines pertaining to the antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty have not been developed. In addition, critical limb ischaemia patients have multiple comorbidities and a higher risk of bleeding. To examine the shortest duration of antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty, we reviewed the preclinical data used to develop the standards for the current angioplasty technique.

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Thrombophilic risk factors and peripheral arterial disease severity

Thrombosis and Haemostasis ◽

10.1160/th09-11-0772 ◽

2010 ◽

Vol 104 (07) ◽

pp. 71-77 ◽

Cited By ~ 16

Author(s):

Elisabetta Favaretto ◽

Cristina Legnani ◽

Michela Cini ◽

Eleonora Conti ◽

Alfio Amato ◽

...

Keyword(s):

Risk Factors ◽

Peripheral Arterial Disease ◽

Arterial Disease ◽

Cross Sectional Study ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Cross Sectional ◽

G20210a Mutation ◽

Peripheral Arterial ◽

Few Data

SummaryFew data are available on thrombophilic risk factors and progression of atherosclerotic peripheral arterial disease (PAD). Thrombophilic alterations can be an aggravating factor when arterial stenoses are present. In a cross-sectional study, we evaluated the presence of the thrombophilic factors fibrinogen, homocysteine, factor (F)VIII, lupus anticoagulant (LAC), FII G20210A, and FV R506Q mutations in 181 patients with PAD at Fontaine’s stage II (claudication), in 110 patients with critical limb ischaemia (CLI), and in 210 controls. Fibrinogen was higher in patients with CLI vs. those with claudication and controls (427.9 ± 10.5 vs. 373.1 ± 5.2 vs. 348.9 ± 7.0 p=0.001, respectively). Homocysteine and FVIII were higher in patients with PAD than in controls, but were similar in patients with CLI and claudication. The prevalence of LAC increased in patients with CLI vs. those with claudication and controls (21.4% vs. 7.8% vs. 5.2% p<0.001, respectively). The prevalence of FII 20210A allele was higher in patients with CLI vs. those with claudication and controls. Using a logistic model, FII G20210A mutation (odds ratio [OR] 19.8, confidence interval [CI] 4.5–87.1, p=0.001), LAC (OR 2.7, CI1.1–6.5, p=0.032), and fibrinogen (OR 1.01, CI 1.00–1.01, p=0.001) were associated with CLI, whereas homocysteine, FVIII, and FV R506Q mutation were not. CLI risk increased according to the number of thrombophilic alterations. In conclusion, altered levels of some important thrombophilic risk factors are independently associated with PAD severity. These data suggest that the presence of two or more thrombophilic risk factors raise the likelihood of PAD being more severe, justifying the need for larger longitudinal studies.

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Performance Appraisal System for Intern doctors in Selected Medical college hospitals of Bangladesh Current situation

Bangladesh Journal of Medical Education ◽

10.3329/bjme.v9i1.36233 ◽

2018 ◽

Vol 9 (1) ◽

pp. 14-17

Author(s):

Riffat Rahim ◽

Iffat Ara ◽

Md Humayun Kabir Talukder ◽

Kazi Khairul Alam

Keyword(s):

Performance Appraisal ◽

Sampling Technique ◽

Junior Doctors ◽

Successful Implementation ◽

Appraisal System ◽

Active Monitoring ◽

Cross Sectional ◽

Formal Assessment ◽

Medical College ◽

Performance Appraisal System

Background: Formal assessment could ensure all junior doctors receive feedback about their performance in the workplace early in their career, essential for professional development. Aim: . This study was aimed to analyze the situation of performance appraisal system of intern doctors in different medical college hospitals of Bangladesh.Method: This descriptive, cross-sectional study was carried out at 9 medical college hospitals(4 govt. and 5 non govt.) for a period of one year(July2016-June 2017) among 52 teachers and 445 intern doctors. Convenience sampling technique was administered. Data were collected by using self administered semi structured questionnaire. Data analysis were done using SPSS version 19.0 software.Results: The study revealed that the medical college hospitals under this study had mostly satisfactory internship training facilities. About 56% interns responded negatively about the utilization of logbook in each major discipline rotation. Around 54% of them responded negatively about the practice of performance appraisal system in their institute About 42.3% of teachers were not satisfied with the current practice of performance appraisal system of interns in their institute. However 27.5% teachers said that they arranged assessment always and 27.5% said that most of the time they arranged assessment for interns. About 35.5% interns blamed lack of interest of teachers about assessment of interns but 40% of teachers said work overload is the most important among the barriers in implementing appraisal system for interns. Around 42.1% interns suggested that existing logbook should be properly used and 48.9% of them suggested that the entire training should be under close supervision of the supervisors. Majority of the teachers were in favor of assessing interns on regular work along with formal assessment, they suggested regular morning session, ward round and bedside teaching should be ensured for the improvement of the standard of training.Conclusions: Proper utilization of logbook, successful implementation of performance appraisal system with feedback, active monitoring committee for the interns were recommended by the study.Bangladesh Journal of Medical Education Vol.9(1) 2018: 14-17

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Patient Perception of Acute Pain Management: Data from Three Tertiary Care Hospitals

Pain Research and Management ◽

10.1155/2017/7459360 ◽

2017 ◽

Vol 2017 ◽

pp. 1-12 ◽

Cited By ~ 9

Author(s):

Elsy Ramia ◽

Soumana C. Nasser ◽

Pascale Salameh ◽

Aline Hanna Saad

Keyword(s):

Pain Management ◽

Acute Pain ◽

Pain Treatment ◽

Tertiary Care ◽

Medication Administration ◽

Pain Medication ◽

Categorical Variables ◽

Cross Sectional ◽

Exact Test ◽

Orthopedic Patients

Introduction. The primary objectives of this study were to assess patients’ description of their acute pain intensity; patients’ attitude towards their pain management during hospitalization; and their overall satisfaction with pain treatment.Methodology. A cross-sectional questionnaire-based study was conducted between October 2014 and March 2015 in three medical centers in Lebanon. All participants’ responses were reported using descriptive statistics. The association between categorical variables was evaluated using Pearsonχ2test or Fisher’s exact test where the expected cell count was < 5.Results. A total of 119 women on the maternity services and 177 patients on the orthopedic services were surveyed. Around 50% of obstetric and 37% of orthopedic patients reported pain to be severe at its highest intensity. In maternity and orthopedic patients, respectively, unfavorable practices included pain not being assessed prior to pain medication administration (19.3% and 30.5%), having to wait for ≥30 minutes before getting the pain medication (14.2% and 11.3%), and pain score not being documented on medical chart (95% and 93.2%). Surprisingly, 94.1% of the maternity and 89.2% of orthopedic patients were satisfied to strongly satisfied with their pain management.Conclusion. Pre- and postoperative pain remain a prevalent problem that requires a consensus and joint efforts for improvement.

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Management of Paediatric Pain: Knowledge and Practice of Healthcare Providers at a Tertiary Centre, Southern Nigeria

Asian Journal of Pediatric Research ◽

10.9734/ajpr/2019/v2i130097 ◽

2019 ◽

pp. 1-8

Author(s):

G. K. Eke ◽

D. C. Briggs

Keyword(s):

Pain Management ◽

Healthcare Providers ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Tertiary Centre ◽

Port Harcourt ◽

Pain Knowledge ◽

Knowledge And Attitude ◽

The University ◽

Clinical Departments

Background: Many disease processes and interventional procedures in paediatrics are associated with pain. In spite of its frequency, it is undertreated globally, exposing children to the risks of long-term physical and psychological sequelae, which can have adverse effects on future treatments. Objectives: To ascertain the knowledge, attitude and practice of healthcare providers towards management of paediatric pain at the University of Port Harcourt Teaching Hospital. Methods: In this cross-sectional survey, a semi-structured and self-administered questionnaire was distributed amongst a convenient sample of physicians and nurses attached to clinical departments/units where children are cared for, and those in educational units, between June and August 2017. Their knowledge and attitude toward pain management were analysed using Epi Info v7 software (CDC, USA). Results: One hundred and ninety seven subjects participated in the study, 95(48.2%) physicians and 102(51.8%) nurses, all of various cadres. Seventy-four percent of them had more than 5 years working experience. One third of participants (30.4%) could name up to 3 non-pharmacological methods of pain management, of which the commonest were cold compress (48(24.4%) with nurses>physicians), followed by hot compress (38(19%)) and distraction (24(12%)). The commonest procedures for which non-pharmacological interventions of pain management were usually applied included immunisation of infants (20%) and venepuncture (17%) while lumbar puncture was the least (1.5%). Half of respondents (52%) had never prescribed/administered morphine to children. Conclusion: Healthcare providers had poor knowledge of paediatric pain management. There is an urgent need to build their capacity to enable optimal relief of pain among paediatric patients.

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Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman

Sultan Qaboos University Medical Journal [SQUMJ] ◽

10.18295/squmj.2021.21.01.016 ◽

2021 ◽

Vol 21 (1) ◽

pp. e116-119

Author(s):

Edwin Stephen ◽

Sara S.H. Al-Adawi ◽

Ibrahim Abdelhady ◽

Hanan Al Mawali ◽

Khalifa Al-Wahaibi

Keyword(s):

Vascular Surgery ◽

Internal Carotid Artery Stenosis ◽

University Hospital ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Abdominal Aneurysm ◽

Arteriovenous Fistulas ◽

Tertiary Centre ◽

Acute Limb Ischaemia ◽

Type B Dissection

Objectives: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. Methods: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. Results: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. Conclusions: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively. KEYWORDS COVID-19; Vascular Surgery; Emergencies; Oman.

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Verteilung des Ödems von Patienten mit chronischer kritischer Ischämie: Eine computertomographische Studie

VASA ◽

10.1024/0301-1526.28.4.265 ◽

1999 ◽

Vol 28 (4) ◽

pp. 265-270 ◽

Cited By ~ 5

Author(s):

Khiabani ◽

Anvar ◽

Rostad ◽

Stranden ◽

Kroese

Keyword(s):

Soft Tissues ◽

Subcutaneous Tissue ◽

Great Part ◽

Critical Limb Ischaemia ◽

Interstitial Tissue ◽

Limb Ischaemia ◽

Oedema Formation ◽

Tissue Pressure ◽

Cross Sectional ◽

Number Of Patients

Background: A substantial number of patients with chronic critical limb ischaemia (CLI) have considerable oedema at the distal leg and foot of non deep venous thrombosis origin. The primary aim of the pre-sent study was to quantify the distribution of oedema in the different tissues of the leg and foot by applying computed tomography and planimetry. The interstitial fluid hydrostatic pressure (Pif) in the subcutaneous tissue was measured to evaluate the effect of oedema on local tissue pressure. Patients and methods: Six men and 12 women with unilateral CLI and peripheral pitting oedema were included. Cross sectional areas (CSA) of subcutaneous tissue, muscle and bone were measured by computer tomography combined with planimetry to assess the distribution of oedema within the soft tissues. Pif was measured by “wick-in-needle” technique. Results: The median total CSA of soft tissue, subcutaneous and muscle tissues at the foot level were respectively 17%, 34% and 9% greater in the limbs with CLI compared to the contralateral limb (p < 0.001). At ankle level these differences were 13%, 30% and 4%, respectively (p < 0.001). At the level of the calf these differences were not significant. Mean Pif in the limbs with CLI was 0.3 mmHg, significantly higher than in limbs without CLI (–1.8 mmHg), (p < 0.003). Conclusion: The study verified oedema of considerable magnitude at the ankle and foot. The great part of the oedema was located within the subcutaneous tissue, which was associated with a relatively moderate, but significant increase in Pif confirming the high compliance of the subcutaneous tissue. The combination of the excessive fluid and increased Pif in the interstitial tissue might aggravate the microcirculation. The aetiology of oedema formation is probably multifactorial.

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Clinical Picture and Microbiological Pattern in 3rd and 4th Degrees of the Pedis Classification of Diabetic Foot Infection

Majalah Kesehatan Pharmamedika ◽

10.33476/mkp.v10i1.683 ◽

2018 ◽

Vol 10 (1) ◽

pp. 008

Author(s):

Kusmardi Sumarjo ◽

Sarwono Waspadji ◽

Rustadi Sosrosumihardjo ◽

Suhendro Suhendro

Keyword(s):

Clinical Picture ◽

Diabetic Foot ◽

Cross Sectional Study ◽

Critical Limb Ischaemia ◽

High Morbidity ◽

Limb Ischaemia ◽

Cross Sectional ◽

Diabetic Foot Infection ◽

Clinical Pictures

<p>Diabetic foot infection (DFI) is one complication of diabetes mellitus that has high morbidity<br />and mortality. The success of management of DFI is influenced by many factor. This study aimed to recognize clinical picture and microbiological pattern in 3rd and 4th degrees of the PEDIS classification. The design was a prospective cross-sectional study conducted in RSCM at March until May 2005. The clinical pictures in 52 DFI’pateints were included to the PEDIS classification with the wound’s odour and crepitation. Microbiological examination was done culture for microorganisms and the antibiotiks sensitivity test. The female were greate <br />(55,8%) than male the greatest age group were at 51-60 years old (44,2%). Poorly controlled blood glucose was found in 88%, duration of wound > 2 weeks in 56%, wound without critical-limb ischaemia in 81% with wound size > 25 cm2 in 58%, with bottom of wound had reached tendons in 75%. Most of the patiens undergroune sepsis (65%), diabetic neouropathy (77%), with odour distance of ≥1 m (65%), and crepitation/gas (63%). We found 96 types of microorganism, of which the greatest number was: E.coli 17,7% with highest sensitivity towards cefepime; S.aureus 15,6% towards co-amoxyclav; Bacteroides spp 4,2% towards co-amoxyclav, sultamicillin and metronidazole.</p>

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EFFECTIVENESS OF PROSTAGLANDIN E1 IN THE PAIN MANAGEMENT OF PATIENTS WITH CRITICAL LIMB ISCHAEMIA- A PROSPECTIVE OBSERVATIONAL STUDY

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2017/801 ◽

2017 ◽

Vol 4 (67) ◽

pp. 4011-4014

Author(s):

John Sajan Kurien ◽

Sansho Elavumkal Ulahannan ◽

Sandeep Abraham Varghese ◽

Saravanan Thangavel ◽

Mubashir Darrussalah ◽

...

Keyword(s):

Pain Management ◽

Observational Study ◽

Prostaglandin E1 ◽

Prospective Observational Study ◽

Critical Limb Ischaemia ◽

Limb Ischaemia

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Knowledge in Pain and Palliative Care in Medical Students From 2 Universities in Mozambique: A Cross Sectional Study

10.21203/rs.3.rs-44900/v1 ◽

2020 ◽

Author(s):

Emília Pinto ◽

Teresa Schwalbach ◽

Ferraz Gonçalves ◽

Jahit Sacarlal ◽

Luisa Castro ◽

...

Keyword(s):

Palliative Care ◽

Pain Management ◽

Medical Students ◽

Medical Training ◽

Medical Schools ◽

Cross Sectional Study ◽

World Health ◽

Sectional Study ◽

Cross Sectional ◽

Exact Test

Abstract Background: Palliative Care (PC) needs have been increasing in low- and middle-income countries. The education of its contents avoids the patients and families´ suffering and therapeutic futility. Aim: to assess the pain and palliative care´s knowledge in Mozambican medical students of the fifth and sixth years. Methods: A cross–sectional study was conducted between August 2018 and July 2019. Data was collected by applying a self-administered survey directed to students from 2 medical schools in Mozambique. Comparison of answer’s frequencies between hospitals was performed using chi-square and Fisher’s exact test. Results: From the 146 participants, 52.7% were female and the median age was 24 years old. Regarding general knowledge: 90.1% think they need to improve their knowledge on pain management, 50.3% of the participants did not know the palliative care World Health Organization´s (WHO) definition. Concerning to therapeutic approach, 36.4% did not have knowledge in control of symptoms, 43.7% did not know the WHO pain management scale, 65.3% did not know how to initiate analgesia for cancer pain. There are significant differences between universities in training related to medical posture on communication to bad news to patients and family as well as training in terminally ill patients. Conclusion: Results show that students from these 2 medical schools have gaps in pain and palliative care knowledge. There is a need to introduce palliative care education in medical training in Mozambique.

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