In a randomised, double-blind study, we investigated rapid extension of epidural analgesia to surgical anaesthesia for emergency Caesarean section. Parturients receiving epidural analgesia in labour who subsequently required Caesarean section were given a test dose of 3 ml lidocaine 2% with epinephrine 1 : 200 000, followed 3 min later by 12 ml lidocaine 2% with epinephrine 1 : 200 000 and fentanyl 75 microg, to which was added 1.2 ml sodium bicarbonate 8.4% (bicarbonate group; n = 20) or saline (saline group; n = 20). Mean (SD [range]) time to surgical anaesthesia was less in the bicarbonate group (5.2 (1.5) [2-8] min) than the saline group (9.7 (1.6) [6-12] min; mean difference 4.5 min (95% CI 3.5-5.5) min; p < 0.001). Maternal side-effects and neonatal outcome were similar between groups. We conclude that pH-adjusted lidocaine 2% with epinephrine and fentanyl is effective for rapidly establishing surgical anaesthesia in patients with a functioning epidural catheter for labour who require emergency Caesarean section.

Fentanyl has a low molecular weight and is lipophilic making it suitable for transdermal administration. However, multiple factors appear to lead to interindividual variation in absorption via this route. Here we describe an unusual case where a patient was found to have twelve 100 μg/hour fentanyl patches in situ which she was using as background analgesia.

BackgroundMany patients with life-limiting illnesses will require analgesia. Patients with complex pain symptoms are commonly prescribed regular strong opioids. A number of factors, both intrinsic and extrinsic can lead to opioid toxicity whilst this can often be managed conservatively; naloxone is sometimes required. Clinical staff who are not familiar with managing patients with palliative care needs may not be aware of the potential adverse effects if naloxone is used inappropriately. Here, we describe two cases where naloxone was used. Both of these patients had metastatic malignancies and were in-patients at an acute trust.AimTo review and reflect on two cases where naloxone was used in patients with terminal malignancies who were receiving regular strong opioids and exhibiting signs of opioid toxicity. To compare the practice seen in the two cases against the available guidance on naloxone use in palliative care patients.MethodsTwo palliative care patients were identified as receiving naloxone for opioid toxicity. Local and national guidance on the use of naloxone in palliative care was used to review the case management.ResultsOne case exhibits the appropriate use of naloxone, which led to a satisfactory outcome. In contrast the other case illustrates inappropriate use of naloxone, leading to severe rebound pain. This review demonstrates the importance of being able to identify when naloxone is necessary in palliative care patients without risking unnecessary reversal of analgesia.ConclusionsThese cases illustrate the importance of appropriate use of naloxone in palliative care patients receiving regular strong opioids. Inappropriate use of naloxone can result in severe rebound pain and opioid withdrawal. Raising awareness of local and national guidelines alongside continued education to clinical staff is vital to ensure the appropriate and safe use of naloxone in palliative care patients.

BackgroundWhen strong opioids are initiated for pain in patients receiving palliative care, practice varies. As a result, there is a risk that patients will receive either sub-therapeutic or potentially toxic doses of opioids. Choice of formulation is important from a patient concordance and cost perspective. In May 2012, the National Institute for Health and Clinical Excellence (NICE) published guidelines on initiating strong opioids for adults with advanced and progressive disease (‘Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults’). We reviewed the prescribing practice on hospital wards and assessed our compliance with the guidance and considered the barriers to compliance.AimTo assess compliance with NICE guidance when initiating strong opioids for pain in adults with a life-limiting illness.MethodsWe identified 20 patients with a life limiting illness and that were initiated on strong opioids for pain during their current hospital admission. We reviewed the medical notes and prescriptions measuring prescribing practice against 10 standards outlined by NICE. The patients were from 12 wards including medical and surgical wards. The data was collected over three months.ResultsOut of the 10 standards, compliance was 100% in three standards, 50% or above in six standards, and less than 50% in one standard.ConclusionsThe results highlighted areas for improvement. The main barrier appeared to be lack of awareness of the guidance. Due to the high turnover of medical staff, continued education is crucial. We have developed an e-learning module, highlighting the guidance, which will be part of the Trust’s mandatory training. The Trust is implementing electronic prescribing and endeavours to include alerts when opioids are prescribed to encourage compliance. With improved compliance, prescribing practice will be safer and the management of pain in our patients will be more effective.

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