Survey of 1057 patients receiving postoperative patient‐controlled epidural analgesia

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...

Audit of a ward-based patient-controlled epidural analgesia service in Ireland

“…Our 3-year audit of 928 patients Our audit shows a hypotension rate of 2%, excessive motor blockade incidence of 1.7% and a very low incidence of 0.7% of excessive sedation. Previous studies examining continuous epidural infusions of bupivacaine and fentanyl [10], bupivacaine and sufentanil [11], including Liu and Wigfull's [12] data, reported comparable incidences of side effects. These studies reported a range of maximal risk for hypotension of 3-8%, motor blockade of 4-12%, sedation of 9-24%, pruritus of 12-28% and respiratory depression of 0.2-1.9%.…”

The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine

“…Consequently, the frequency of intermittent RR counting is variable. In a study by Wigfull and Welchew [16], RR was recorded every 30 minutes for the first 2 postoperative hours, hourly for 10 hours, and every 4 hours thereafter. Furthermore, after PACU discharge, Rygnestad et al [20] recorded patient RR every 2 hours for the duration of the pain management period.…”

Comparison of the prophylactic anti‐emetic efficacy of ramosetron and ondansetron in patients at high‐risk for postoperative nausea and vomiting after total knee replacement

“…Epidural analgesia is used in these patients because it is has better analgesic efficacy and is associated with a better rehabilitation profile, shortened hospital length of stay, reduced opioid use, and fewer side-effects [12][13][14]. However, PCEA with opioids is associated with a high incidence of PONV [15][16][17][18]. Effective prophylaxis of PONV is invariably linked to the quality and the extent of pain relief in patients at high risk for PONV because patients may become reluctant to initiate a bolus dose or increase the basal rate of PCEA to obtain adequate pain relief.…”