Anaesthetics

To the Editor: We read with interest the article by Clarke et al1 and the accompanying editorial by Knoblanche,2 and are concerned that they may be interpreted as endorsing the use of the anaesthetic agent propofol in sedation techniques by personnel inadequately trained in anaesthetic techniques. Cases reported to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity confirm the risk of serious morbidity and mortality associated with these procedures. Our report for the triennium 1997–1999 will include two deaths at endoscopy where a non-specialist administered the sedation or anaesthetic. In both of these cases, propofol was used. The circumstances described by Clarke et al are exceptional. They combine a scrupulous adherence to the professional guidelines3 and a significant involvement by the administration of the endoscopy centre in the selection, education and on-going training of the general practitioner sedationists. They include incident reporting of adverse events and non-standard treatments as part of a quality assurance program. Although not specified, there is also, presumably, access to high-quality back-up. This level of attention to detail is by no means universal. We would like to endorse several observations made in the articles: For a procedure to be considered sedation, it is imperative that the drugs used are not intended to, and do not, cause loss of consciousness or the loss of protective reflexes or spontaneous ventilation; by definition, this would be anaesthesia. Proper selection and careful medical assessment of patients is very important, and training must enable the identification of patients at higher risk. People administering sedation must have knowledge of the pharmacology of the agents being administered and modifications necessary because of concurrent therapeutic regimens or disease states. They must also ensure adequate intraprocedure monitoring is provided, that they have experience in interpretation of abnormal indices, and that they can manage any complications arising from the procedure, with particular emphasis on airway management and cardiovascular resuscitation. There may be benefits with the use of propofol, but the guidelines, designed for patient safety, clearly state: "Intravenous anaesthetic agents such as propofol must only be used by an anaesthetist."3 Technological advances in non-invasive and minimally invasive procedures have led to an explosion in demand for sedation of increasing complexity in areas removed from the traditional operating room environment. Consequently, demand for sedation by non-anaesthetists is likely to grow. It is important that the standard of care and patient safety be maintained in all these circumstances. The concern is not whether the practitioner administering the sedation is a general practitioner or a specialist, but whether he or she has the training and skills necessary to function as an anaesthetist. The terms "general practitioner sedationist" and "non-anaesthetist" might give an impression of diminished risk, which is not supported by the experience of this committee.

Jon P Clarke · Anthony C Clarke FRCP, FRACP · Lybus C Hillman MD, FRACP

In reply: We thank Clarke and Mackay and Hughes for their interest and comments. We accept that a sample larger than the 28 000 endoscopies we reported1 would be required to establish the true incidence of death or other catastrophic complications of our sedation service. As the mortality rate is expected to be so low, it would take many years to achieve an adequate sample size. It is even difficult to determine the mortality from endoscopy in Australia, as quantifying all the endoscopies performed is problematic, and the Royal Australian and New Zealand College of Anaesthetists believes that not all deaths occurring from endoscopy are reported to anaesthetic mortality committees.2 It is essential that any sedation service is carefully planned, and that all doctors providing sedation receive adequate training and follow the protocols and guidelines of the endoscopy centre. However, we challenge the opinion that only anaesthetists should use propofol. We have not been able to find any clinical safety studies that demonstrate that only anaesthetists are able to use propofol safely. We believe the results of our study show that, when propofol is used in the manner described in the article, the rate of ventilatory and other complications is low (but clearly not zero). There is no reason to believe that the propofol component of the sedation regimen increased the rate of ventilatory problems. Indeed, it might, through its short duration of action, minimise such problems. To arbitrarily exclude the use of propofol by appropriately trained GP sedationists would deny many patients the manifest benefits of this drug. Importantly, our GPs have been shown capable of successfully managing the problems of airway obstruction and apnoea that were encountered — whatever the cause. We agree with Mackay and Hughes that the GP sedationists need to have the anaesthesia skills necessary to maintain patient ventilation, as well as an excellent understanding of all the drugs they use. Anaesthetists play a major role in improving safety standards in the provision of sedation for endoscopy through codifying the standards required,3 assisting the training of staff, and delivering sedation services to high-risk patients. But many patients can be successfully sedated without a specialist anaesthetist being present. We argue there is no evidence that these patients should receive a suboptimal regimen. Most specialist anaesthetists have a more valuable role to fill than providing sedation for straightforward endoscopies.

Jon P Clarke

Sedation is a difficult concept to define, as it includes a continuum from anxiolysis to anaesthesia. The point at which sedation becomes anaesthesia is generally accepted as occurring when the patient becomes unresponsive to verbal commands.1-3 Sedation is a depression of, rather than a loss of, consciousness, and may be combined with analgesia and amnesia to facilitate otherwise unpleasant and painful procedures. There is a large demand for sedation with endoscopy in Australia, although this is not universal practice.4 For instance, most colonoscopies in Germany are performed without sedation. There has been serious concern as to the safety of sedation for endoscopy following a prospective audit of gastroscopy and sedation in the United Kingdom in 1994. This audit found a 0.05% (1 in 2000) 30-day mortality.5 Although arguable, a third of these deaths were attributed to complications of sedation. There have been no comparable large-scale audits reported since, but anecdotal reports of mortality persist. The concern becomes more apparent when the comparison is made to the Australian anaesthesia-related death rate of less than 1 in 63 000.6 There are no reliable Australian data on deaths related to sedation. Consequently, professional documents have been formulated in the UK, the United States, Australia and New Zealand based on first principles and consensus, rather than on substantial evidence. In this issue of the Journal (page 158), the audit by Clarke et al on sedation for endoscopy7 primarily demonstrates how effective these professional guidelines have been. With the universal use of dedicated trained sedationists, supplemental oxygen, monitoring of pulse oximetry, blood pressure and respiration, patient selection and an accredited facility, there was no mortality reported in 28 472 endoscopies. The only caveat to this mortality rate is that postdischarge follow-up was limited to one telephone call. Notwithstanding this good news, most of the interest generated in this report will be because it describes general practitioner sedationists using propofol. The GPs in this audit had selection criteria, training and a maintenance-of-standards program that was entirely consistent with the current guidelines.1 Furthermore, complex or high-risk patients were transferred to hospitals (numbers unknown) or to the care of an anaesthetist (21.4%), which again is in keeping with the guidelines.1 The departure from the guidelines occurs with the use of propofol — the guidelines do not allow medical practitioners other than anaesthetists to use this agent. This applies to all intravenous anaesthetic agents (eg, methohexitane and ketamine), largely because of the rapidity with which sedation becomes anaesthesia. Sedation is achieved with propofol at about a third of the anaesthetic blood concentration or dose. Problems arise with propofol because of the individual variation of the anaesthetic concentration or dose, which in itself can vary by a factor of three, and the synergistic effects of narcotics and benzodiazepines, which may reduce the anaesthetic concentration or dose by as much as 50%. Propofol is further complicated by having its peak effect at about four minutes, making titration difficult. However, propofol is redeemed by the short redistribution half-life of 2–8 minutes and the failure of blood concentrations to achieve significant levels during its long elimination half-life (3–8 hours), owing to its extremely high clearance rate. Propofol is approved in Australia for conscious sedation. The real issue is what is the intent of the propofol administration. If the intent is loss of consciousness, then it is anaesthesia, and the drug should be administered by an anaesthetist in an institution equipped and licensed for anaesthesia. In New South Wales, institutions have been prosecuted after adverse patient outcomes for administering anaesthesia with such agents while not licensed. It is difficult in this audit, because of the failure to differentiate the propofol doses used by the GPs (78.6% of cases) and the anaesthetists (21.4% of cases), to determine the doses used by the GPs. However, the doses appear consistent with planned sedation. Nevertheless, GPs had a higher incidence of adverse events (not reaching statistical significance) and, significantly, a higher intervention rate for respiratory adverse events than the anaesthetists, even though complex patients and procedures were allocated to anaesthetists. In summary, the audit by Clarke et al supports the effectiveness of the current guidelines for sedation. The use of propofol in circumstances defined by current guidelines may be sufficiently safe when the agent is administered by such appropriately trained medical practitioners. Propofol and other intravenous anaesthetic agents should not otherwise be used by medical practitioners, except those who are trained in anaesthesia.

Greg E Knoblanche

Objective: To determine the incidence of adverse events related to an endoscopy sedation regimen that included propofol, delivered by general practitioner (GP) sedationists.Design: Audit of reports of sedation-related adverse events in patients undergoing endoscopy. A sample of 1000 patients' medical records was also reviewed to determine the drugs and dosages used and the proportion of sedations delivered by GPs.Setting and participants: All patients undergoing gastroscopy and/or colonoscopy from January 1996 to December 2000 in two private endoscopy centres in Canberra. Sedation was provided by GPs or a specialist anaesthetist, in most cases using a drug regimen that included propofol.Main outcome measures: Incidences of respiratory arrest, airway obstruction, hypoxia requiring intervention, hypotension, and death; number of interventions to correct these events, including extra airway management, bag-mask ventilation, intravenous fluid infusion, endotracheal intubation and the use of reversal agents, and admission to hospital.Results: 28 472 procedures were performed in the five years. There were 185 sedation-related adverse events (6.5/1000 procedures; 95% CI, 5.6–7.4): 107 for airway or ventilation problems (3.8/1000) and 77 hypotensive episodes (2.7/1000). Respiratory-related adverse events were more common in patients managed by GPs than anaesthetists, but this was not significant (P = 0.1). Interventions were recorded in 234 patients (8.2/1000; 95% CI, 7.2–9.3): 123 to maintain ventilation, and 111 intravenous infusions. GPs were more likely than anaesthetists to intervene to manage respiratory-related adverse events (P = 0.03). Four patients required transfer or admission to hospital. No patients required endotracheal intubation, and there were no deaths.Conclusions: The GP sedationists encountered a low incidence of adverse events, which they managed effectively. It appears that appropriately selected and trained GPs can safely use propofol for sedation during endoscopy.

Anthony C Clarke FRCP, FRACP · Louise Chiragakis MA · Lybus C Hillman MD, FRACP · Graham L Kaye FRACP

The specialty of anaesthesia has seen rapid development of its scientific and clinical basis and equally rapid changes in clinical practice, often driven by the quality and efficiency pressures of modern healthcare delivery. Prevention. Australia has been a world leader in establishing confidential audits of anaesthetic-related deaths, and, more recently, audits of critical incidents.1 Australian anaesthesia is among the safest in the world. The potential to further improve the quality and efficiency of patient care by increased anaesthetic involvement in pre- and postoperative care is increasingly recognised. Patient-controlled analgesia and prolonged epidural analgesia have become routinely available in most hospitals.2 The range of techniques and drugs used is increasing rapidly as we develop a better understanding of the physiology of pain. This has enabled many elderly or "sick" patients to have major surgery, and for other patients to have a much shorter postoperative hospital stay. The crossover from acute to chronic pain is being clinically recognised earlier, and early interventions to treat neuropathic postoperative pain are more common. Most elective surgery patients now arrive in hospital only shortly before their operation. This requires comprehensive preadmission patient assessment, intraprofessional communication and teamwork. Perioperative services, including preadmission clinics staffed by anaesthetists and specialised nurses, are becoming widespread. This has improved patient outcomes, reduced length of stay3 and led to enormous cost savings for the health system generally. Diagnosis. Continuous intraoperative monitoring of many patient variables has become routine and has been shown to improve patient outcomes. The technological development of anaesthetic monitors and "machines" is continuing. Continuous monitoring of the heart by transoesophageal echocardiography is becoming widespread in cardiac surgery. As a low-morbidity procedure providing unparalleled diagnostic information, it promises to become widespread in "sick" patients having non-cardiac surgery. There is some controversy about the use of monitoring aimed at identifying intraoperative awareness. The phenomenon of awareness under general anaesthesia is well recognised, although patients' fear of this may be disproportionate to its actual incidence. New devices (BIS monitoring) that use processed electroencephalographic data to (possibly) detect awareness in individual patients are being evaluated.4 In the United States, media discussion of the problem of awareness, and the possible "prevention" of this by monitoring, has verged on product promotion. Interventions. The widespread adoption of the laryngeal mask has revolutionised airway management. Based on this experience, the appropriate use of the laryngeal mask and endotracheal intubation outside the operating theatre needs to be reviewed. A number of new (and old) drugs are changing anaesthetic practice. Sevoflurane, an inhalational anaesthetic with short action and acceptable smell, has largely displaced halothane, particularly in children. A newer inhalational agent, desflurane, which has even shorter recovery but an unpleasant smell, will probably become widely used for relaxant anaesthesia. Remifentanil, an opioid with a remarkably short duration of action, also promises to change intraoperative anaesthesia, in particular by enabling extremely rapid recovery from deep general anaesthesia. The "setrons" (serotonin 5-HT3 receptor antagonists) have improved the management of perioperative nausea and vomiting. There is renewed interest in ketamine (an NMDA [N-methyl-d-aspartate] antagonist), particularly for pain prevention and management. New analgesics include injectable non-steroidal anti-inflammatory drugs (eg, ketorolac) and tramadol, an opioid which possesses novel non-opiate properties. Combined general and epidural anaesthesia is becoming widespread for major surgery, particularly as the epidural can readily be used for prolonged postoperative analgesia. Cardiac anaesthesia is changing from the traditional approach based on postoperative overnight ventilation to a variety of "fast-track" techniques, including the use of high thoracic epidurals and short-acting drugs. Recent studies identifying the benefits of perioperative β-blockade to prevent myocardial ischaemia for as long as six months postoperatively are increasing the use of this intervention. The adverse effects of inadvertent mild hypothermia are now better recognised, and techniques such as warming of intraoperative fluids and forced-air patient warming are becoming standard. Anaesthetists are now widely involved in intensive/critical care, pain medicine, and preoperative preparation. Complex imaging or therapeutic procedures (such as magnetic resonance imaging, brachytherapy, and endoscopy) mean that anaesthetists are increasingly required outside the operating theatre. There is also a broad need for hospital-based doctors who have procedural skills together with knowledge of acute medicine and perioperative care.5 These demands and pressures mean that the role of anaesthetists (or "hospitalists") may change considerably in the next decade.

Ross K Kerridge

Although evidence-based intensive care medicine is gradually developing, progress in clinical trials has been hampered by the small number of patients, broad range of diagnostic categories, and lack of diagnostic criteria and illness severity measures. Prevention. Preventing critical illness has become a focus of intensive care practice. As cardiac or respiratory arrest in hospital wards carries substantial mortality, it is essential that deterioration of a patient's condition be recognised as early as possible. In a detailed observational study conducted in three Australian acute-care hospitals,1 at least 50% of patients who had an arrest were found to have had recognisable deterioration prior to the arrest. Ideally, it should be mandatory for nursing staff to call an emergency team if, during routine observations, they notice deterioration in a patient. Where such a system exists, the number of ward-based in-hospital cardiac arrests has fallen by 80%, with a 32% fall in all-cause mortality. Diagnosis. Standardising and defining the illnesses encountered in the intensive care unit (ICU) has allowed the creation of "illness severity scores", which combine information on pre-existing illness, diagnosis and physiological derangement to predict outcome. Actual outcome is compared with predicted outcome to produce a "standardised mortality rate". Recently, widespread application of these methods has improved reliability and comparability of clinical studies. Intervention. Systematic study of standard ICU therapies is relatively new. Debate over simple questions, such as what tidal volume should be used for ventilator settings, has raged for many years. The Australasian method uses a tidal volume of 7 mL/kg (to prevent barotrauma), while the US method uses a tidal volume of 10–15 mL/kg (to prevent atelectesis). In the Acute Respiratory Distress Syndrome (ARDS) study,2 in which 861 ventilated patients with ARDS were randomly allocated to receive low-volume ventilation or standard-volume ventilation, mortality was lower in the low-volume group (31% v 39.8%; P = 0.0007). A study by the Australian and New Zealand Intensive Care Society Clinical Trials Group (CTG) of the role of dopamine in preventing acute renal failure is another striking example of a known "proven" therapy finally meeting scientific rigour and failing.3 Red-cell transfusion has been a cornerstone of critical-care practice for many years. Routine transfusions were given to maintain the haemoglobin concentration at 100 g/L, with the aim of maximising flow and oxygen-carrying capacity. In 1999, the Canadian Critical Care Trials Group reported on the first randomised controlled trial of blood transfusion in ICU,4 which compared a conservative blood transfusion strategy (Hb 70–90 g/L) with a liberal transfusion strategy (Hb 90–110 g/L). Fewer patients in the conservative group died than in the liberal group (18.7% v 23.3%; P = 0.11). The rate of red blood cell transfusion was 2.6 units per patient in the conservative group versus 5.6 units per patient in the liberal group. The potential for saving a valuable resource, blood, without worsening outcome is large. Reducing the amount of blood transfused would also lower the risk of transfusion-related infections. Are the results of trials changing practice? To evaluate the Australian response to the transfusion study,4 the CTG surveyed transfusion practice in Australia in 2000. The national results of the survey are not yet available, but in our own unit there was compliance with the conservative transfusion protocol in all cases except one, in which transfusion was demanded by the surgical consultant preoperatively. After a Cochrane study showed that the use of intravenous albumin for resuscitation was associated with a higher death rate, the use of albumin in the United Kingdom and Europe fell by 20%. In Australia, the CTG has begun a trial to allocate 7000 patients randomly to treatment with either colloid (albumin) or crystalloid fluids for resuscitation. There is a need for definitive studies rather than meta-analysis, especially in the diverse ICU patient population. The elucidation of the inflammatory cascade and pro-coagulant pathways in septic shock (a leading cause of death in ICU) has led to new therapies using naturally occurring anti-inflammatory and anticoagulant proteins synthesised in vitro. Although antiendotoxin antibody studies have been disappointing, activated protein C, which has anticoagulant and anti-inflammatory properties, appears promising. Protein C is activated by thrombin coupled to thrombomodulin. Thrombomodulin is down-regulated in sepsis by inflammatory cytokines. A low plasma level of activated protein C is a marker of sepsis and is associated with death from sepsis. In a study of 1690 patients performed in 164 centres in 11 countries, infused activated protein C was shown to decrease the mortality due to sepsis.5 Furthermore, activated protein C is showing promise for treatment of meningococcal septicaemia. Basic research into understanding the inflammatory system and its inter-relation with the coagulation pathway in sepsis may pay clinical dividends in treating septic shock. The past decade has seen ICU evolve from an experience-based to an increasingly scientifically based practice. Continued advances should see further improvements in patient survival rates.

Anthony J Bell MD FRACP · Andrew J Turner FRACP

Year of the volunteer Malaria, malnutrition and MSF This is a personal account of my brief time in Burundi as a volunteer doctor with Mèdecins Sans Frontières (MSF) at the beginning of 2001. Burundi is a small nation in central Africa (bounded by the Democratic Republic of Congo, Rwanda and Tanzania) which has suffered from problems between the Hutu and Tutsi "ethnic groups", similar to those for which Rwanda is better known. Unlike Rwanda, the war between government troops and rebel forces continues in Burundi. MSF has been in Burundi since 1992, providing basic healthcare, nutrition programs, surgical services and epidemiological intervention. In late 2000, a malaria epidemic began in Burundi's highland regions where transmission is normally low, and thus the population largely not immune. Malnutrition rates also increased and MSF rapidly expanded its usual program in an attempt to control these new health problems. David W Evans MJA 2001; 175: 575-576 "Asama." Once again, the first thing I have learnt to say in the local language is "open your mouth". "Asama." Looking along the ward, where the sickest children in the feeding centre are admitted, I can make out enough tiny figures among the overflow of beds and mosquito nets, and mothers with their pots and pans and other children, to know that we will be demanding a lot more open mouths before the morning is over. MSF's therapeutic feeding centre opened a few days before my arrival. Local mud bricks, wood and plastic sheeting, combined with MSF water bladders, piping and generators, have made a 600-bed centre out of this block, next to a regroupment camp from the mid-1990s, when the population was being systematically displaced to "flush out" rebels. It will end up housing over 1000 people when the mothers and siblings, and occasionally fathers, of the malnourished children are included. We start the day's work with the night's admissions. Despite struggling to read the French scribble of the MSF doctor who took the call, it seems that the condition of many of the children has improved from just a few doses of artemether (an antimalarial) and some rehydration. Some, of course, have not responded and it is difficult to reassure their mothers, looking desperately at their children unconscious with cerebral malaria and then hopefully at the Burundian nurse and me, that these children will recover. I explain the basics of our malaria treatment in bad French, which is translated into Kirundi, and the mother smiles. With absolutely no idea of what she ended up hearing, we move on. "Asama." There are about 60 children in this so-called "special care" ward. We need to discharge about 20 to the normal wards each day just to keep the numbers manageable. Every day, admissions seem to increase. Mothers are walking for hours with their marasmic, febrile children to reach the feeding centre here, and every afternoon our minibuses arrive filled with children who present to the MSF supplementary feeding centres throughout the province, but who are too malnourished to be managed with supplementary feeding alone. We know that some children die on the way and, of course, despite all the efforts of the Burundian nurses and MSF workers, some also die after admission. It is hard to consider the beauty of this place alongside the death and illness brought by malaria and war. Taking a break from the ward round, I stand outside with the Swedish nurse whose job it is to manage all this. We stare beyond the adjacent construction site — to be another feeding centre by the end of the week — and remark on the beauty of the clouds as they drift up the mountains to unveil the miniature figures marching through the rice fields below. Then she points out that the stagnant water of these rice fields is probably the source of all this malaria and the mountains here blur with the mountains we see from the United Nations plane on the way from the capital, Bujumbura — the mountains that are almost impossible to cross because of rebel attacks, and where, a week before my arrival in Burundi, rebels stopped a bus from Rwanda and killed everyone on board. This made the international news because an English volunteer teacher was on the bus. I have no idea how many other buses are stopped and their occupants massacred without the incident being reported in the international media. Back on the round, we have a glimpse of what medicine must have been like 150 years ago back in Sydney. Happily, the patient is getting better. So is her mother, who gave birth overnight in her sick child's bed. The other mothers helped her through the early labour, and then the night nurse apparently just parked the medication trolley and popped the gloves on for the delivery. We do our review of malaria treatment and nutrition status for the older child, a baby check on her new brother, a quick obstetrics review of the mother's postdelivery condition, and move on. At lunch we hear that another woman gave birth that morning in one of the transfer minibuses. The visiting epidemiologist from MSF headquarters in Europe is left with the problem of incorporating births into the weekly activity report of MSF's nutritional service. Besides the addition of chips to the usual menu of fried potatoes and boiled potatoes, there is good news at lunch. A 12-year-old girl, who was brought to the local hospital two weeks ago and urgently transferred to the closest MSF surgical service, was back and making a good recovery. She was severely beaten by bandits who stole the goats she and two other children were herding. The other two children, both younger than her, were stabbed to death in the attack. We choose to focus on her recovery. The two other Australians and I can only follow the conversation for so long before the French starts to sound like Kirundi and we sneak off for a quiet anglophone coffee before heading back to work. The afternoon brings seemingly endless queues of children, all apparently identified as having fever since the end of the morning rounds. And so begins the almost impossible challenge of distinguishing malaria from typhus from typhoid from the remaining diseases in the tropical medicine textbook, with only a stethoscope. Then the minibuses begin to arrive. We operate a simple triage system: any child who is unconscious or fitting is seen first. Fearing that we may soon have to resuscitate the Burundian nurse, who has been on admissions all day, all the expatriate medical staff and as many Burundian nurses as can be spared from the wards finish the admissions by torchlight while our logistician gets the generator working for overnight. Many of the children are febrile at admission but almost all the mothers report treatment already with chloroquine. It has been fairly clear since the beginning of the epidemic that resistance to chloroquine is high. No doubt the treatment failure rate contributes to the extraordinary patient overflow in the province's health centres, where triage has become an exercise in crowd control and diagnosing malaria has become guesswork in preference to ordering thousands of thick films made with out-of-date reagents. As we finish the admissions for the day, we hope that the results of MSF's malaria resistance study will soon be available to promote a new national policy with a first-line treatment that actually works. After a dinner of potatoes, most of us head off to the local bar for warm beer and some social time with the Burundian staff. The publican by night is a nutritional assistant by day, and so supplies almost all of the town with nutrients of one form or another. A Burundian version of Tom Waits is singing for beer, but the more beers he drinks the more he seems to sing. I order a soft drink and turn up the two-way radio — the MSF equivalent of the on-call page. Remembering my last call, when the first note reporting a pregnant woman of 38 weeks' gestation with eclampsia and a transverse lie was a joke from one of the other doctors but the 3:00 am postpartum haemorrhage following a cervical tear was not, I lean towards our expat midwife and quietly ask if she objects to being woken up overnight. Reassured by her response, I pass by the hospital before bed. Despite the flicker of the kerosene lamps, the conjunctivae of the woman who had a caesarean that morning seem pink enough and her urine output is good. No-one is in labour. The Burundian night nurse and I decide to treat a newly admitted child for cerebral malaria, despite the mother's insistence that her son was bewitched. At least we can treat malaria. The greatest challenge to sleeping is not so much the bursts of static from the on-call handset, but the MSF pig rooting around outside the bungalow. Plastic sheeting and bamboo muffles only so much sound. I know the pig is roaming the garden at night because the Europeans want him fat for eating as soon as the Australians, apparently the only conscientious objectors to eating one's pets, leave. I don't think about it. You can only focus on one day at a time here. I know that tomorrow we will see the same wizened, marasmic and puffy kwashiorkor faces, as well as a few new children of both expressions, febrile from malaria, but hopefully no children will die overnight. And I hope we can discharge more than we admit. All of us working in these hills at the moment are simply aiming to pass the peak of this epidemic. We'll know we're winning when we start demanding "asama" less often each morning. Authors' details Mèdecins Sans Frontières, Sydney, NSW. David W Evans, BScMed(Hons), MB BS(Hons), Medical Coordinator, MSF Mozambique. Reprints will not be available from the author. Correspondence: Dr D Evans, C/- Mèdecins Sans Frontières, Suite C, Level 1, 263 Broadway, Glebe, NSW 2037 . officeATsydney.msf.org Make a comment Mother and child at MSF therapeutic feeding centre, Burundi. Photograph by Joanna Ladomirska, courtesy of Médecins Sans Frontières, Sydney Population, 6.6 million Total fertility rate, 6.2 babies/woman Life expectancy at birth, 46 years Death rate, 16.36/1000 population Back to text

David W Evans

Year of the volunteer Arrival and departure As the small jet circled the dirt landing strip, I felt apprehensive. The briefing in Nairobi had been very detailed, but hadn't really allayed my fears. I struggled with my emotions and too many unanswerable questions. Why was I going to Somalia in the middle of a civil war, a war about which I knew so very little? What were the risks and what did I hope to achieve? Haydn Perndt MJA 2001; 175: 577-578 The plane touched down and some detail now appeared out of the desert haze. A number of four-wheel-drive vehicles were gathered around the perimeter of the airstrip. There was only one small ramshackle building standing intact. Armed men slouched in torpid menace. The identifying flag of the International Committee of the Red Cross was reassuring. Welcome to Mogadishu. The drive to the hospital of Keysaney, in the north of the divided city, wove through an urban landscape of chaos and destruction. Ten years of civil war had left the country in an anarchic state. Little effective social structure or function remained. As a Red Cross volunteer, I was a member of a flying surgical team responsible for emergency surgical care for victims of the conflict. It all seemed a long way from the island of Espiritu Santo where I'd had my first volunteer experience some years before . . . . . . That had been a very different arrival. The plane had swooped low over an azure lagoon, the island an explosion of vivid green. Coconut trees fringed the single runway. Smiling Melanesian faces welcomed me as I stepped onto the tarmac. I was to work on this dot in the middle of the Pacific for two years, as a medical officer for a 110-bed hospital. The job description read, "A doctor with obstetric and paediatric skills is required to give anaesthesia at the Northern District Hospital. Tropical medicine would also be useful". Having recently completed my specialty training, I was at least happy about the anaesthesia, but knew the other areas would need quite a lot of resuscitation! It proved to be one of the most rewarding periods in my career, the first of many volunteer experiences. I was extremely fortunate to work with a capable and easy-going expatriate surgeon and a shy, but very competent, Ni-Vanuatu anaesthetist counterpart. The theatre sessions were always great fun. I spent my time at the Northern District Hospital doing outpatient clinics, looking after the medical and tuberculosis wards, as well as giving anaesthesia for a fascinating variety of general surgery and emergency obstetrics. "Walking" clinics into "Middle Bush" with a Catholic nun added an extra dimension to my understanding of ambulatory medicine. Consultations took place under the eaves at the end of a thatched "long house" with nearly the whole village looking on. I was reasonably fluent in Bislama (the lingua franca of the 70-island archipelago), and this helped with the medical work and social activities. There was always a feast at the end of a day's clinic. The mountains of "lap-lap" (grated taro, banana or cassava with coconut cream wrapped in banana leaves and cooked slowly in a pit in the ground) were almost as daunting as the numbers of patients. The "Middle Bush" people were surprisingly healthy compared with the town dwellers, whose Western life-style was encouraging the development of the Western diseases of diabetes and hypertension. A rudderless night in a storm off the south coast in the rural health boat "cured" me of any nautical medical inclinations. It was a pity, as this was the only way to see the west coast of Santo. Some months later, I did, however, explore some of this area on foot during a five-day leprosy survey. The two years in Espiritu Santo flashed by. I was very sad when the time came to leave. There were so many good friends and I'd had so many wonderful experiences. But why had I gone to Espiritu Santo in the first place? What had taken me from the security of a "staff" position in a paediatric teaching hospital in Canada to a tropical island on the other side of the world? I still wonder at the serendipity of that initial volunteer opportunity. It was an experience which was to change my life and redirect my professional energies irrevocably. The years have certainly altered my expectations of the challenges and rewards of working in developing countries. I have had the opportunity to visit, live and work in quite a few different countries — over 20 at last count. Mostly, I taught anaesthesia, to medical assistants, nurses, doctors and medical students — in fact, to anyone who was interested. I must confess that I have learned far more than I taught . . . For nearly a decade I was involved in the annual Pacific Anaesthetic Refresher Courses, which took place at the Colonial War Memorial Hospital in Suva, Fiji. The driving force for these courses was a small group of ex-Pacific volunteers who, like me, had been bitten by the "Pacific virus" and wanted to continue helping their Pacific colleagues. Over the years, anaesthetists from almost every Pacific Island nation in Melanesia, Micronesia and Polynesia have attended these courses. The Australian Society of Anaesthetists sponsored and encouraged this activity, with a number of ASA presidents even going to Suva to teach. The courses were so successful that they attracted Australian Government financial support through AusAID (the Australian Agency for International Development) grants. The World Federation of Societies of Anaesthesiologists also helped. The Pacific Society of Anaesthetists has now taken over the running of this annual Continuing Medical Education program, with Australian anaesthetists still volunteering as lecturers and locums. Opportunities for further experience increased dramatically during my eight years on the Education Committee of the World Federation of Societies of Anaesthesiologists. I now became involved in international development work with an energetic and financially well-resourced committee. At times these activities seemed to engulf the other, more sensible parts of my life. What kept me doing them? Opportunities and challenging positions for medical volunteers abound. Websites and professional journals carry tempting advertisements. In general, activities fall broadly into either "service" or "development" roles. The Australian Rotary Interplast (Plastic and Reconstructive) Surgery tours to the Pacific started as a charitable venture. This has become a two-million-dollar, Australian Government-supported aid program. Known as the Pacific Island Project, it now encompasses many specialties, including otolaryngology, orthopaedics, ophthalmology and cardiology, and depends entirely on the time of the volunteer doctors involved. A number of professional colleges and societies have been very proactive in the development area. The Australian Society of Anaesthetists established the first postgraduate training program in anaesthesia for the south-west Pacific in Suva. This led the way for postgraduate training programs in Fiji in four other medical specialties. The Royal Australian College of Surgeons now oversees this AusAID-funded project. The Royal Australasian College of Physicians has been involved for many years in the Master of Medicine programs in Papua New Guinea. Professional organisations have become important partners in the realisation of the Australian Government's regional development objectives. As the small aircraft left Mogadishu for the last time, I reflected on my three months in Somalia. The Flying Surgical Team had worked all over the country, from Berbera in the north, to Merca in the south, as well as behind the rebel lines of an unknown civil war in neighbouring Djibouti. We had operated in derelict hospitals, an old prison and in a desert dispensary. The team had shared some intense experiences. I was privileged to have been part of an international effort to bring peace to Somalia. But there remained so much more to do. Authors' details Hobart, TAS. Haydn Perndt, FFARCS, FANZCA, Anaesthetist, Royal Hobart Hospital. Reprints will not be available from the author. Correspondence: Dr H Perndt, GPO Box 1060-L, Hobart, TAS 7001. Make a comment Population, 9.7 million Total fertility rate, 7.1 babies/woman Life expectancy at birth, 47 years Death rate, 18.35/1000 population Back to text "Middle bush" clinic and Sister Beatrice. Back to text "Ples Blong Katen man" — operating theatre, Santo. Back to text

Haydn Perndt

Editorial Chronic pain in children Despite the effects on children and their families, children's pain is often under-recognised MJA 2001; 175: 453-454 The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".1 Implicit in this definition is that pain is a subjective experience and is modulated not only by biological factors, but also by previously painful experiences, the meaning and context of the pain, fear, anxiety, depression, and a range of other factors. Chronic pain is defined as continuous or recurrent pain that persists past the normal time of healing, most commonly about three months' duration.1 If chronic pain refers simply to any pain with this predetermined duration, then all persistent pain of childhood, such as that related to chronic disease (eg, cancer, arthritis, sickle-cell disease), neuropathic pain (eg, complex regional pain syndrome, phantom limb pain) and recurrent pain syndromes (eg, migraine, recurrent abdominal pain), could be classified as causes of chronic pain in children. Little is known about the epidemiology of chronic pain in children. A recent random survey of more than 6000 children in the Netherlands aged 0-18 years indicated an overall prevalence of 25%.2 The prevalence of chronic pain increased with age, and was significantly higher for girls, particularly girls 12-14 years old. The most common types of pain were limb, abdominal pain or headache. Half of the respondents who had experienced chronic pain reported multiple sites of pain, and a third experienced pain as frequent and severe.2 Multiple sites of pain and severe pain were reported more often by girls. The combination of headache and abdominal pain was reported most frequently. These findings indicate that chronic pain is common in children and adolescents. In this issue of the Journal, Chalkiadis presents the first report on chronic pain in children in Australia.3 It is a prospective, descriptive study of the demographic and clinical characteristics of 207 children presenting to the Chronic Pain Clinic at the Royal Children's Hospital, Melbourne, over a two-year period. The study reveals that chronic pain had disturbing consequences for many children. The incidence of school absenteeism, sleep disruption and inability to play sport was high. Implied in these data is a significant psychological burden for the children and the families caring for them. Despite a relatively high prevalence of chronic pain in paediatrics and its significant physical, psychological, social and economic impact on children and their families, it is often under-recognised by clinicians. The reasons for this are multiple and include children's dependency on caregivers to be their advocate. Children with chronic pain can often be met with a dismissive attitude from their caregivers, especially if no organic cause of their pain is found. Furthermore, the advancement in our understanding of the pharmacology of analgesics in children is a relatively recent development.4 The extent to which children may suffer from inadequately managed chronic pain is not known. Recently, in the United States, a major study of children in the terminal phase of cancer painted a chilling picture of suffering, including a high incidence of problems associated with the treatment of pain.5 According to the parents surveyed, 89% of the children suffered "a lot" or "a great deal" from at least one symptom in their last month of life, most commonly pain, fatigue, or dyspnoea. Of the children who were treated for specific symptoms, treatment was successful in 27% of those with pain and 16% of those with dyspnoea.5 Given the many physical and psychological variables in children experiencing chronic pain and the different modalities of treatment now available, the assessment of a child with chronic pain needs to be comprehensive. The team approach involves: an assessment of the physical, psychological and environmental parameters; developing pain management strategies, including pharmacological and non-pharmacological approaches; and individual and family therapy as required. The long term outcomes of these strategies are not known, although Chalkiadis's report reveals at least short term benefit. There has been a long-standing recognition of the need for a comprehensive assessment of chronic pain in adults. In Australia, this has led to multidisciplinary pain centres in many of the major teaching hospitals. In addition, five medical specialist bodies recently came together to form a single physician training program and examination process for the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. In contrast, it is only in recent years that a team approach to chronic pain in children has evolved in Australia and other countries. It is disturbing to read in Chalkiadis's report that only three paediatric centres in Australia and New Zealand have chronic pain management services which meet the minimum requirements for multidisciplinary staffing. Given the prevalence of chronic pain in children and the potentially serious physical and psychological consequences, a review of these services for children is required. On the basis of US data,5 strategies for the incorporation of pain management and palliative care principles into the care of children with life-threatening and life-limiting illness are a high priority. John J Collins Head, Pain and Palliative Care Service Lynette J Lane Coordinator, Chronic Pain Clinic, Pain and Palliative Care Service Susan Thompson Child and Adolescent Psychiatrist, Chronic Pain Clinic The Children's Hospital at Westmead, Sydney, NSW Merskey H, Bogduk N, editors. Classification of chronic pain: description of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press, 1994. Perquin CW, Hazebroek-Kampschreur AAJM, Hunfeld JAM, et al. Pain in children and adolescents: a common experience. Pain 2000; 87: 51-58. Chalkiadis GA. Management of chronic pain in children. Med J Aust 2001; 175: 476-479. McGrath PJ, Unruh AM, Branson SM. Chronic nonmalignant pain with disability. In: Tyler DC, Krane EJ, editors. Advances in Pain Research and Therapy. Volume 15. New York: Raven Press, 1988. Wolfe J, Grier HE, Klar N, et al. Symptoms and suffering at the end of life in children with cancer. N Engl J Med 2000; 342: 326-333. Make a comment

John J Collins · Lynette J Lane · Susan Thompson

Healthcare Management of chronic pain in children George A Chalkiadis MJA 2001; 175: 476-479 For editorial comment, see Collins et al. Abstract - Methods - Results - Discussion - Reference - Authors' details - - - More articles on Paediatrics Abstract Objectives: To describe the demography, clinical characteristics, treatment, functional limitations and outcomes of patients referred to a paediatric multidisciplinary pain clinic. Design: Prospective data collection, descriptive study. Patients and setting: Tertiary referral centre pain clinic (Royal Children's Hospital, Melbourne) over two years (March 1998 - March 2000). Main outcome measures: Pain profile; functional disability (school absenteeism, sleep disturbance and inability to perform sport); treatments received; outcome. Results: 207 patients (mean age, 13.1 years; 73% females; 29% rural residents) were referred in the two years. Concomitant medical conditions were present in 106/207 (51%) patients, the commonest being cerebral palsy or spasticity (22 patients) and malignancy (18). Complex regional pain syndrome was diagnosed in 44 patients. Functional disability due to pain included school absenteeism (95% of school attenders), sleep disruption (71% of all patients) and inability to perform sport (90% of those able to participate in sport previously). Of the 105 patients who missed five or more days of school because of pain, 93 attended school regularly after treatment. Sleep disturbance improved in 129/146 (88%) patients, and 129/147 (88%) resumed sporting activity after multidisciplinary intervention. Outcome was classified as good in 134 patients (65%), moderate in 32 (15%) and poor in 16 (8%). Conclusions: Chronic pain in children and adolescents often results in considerable functional disability. Functional improvement can be achieved using a multidisciplinary approach to pain management in children. No data are available on the prevalence or incidence of paediatric chronic pain in Australia, and only limited data exist on the functional limitation that chronic and recurrent pain has on affected children, their parents and siblings.1 Specialised integrated pain management clinics that offer cognitive behavioural therapy programs are successful in the management of adults with chronic pain,2 but few programs exist for children and adolescents in Australia. As no Australian epidemiological or demographic data exist for children and adolescents with chronic pain, I performed a prospective, descriptive study to investigate the demography, clinical characteristics, treatment, functional limitations and outcomes of patients referred to a paediatric multidisciplinary pain clinic. Methods Patient population The Royal Children's Hospital is a tertiary paediatric referral centre servicing Victoria. A multidisciplinary clinic for children and adolescents with chronic pain, the Children's Pain Management Clinic, was established in March 1998. From March 1998 to March 2000, patients aged 0-18 years of age were prospectively and consecutively included in the analysis. The Statistical Local Areas defined by the Australian Bureau of Statistics3 were used to classify residential location as rural or metropolitan Victoria. Interviewers All patients were assessed by one of three paediatric anaesthetists. The initial interview involved taking a full medical and social history and physical examination of the patient in the presence of one or both parents. One or more allied health professionals (physiotherapist, occupational therapist or clinical psychologist) also assessed the children. Interview The interview followed a structured format. Responses to questions were obtained from both child and parent(s), unless the child was cognitively impaired, in which case the parent(s) or carer provided information. The questions related to diagnostic information (nature, site and intensity of the pain), functional disability (time off school, inability to partake in sporting activities) and sleep dysfunction. Definitions Chronic pain was defined as "pain persisting beyond the time of healing or pain which is persistent or near constant for three months or longer".4 Complex regional pain syndrome (CRPS) Types I and II were diagnosed according to previously published criteria.5 CRPS is a condition in which pain and disability are sustained, out of proportion to an initiating noxious event, by mechanisms that are still incompletely understood. Diagnosis is based on clinical findings, including allodynia (non-painful stimulus eliciting pain) or hyperalgesia (exaggerated sensitivity to pain) beyond the territory of a single peripheral nerve, oedema, skin blood flow abnormality (colour and/or temperature change) or abnormal sudomotor (sweating) activity. CRPS Type I is distinguished from Type II in that Type II follows nerve injury. Pain intensity was assessed by a pain assessment tool appropriate for the patient's age and cognition: Eland pain diagram; visual analogue scale; verbal numerical rating (1-10) scale; Wong-Baker faces; and parental or carer report in the case of non-verbal patients, toddlers and those with cognitive impairment. Outcomes were recorded as: Good: Marked reduction in the intensity of pain (no or minimal pain) and marked functional improvement (return to school and sport where applicable, and resumption of normal sleep pattern); Moderate: Partial reduction in pain intensity and/or some functional improvement (return to school or sport where applicable or resumption of normal sleep pattern); or Poor: No improvement in pain intensity or functional activity. Outcome was classified as unknown if there was no follow-up. The frequency and duration of follow-up were as clinically indicated. Results Over the two-year study period, 207 patients aged 1-18 years were referred to the Children's Pain Management Clinic (Box 1). Most patients (57%) were referred by orthopaedic surgeons. Medical conditions and associated disability Concomitant medical conditions (Box 2) were present in 106 (51%) patients. The disease process, its treatment, complications of the disease or side effects of the treatment accounted for the pain experienced by 93 of these 106 patients. A clear organic precipitant to the pain was identified in 39 of the 101 patients with no pre-existing medical condition. The cause of pain in these patients was neuropathic (nerve injury, nerve entrapment or neuroma) in 20 patients, soft tissue injury in 14, bone- or joint-related in four, and renal colic in one. In 62 of these 101 patients, no clear aetiology was found. The abdomen (10 patients) was the most common single site of presenting pain in this group, followed by headache or facial pain (9), multiple sites of pain (9), and pain in the foot (9), hand or forearm (8), knee (7), leg (5), back (2), shoulder (1), chest (1) and neck (1). CRPS was diagnosed in 44 of the 207 patients (Type I, 40 patients; Type II, 4 patients). Females (33 patients) and the lower limb (33 patients) were predominantly affected. Mean age was 13.7 (range, 9-17) years. CRPS was precipitated by minor trauma in 18 patients, and lower-limb surgery in six patients. No precipitant was identified in nine patients. Overall, 105 patients (95% of school attenders) missed at least five days of school because of pain (independent of medical appointments) (Box 3). There were 147 (71%) patients with impaired ability to participate in sport because of their pain. Of the remaining 60 patients, 43 were unable to participate in sport because of their concomitant condition, and 17 had no such inability on presentation. Overall, 146 patients (71%) suffered daily or almost daily sleep disruption attributable to pain. Of this group, 140 (96%) patients woke up three times or less. Parents of children with cerebral palsy, cognitive impairment or intellectual disability reported sleep disruption in 16 of 22 patients. Waking each night in these patients was more frequent and difficult to manage. Interventions Medications prescribed are listed in Box 4, and interventions are listed in Box 5. Individuals may have received one or more of these simultaneously or consecutively. No medication was prescribed in 75 of 207 (36%) patients; however, this group may have received any one or more of the interventions listed. The median duration of follow-up was four months (range, 2 weeks to 16 months). Patients diagnosed with CRPS were treated as inpatients (26 patients) or outpatients (18 patients) depending on the severity of their condition. Inpatients underwent a more intense and structured rehabilitation program tailored to their individual requirements. This involved cognitive behavioural therapy, physiotherapy (with graded return to physical activity) and re-integration into school and social activities. The median length of hospital stay was five days. Outcomes Outcome was good in 134 (65%) patients, moderate in 32 (15%), poor in 16 (8%) and unknown in 25 (12%). Box 6 shows the outcomes for patients diagnosed with CRPS. Of the 29 patients who had missed more than 40 days of school because of pain, 23 began attending school regularly once treatment for their pain syndrome commenced. Ten successfully underwent a graded return-to-school program coordinated in conjunction with the school, the Royal Children's Hospital Education Institute and the Children's Pain Management Clinic. Of the 76 patients who had missed between five and 40 days of school and who completed follow-up, 70 attended school regularly after intervention. Of the 147 patients who had impaired ability to participate in sport because of pain, 129 (88%) regained the ability after treatment. Sleep disturbance was successfully managed in 129 of 146 patients (88%). Most (122 patients or their parents) reported uninterrupted sleep as a result of either analgesic intervention or successful use of relaxation techniques. The remaining seven patients (or their parents) reported marked improvement in the frequency of waking and less troublesome return to sleep when they woke during the night. Twelve (6%) of the 207 patients died of their underlying terminal condition or its complications. There were three complications related to therapy for pain. Two were epidural-related in patients with cerebral palsy and CRPS: both developed back pain and fever. One had an epidural infection and the other paraspinous myositis with possible osteomyelitis. One patient developed paraesthesiae after lumbar sympathetic nerve block. All three patients recovered with no long-term sequelae. Discussion In my study, chronic pain in children and adolescents was associated with considerable functional limitation, most commonly school absenteeism, sleep disturbance and inability to perform sporting activities. The duration of school absenteeism was significant and could be expected to affect school performance, although this was not specifically recorded. Previous studies from other countries have reported on the incidence of functional disability in relation to specific painful sites or conditions.1 In our patients, chronic pain, irrespective of aetiology or site, commonly resulted in significant functional disability. More females than males were referred in all age brackets. CRPS, headache, fibromyalgia, recurrent abdominal pain and somatoform pain all occur more frequently in females than in males aged less than 18 years.6 More than a third of all patients referred were aged 12 years or less. Recurrent abdominal pain is commonly reported in this age group.7 However, only 11% of children in this age group referred to our clinic complained of abdominal pain, whereas half presented with limb pain. This may indicate that recurrent abdominal pain is successfully dealt with and understood by paediatricians, whereas limb pain is more likely to be referred. Patients from rural Victoria accounted for 29% of all referrals, in keeping with the population distribution in Victoria.3 This has implications regarding the provision of education of general practitioners and services to rural areas. CRPS was diagnosed in 21% of patients referred. The lower limb was more commonly involved than the upper, and females were more often affected than males. Previous studies from the United States8 and Sweden9 have shown a similar ratio of limb involvement. In these studies, females were more commonly affected than in this study (5 and 13 times more often than males, respectively). Unlike in those studies, in which a large percentage of girls with CRPS were active in sports, gymnastics, skating and dance, this was true for only 10% of our patients. Children and adolescents with cerebral palsy made up the largest single group of patients with a concomitant condition. Locating the source of pain can be difficult in this group,10 especially in those with cognitive impairment. Hip and/or back pain was the source in 55%. Spasticity itself can cause pain11 and contributes to deformity, subluxation, dislocation, capsulitis and osteoarthritis in these regions. Sleep disruption was more frequent and problematic in these children, both overall and on a nightly basis. Addressing pain resulted in most patients sleeping uninterrupted through the night. Eliminating or minimising sleep disruption is of obvious benefit to the child and carers.12 The nature and management of chronic pain in children and adolescents differs from that in adults. Bullying, sexual or physical abuse, marital disharmony and difficulties at school may all contribute to abnormal pain behaviour in children. Family therapy may be indicated, as family situations can contribute to exacerbating and maintaining pain behaviour in children. Parents as well as afflicted children often need to be taught behavioural modification and pain-coping strategies. Abolition of pain, particularly in patients with chronic conditions, is not always achievable. The diverse aetiologies which manifest as pain behaviour necessitate a coordinated, multidisciplinary approach. My results support this multidisciplinary approach and focus on regaining function and minimising pain behaviour. The lack of a psychologist (a psychologist was initially a team member, but only for three months) and psychiatrist as integral team members may have contributed to the poor outcomes observed in some patients. Poor outcome was commonest in patients from chaotic family environments or in those with moderate intellectual disability. The latter are least likely to respond to cognitive behavioural techniques. Behavioural modification is better suited to this group, but may be difficult and time consuming to implement. A recent unpublished survey of tertiary paediatric hospitals in Australia and New Zealand, conducted by the Paediatric Pain Working Party of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists, revealed that only three centres in Australia and New Zealand have chronic pain management services which meet their minimum requirements for multidisciplinary staffing.13 Given the magnitude of functional disability demonstrated in our population, the provision of funding for paediatric chronic pain services requires urgent attention. The socioeconomic cost of chronic pain in children and adolescents is considerable. Although not specifically addressed in this study, it was apparent that there were implications for the child (education, self-esteem, friendships), the parents (time off work caring for the child and attending appointments, cost of medication, hospitalisation and complementary therapies) and the healthcare system (medical care, including serial referrals to multiple specialists, medication and hospitalisation and allied healthcare costs). Future studies should address the prevalence and epidemiology of pain in Australian children and adolescents, the early identification of those in whom significant functional disability exists and the cost-benefits of establishing multidisciplinary paediatric pain centres. Future directions should include education programs for GPs, paediatricians, schoolteachers and counsellors and allied health professionals to recognise early warning signals such as school absenteeism, frequent sick bay attendances, failure to respond to treatment, and poor school sports participation. References Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. J Dev Behav Pediatr 2000; 21: 58-69. Becker N, SjØgren P, Bech P, et al. Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared with general practice: a randomised controlled trial. Pain 2000; 84: 203-211. Australian Bureau of Statistics. Melbourne. A Social Atlas. 1996. Census of Population and Housing. Canberra: Commonwealth of Australia, 1998. (Catalogue no. 2030.2.) McGrath PJ, Finley GA. Chronic and recurrent pain in children and adolescents. Progress in Pain Research and Management, Vol. 13. Seattle: IASP Press, 1999. Boas RA. Complex regional pain syndromes: symptoms, signs, and differential diagnosis. In: Janig W, Stanton-Hicks M, editors. Reflex Sympathetic Dystrophy: A Reappraisal. Progress in Pain Research and Management, Vol. 6. Seattle: IASP Press, 1999; 82. Perquin CW, Hazebroek-Kampschreur AAJM, Hunfield JAM, et al. Pain in children and adolescents: a common experience. Pain 2000; 87: 51-58. Faull C, Nicol AR. Abdominal pain in six-year-olds: an epidemiological study in a new town. J Child Psychol Psychiatr 1986; 27: 251-260. Wilder RT, Wolohan M, Masek BJ, et al. Reflex sympathetic dystrophy in children and adolescents: a follow-up of a cohort of 70 patients and development of a treatment algorithm. J Bone Joint Surg Am 1992; 6: 910-919. Olsson GL, Arnér S, Hirsch G. Reflex sympathetic dystrophy in children. In: Tyler DC and Krane EJ, editors. Advances in pain research and therapy, Vol 15. New York: Raven Press, 1990; 323-331. Nolan J, Chalkiadis GA, Low J, et al. Anaesthesia and pain management in cerebral palsy. Anaesthesia 2000; 55: 32-41. Barwood S, Ballieu C, Boyd R, et al. The analgesic effects of botulinum toxin A: a randomised, double blind, placebo controlled clinical trial. Dev Med Child Neurol 2000; 42: 116-121. Lewin DS, Dahl RE. Importance of sleep in the management of pediatric pain. J Dev Behav Pediatr 1999; 20: 244-252. Requirements for multidisciplinary pain centres offering training in pain medicine. Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists College Policy Document PM2, 2000. (Received 28 Nov 2000, accepted 18 Jun 2001) Authors' details The Royal Children's Hospital, Melbourne, VIC. George A Chalkiadis, DA, FANZCA, Anaesthetist, and Co-ordinator Pain Management. Reprints will not be available from the author. Correspondence: Dr GA Chalkiadis, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052. chalkiagATcryptic.rch.unimelb.edu.au Make a comment 1: Demographic data Residential location Age* (years) Number (%) Female City Rural Other† 0-9 27 (13%) 70% 17 8 2 10-12 47 (23%) 64% 33 11 3 13-15 75 (36%) 73% 53 20 2 16-18 58 (28%) 83% 36 21 1 All 207 (100%) 73% 139 60 8 *Mean age, 13.1 years (range, 1-18 years); median age, 13 years. †These patients resided in the Australian Capital Territory, New South Wales or South Australia. Back to text 2: Concomitant medical conditions Condition Number Cerebral palsy/spasticity 22* Malignant tumours 18 Scoliosis 11* Benign tumours 7 Cystic fibrosis 6 Fibromyalgia 5 Intellectual delay 4 Talipes equinovarus or flat feet 4 Vertebral or spinal cord abnormalities 4 Others 33 *Four patients had both scoliosis and cerebral palsy, one had Duchenne muscular dystrophy and scoliosis and one had spinal muscular atrophy and scoliosis. Back to text 3: School days missed because of pain Number of school days missed * Nine children did not miss any days. †Seven children no longer attended school because of their pain. na= Not applicable; patients were unable to attend school because of a concomitant condition or because they were not of school age. Back to text 4: Medications prescribed Number of patients Tricyclic antidepressant (amitriptyline or nortriptyline) 78 Paracetamol 21 Non-steroidal anti-inflammatory drug (oral or topical, including COX-2 inhibitors) 31 Opioid: oxycodone (oral) or morphine (oral, subcutaneous or intravenous) 21 Anticonvulsants (carbamazepine, sodium valproate or gabapentin) 10 Clonidine (oral, intravenous or transdermal) 14 Benzodiazepines (diazepam, clonazepam) 7 Mexiletine 10 Capsaicin 7 Ketamine (intravenous) 5 Buscopan 2 Others (gaviscon, omeprazole, quinine, vitamin C) 1 for each medication Back to text 5: Interventions Number of patients Acupuncture 15 Relaxation techniques 98 Trigger point injection 7 Tendon, neuroma or joint injection 12 Nerve block 29* Epidural 28† Psychology/psychiatry 84 Physiotherapy 126 Iontophoresis (dexamethasone) 11 Self-administered medication 132 *62 blocks performed on 29 patients. †3 patients received 2 epidurals each. Back to text 6: Outcome in patients with complex regional pain syndrome Outcome* Upper limb Lower limb Good 8 26 Moderate 1 6 Poor 2 1 *Good: marked reduction in pain and marked functional improvement. Moderate: some reduction in pain and some functional improvement. Poor: no improvement in pain or functional ability. Back to text

George A Chalkiadis

Editorials Awareness during general anaesthesia: is it worth worrying about? Bispectral index monitoring may be a solution to the problem MJA 2001; 174: 212-213 Patients rightfully expect that they will have no memory of their surgery when it is performed under general anaesthesia. However, the incidence of postoperative recall of intraoperative events ("awareness") is about 1 in 1000 in patients undergoing non-cardiac surgery and greater than 3 in 1000 in cardiac surgical patients.1 As about two million general anaesthetics are performed each year in Australia, about 2000 patients will suffer an episode of awareness. This makes awareness one of the most common serious complications of anaesthesia.1-7Chilling accounts of intraoperative awareness abound in the medical literature and lay press.3,8,9 Patients who have experienced awareness during anaesthesia report the perception of paralysis, conversations, and surgical manipulations, accompanied by feelings of helplessness, fear and pain. While patients usually recognise the event as real, few are willing to report the experience to their anaesthetist for fear of being disbelieved or ridiculed. Post-traumatic stress disorder may develop as a devastating sequel of awareness.9 Why does awareness occur? Anaesthetic requirement is a balance between the amount of anaesthetic administered and the state of arousal of the patient. During any operation, the intensity of stimulation varies markedly, with the most potent noxious stimulus, endotracheal intubation, occurring at the beginning of the procedure. At the same time, the haemodynamic effects of the anaesthetic drugs may limit the amount that can be safely given. Thus, critical imbalances between anaesthetic requirement and delivery may occur. Marked interindividual variation in anaesthetic requirement, the use of muscle relaxants, and lack of a proven monitor for awareness compound the problem. In addition, awareness may occur as a result of anaesthetist error or technical mishaps.10 In an era of sophisticated intraoperative monitoring, it may surprise many non-anaesthetists (and our patients) that we are unable to guarantee loss of consciousness during surgery. A definitive monitor for awareness has been described as the "Holy Grail" of anaesthesia.11 Clinical signs of somatic or autonomic responsiveness have always been the mainstay of anaesthetic depth monitoring, but they lack proven utility in detecting awareness.5 Other techniques (the isolated forearm technique,12 frontalis electromyogram13 and lower-oesophageal contractility14) have similarly been unreliable. Promising technologies such as auditory evoked potential15 and heart-rate variability16 monitoring await wide availability and acceptance into clinical practice. Many attempts have been made to produce a simplified interpretation of the electroencephalograph (EEG) that predicts anaesthetic depth,11 but, in most cases, these were unsatisfactory.17 Recently, sophisticated pattern recognition systems that assess multiple features of the EEG have been developed. One such monitor, the bispectral index (BIS) (Aspect Medical Systems Inc, MA, USA), displays a single number derived from bispectral analysis of the EEG. The BIS ranges from 0 to 100, values below 60 being associated with unconsciousness. It has been shown to be a reliable indicator of level of consciousness18,19 and to improve operating room utilisation and reduce costs (by allowing faster patient turnover and reducing the use of drugs).18 Is BIS monitoring a reliable method of detecting and preventing awareness during anaesthesia? According to Aspect Medical Systems' product information, more than 1.2 million patients have been monitored with BIS and only 41 have reported awareness. Many of those experiencing awareness recorded a BIS value of greater than 65. This low reporting rate either represents an underestimate of the true incidence of awareness or reflects the effectiveness of BIS monitoring in preventing awareness. A suitably designed randomised trial could help to answer this clinically important question,20 although it has been argued that the low incidence of awareness under anaesthesia would necessitate a prohibitively large trial (about 50 000 patients).7,21 However, if a high-risk group could be identified, adequate power could be achieved with a much smaller sample size.20 Obstetric, cardiac and trauma patients are among those who are more likely to report awareness during anaesthesia.2 A study of 2300 patients in this group would be sufficient to reliably detect a decrease in incidence of awareness from 1% to 0.1% resulting from a more effective monitor (a = 0.05; b = 0.2). This large treatment effect is realistic for two reasons: (i) the acceptance of a monitor into routine anaesthetic practice would require a convincing demonstration of benefit; and (ii) the rate of awareness during BIS monitoring is thought to be extremely low. We are currently undertaking such a trial in Australia, New Zealand and Hong Kong (for further details, see our website at <http://www.b-aware-trial.org>). While widespread use of BIS would certainly incur considerable cost for acquisition and ongoing expenses, this should be balanced against the ability of BIS monitoring to improve anaesthetic drug titration (thereby decreasing drug and recovery-room costs18), the potential to prevent costly litigation, and the possibility of reducing the level of patient anxiety about awareness (up to 54% of patients due to undergo surgery are concerned about awareness6). We believe that if a monitor was proven to decrease the incidence of awareness in an appropriately designed and conducted trial, the costs would be justified. Our patients expect nothing less. Kate Leslie Anaesthetist, Royal Melbourne Hospital, Melbourne, VIC Honorary Senior Fellow, Department of Pharmacology, University of Melbourne kate.leslieATmh.org.au Paul S Myles Head of Anaesthesia Research Alfred Hospital, Melbourne, VIC Associate Professor Department of Epidemiology and Preventative Medicine, Monash University Competing interests: Aspect Medical Systems Inc have provided some funding for a multicentre awareness monitoring trial (the B-Aware Trial), designed and independently conducted by us. Dowd M, Cheng D, Karski J, et al. Intraoperative awareness in fast-track cardiac anaesthesia. Anesthesiology 1998; 89: 1068-1073. Liu W, Thorp T, Graham S, et al. Incidence of awareness with recall during general anaesthesia. Anaesthesia 1991; 46: 435-437. Lyons G, Macdonald R. Awareness during Caesarean section. Anaesthesia 1991; 46: 62-64. Ranta S, Ranta V, Aromaa U. The claims for compensation for awareness with recall during general anaesthesia in Finland. Acta Anaesthesiol Scand 1997; 41: 356-359. Phillips A, McLean R, Devitt J, et al. Recall of intraoperative events after general anaesthesia and cardiopulmonary bypass. Can J Anaesth 1993; 40: 922-926. Myles P, Williams D, Hendrata M, et al. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients. Br J Anaesth 2000; 84: 6-10. Sandin R, Enlund G, Samuelsson P, et al. Awareness during anaesthesia: a prospective case study. Lancet 2000; 355: 707-711. Macleod AD, Maycock E. Awareness during anaesthesia and post traumatic stress disorder. Anaesth Intensive Care 1992; 20: 378-382. Cobcroft M, Forsdick C. Awareness under anaesthesia: the patients' point of view. Anaesth Intensive Care 1993; 21: 837-843. Domino K, Posner K, Caplan R, et al. Awareness during anesthesia: a closed claims analysis. Anesthesiology 1999; 90: 1053-1061. Todd M. EEGs, EEG processing, and the bispectral index. Anesthesiology 1998; 89: 815-817. Bogod D, Orton J, Oh T. Detecting awareness during general anaesthetic caesarian section. Anaesthesia 1990; 45: 279-284. Edmonds HL. Anesthetic adequacy, surface EMG, and quantitated EEG. Acta Anaesthesiol Scand 1993; 37(Suppl 100): 102-104. Raftery S, Enever G, Prys RC. Oesophageal contractility during total i.v. anaesthesia with and without glycopyrronium. Br J Anaesth 1991; 66: 566-571. Thornton C, Konieczko K, Jones JG, et al. Effect of surgical stimulation on the auditory evoked response. Br J Anaesth 1988; 60: 372-378. Sleigh J, Donovan J. Comparison of bispectral index, 95% spectral edge frequency and approximate entropy of the EEG, with changes in heart rate variability during induction of general anaesthesia. Br J Anaesth 1999; 82: 666-671. Sigl JC, Chamoun NG. An introduction to bispectral analysis for the electroencephalogram. J Clin Monit 1994; 10: 392-404. Gan T, Glass P, Windsor A, et al. Bispectral Index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology 1997; 87: 808-815. Leslie K, Sessler DI, Schroeder M, et al. Propofol blood concentration and the Bispectral Index predict suppression of learning during propofol/epidural anesthesia in volunteers. Anesth Analg 1995; 81: 1269-1274. Myles P. Why we need large randomized studies in anaesthesia. Br J Anaesth 1999; 83: 833-834. Simini B. Awareness of awareness during general anaesthesia. Lancet 2000; 355: 672-674.

Kate Leslie · Paul S Myles

Defining Moments In Medicine Anaesthesia MJA 2001; 174: 17-18 New anaesthetic agents: Anaesthesia has been revolutionised over the past 50 years by the development of new anaesthetic agents. In 1957, the volatile agent halothane supplanted ether as the anaesthetic of choice. It is more pleasant for patients, potent and non-flammable. Later refinements were isoflurane and sevoflurane, the latter being particularly useful in children. Another key change was the introduction, in 1952, of the first short-acting, depolarising muscle relaxant, suxamethonium, while in 1967 pancuronium replaced d-tubocurarine as the main long-acting, non-depolarising muscle relaxant. The intravenous induction agent propofol (1986) was a major improvement on thiopentone, while the local anaesthetic bupivacaine (1963) provides longer duration of action for regional anaesthesia. Monitoring of anaesthetic deaths: Australia has led the world in the quality and safety of anaesthesia. In 1960, Ross Holland (Director of Anaesthesia at Lidcombe Hospital, Sydney) pioneered investigation of deaths associated with anaesthesia and education of anaesthetists to reduce anaesthesia-related mortality in New South Wales. Other States followed, and national data have been published triennially since 1985, documenting the safety of anaesthesia in Australia. Faculty of Anaesthetists: In 1952, postgraduate training in anaesthesia was formalised with the formation of the Faculty of Anaesthetists within the Royal Australasian College of Surgeons. In 1992, the Faculty became the Australian and New Zealand College of Anaesthetists. It has accredited training programs in Australia, New Zealand, Hong Kong, Malaysia and Singapore. Anaesthesia as an academic discipline: Anaesthesia advanced as an academic discipline in Australia with the appointment in 1962 of Douglas Joseph to the first chair in anaesthetics -- the Nuffield Chair at the University of Sydney. Subsequently, other chairs in anaesthesia were established in Brisbane, Melbourne, Sydney, Newcastle, Adelaide and Perth. Launch of Anaesthesia and Intensive Care: The journal Anaesthesia and Intensive Care was launched by the Australian Society of Anaesthetists in 1972. Specific training in intensive care: The world's first training and examination system in intensive care was established by the Faculty of Anaesthetists in 1976. After formation of the College of Anaesthetists, a Faculty of Intensive Care was inaugurated in 1993, with Geoff Clarke (Head of Intensive Care, Royal Perth Hospital) as the first Dean. Specific training in pain medicine: Training in pain medicine was begun by the College of Anaesthetists in 1996, and in 1998 a multidisciplinary Faculty of Pain Medicine was formed, with Michael Cousins (Head of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney) as the first Dean. Board members are drawn from the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Physicians and its Faculty of Rehabilitation Medicine, the Royal Australasian College of Surgeons and the Royal Australian and New Zealand College of Psychiatrists. Minimum standards for anaesthesia: Minimum standards for anaesthesia have been developed progressively and published over the past 50 years by the Faculty, and later College, of Anaesthetists. They have had a major impact on development of standards in hospitals throughout Australia, New Zealand and South-East Asia. Improved patient monitoring: Equipment that allows beat-by-beat monitoring of oxyhaemoglobin levels by pulse oximetry and breath-by-breath monitoring of end-tidal carbon dioxide levels by capnometry has significantly improved the safety of anaesthesia. Both became widely available in the 1980s and were required to meet Australian and other countries' standards. Laryngeal mask: Described by Archie Brain (Reading, UK) in 1983, this mask is an airway device that provides a hands-free method of maintaining the airway without intubation. It has become popular with many anaesthetists and is useful in situations when intubation is difficult. Medical retrieval of the critically ill: From the 1960s onwards, medical retrieval of the critically ill has provided intensive care and safe transport to major centres from anywhere in Australia. These multidisciplinary, multimodal services have extended the vision of John Flynn (founder of the Royal Flying Doctor Service) in an extraordinary way. J E (Fred) Gilligan (Director of Retrieval and Resuscitation, Royal Adelaide Hospital) is one of the longest-serving leaders in this field. Malignant hyperthermia: In 1960, the familial disease malignant hyperthermia, which is triggered by some anaesthetic agents in susceptible individuals, was first described by Michael Denborough and colleagues from Royal Melbourne Hospital. Recognition of the genetic nature of this disease has allowed members of affected families to be screened, while awareness of the early changes and appropriate management, including dantrolene and intensive care, has reduced mortality from around 80% to less than 10%. Continuing medical education: CME in anaesthetics has developed and expanded in Australia from its beginnings at section meetings of the Australasian Medical Congress (British Medical Association) in the 1950s. Indeed, in 1996, the Australian Society of Anaesthetists hosted the World Congress of Anaesthesiology in Sydney, with nearly 6000 delegates. Furthermore, Australian anaesthetists have conducted education and examinations in the South Pacific region, Papua New Guinea, Hong Kong, Malaysia and Singapore. Garry D Phillips Professor of Anaesthesia and Intensive Care Flinders Medical Centre, Adelaide, SA Above photograph of surgeons, 1959. (Courtesy of Wolfgang Sievers) Make a comment

Garry D Phillips