50 results found
Scott W, Guildford BJ, Badenoch J, et al., 2021, Feasibility randomized-controlled trial of online acceptance and commitment therapy for painful peripheral neuropathy in people living with HIV: The OPEN study, EUROPEAN JOURNAL OF PAIN, Vol: 25, Pages: 1493-1507, ISSN: 1090-3801
Merlin JS, Hamm M, Cameron FDA, et al., 2021, SPECIAL ISSUE HIV and CHRONIC PAIN (The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field), AIDS Care: psychological and socio-medical aspects of AIDS-HIV, Pages: 1-9, ISSN: 0954-0121
Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.
Kemp HI, Kennedy DL, Vollert J, et al., 2021, Chronic pain and cognitive impairment: a cross-sectional study in people living with HIV, AIDS Care: psychological and socio-medical aspects of AIDS-HIV, Pages: 1-14, ISSN: 0954-0121
Cognitive impairment and chronic pain are amongst the most prevalent neurological sequelae of HIV infection, yet little is understood about the potential bidirectional relationship between the two conditions. Cognitive dysfunction can occur in chronic pain populations whilst those with cognitive impairment can display modified responses to experimentally induced painful stimuli. To date, this has not been explored in HIV cohorts.This study aimed to identify any contribution of chronic pain to cognitive impairment in HIV and to determine differences in pain characteristics between those with and without cognitive dysfunction.This was an observational cohort study involving people living with HIV (n = 148) in the United Kingdom. Participants underwent validated questionnaire-based measurement of pain severity, interference and symptom quality as well as conditioned pain modulation and quantitative sensory testing. All participants completed a computer-based cognitive function assessment.Fifty-seven participants met the criteria for cognitive impairment and 73 for chronic pain. The cognitive impairment group had a higher prevalence of chronic pain (p = 0.004) and reported more neuropathic symptoms (p = 0.001). Those with chronic pain performed less well in emotional recognition and verbal learning domains. The interaction identified between chronic pain and cognitive dysfunction warrants further exploration to identify causal links or shared pathology.
Sipilä R, Kemp H, Harno H, et al., 2021, Health-related quality of life and pain interference in two patient cohorts with neuropathic pain: breast cancer survivors and HIV patients, Scandinavian Journal of Pain, Vol: 21, Pages: 512-521, ISSN: 1877-8860
OBJECTIVES: Persistent pain is common in HIV patients and breast cancer (BC) survivors. The aim of this study was to compare two patient groups with neuropathic pain (NP) regarding several psychological variables and Health-related Quality of Life. Although, treatment of pain is always planned individually, the knowledge of the differences and similarities between the patient groups may help us to understand more precisely the targets of the interventions for pain. METHODS: Eighty nine BC and 73 HIV patients with symptoms of neuropathic pain (patients with ≥3/7 in the Douleur Neuropathique four interview part (DN4i)) participated in a cross-sectional study. Patients completed questionnaires about mood (HADS), symptoms of insomnia (ISI), pain catastrophizing (PCS), personality (TIPI), Mental and Physical Health-related Quality of Life (M/PHrQoL, RAND/SF-36), and pain intensity and interference (BPI). Analyses were applied by using t-tests and linear regression to assess associations between the studied factors. RESULTS: HIV patients reported higher anxiety (p<0.001), depressive symptoms (p<0.001), pain catastrophizing (p<0.001) and pain interference (p<0.001), poorer sleep (p<0.001), and lower HrQoL in all dimensions compared with BC survivors. There were significant differences in personality traits extraversion, emotional stability, and agreeableness between the two patient groups. In HIV patients, pain interference (β=-0.344, p<0.001) and mood (β=-0.580, p<0.001) and in the BC group, mood (β=-0.591, p<0.001), extraversion (β=0.229, p=0.005) and sleep (β=-0.154, p=0.042) associated with MHrQoL. Pain interference (HIV β=-0.645, p<0.001, BC β=-0.491, p<0.001) and age (HIV β=-0.016, p=0.042 and BC β=-0.018, p=0.019) associated with PHrQoL in both groups, and catastrophizing in the BC group (β=-0.303, p<0.001). CONCLUSIONS: HIV patients and BC survivors with neuropathic pain, mea
Odor PM, Bampoe S, Lucas DN, et al., 2021, Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study, ANAESTHESIA, Vol: 76, Pages: 759-776, ISSN: 0003-2409
Scott W, Badenoch J, del Solar MGCM, et al., 2021, Acceptability of psychologically-based pain management and online delivery for people living with HIV and chronic neuropathic pain: a qualitative study, SCANDINAVIAN JOURNAL OF PAIN, Vol: 21, Pages: 296-307, ISSN: 1877-8860
Gupta S, Kennedy D, Wu C, et al., 2021, Cold sensitivity and intolerance in healthy volunteers: an experimental study, Publisher: WILEY, Pages: 134-134, ISSN: 0003-2409
Gupta S, Kemp H, Vollert J, et al., 2021, A pilot study of cold intolerance and pain sensitivity in healthy volunteers: a survey-based study, Publisher: WILEY, Pages: 133-133, ISSN: 0003-2409
Kemp HI, Corner E, Colvin LA, 2020, Chronic pain after COVID-19: implications for rehabilitation, BRITISH JOURNAL OF ANAESTHESIA, Vol: 125, Pages: 436-440, ISSN: 0007-0912
Odor PM, Bampoe S, Moonesinghe SR, et al., 2020, General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study, ANAESTHESIA, Vol: 76, Pages: 460-471, ISSN: 0003-2409
Petropoulos IN, Al-Mohammedi A, Chen X, et al., 2020, The utility of corneal nerve fractal dimension analysis in peripheral neuropathies of different etiology, Translational Vision Science and Technology, Vol: 9, ISSN: 2164-2591
Purpose: Quantification of corneal confocal microscopy (CCM) images has showna significant reduction in corneal nerve fiber length (CNFL) in a range of peripheralneuropathies. We assessed whether corneal nerve fractal dimension (CNFrD) analysis,a novel metric to quantify the topological complexity of corneal subbasal nerves, candifferentiate peripheral neuropathies of different etiology.Methods: Ninety patients with peripheral neuropathy, including 29 with diabeticperipheral neuropathy (DPN), 34 with chronic inflammatory demyelinating polyneuropathy (CIDP), 13 with chemotherapy-induced peripheral neuropathy (CIPN), 14with human immunodeficiency virus-associated sensory neuropathy (HIV-SN), and 20healthy controls (HCs), underwent CCM for estimation of corneal nerve fiber density(CNFD), CNFL, corneal nerve branch density (CNBD), CNFrD, and CNFrD adjusted forCNFL (ACNFrD).Results: In patients with DPN, CIDP, CIPN, or HIV-SN compared to HCs, CNFD (P =0.004–0.0001) and CNFL (P = 0.05–0.0001) were significantly lower, with a further significant reduction among subgroups. CNFrD was significantly lower in patients with CIDPcompared to HCs and patients with HIV-SN (P = 0.02–0.0009) and in patients with DPNcompared to HCs and patients with HIV-SN, CIPN, or CIDP (P = 0.001–0.0001). ACNFrDwas lower in patients with CIPN, CIDP, or DPN compared to HCs (P = 0.03–0.0001) and inpatients with DPN compared to those with HIV-SN, CIPN, or CIDP (P = 0.01–0.005).Conclusions: CNFrD can detect a distinct pattern of corneal nerve loss in patients withDPN or CIDP compared to those with CIPN or HIV-SN and controls.Translational Relevance: Various peripheral neuropathies are characterized by acomparable degree of corneal nerve loss. Assessment of corneal nerve topology byCNFrD could be useful in differentiating neuropathies based on the pattern of loss.
Kemp HI, Eliahoo J, Vase L, et al., 2020, Meta-analysis comparing placebo responses in clinical trials of painful HIV-associated sensory neuropathy and diabetic polyneuropathy, Scandinavian Journal of Pain, Vol: 20, Pages: 439-449, ISSN: 1877-8860
Background and aims The placebo response has been identified as one factor responsible for the lack of therapeutic trials with positive outcomes in neuropathic pain. Reviews have suggested that certain neuropathic pain conditions, including HIV-associated sensory neuropathy (HIV-SN), exhibit a greater placebo response than other neuropathic aetiologies. If true, such a finding could substantially affect clinical trial design and therapeutic developments for these conditions. This study aimed to identify any difference in placebo response between trials of systemic pharmacological intervention in HIV-SN and a comparable neuropathic condition, diabetic polyneuropathy (DPN) and to identify factors influencing the placebo response. Methods A systematic review search to identify randomised, double-blind studies of systemic pharmacological interventions for painful HIV-SN and DPN published between January 1966 and June 2019 was performed. A meta-analysis of the magnitude of placebo response and the proportion of placebo responders was conducted and compared between the two disease conditions. A meta-regression was used to assess for any study and participant characteristics that were associated with the placebo response. Only studies meeting a methodological quality threshold were included. Results Seventy-five trials were identified. There was no statistically significant difference in the proportion of placebo responders (HIV-SN = 0.35; versus DPN = 0.27, p = 0.129). The difference observed in the magnitude of the placebo response [pain reduction of 1.68 (1.47-1.88) DPN; 2.38 (1.87-2.98) in HIV-SN] was based on only 2 trials of HIV-SN and 35 of DPN. Potential factors influencing the placebo response such as psychological measures, were reported inconsistently. Conclusions We found no statistically significant difference in the placebo response rate between painful HIV-SN and DPN. Too few studies were available that reported the
Meyer-Friessem CH, Attal N, Baron R, et al., 2020, Pain thresholds and intensities of CRPS type I and neuropathic pain in respect to sex, EUROPEAN JOURNAL OF PAIN, Vol: 24, Pages: 1058-1071, ISSN: 1090-3801
Kennedy DL, Kemp H, Wu C, et al., 2020, Determining real change in conditioned pain modulation: a repeated measures study in healthy volunteers, Journal of Pain, Vol: 21, Pages: 708-721, ISSN: 1526-5900
Conditioned pain modulation (CPM) is a potentially useful biomarker in pain populations; however, a statistically robust interpretation of change scores is required. Currently, reporting of CPM does not consider measurement error. Hence, the magnitude of change representing a “true” CPM effect is unknown. This study determined the standard error of measurement (SEM) and proportion of healthy participants showing a “true” CPM effect with a standard CPM paradigm. Fifty healthy volunteers participated in an intersession reliability study using pressure pain threshold (PPT) test stimulus and contact heat, cold water, and sham conditioning stimuli. Baseline PPTs were used to calculate SEM and >±2 × SEM to determine CPM effect. SEM for PPT was .21 kg/cm2. An inhibitory CPM effect (>+2 SEM) was elicited in 59% of subjects in response to cold stimulus; in 44% to heat. Intrasession and intersession reliability of within-subject CPM response was poor (kappa coefficient <.36). Measurement error is important in determining CPM effect and change over time. Even when using reliable test stimuli, and incorporating measures to limit bias and error, CPM intersession reliability was fair and demonstrated a large degree of within-subject variation. Determining “true” change in CPM will underpin future interrogations of intraindividual differences in CPM.
Scott W, del Solar MGCM, Kemp H, et al., 2020, A qualitative study of the experience and impact of neuropathic pain in people living with HIV, PAIN, Vol: 161, Pages: 970-978, ISSN: 0304-3959
Brinkler R, Edwards Z, Abid S, et al., 2019, A survey of antenatal and peripartum provision of information on analgesia and anaesthesia, ANAESTHESIA, Vol: 74, Pages: 1101-1111, ISSN: 0003-2409
Kemp HI, Laycock H, Costello A, et al., 2019, Chronic pain in critical care survivors: a narrative review, British Journal of Anaesthesia, Vol: 123, Pages: e372-e384, ISSN: 1471-6771
Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.
Kemp HI, Cook TM, 2019, Perioperative anaphylaxis – what’s the risk?, Southern African Journal of Anaesthesia and Analgesia, Vol: 25, Pages: 4-6, ISSN: 2220-1181
Capturing data about rare, hazardous events in perioperative care is challenging. The United Kingdom’s National Audit Project (NAP) programme, commissioned by the Royal College of Anaesthetists, endeavours to provide practical information for clinicians by systematically examining a large series of such events.1 Each NAP has focused on a different topic, and most recently the Sixth National Audit Project, ‘NAP6’, investigated life-threatening perioperative allergic reactions. A review of the methodology and findings of previous NAPs has previously been published in this journal.
Sturm D, Vollert J, Greiner T, et al., 2019, Implementation of a Quality Index for Improvement of Quantification of Corneal Nerves in Corneal Confocal Microcopy Images: A Multicenter Study., Cornea
PURPOSE: Corneal confocal microscopy (CCM) is an imaging method to detect loss of nerve fibers in the cornea. The impact of image quality on the CCM parameters has not been investigated. We developed a quality index (QI) with 3 stages for CCM images and compared the influence of the image quality on the quantification of corneal nerve parameters using 2 modes of analysis in healthy volunteers and patients with known peripheral neuropathy. METHODS: Images of 75 participants were a posteriori analyzed, including 25 each in 3 image quality groups (QI 1-QI 3). Corneal nerve fiber length (CNFL) was analyzed using automated and semiautomated software, and corneal nerve fiber density and corneal nerve branch density were quantified using automated image analysis. Three masked raters assessed CCM image quality (QI) independently and categorized images into groups QI 1-QI 3. In addition, statistical analysis was used to compare interrater reliability. Analysis of variance was used for analysis between the groups. Interrater reliability analysis between the image ratings was performed by calculating Fleiss' kappa and its 95% confidence interval. RESULTS: CNFL, corneal nerve fiber density, and corneal nerve branch density increased significantly with QI (P < 0.001, all post hoc tests P < 0.05). CNFL was higher using semiautomated compared with automated nerve analysis, independent of QI. Fleiss kappa coefficient for interrater reliability of QI was 0.72. CONCLUSIONS: The quantification of corneal nerve parameters depends on image quality, and poorer quality images are associated with lower values for corneal nerve parameters. We propose the QI as a tool to reduce variability in quantification of corneal nerve parameters.
Kemp H, Laycock H, Costello A, et al., 2019, Chronic pain in critical care survivors, BJA: British Journal of Anaesthesia, ISSN: 1471-6771
Chronic pain is an important problem following critical care admission. Estimates of prevalence of chronic pain in the year following discharge range from 14-77% depending on the type of cohort, the tool used to measure pain and the time point when pain was assessed. The majority of data available comefrom studies using health-related quality of life tools,although some have included pain-specific tools. Nociceptive, neuropathic and nociplastic pain can occur in critical caresurvivors butlimited information about aetiology, body site and temporal trajectory of pain is currently available. Older age, pre-existing pain andmedicalco-morbidity have been associated with pain after critical careadmission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow up period are required to confirm prevalence, identify risk factors, explore anyassociation between acute and chronic pain in this setting, determine underlying pathological mechanisms and inform the development of future analgesic interventions.
Scott W, Arkuter C, Kioskli K, et al., 2018, Psychosocial factors associated with persistent pain in people with HIV: A systematic review with meta-analysis, Pain, Vol: 159, Pages: 2461-2476, ISSN: 0304-3959
Chronic pain remains a prevalent and disabling problem for people living with HIV in the current antiretroviral treatment era. Psychosocial treatments may have promise for managing the impact of this pain. However, research is needed to identify psychosocial processes to target through such treatments. The current systematic review and meta-analysis examined the evidence for psychosocial factors associated with pain, disability, and quality of life in people living with HIV and persistent pain. Observational and experimental studies reporting on the association between one or more psychosocial factors and one or more pain-related variables in an adult sample of people living with HIV and pain were eligible. Two reviewers independently conducted eligibility screening, data extraction, and quality assessment. Forty-six studies were included in the review and 37 of these provided data for meta-analyses (12,493 participants). “Some” or “moderate” evidence supported an association between pain outcomes in people with HIV and the following psychosocial factors: depression, psychological distress, posttraumatic stress, drug abuse, sleep disturbance, reduced antiretroviral adherence, health care use, missed HIV clinic visits, unemployment, and protective psychological factors. Surprisingly, few studies examined protective psychological factors or social processes, such as stigma. There were few high-quality studies. These findings can inform future research and psychosocial treatment development in this area. Greater theoretical and empirical focus is needed to examine the role of protective factors and social processes on pain outcomes in this context. The review protocol was registered with PROSPERO (CRD42016036329).
Watson X, Chereshneva M, Odor PM, et al., 2018, Adoption of lung protective ventilation IN patients undergoing emergency laparotomy: the ALPINE study. A prospective multicentre observational study, British Journal of Anaesthesia, Vol: 121, Pages: 909-917, ISSN: 0007-0912
BackgroundEmergency abdominal surgery is associated with a high risk of postoperative pulmonary complications (PPCs). The primary aim of this study was to determine whether patients undergoing emergency laparotomy are ventilated using a lung-protective ventilation strategy employing tidal volume ≤8 ml kg−1 ideal body weight−1, PEEP >5 cm H2O, and recruitment manoeuvres. The secondary aim was to investigate the association between ventilation factors (lung-protective ventilation strategy, intraoperative FiO2, and peak inspiratory pressure) and the occurrence of PPCs.MethodsData were collected prospectively in 28 hospitals across London as part of routine National Emergency Laparotomy Audit (NELA). Patients were followed for 7 days. Complications were defined according to the European Perioperative Clinical Outcome definition.ResultsData were collected from 568 patients. The median [inter-quartile range (IQR)] tidal volume observed was 500 ml (450–540 ml), corresponding to a median tidal volume of 8 ml kg−1 ideal body weight−1 (IQR: 7.2–9.1 ml). A lung-protective ventilation strategy was employed in 4.9% (28/568) of patients, and was not protective against the occurrence of PPCs in the multivariable analysis (hazard ratio=1.06; P=0.69). Peak inspiratory pressure of <30 cm H2O was protective against development of PPCs (hazard ratio=0.46; confidence interval: 0.30–0.72; P=0.001). Median FiO2 was 0.5 (IQR: 0.44–0.53), and an increase in FiO2 by 5% increased the risk of developing a PPC by 8% (2.6–14.1%; P=0.008).ConclusionsBoth intraoperative peak inspiratory pressure and FiO2 are independent factors significantly associated with development of a postoperative pulmonary complication in emergency laparotomy patients. Further studies are required to identify causality and to demonstrate if their manipulation could lead to better clinical outcomes.
Kemp HI, Rice AS, Adonis A, et al., 2018, Human T-Lymphotrophic Virus - a neglected cause of chronic pain?, PAIN, Vol: 159, Pages: 1433-1437, ISSN: 0304-3959
Rice ASC, Finnerup NB, Kemp HI, et al., 2018, Sense and sensibility-logical approaches to profiling in animal models Reply, PAIN, Vol: 159, Pages: 1428-1429, ISSN: 0304-3959
Kemp H, Marinho S, Cook TM, et al., 2018, An observational national study of anaesthetic workload and seniority across the working week and weekend in the UK in 2016: the 6th National Audit Project (NAP6) Activity Survey, British Journal of Anaesthesia, Vol: 121, Pages: 134-145, ISSN: 1471-6771
BACKGROUND: UK national anaesthetic activity was studied in 2013 but weekend working was not examined. Understanding changes since 2013 in workload and manpower distribution, including weekends, would be of value in workforce planning. METHODS: We performed an observational survey of NHS hospitals' anaesthetic practice in October 2016 as part of the 6th National Audit Project of the Royal College of Anaesthetists (NAP6). All cases cared for by an anaesthetist during the study period were included. Patient characteristics and details of anaesthetic conduct were collected by local anaesthetists. RESULTS: Responses were received from 342/356 (96%) hospitals. In total, 15 942 cases were reported, equating to an annual anaesthetic workload of ≈3.13 million cases. Approximately 95% (9888/10 452) of elective and 72% (3184/4392) of emergency work was performed on weekdays and 89% (14 145/15 942) of activity was led by senior (consultant or career grade) anaesthetists and 1.1% (180/15942) by those with <2 yr anaesthetic experience. During weekends case urgency increased, the proportion of healthy patients reduced and case mix changed. Cases led by senior anaesthetists fell to 80% (947/1177) on Saturday and 66% (342/791) on Sunday. Senior involvement in obstetric anaesthetic activity was 69% (628/911) during the week and 45% (182/402) at weekends, compared with 93% (791/847) in emergency orthopaedic procedures during the week and 89% (285/321) at weekends. Since 2013, the proportion of obese patients, elective weekend working, and depth of anaesthesia monitoring has increased [12% (1464/12 213) vs 2.8%], but neuromuscular monitoring has not [37% (2032/5532) vs 38% of paralysed cases]. CONCLUSIONS: Senior clinicians deliver most UK anaesthesia care, including at weekends. Our findings are important for any planned workforce reorganisation to rationalise 7-day working.
Cook TM, Harper NJN, Farmer L, et al., 2018, Anaesthesia, surgery, and life-threatening allergic reactions: protocol and methods of the 6th National Audit Project (NAP6) of the Royal College of Anaesthetists, British Journal of Anaesthesia, Vol: 121, Pages: 124-133, ISSN: 1471-6771
BACKGROUND: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists. METHODS: The Sixth National Audit Project (NAP6) of the Royal College of Anaesthetists examined the incidence, predisposing factors, management, and impact of life-threatening perioperative anaphylaxis in the UK. NAP6 included: a national survey of anaesthetists' experiences and perceptions; a national survey of allergy clinics; a registry collecting detailed reports of all Grade 3-5 perioperative anaphylaxis cases for 1 yr; and a national survey of anaesthetic workload and perioperative allergen exposure. NHS and independent sector (IS) hospitals were approached to participate. Cases were reviewed by a multi-disciplinary expert panel (anaesthetists, intensivists, allergists, immunologists, patient representatives, and stakeholders) using a structured process designed to minimise bias. Clinical management and investigation were compared with published guidelines. This paper describes detailed study methods and reports on project engagement by NHS and IS hospitals. The methodology includes a new classification of perioperative anaphylaxis and a new structured method for classifying suspected anaphylactic events including the degree of certainty with which a causal trigger agent can be attributed. RESULTS: NHS engagement was complete (100% of hospitals). Independent sector engagement was limited (13% of approached hospitals). We received >500 reports of Grade 3-5 perioperative anaphylaxis, with 266 suitable for analysis. We identified 199 definite or probable culprit agents in 192 cases. CONCLUSIONS: The methods of NAP6 were robust in identifying causative agents of anaphylaxis, and support the accompanying analytical papers.
Marinho S, Kemp H, Cook TM, et al., 2018, Cross-sectional study of perioperative drug and allergen exposure in UK practice in 2016: the 6th National Audit Project (NAP6) Allergen Survey, British Journal of Anaesthesia, Vol: 121, Pages: 146-158, ISSN: 1471-6771
BACKGROUND: Details of the current UK drug and allergen exposure were needed for interpretation of reports of perioperative anaphylaxis to the 6th National Audit Project (NAP6). METHODS: We performed a cross-sectional survey of 356 NHS hospitals determining anaesthetic drug usage in October 2016. All cases cared for by an anaesthetist were included. RESULTS: Responses were received from 342 (96%) hospitals. Within-hospital return rates were 96%. We collected 15 942 forms, equating to an annual caseload of 3.1 million, including 2.4 million general anaesthetics. Propofol was used in 74% of all cases and 90% of general anaesthetics. Maintenance included a volatile agent in 95% and propofol in 8.7%. Neuromuscular blocking agents were used in 47% of general anaesthetics. Analgesics were used in 88% of cases: opioids, 82%; paracetamol, 56%; and non-steroidal anti-inflammatory drugs, 28%. Antibiotics were administered in 57% of cases, including 2.5 million annual perioperative administrations; gentamicin, co-amoxiclav, and cefuroxime were most commonly used. Local anaesthetics were used in 74% cases and 70% of general anaesthetics. Anti-emetics were used in 73% of cases: during general anaesthesia, ondansetron in 78% and dexamethasone in 60%. Blood products were used in ≈3% of cases, gelatin <2%, starch very rarely, and tranexamic acid in ≈6%. Chlorhexidine and povidone-iodine exposures were 74% and 40% of cases, and 21% reported a latex-free environment. Exposures to bone cement, blue dyes, and radiographic contrast dye were each reported in 2-3% of cases. CONCLUSIONS: This survey provides insights into allergen exposures in perioperative care, which is important as denominator data for the NAP6 registry.
Harper NJN, Cook TM, Garcez T, et al., 2018, Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6), British Journal of Anaesthesia, Vol: 121, Pages: 159-171, ISSN: 1471-6771
BACKGROUND: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists. METHODS: The 6th National Audit Project (NAP6) on perioperative anaphylaxis collected and reviewed 266 reports of Grades 3-5 anaphylaxis over 1 yr from all NHS hospitals in the UK. RESULTS: The estimated incidence was ≈1:10 000 anaesthetics. Case exclusion because of reporting delays or incomplete data means true incidence might be ≈70% higher. The distribution of 199 identified culprit agents included antibiotics (94), neuromuscular blocking agents (65), chlorhexidine (18), and Patent Blue dye (9). Teicoplanin comprised 12% of antibiotic exposures, but caused 38% of antibiotic-induced anaphylaxis. Eighteen patients reacted to an antibiotic test dose. Succinylcholine-induced anaphylaxis, mainly presenting with bronchospasm, was two-fold more likely than other neuromuscular blocking agents. Atracurium-induced anaphylaxis mainly presented with hypotension. Non-depolarising neuromuscular blocking agents had similar incidences to each other. There were no reports of local anaesthetic or latex-induced anaphylaxis. The commonest presenting features were hypotension (46%), bronchospasm (18%), tachycardia (9.8%), oxygen desaturation (4.7%), bradycardia (3%), and reduced/absent capnography trace (2.3%). All patients were hypotensive during the episode. Onset was rapid for neuromuscular blocking agents and antibiotics, but delayed with chlorhexidine and Patent Blue dye. There were 10 deaths and 40 cardiac arrests. Pulseless electrical activity was the usual type of cardiac arrest, often with bradycardia. Poor outcomes were associated with increased ASA, obesity, beta blocker, and angiotensin-converting enzyme inhibitor medication. Seventy per cent of cases were reported to the hospital incident reporting system, and only 24% to Medicines and Healthcare products Regulatory Agency via the Yellow Card Scheme. CONCLUSIONS: The overall incidence of perioperative anaphyl
Egner W, Cook TM, Garcez T, et al., 2018, Specialist perioperative allergy clinic services in the UK 2018: Results from the Royal College of Anaesthetists Sixth National Audit Project (NAP6) investigation of perioperative anaphylaxis, Clinical and Experimental Allergy, Vol: 48, Pages: 846-861, ISSN: 0954-7894
BackgroundThe Royal College of Anaesthetists 6th National Audit Project examined Grade 3‐5 perioperative anaphylaxis for 1 year in the UK.ObjectiveTo describe the causes and investigation of anaphylaxis in the NAP6 cohort, in relation to published guidance and previous baseline survey results.MethodsWe used a secure registry to gather details of Grade 3‐5 perioperative anaphylaxis. Anonymous reports were aggregated for analysis and reviewed in detail. Panel consensus diagnosis, reaction grade, review of investigations and clinic assessment are reported and compared to the prior NAP6 baseline clinic survey.ResultsA total of 266 cases met inclusion criteria between November 2015 and 2016, detailing reactions and investigations. One hundred and ninety‐two of 266 (72%) had anaphylaxis with a trigger identified, of which 140/192 (75%) met NAP6 criteria for IgE‐mediated allergic anaphylaxis, 13% lacking evidence of positive IgE tests were labelled “non‐allergic anaphylaxis”. 3% were non‐IgE‐mediated anaphylaxis. Adherence to guidance was similar to the baseline survey for waiting time for clinic assessment. However, lack of testing for chlorhexidine and latex, non‐harmonized testing practices and poor coverage of all possible culprits was confirmed. Challenge testing may be underused and many have unacceptably delayed assessments, even in urgent cases. Communication or information provision for patients was insufficient, especially for avoidance advice and communication of test results. Insufficient detail regarding skin test methods was available to draw conclusions regarding techniques.Conclusion and Clinical RelevanceCurrent clinical assessment in the UK is effective but harmonization of approach to testing, access to services and MHRA reporting is needed. Expert anaesthetist involvement should increase to optimize diagnostic yield and advice for future anaesthesia. Dynamic tryptase evaluation improves detection of tryptase release where peak tryptase is &l
Harper NJN, Cook TM, Garcez T, et al., 2018, Anaesthesia, surgery, and life-threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6), British Journal of Anaesthesia, Vol: 121, Pages: 172-188, ISSN: 1471-6771
BACKGROUND: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists. There is little published information on management and outcomes of perioperative anaphylaxis in the UK. METHODS: The 6th National Audit Project of the Royal College of Anaesthetists (NAP6) collected and reviewed 266 reports of Grade 3-5 anaphylaxis from all UK NHS hospitals over 1 yr. Quality of management was assessed against published guidelines. RESULTS: Appropriately senior anaesthetists resuscitated all patients. Immediate management was 'good' in 46% and 'poor' in 15%. Recognition and treatment of anaphylaxis were prompt in 97% and 83% of cases, respectively. Epinephrine was administered i.v. in 76%, i.m. in 14%, both in 6%, and not at all in 11% of cases. A catecholamine infusion was administered in half of cases. Cardiac arrests (40 cases; 15%) were promptly treated but cardiac compressions were omitted in half of patients with unrecordable BP. The surgical procedure was abandoned in most cases, including 10% where surgery was urgent. Of 54% admitted to critical care, 70% were level 3, with most requiring catecholamine infusions. Ten (3.8%) patents (mostly elderly with cardiovascular disease) died from anaphylaxis. Corticosteroids and antihistamines were generally administered early. We found no clear evidence of harm or benefit from chlorphenamine. Two patients received vasopressin and one glucagon. Fluid administration was inadequate in 19% of cases. Treatment included sugammadex in 19 cases, including one when rocuronium had not been administered. Adverse sequelae (psychological, cognitive, or physical) were reported in one-third of cases. CONCLUSIONS: Management of perioperative anaphylaxis could be improved, especially with respect to administration of epinephrine, cardiac compressions, and i.v. fluid. Sequelae were common.
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