A Plethora of Procedures A Plethora of Procedures in a Persistent Pain in a Persistent Pain Patient Patient – Panoply or Pot Pourri?– Panoply or Pot Pourri?A Proceduralist’s A Proceduralist’s

PerspectivePerspective ((An exercise in An exercise in

alliteration)alliteration)

Mark Davies Mark Davies Snr Staff Anaesthetist Snr Staff Anaesthetist

‘‘Panoply’Panoply’

From the Greek ‘Pan Hopla’From the Greek ‘Pan Hopla’ Full weapons or toolsFull weapons or tools Refers to the full armour Refers to the full armour suit of the Hoplitesuit of the Hoplite

Helmet, breastplate, shield Helmet, breastplate, shield and greaves (along with and greaves (along with sword and lance)sword and lance)

PanoplyPanoply

Also PanoplyAlso Panoply

(An Alabama Arts Festival)

‘‘Pot Pourri’Pot Pourri’

From the French – Literally From the French – Literally ‘rotten pot’‘rotten pot’

An assortment or medleyAn assortment or medley A fragrant mixture of dried A fragrant mixture of dried flower petalsflower petals

Pot PourriPot Pourri

Disclaimer:Disclaimer:Declare No InterestDeclare No Interest

Case PresentationCase Presentation – Mrs B. B. 35 YO – Mrs B. B. 35 YO FemaleFemale Admitted JHH 1/9/08 for management Admitted JHH 1/9/08 for management of painful ulcer on lower left leg of painful ulcer on lower left leg (including ultrasound therapy and (including ultrasound therapy and 22ndnd daily dressing changes) daily dressing changes)

Scaly weeping patch over lateral Scaly weeping patch over lateral left ankle first noted 2004, left ankle first noted 2004, increasing size, biopsy May 2006 increasing size, biopsy May 2006 (non-specific dermatitis), post (non-specific dermatitis), post biopsy skin infection (6 weeks biopsy skin infection (6 weeks antibiotics)antibiotics)

March 2008 completed 23 hyperbaric March 2008 completed 23 hyperbaric treatments but wound persisted, treatments but wound persisted, ketamine and temazepam instituted ketamine and temazepam instituted for dressing changesfor dressing changes

2,000 words worth of 2,000 words worth of picturespictures

Beauty May Be Only Skin Beauty May Be Only Skin Deep:Deep:

Background HistoryBackground History

McCune-Albright Syndrome under care of McCune-Albright Syndrome under care of endocrinologist for many yearsendocrinologist for many years

Initially diagnosed when aged 3Initially diagnosed when aged 3 Precocious puberty (5YO), Café-au-lait neck Precocious puberty (5YO), Café-au-lait neck and occiput, polyostotic fibrous dysplasia and occiput, polyostotic fibrous dysplasia skull, legs, arms and pelvisskull, legs, arms and pelvis

Left oophorectomy aged 15Left oophorectomy aged 15 11stst available inpatient records from February available inpatient records from February 1992 (18 YO) when admitted with “tension-1992 (18 YO) when admitted with “tension-vascular” headachevascular” headache

Receiving thyroxin and Rocaltrol prior to Receiving thyroxin and Rocaltrol prior to that admission (History of hypophosphataemic that admission (History of hypophosphataemic Rickets and hypothyroidism), OCPRickets and hypothyroidism), OCP

McCune - Albright McCune - Albright SyndromeSyndrome First described in 1937 by both Donovan First described in 1937 by both Donovan McCune and Fuller Albright independentlyMcCune and Fuller Albright independently

Characterised by at least two of:Characterised by at least two of:– Autonomous endocrine hyperfunction such as Autonomous endocrine hyperfunction such as precocious puberty, thyrotoxicosis, pituitary precocious puberty, thyrotoxicosis, pituitary gigantism, Cushing’s gigantism, Cushing’s

– Polyostotic fibrous dysplasia (particularly of skull Polyostotic fibrous dysplasia (particularly of skull or long bones)or long bones)

– Café-au-lait spots with irregular edges (“Coast-of-Café-au-lait spots with irregular edges (“Coast-of-Maine Lesions”)Maine Lesions”)

McCune, D. J.; Bruch, H. Progress in pediatrics: McCune, D. J.; Bruch, H. Progress in pediatrics: osteodystrophia fibrosa. Am. J. Dis. Child. 54: 806-848, osteodystrophia fibrosa. Am. J. Dis. Child. 54: 806-848, 19371937 Albright, F.; Butler, A. M.; Hampton, A. O.; Smith, P. Albright, F.; Butler, A. M.; Hampton, A. O.; Smith, P. Syndrome characterized by osteitis fibrosa disseminata, Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction, with areas of pigmentation and endocrine dysfunction, with precocious puberty in females: report of five cases. New precocious puberty in females: report of five cases. New Eng. J. Med. 216: 727-746, 1937Eng. J. Med. 216: 727-746, 1937

Café-au-laitCafé-au-lait (“Coast-of-Maine Lesion”)(“Coast-of-Maine Lesion”)

Fibrous dysplasiaFibrous dysplasia

McCune - Albright McCune - Albright SyndromeSyndrome Rare condition - UK population prevalence Rare condition - UK population prevalence estimated 1:100,000 to 1:1,000,000estimated 1:100,000 to 1:1,000,000

Post-zygotic mutation of GNSA1 (Gs alpha) gene Post-zygotic mutation of GNSA1 (Gs alpha) gene (chromosome 20) in one stem cell(chromosome 20) in one stem cell

All descendant cells affected, other calls are All descendant cells affected, other calls are not (mosaicism). Germ-line mutation thought to not (mosaicism). Germ-line mutation thought to be lethal therefore mosaic is the only seen be lethal therefore mosaic is the only seen phenotypephenotype

Failure of normal regulation of cell membrane Failure of normal regulation of cell membrane G-proteins results in over-production of cAMP G-proteins results in over-production of cAMP with multiple consequences (such as excessive with multiple consequences (such as excessive hormone production) hormone production)

Association with sudden cardiac death but no Association with sudden cardiac death but no known characteristic arrhythmiasknown characteristic arrhythmias

Adenyl cyclase upregulation in Adenyl cyclase upregulation in McCune-Albright SyndromeMcCune-Albright Syndrome

More Background from More Background from the Mouldy Recordsthe Mouldy Records Oct 1992 - Admission for abdominal Oct 1992 - Admission for abdominal pain, H/O multiple ovarian pain, H/O multiple ovarian cysts, ?ruptured ovarian cyst, cysts, ?ruptured ovarian cyst, conservative managementconservative management

Jan 1993 - Admission for Jan 1993 - Admission for pamidronate therapy, causalgia pamidronate therapy, causalgia dorsolateral right foot secondary dorsolateral right foot secondary to common peroneal lesion after to common peroneal lesion after right leg osteotomy noted - no right leg osteotomy noted - no specific analgaesic regimespecific analgaesic regime

Now the Fun Starts:Now the Fun Starts:July to Sept 1993 July to Sept 1993 9/7/93 - Admitted JHH with fractured left femur (recurrent)9/7/93 - Admitted JHH with fractured left femur (recurrent) Transferring with crutches, fell, painful left hip and thighTransferring with crutches, fell, painful left hip and thigh Fracture diagnosed ? on clinical grounds (grossly dysmorphic Fracture diagnosed ? on clinical grounds (grossly dysmorphic

femur)femur) Initially IM pethidine - 19 injections in 3 days, H-R Initially IM pethidine - 19 injections in 3 days, H-R

tractiontraction 13/7 - APS involved - PCA (pethidine, morphine, fentanyl) 13/7 - APS involved - PCA (pethidine, morphine, fentanyl) 15/7 - 21/7 Femoral nerve catheter - Burstal - (persistent 15/7 - 21/7 Femoral nerve catheter - Burstal - (persistent

lateral thigh pain)lateral thigh pain) 23/7 - Methadone commenced23/7 - Methadone commenced Relaxation tapes and meditation techniques noted to Relaxation tapes and meditation techniques noted to

significant component of pain management techniquessignificant component of pain management techniques 10/8 - Mood lability with incident pain noted10/8 - Mood lability with incident pain noted 10/8 - Traction removed, out in chair 25/810/8 - Traction removed, out in chair 25/8 Off to hydrotherapy, up in FSF, discharged 1/9Off to hydrotherapy, up in FSF, discharged 1/9

More Fun: Late 1993 - More Fun: Late 1993 - 19941994

Craniotomy Nov 1993 - Craniotomy Nov 1993 - Decompression right optic nerveDecompression right optic nerve

Admitted 2/1/1994 - 10/1/1994 Admitted 2/1/1994 - 10/1/1994 severe intractable migrainesevere intractable migraine

Craniotomy March 1994 - Craniotomy March 1994 - Decompression left optic nerve Decompression left optic nerve (visual acuity both eyes 6/18, (visual acuity both eyes 6/18, left lateral upper quadrant left lateral upper quadrant blindness)blindness)

So So MuchMuch Fun 1995/96 Fun 1995/96

27/12/95 – Significant visual 27/12/95 – Significant visual deterioration associated with deterioration associated with migraine episode but no recovery of migraine episode but no recovery of vision with headache resolutionvision with headache resolution

10/1/96 to 19/1/96 – Booked 10/1/96 to 19/1/96 – Booked admission, right optic nerve admission, right optic nerve decompressiondecompression– Vision: R light/dark (some post-op Vision: R light/dark (some post-op improvement), L 6/6improvement), L 6/6

– My first contact (PCA manipulation) My first contact (PCA manipulation)

Mid 1996: Shit Happens Mid 1996: Shit Happens (Again)(Again)(Admission 28/5/96 to 6/6/96)(Admission 28/5/96 to 6/6/96) Fall from crutches in supermarketFall from crutches in supermarket ?#R radius and ulna, ?#L subcapital ?#R radius and ulna, ?#L subcapital NOFNOF

Morphine infusion, PCAMorphine infusion, PCA 30/5/96 - Seen by sexual assault 30/5/96 - Seen by sexual assault service, Psych liaison involvement service, Psych liaison involvement requestedrequested

2/6/96 – Psych liaison, recurrent 2/6/96 – Psych liaison, recurrent nightmares notednightmares noted

6/6/96 – Discharged, R arm in cast6/6/96 – Discharged, R arm in cast

Pause for Amusing Pause for Amusing PicturePicture

1998: Now Non-Chargeable 1998: Now Non-Chargeable (But Still Anglican)(But Still Anglican) 24/4/98 – Admitted with severe headache 24/4/98 – Admitted with severe headache and deteriorating vision R eyeand deteriorating vision R eye

Neurosurgical review – Visual Neurosurgical review – Visual disturbance settleddisturbance settled

Dr S Lord’s first contact with BBDr S Lord’s first contact with BB 27/4/98 – Discharged, discharge 27/4/98 – Discharged, discharge diagnoses included “anxiety disorder” diagnoses included “anxiety disorder” and H/O sexual assault again notedand H/O sexual assault again noted

Noted to be living with friends, Noted to be living with friends, ambulant on crutches and reasonably ambulant on crutches and reasonably independentindependent

But…But…

…“…“Wait…There’s More”Wait…There’s More”

A Little Less A Little Less Cryptic:Cryptic:

Readmitted 28/4/98Readmitted 28/4/98

Headache, vomiting +++Headache, vomiting +++ Anxiety disorder and depression secondary to chronic Anxiety disorder and depression secondary to chronic

illness and sexual assault again notedillness and sexual assault again noted 28/4/98 – C/O RIF pain28/4/98 – C/O RIF pain

– Enrolled into ‘Appendicitis Study’Enrolled into ‘Appendicitis Study’– But U/S suggested R ovarian cystBut U/S suggested R ovarian cyst

29/4/98 – C/O visual loss L eye, neurology review 29/4/98 – C/O visual loss L eye, neurology review advised against opioids, PCA stopped, regular advised against opioids, PCA stopped, regular droperidol and ergotaminedroperidol and ergotamine

Decreased LOC 2hrs after ceasing PCA and starting Decreased LOC 2hrs after ceasing PCA and starting droperidol, given naloxone – “feels odd”droperidol, given naloxone – “feels odd”

30/4/98 – Bilateral greater occipital nerve blocks, no 30/4/98 – Bilateral greater occipital nerve blocks, no benefitbenefit

1/5/98 – Physiotherapy input re management of 1/5/98 – Physiotherapy input re management of headachesheadaches

2/5/98 – Hot packs, neck pillow, encouraged with 2/5/98 – Hot packs, neck pillow, encouraged with mobilisation, simple analgaesics, gradual improvementmobilisation, simple analgaesics, gradual improvement

7/5/98 - Discharged7/5/98 - Discharged

Somewhat Less Than a Somewhat Less Than a Thousand Words:Thousand Words:

Another Excremental Another Excremental Event:Event: 13/9/99 - Admitted JHH after fall onto L hip13/9/99 - Admitted JHH after fall onto L hip Severe pain L hip, unable to weight-bear, syncopal Severe pain L hip, unable to weight-bear, syncopal

episode asociated with painepisode asociated with pain X-Ray - ?new # L hipX-Ray - ?new # L hip Bed-rest, PCA till 30/9/99Bed-rest, PCA till 30/9/99 23/9/99 - Liaison psychiatry contact:23/9/99 - Liaison psychiatry contact:

– Poor mood and sleep disturbance (nightmares) Poor mood and sleep disturbance (nightmares) notednoted

– Current suicidal thoughts deniedCurrent suicidal thoughts denied– History of sexual assault 4 years previously, History of sexual assault 4 years previously, had subsequently accessed a number of mental had subsequently accessed a number of mental health serviceshealth services

– Suicide attempts in past, most recently early Suicide attempts in past, most recently early that yearthat year

– Noted to be employing various alternate methods Noted to be employing various alternate methods of stress management (eg meditation and Reiki)of stress management (eg meditation and Reiki)

– Assessed as mixed picture of depression and Assessed as mixed picture of depression and post-traumatic stress responsepost-traumatic stress response

2/10/99 - Transferred to RNH and an unavailable set 2/10/99 - Transferred to RNH and an unavailable set of mouldy medical recordsof mouldy medical records

Moving Right Along…Moving Right Along…

23/11/00 to 30/11/00 - Craniotomy for L optic 23/11/00 to 30/11/00 - Craniotomy for L optic nerve decompression - some improvement, now nerve decompression - some improvement, now blind in R eye.blind in R eye.

9/12/00 to 17/12/00 - Headache, dysphasia, 9/12/00 to 17/12/00 - Headache, dysphasia, tinnitus - ?raised post-op ICP / ?tinnitus - ?raised post-op ICP / ?epileptiform eventepileptiform event

22/1/01 to 25/1/01 - Headache, worsening 22/1/01 to 25/1/01 - Headache, worsening visual impairment, steroid therapyvisual impairment, steroid therapy

30/5/01 to 11/6/01 - Elective admission for L 30/5/01 to 11/6/01 - Elective admission for L optic nerve decompression, now essentially optic nerve decompression, now essentially blind, persistent post-operative headache, blind, persistent post-operative headache, further psych liaison contact re depression further psych liaison contact re depression and fears for future, discharged on and fears for future, discharged on transdermal fentanyltransdermal fentanyl

More Admissions!More Admissions!(and Buddism)(and Buddism) 30/10/02 - Booked admission, 30/10/02 - Booked admission, laparoscopic aspiration ovarian cystlaparoscopic aspiration ovarian cyst

26/11/04 - Booked admission for 26/11/04 - Booked admission for uterine curettage (now Buddist)uterine curettage (now Buddist)

11/8/05 - Zometa (zoledronic acid) 11/8/05 - Zometa (zoledronic acid) infusioninfusion

22/11/05 to 25/11/05 - 10 day H/O 22/11/05 to 25/11/05 - 10 day H/O headache preceeding complete loss of headache preceeding complete loss of vision L eye and L ptosis, steroid vision L eye and L ptosis, steroid therapy - slight improvementtherapy - slight improvement

15/12/05 - Zometa infusion15/12/05 - Zometa infusion

Another 1000 WordsAnother 1000 Words

What Happens Next?What Happens Next?

Oh for a Decent Oh for a Decent Retrospectoscope…Retrospectoscope… May 2006 - Biopsy skin lesion L ankle, ‘non-May 2006 - Biopsy skin lesion L ankle, ‘non-

specific dermatitis’…but it didn’t stay that wayspecific dermatitis’…but it didn’t stay that way 3/8/06 - First mention of bilateral THR’s 3/8/06 - First mention of bilateral THR’s

(performed at RNSH) - in bone scan report (performed at RNSH) - in bone scan report 25/8/06 - 6/10/06 - Under care of Out-and-About 25/8/06 - 6/10/06 - Under care of Out-and-About

team for management of presumed osteomyelitis L team for management of presumed osteomyelitis L tib and fibtib and fib

30/10/06 to 27/11/06 - Inpatient in RNC, bed-30/10/06 to 27/11/06 - Inpatient in RNC, bed-rest, ulcer dressings (many under sedation / rest, ulcer dressings (many under sedation / anaesthesia) , oxygen therapyanaesthesia) , oxygen therapy

8/1/07 to 16/3/07 - Inpatient in RNC, further 8/1/07 to 16/3/07 - Inpatient in RNC, further bed-rest, oxygen therapy, antifungal therapy, bed-rest, oxygen therapy, antifungal therapy, sedation and ketamine facilitated dressing sedation and ketamine facilitated dressing changes. Discharged after significant reduction changes. Discharged after significant reduction in ulcer size (again)in ulcer size (again)

““And Now for And Now for Something Completely Something Completely Different”…Different”… 20/3/07 to 3/4/07 - 5 day-only admissions for 20/3/07 to 3/4/07 - 5 day-only admissions for sedation / GA facilitated dressing changessedation / GA facilitated dressing changes– Unbelievable amount of paperwork, average 40+ pages per Unbelievable amount of paperwork, average 40+ pages per

admission:admission: Front sheetFront sheet Discharge summary (generally blank)Discharge summary (generally blank) 10 page RFA (sometimes two), mostly blank10 page RFA (sometimes two), mostly blank Clinical pathway guidelines / pre-admission checklistClinical pathway guidelines / pre-admission checklist 2 page nicotine dependent care assessment form (blank - non-2 page nicotine dependent care assessment form (blank - non-smoker)smoker)

Short stay recordShort stay record Falls / Patient Risk Assessment - Always completed, but with Falls / Patient Risk Assessment - Always completed, but with little consistencylittle consistency

Same Day Follow-up phone call form - sometimes completedSame Day Follow-up phone call form - sometimes completed Operating Room Registered Nurses Report (“No count required”)Operating Room Registered Nurses Report (“No count required”) Peri-operative ReportPeri-operative Report On one occasion - Operating Room ‘Down-Time’On one occasion - Operating Room ‘Down-Time’ Data Sheet Data Sheet (clearly labeled “DO NOT PLACE IN MEDICAL RECORD”)(clearly labeled “DO NOT PLACE IN MEDICAL RECORD”)

Our Problem?Our Problem?

Meanwhile, at St. Meanwhile, at St. Elsewhere’s…Elsewhere’s…

25/6/07 - Admitted RPAH for review of leg 25/6/07 - Admitted RPAH for review of leg ulcer careulcer care

Long term severe pain at ulcer site noted Long term severe pain at ulcer site noted with local tenderness and more generalised with local tenderness and more generalised bony pain (exacerbated by bisphosphonate bony pain (exacerbated by bisphosphonate infusions)infusions)

Biopsies inconclusive, pyoderma gangrenosum, Biopsies inconclusive, pyoderma gangrenosum, infection or vasculitis unlikelyinfection or vasculitis unlikely

Possibly venous stasis ulcerPossibly venous stasis ulcer Low positive ßHCG, wished to continue viable Low positive ßHCG, wished to continue viable pregnancy - non-viable on repeat ßHCG, pregnancy - non-viable on repeat ßHCG, hysteroscopy D&Chysteroscopy D&C

Started pregabalin and increasing Started pregabalin and increasing nortriptylinenortriptyline

HBO - A Cable Television HBO - A Cable Television Channel Channel andand a Wound a Wound TreatmentTreatment 18/2/08 to 20/3/08 - 23 18/2/08 to 20/3/08 - 23 hyperbaric oxygen treatments hyperbaric oxygen treatments at POWHat POWH

Biggest problem - Pain with Biggest problem - Pain with dressing changesdressing changes

Pain managed with oral Pain managed with oral ketamine and temazepamketamine and temazepam

Minor improvementMinor improvement

Irrelevance or Irrelevance or Irreverence?Irreverence?

So Much for the Background…So Much for the Background…Now the ForegroundNow the Foreground

331/2 1/2 monthmonth admission to RNCadmission to RNC Inpatient from Sept to mid-DecInpatient from Sept to mid-Dec 4 volumes of mould to add to 4 volumes of mould to add to digital archivedigital archive

4 page Discharge Summary4 page Discharge Summary 3 page Coding Summary:3 page Coding Summary:

– 13 coded diagnoses13 coded diagnoses– 76 coded procedures76 coded procedures

Commode-or / Commodore?Commode-or / Commodore?

‘‘Highlights’ [sic] of Highlights’ [sic] of AdmissionAdmission

1/9/08 - Admitted under dermatologists 1/9/08 - Admitted under dermatologists for inpatient ulcer management (daily for inpatient ulcer management (daily dressings, ultrasound, various Ix)dressings, ultrasound, various Ix)

2/9/08 - ?Neuropathic pain, Pain 2/9/08 - ?Neuropathic pain, Pain Service input requestedService input requested

3/9/08 - APS review, O/T for dressing 3/9/08 - APS review, O/T for dressing changes arranged changes arranged

3/9/08 - HIPS / Hayes review3/9/08 - HIPS / Hayes review– Continue ketamine / temazepam for dressingsContinue ketamine / temazepam for dressings– Suggested Liaison Psych input for help Suggested Liaison Psych input for help applying relaxation techniques and general applying relaxation techniques and general supportsupport

More ‘Highlights’More ‘Highlights’

5/9/08 - O/T for dressings, 5/9/08 - O/T for dressings, oxycodone addedoxycodone added

8/9/08, 10/9, 12/9, 15/9, 17/9, 8/9/08, 10/9, 12/9, 15/9, 17/9, 19/9 - O/T for dressings19/9 - O/T for dressings

22/9 - O/T for uterine curette 22/9 - O/T for uterine curette (endometrial polyp) and leg (endometrial polyp) and leg dressingdressing

22/9 to 24/10 - continued with 22/9 to 24/10 - continued with 3rd to 4th daily O/T dressing 3rd to 4th daily O/T dressing changeschanges

So Now We VAC So Now We VAC (That Sucks)(That Sucks) 27/10/08 - VAC dressing applied27/10/08 - VAC dressing applied

– Detailed regime of downward Detailed regime of downward suction adjustment steps if not suction adjustment steps if not toleratedtolerated

27/10 evening27/10 evening– VAC not tolerated despite PCAVAC not tolerated despite PCA– Suction reduced, Anaesthetic Suction reduced, Anaesthetic registrar contacted, ketamine registrar contacted, ketamine infusioninfusion

This Also Sucks:This Also Sucks:

28/10 - APS / Complex Pain 28/10 - APS / Complex Pain review (Lord)review (Lord)

Noted non-medical strategies: eg meditationNoted non-medical strategies: eg meditation Medical strategies: including methadone and Medical strategies: including methadone and ketamineketamine

Management through RPAH pain clinic (HIPS Management through RPAH pain clinic (HIPS waiting list)waiting list)

Failed trials of gabapentin, pregabalin, Failed trials of gabapentin, pregabalin, nortriptylinenortriptyline

Recommended increases in ketamine, Recommended increases in ketamine, oxycodone and PCA dosesoxycodone and PCA doses

Consultation regarding regional anaesthesia Consultation regarding regional anaesthesia optionsoptions

HIPS Consult DaviesHIPS Consult Davies4th HIPS Consultant:4th HIPS Consultant:

Meanwhile…Meanwhile…

28/10/08 pm - MET call, “bizarre behaviour”, ?28/10/08 pm - MET call, “bizarre behaviour”, ?ketamine SFX, BP 175/105, HR 130 (sinus)ketamine SFX, BP 175/105, HR 130 (sinus)

Troponin normal, ECG unremarkableTroponin normal, ECG unremarkable VAC now removedVAC now removed Ketamine reduced then ceased on 29/10 after Ketamine reduced then ceased on 29/10 after further “dissociative episode”further “dissociative episode”

30/10 - Further episodes of panic off ketamine 30/10 - Further episodes of panic off ketamine - described phenomena of PTSD related to - described phenomena of PTSD related to sexual assault and separate panic attacks, PCA sexual assault and separate panic attacks, PCA off, oral oxycodone, option of lignocaine off, oral oxycodone, option of lignocaine infusion discussed, BB reluctant as would infusion discussed, BB reluctant as would involve move to monitored bedinvolve move to monitored bed

1/11 - Opioid withdrawal episode (dose error)1/11 - Opioid withdrawal episode (dose error)

……A Procedure:A Procedure:

3/11/08 - Left infragluteal sciatic 3/11/08 - Left infragluteal sciatic nerve catheter inserted under U/S and nerve catheter inserted under U/S and nerve stimulator guidancenerve stimulator guidance

4/11 - Initially pain-free but pain 4/11 - Initially pain-free but pain began to recur in eveningbegan to recur in evening

5/11 - No nerve block despite increased 5/11 - No nerve block despite increased in fusion and bolusin fusion and bolus

6/11 - Sciatic catheter out, sharp 6/11 - Sciatic catheter out, sharp burning pain unchanged but bone pain burning pain unchanged but bone pain much bettermuch better

7/11 - Dressing change in theatre (was 7/11 - Dressing change in theatre (was delayed by lack of OT time) delayed by lack of OT time)

Another Procedure:Another Procedure:

11/11/08 - Left mid-thigh sciatic catheter inserted (U/S, 11/11/08 - Left mid-thigh sciatic catheter inserted (U/S, nerve stim)nerve stim)

11/11/08 to 14/11/08 - Pain free, recovery of initial motor 11/11/08 to 14/11/08 - Pain free, recovery of initial motor block on 11/11block on 11/11

14/11 - Tingling of lips, infusion suspended (was ropivacaine 14/11 - Tingling of lips, infusion suspended (was ropivacaine 20mg/hour, clonidine 15mcg/hour)20mg/hour, clonidine 15mcg/hour)

15/11 - Pain back, infusion resumed, pain resolved, low BP and 15/11 - Pain back, infusion resumed, pain resolved, low BP and HR, clonidine removed and rate reduced (14mg/hour)HR, clonidine removed and rate reduced (14mg/hour)

16/11 - Pain returning, infusion rate increased again16/11 - Pain returning, infusion rate increased again 20/11 - Temp 37.9, sciatic catheter removed (Day 10), dressing 20/11 - Temp 37.9, sciatic catheter removed (Day 10), dressing

changes undertaken on ward throughout period of continuous changes undertaken on ward throughout period of continuous block, common peroneal nerve conduction studies performed block, common peroneal nerve conduction studies performed (while catheter in situ), bolus prior to removal(while catheter in situ), bolus prior to removal

21/11 - Pain returned but mood good21/11 - Pain returned but mood good 23/11 - Gate leave to attend meditation centre, episode of 23/11 - Gate leave to attend meditation centre, episode of

palpitations with HR 140 while at homepalpitations with HR 140 while at home 25/11 - ?ulcer larger, loss of adjacent skin integrity25/11 - ?ulcer larger, loss of adjacent skin integrity 28/11 - cardiology consult, ?SVT, start verapamil28/11 - cardiology consult, ?SVT, start verapamil

A Meeting:A Meeting:

Interventional pain management options Interventional pain management options discussed:discussed:– Implanted nerve catheterImplanted nerve catheter– Implanted intrathecal delivery deviceImplanted intrathecal delivery device– Spinal cord stimulatorSpinal cord stimulator– Peripheral nerve stimulatorPeripheral nerve stimulator– Sympathetic block / neurolysis Sympathetic block / neurolysis

‘‘And The Winner is…’And The Winner is…’

Lumbar Sympathectomy!…Performed 4/12/08Lumbar Sympathectomy!…Performed 4/12/08

Why?Why?

Why?Why?

Pain with neuropathic descriptorsPain with neuropathic descriptors Possible role of vascular Possible role of vascular insufficiencyinsufficiency

Duration of effect may offer Duration of effect may offer appropriate time-frame for appropriate time-frame for significant ulcer healingsignificant ulcer healing

Practicable - Resources immediately Practicable - Resources immediately availableavailable

Probably lower risk than most other Probably lower risk than most other considered optionsconsidered options

Outcome:Outcome: 9/12/08 - Case review (Lord):9/12/08 - Case review (Lord):

– Sympathectomy evident (limb warming and Sympathectomy evident (limb warming and increased perfusion)increased perfusion)

– Bone pain now absentBone pain now absent– Incident pain unalteredIncident pain unaltered– Superficial ulcer pain persistingSuperficial ulcer pain persisting– Intranasal ketamine administration device Intranasal ketamine administration device arrangedarranged

– Support further self-management strategiesSupport further self-management strategies 10/12 - Cardiology review:10/12 - Cardiology review:

– ‘‘Benign SVT’, ceased verapamil, start Benign SVT’, ceased verapamil, start flecainideflecainide

17/12 - Discharged (to home), follow-up rehab in 17/12 - Discharged (to home), follow-up rehab in RP Day HospitalRP Day Hospital

Subsequent to Subsequent to Discharge:Discharge: Pain remains problematicPain remains problematic Awaiting MDPAC - Initially Awaiting MDPAC - Initially issues with completion of issues with completion of HIPS Patient Screening HIPS Patient Screening Questionnaire Questionnaire

Medical reviews with Booth Medical reviews with Booth 17/12/08, Pacey 5/2/09 and 17/12/08, Pacey 5/2/09 and 20/5/09, and Hayes 9/4/0920/5/09, and Hayes 9/4/09

Epilogue: Re-Presented Epilogue: Re-Presented 12/08/09:12/08/09:

One Last Procedure - One Last Procedure - ‘For the Road’ ‘For the Road’ (Literally)(Literally) Femoral nerve block and Femoral nerve block and catheter insertion to catheter insertion to provide analgesia during provide analgesia during transfer to RNSH for transfer to RNSH for management of Left Femoral management of Left Femoral FractureFracture

It workedIt worked

So…Pain Procedures in So…Pain Procedures in the Persistent Pain the Persistent Pain Patient?Patient? Panoply or Pot Pourri?Panoply or Pot Pourri? … … PossiblyPossibly Part Placebo?Part Placebo? … … ProbablyProbably Panacea?Panacea?

…Piss Off!