To replace or not to replace? - Partial coning and a sixth nerve palsy secondary due to displacement of a tunnelled intrathecal catheter for pain control.

We report the displacement of a tunnelled intrathecal catheter causing significant cerebrospinal fluid (CSF) leak, resulting in partial coning and a sixth nerve palsy. The patient had advanced malignant mesothelioma and all other methods of pain control had been unsuccessful. As far as we are aware, there are no published reports of early replacement of an intrathecal catheter in patients with neurological sequelae. Surgical re-siting of the intrathecal catheter produced good pain relief for many months. Doctors involved in the use of indwelling intrathecal catheters for pain control must be aware of the risk of significant neurological sequelae but should not dismiss re-establishment of intrathecal therapy in the presence of significant neurological complications.

Provision of training in chronic pain management for specialist registrars in the United Kingdom.

A study published in 1992 highlighted wide variations in the provision of training in pain management. In this survey, data were collected from both pain clinicians and Programme Directors of the Schools of Anaesthesia to see if there had been any changes in training patterns since the introduction of the Calman training scheme. There did not seem to be a uniform improvement in the provision of training in pain management for Specialist Registrars and many may reach their Certificate of Completion of Specialist Training without a basic knowledge of chronic pain. It is thought that at the present time there will be few Specialist Registrars with sufficient training to take up consultant posts in pain management unless they compete for the much sought after, and often not fully funded, pain fellowships outside their rotations.

Diamorphine and bupivacaine mixtures: an in vitro study of microbiological safety.

A small survey confirms that epidural infusions are often prepared by clinicians and solutions may be changed each day because of fears of microbiological contamination. We have assessed the microbiological safety of six mixtures of diamorphine (0.01-1.0%) and bupivacaine (0.1-0.5%) representing the spectrum of clinically useful concentrations for use as extradural infusions. The solutions were studied for antibacterial activity against common contaminants of fluids: Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis and a coagulase negative Staphylococcus sp. A saline control was included. Challenge experiments used an inoculum of approximately 5.0 x 10(6) cfu/ml. Mixtures were incubated at 30 degrees C for up to 7 days. Viable counts of all organisms decreased with time for all the formulations tested. Formulations containing 0.5% bupivacaine were rapidly bactericidal, and increasing diamorphine concentrations increased this effect. Formulations with 0.5% bupivacaine had more activity than those with 0.1% bupivacaine. Mixtures of diamorphine and bupivacaine in concentrations used clinically have bactericidal activity against commonly encountered skin organisms. The common practice of changing every day epidural infusions containing these drugs is unnecessary.

Clinical terms project: a coding system for clinicians.

Advances in information management and technology are necessary for improved communication, research and resource management in the health service. The medical profession must be closely involved in the development of a computer-based communications network if it is to be clinically useful and acceptable. The Read codes have been developed by clinicians and form the basis of an entire clinical information system.

Phantom limb pain.

Phantom limb pain is a common sequel to amputation, whether traumatic or surgical. Provision of a pain-free interval before surgery is likely to reduce the incidence of the condition. The possible mechanisms of pain perception in an absent body part and the reasons for the frequent failure of conventional therapy are discussed here.

Dural puncture during attempted stellate ganglion block.

Dural puncture is rarely reported as a complication of stellate ganglion blockade. Breach of the dura occurred in the case described because of the anatomy of the cervical spine.