Doing more with less
Transcript of Doing more with less
Editorial 1
Cervical immobilisationcollars in ICU: friend or foe?
The incidence of cervical spine injury
among patients who have suffered blunt
polytrauma is consistently 5% [1,2].
The incidence is even higher amongst
patients who have suffered head injury,
supraclavicular fractures or other non-
contiguous spinal injuries [2–4]. The
impact of these injuries is significant for
the victim and society with a national
annual incidence of 1000 cervical spinal
cord injuries [5] and 100 per 100 000
traumatic brain injuries occurring in the
United Kingdom [6].
A missed or delayed diagnosis of
an unstable cervical spine injury will
increase the likelihood of complica-
tions, being associated with 10 times
the rate of neurological sequelae [7]. In
one pre-Advanced Trauma Life Sup-
port (ATLS) guidelines [8] series, 10%
of patients initially neurologically intact
on arrival in hospital developed a neu-
rological deficit during their emergency
care [9]. A high index of suspicion for
cervical injury is entirely appropriate in
the initial care of any polytrauma
patient and ATLS guidelines have
helped reinforce this approach. As a
result, the most common clinical scen-
ario is who can safely be mobilised and
have their collar removed, i.e. have
their cervical spine ‘cleared’.
Rigid cervical collars seem a reason-
able extrication and transfer adjunct
when used with full (i.e. cervical and
thoracolumbar) spinal immobilisation
and lateral restraints, e.g. sandbags and
taping, but one review concluded there
was insufficient evidence to support
treatment guidelines or standards on
prehospital cervical immobilisation [10].
A London Ambulance Service training
order states that ‘the use of spinal
immobilisation is mandatory in all
unconscious injured patients’, specifying
a correctly-fitting collar and adjuncts
[11]. What actually happens to this
patient in hospital once their cervi-
cal collar has been applied in the
community?
The exclusion of cervical injury on
clinical grounds is reliable with a per-
formance rivalling that of screening
radiographs provided the patient is alert,
has not consumed alcohol or other
intoxicants and no neck signs, relevant
neurological deficits or distracting injur-
ies are present [12–14]. Unfortunately,
patients suitable for clinical exclusion of
cervical injury are by definition less
severely injured and unlikely to require
immobilisation for an extended period.
Unconscious or polytraumatised pati-
ents, 25% of whom have suffered a
severe head injury [15], will require
ICU admission. Despite a number of
clinical guidelines [8,16–18] there is no
clear consensus opinion on what is
required to exclude cervical instability
[19,20]. Therefore following polytrau-
ma, patients admitted to ICU will have
cervical spine injury excluded by one of
two strategies:
1 A normal clinical assessment, par-
ticularly in the absence of MRI or
dynamic fluoroscopy
2 Upon the basis of imaging, i.e. any of
plain films, CT, MRI or dynamic
fluoroscopy. One UK survey showed
48% of ICU’s would consider an
unconscious patient’s cervical spine
clear on the basis of a single lateral plain
film, despite a typical false negative rate
of 15% [20].
The first approach is common but
far from universally accepted [21] and
ensures trauma patients admitted to
ICU often face long delays awaiting
clinical evaluation. In addition, the
effects of head injury in 25% of cases
may never allow meaningful clinical
assessment. Many studies estimate the
risk of an isolated ligamentous injury,
the greatest fear of excluding cervical
spine injury using plain radiographs or
CT, to be well below 1% of evalua-
tions and possibly under 0.1%
[17,22,23]. In the largest study of plain
radiographs to date, only 0.2% of
cervical spine injuries missed were
deemed unstable [24].
Prolonged immobilisation with cer-
vical collar usage is associated with
significant morbidity, most complica-
tions occurring within 48–72 h [22,25].
Most studies investigating cervical col-
lars have used healthy volunteers and
the design of cervical orthoses urgently
requires further clinical evaluation.
Pressure sores related to collars or bed
sores may occur in up to 44% of patients
and can act as a source of sepsis and
require skin grafting [22,26]. Extrica-
tion or rigid collars are inappropriate for
prolonged use in ICU, exerting high
cutaneous pressures and producing
unacceptable rates of necrosis. Elevated
intracranial pressure and obstructed CSF
and venous flow compromise the care
and outcome of patients with head
injuries [27–30]. Airway complications
include difficult intubation [31,32]
and ventilator-associated pneumonia.
Among elderly patients with cervical
spine injuries 26.8% died during treat-
ment, principally due to respiratory
complications [33], and mobilisation
must be seen as a management priority
to reduce chest-related morbidity and
mortality [34]. Venous access is more
difficult and central lines are difficult to
maintain with higher rates of line-
related sepsis [35,36]. At least four
skilled staff are required to log roll the
patient and at least seven for transfers, so
barrier nursing becomes effectively
impossible. Secondary cross contamin-
ation is a hazard for all ICU patients, and
ultimately the entire hospital follow-
ing ward discharge [37,38]. Additional
complications include thromboembo-
lism, gastrostasis and failure of enteral
nutrition.
Though the purpose of the cervical
collar is to maintain the cervical spine in
a neutral position with as little displace-
ment as possible, there is evidence that
collars do not reliably achieve this, one
study concluding ‘Full cervical immo-
bilisation is a myth’ [39]. Collars may
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� 2003 Blackwell Publishing Ltd 1051
actually promote paradoxical motion of
vertebrae and risk cord compromise
especially at the cervicothoracic junc-
tion [39–41] and inappropriately sized
or applied collars exaggerate vertebral
malalignment. Active and forceful neck
movement in patients emerging from
sedation, head injured or agitated
patients wearing a cervical collar may
actually increase the risk of neuro-
logical deterioration requiring either
re-sedation or collar removal.
Among an ICU trauma population
with possible cervical spine injury,
equally effective immobilisation may
be achieved without a cervical collar at
all: one study comparing soft, semirigid
and rigid collars with sandbags and tape
found the latter to provide the most
effective immobilisation [42]. It is highly
likely within ICU, with its inherent
close monitoring and nursing, that
appropriate use of sedation, analgesia
and selective neuromuscular blockade
coupled with sand bags and tape may be
as effective as cervical collars in immo-
bilizing the cervical spine. Therefore, if
the application of a device such as a
cervical collar results in this level of
morbidity and at risk patients may be
managed without one, should its con-
tinued widespread use in ICU be aban-
doned? The balance of risk shifts further
in this direction when one considers that
approximately 90–95% of polytrauma
victims have no underlying neck injury
at all, and in those at risk the vast
majority of injuries can be excluded
with plain films and combined CT,
questioning the absolute requirement
for clinical evaluation. Finally, there is
little indication of the reliability of
clinical criteria within ICU: in one
study, 2% of cervical injuries were
missed in conscious patients [21] and
how does one interpret neck pain in
the individual who has been wearing a
collar for several days?
One argument often given in favour
of collars is that they stop people
‘forgetting the neck’ but there are
plenty of conditions which one
shouldn’t, but could, forget, e.g. unsta-
ble thoracolumbar spine, absent cranial
bone flap, or a difficult airway or
intubation: these can be remembered
with protocols or alternative prompts,
e.g. forehead notes or foot of bed
labels rather than a constricting neck
band.
There is probably little doubt that
cervical extrication collars should con-
tinue to be used by ambulance personnel
and in emergency departments, in con-
junction with lateral restraints and tho-
racolumbar spinal immobilisation. The
cervical collar has become a standard of
prehospital and initial care following
trauma but this is in the absence of
category A or B evidence [43], and we
must certainly examine its attributes
critically beyond this time. Among the
ICU trauma population, where the vast
majority of patients do not have a cervical
injury, the frequent complications and
morbidity of collars becomes increas-
ingly unacceptable. Cervical collars may
not effectively immobilise the neck at all
and critically ill patients, being closely
monitored and nursed, can achieve cer-
vical immobilisation with alternative
techniques, e.g. sand bags and taping.
The practice of insisting patients languish
for days or weeks in a collar awaiting a
clinical evaluation lacks evidence and
almost all significant cervical injuries are
reliably excluded with plain films and
combined CT. An equally effective
approach, avoiding much morbidity,
may be to transfer trauma victims to
ICU in a cervical collar, but have it
removed at the earliest possible oppor-
tunity. A pile of discarded collars at the
door of ICU will allow it to be reapplied
for subsequent transfers or to manage
certain identified cervical injuries.
C. G. T. Morris
E. McCoy
Royal Victoria Hospital,
Belfast BT12 6BA, UK
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2 Demetriades D, Charalambides K,
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pital. Neurosurgery 2002; 50: S7–17.
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Clearance of cervical injury in the
obtunded patient. Injury 1998; 29:
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13 Velhamos GC, Theodoru D, Tate-
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evaluation in the alert, asymptomatic
blunt trauma victim: much ado about
nothing? Journal of Trauma 1996; 40:
768–74.
14 Hoffman JR, Mower WR, Wolfson
AB. Validity of a set of clinical criteria
to rule out injury to the cervical
spine in patients with blunt trauma.
New England Journal of Medicine 2000;
343: 94–9.
15 Michael DB, Guyot DR, Darmody
WR. Coincidence of head and cervi-
cal injury. Journal of Neurotrauma
1989; 6: 177–89.
16 http://www.trauma.org
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for The Surgery of Trauma. Journal of
Trauma 1998; 44: 941–6.
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bility in trauma patients 2000 EAST.
http://www.east.org.
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et al. Evaluation of the cervical spine
in the polytrauma patient. Spine 2000;
25: 2884–91.
20 Gupta KJ, Clancy M. Discontinuation
of cervical spine immobilisation in
unconscious patients with trauma in
intensive care units- telephone survey
of practice in South and West
Region. British Medical Journal 1997;
314: 1652–5.
21 Brooks RA, Willett KM. Evaluation
of the Oxford Protocol For Total
Spinal Clearance in the Unconscious
Trauma Patient. Journal of Trauma
2001; 50: 862–7.
22 Davis JW, Kaups KL, Cunningham
MA et al. Routine evaluation of the
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with dynamic fluoroscopy: a reap-
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1044–7.
23 Davis JW, Phreaner DL, Hoyt DB,
Mackersie RC. The etiology of
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24 Mower WR, Hoffman JR, Pollack
CV Jr, Zucker MI, Browne BJ,
Wolfson AB, The NEXUS Group.
Use of plain radiography to screen for
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Emergency Medicine 2001; 38: 1–7.
25 Ajani AE, Cooper DJ, SceinKestel
CD et al. Optimal assessment of
cervical spine trauma in severe
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32 Gabbott DA. Laryngoscopy using the
McCoy Laryngoscope after applica-
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33 Lieberman IH, Webb JK. Cervical
injuries in the elderly. Journal of Bone
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877–81.
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39 Hughes SJ. How effective is the
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Grob D, Daniels W. The effectiveness
of various cervical orthoses. An in
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used models. Spine 1996; 15: 1624–9.
41 Alberts LR, Mahoney CR, Neff JR.
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42 Podolsky S, Baraff LJ, Simon RR,
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Editorial 2
Doing more with less
Over the past few years, anaesthetic
drug budgets have remained relatively
static, while some departments have
seen active cost reduction programmes
implemented. Over a similar period,
the number of surgical operations per-
formed nationally has increased by
about 20% [1,2]. The complexity of
surgery also appears to be increasing,
with the spending on the five most
common surgical procedures having
gone up by at least 50% from 1998 to
2002 [3]. Combining these statistics
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� 2003 Blackwell Publishing Ltd 1053
clearly demonstrates that the average per
case cost of anaesthesia has decreased.
This is all the more remarkable, given
the high quality of care which we are
expected to provide and that we have
been able to introduce some new
anaesthetic agents during this period.
Whenever budgets come under scru-
tiny, attention is always drawn to the
top spending items. However, appro-
priate cost considerations are needed
since these items include expensive
drugs (high cost per treatment, e.g.
chemotherapy agents) and drugs whose
costs are high because they are used in a
high number of treatments (top line
agents); these latter agents invariably
include anaesthetics. In recent times, we
have seen relatively few new anaesthetic
drugs (and the prospect of others seems
remote), so those there are stand out
dramatically. Increasingly, anaesthetists
are being forced to defend their use of
these agents and sound evidence on
which to base our arguments can be
difficult to find. We are usually aware of
some small clinical benefit, such as faster
recovery, greater cardiovascular stability
or improved ease of use, but demon-
strating clear differences in patient out-
come or indirect financial benefits is
rather more difficult.
For example, in my own subspecial-
ity of day surgery, given the perceived
clinical and financial benefits of rapid
recovery from anaesthesia leading to
early discharge from hospital, the
majority of controlled clinical trials
show, at best, only slightly earlier
awakening and no difference in dis-
charge times following anaesthesia with
sevoflurane, desflurane or propofol
compared with isoflurane. The fact that
there is no clear difference between
discharge times for a variety of agents
used for maintenance of anaesthesia in
this setting, it is more likely that other
clinical or administrative factors have a
greater influence than the agent used for
the anaesthetic., A recent economic
analysis in Anaesthesia concluded that
propofol-isoflurane was a more cost-
effective option for day surgery than
anaesthesia based primarily on either
propofol or sevoflurane [4]. Although
propofol demonstrated the well-known
reduction in postoperative nausea and
vomiting (PONV), this was at a cost of
about £300 per case prevented.
While the randomised controlled trial
is the ‘gold standard’ for evidence-based
medicine, these trials do have some
limitations. They invariably involve
some degree of compromise, meaning
that they may not truly reflect optimal
administration of the anaesthetics under
consideration. For example, studies
comparing intravenous and inhaled
anaesthetics often mandate the use of
opioid analgesics in all groups despite
them not always being necessary in
association with inhaled anaesthesia,
with which they certainly increase the
incidence of PONV [5,6] and may
delay recovery. Furthermore, fresh gas
flows are often far higher than necessary
[4], thereby increasing costs consider-
ably. In addition, randomised trials
often only include relatively healthy
patients. The Department of Health
expects that 75% of elective surgery
will be performed on a day-case basis by
2005 [7]. Patient selection criteria have
already been broadened considerably [8]
and it is likely that older and sicker
patients will increasingly present as day
cases. Newer anaesthetic agents may
offer specific advantages for such patient
groups. For example, induction with
sevoflurane causes less reduction in
arterial blood pressure in elderly patients
compared to propofol [9,10]. Similarly,
times to awakening, orientation and
tracheal extubation were all significantly
shorter following sevoflurane-remifent-
anil compared to sevoflurane alone in
obese (body mass index > 30 kgm)2)
patients undergoing laparoscopic chol-
ecystectomy [11], a group in whom
delayed recovery would surely be dis-
advantageous. Other outcome differ-
ences may be too subtle to measure.
Nurses working in the day case unit
frequently report that ‘specialist’ day-
case anaesthetists achieve quicker and
smoother recovery of their patients than
their colleagues who visit the unit on an
‘occasional’ basis (British Association of
Day Surgery, personal communication),
perhaps in part reflecting the use of
newer anaesthetic drugs.
Focusing on the ‘headline’ drugs in
pharmacy reports can miss other signifi-
cant sources of expense. Regular and
frequent use of ‘cheap’ drugs which are
inappropriate can amount to quite a
substantial cost, especially if harmful
effects are also produced. For example,
metoclopramide is still often prescribed
as a prophylactic anti-emetic, yet it is
almost totally ineffective in preventing
PONV [12]. The combined costs of a
useless drug, managing the outcome
which it fails to prevent and treating the
adverse effects which it induces all make
metoclopramide the least cost-effective
anti-emetic [13]. In a similar way, mor-
phine is an inexpensive analgesic, yet its
routine intra-operative administration to
patients having intermediate day surgery
procedures (e.g. inguinal hernia repair,
varicose vein surgery) often results in
delayed recovery, sedation, dizziness and
PONV. While this might be acceptable if
pain relief were problematic, in practice
the vast majority of such patients are
comfortable after a non-steroidal anti-
inflammatory drug and wound infiltra-
tion with local anaesthetic [14].
What of the future, will we be allowed
any new drugs? This may already be a
somewhat academic point, as the num-
ber of potential new anaesthesia-related
drugs in active development is severely
limited. Several pharmaceutical com-
panies which were once prominent in
our field are no longer investing in
research programmes. This is partially
because they now see no possibility of
recovering their development costs,
even if a promising compound could
be brought to market. As more of our
products become generic, we can also
expect to see far less financial support
from the pharmaceutical industry for
research, education and meetings. Some
of the major sponsors of large national
meetings have already gone and the
available pool is rapidly shrinking. It
has been argued that education could be
provided at a far lower cost than that
associated with drug company spon-
sorship [15]. But who will attend educa-
tional activities, increasingly encroaching
into our ‘free’ time, without at least a
reasonable venue, edible food and reput-
able speakers?
As the health service struggles to
modernise, some new money is being
made available to facilitate change.
The expansion of day surgery was
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1054 � 2003 Blackwell Publishing Ltd
announced along with the commitment
of £68 million between 2002 and 2004
[16] and some of this money should be
directed towards anaesthesia so that we
may use those drugs which we believe
offer advantages to our patients rather
than continuing to struggle to do more
with less.
Ian Smith
Stoke-on-Trent
References1 Office of Health Economics. Com-
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2 Department of Health. Hospital
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3 Department of Health. NHS Refer-
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4 Elliott RA, Payne K, Moore JK et al.
Clinical and economic choices in
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5 Shakir AAK, Ramachandra V, Hasan
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6 Smith I. PONV associated with
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8 NHS Modernisation Agency. National
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9 Thwaites A, Edmends S, Smith I.
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10 Kirkbride DA, Parker JL, Williams
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11 Song D, Whitten CW, White PF.
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recovery for obese outpatients
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2000; 90: 1111–3.
12 Domino KB, Anderson EA, Polissar
NL, Posner KL. Comparative efficacy
and safety of ondansetron, droperidol,
and metoclopramide for preventing
postoperative nausea and vomiting: a
meta-analysis. Anesthesia and Analgesia
1999; 88: 1370–9.
13 Watcha MF, Smith I. Cost-effective-
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ambulatory surgery. Journal of Clinical
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14 Jakobsson J. Postoperative Pain and
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15 Moynihan R. Drug company spon-
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placed at a fraction of its cost. British
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16 Department of Health. Day surgery:
Operational Guide. Waiting, booking
and choice 2002.
DisclaimerThe author has received research funds
and honoraria from various pharmaceu-
tical companies, but particularly from
Abbott Laboratories.
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