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Mark Davies Snr Staff Anaesthetist

A Plethora of Procedures in a Persistent Pain Patient – Panoply or Pot Pourri? A Proceduralist’s Perspective ( An exercise in alliteration). Mark Davies Snr Staff Anaesthetist. ‘Panoply’. From the Greek ‘Pan Hopla’ Full weapons or tools Refers to the full armour suit of the Hoplite

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Mark Davies Snr Staff Anaesthetist

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  1. A Plethora of Procedures in a Persistent Pain Patient – Panoply or Pot Pourri?A Proceduralist’s Perspective(An exercise in alliteration) Mark Davies Snr Staff Anaesthetist

  2. ‘Panoply’ • From the Greek ‘Pan Hopla’ • Full weapons or tools • Refers to the full armour suit of the Hoplite • Helmet, breastplate, shield and greaves (along with sword and lance)

  3. Panoply

  4. Also Panoply (An Alabama Arts Festival)

  5. ‘Pot Pourri’ • From the French – Literally ‘rotten pot’ • An assortment or medley • A fragrant mixture of dried flower petals

  6. Pot Pourri

  7. Disclaimer:Declare No Interest

  8. Case Presentation – Mrs B. B. 35 YO Female • Admitted JHH 1/9/08 for management of painful ulcer on lower left leg (including ultrasound therapy and 2nd daily dressing changes) • Scaly weeping patch over lateral left ankle first noted 2004, increasing size, biopsy May 2006 (non-specific dermatitis), post biopsy skin infection (6 weeks antibiotics) • March 2008 completed 23 hyperbaric treatments but wound persisted, ketamine and temazepam instituted for dressing changes

  9. 2,000 words worth of pictures

  10. Beauty May Be Only Skin Deep:

  11. Background History • McCune-Albright Syndrome under care of endocrinologist for many years • Initially diagnosed when aged 3 • Precocious puberty (5YO), Café-au-lait neck and occiput, polyostotic fibrous dysplasia skull, legs, arms and pelvis • Left oophorectomy aged 15 • 1st available inpatient records from February 1992 (18 YO) when admitted with “tension-vascular” headache • Receiving thyroxin and Rocaltrol prior to that admission (History of hypophosphataemic Rickets and hypothyroidism), OCP

  12. McCune - Albright Syndrome • First described in 1937 by both Donovan McCune and Fuller Albright independently • Characterised by at least two of: • Autonomous endocrine hyperfunction such as precocious puberty, thyrotoxicosis, pituitary gigantism, Cushing’s • Polyostotic fibrous dysplasia (particularly of skull or long bones) • Café-au-lait spots with irregular edges (“Coast-of-Maine Lesions”) • McCune, D. J.; Bruch, H. Progress in pediatrics: osteodystrophia fibrosa. Am. J. Dis. Child. 54: 806-848, 1937 • Albright, F.; Butler, A. M.; Hampton, A. O.; Smith, P. Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction, with precocious puberty in females: report of five cases. New Eng. J. Med. 216: 727-746, 1937

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

  14. Fibrous dysplasia

  15. McCune - Albright Syndrome • Rare condition - UK population prevalence estimated 1:100,000 to 1:1,000,000 • Post-zygotic mutation of GNSA1 (Gs alpha) gene (chromosome 20) in one stem cell • All descendant cells affected, other calls are not (mosaicism). Germ-line mutation thought to be lethal therefore mosaic is the only seen phenotype • Failure of normal regulation of cell membrane G-proteins results in over-production of cAMP with multiple consequences (such as excessive hormone production) • Association with sudden cardiac death but no known characteristic arrhythmias

  16. Adenyl cyclase upregulation in McCune-Albright Syndrome

  17. More Background from the Mouldy Records • Oct 1992 - Admission for abdominal pain, H/O multiple ovarian cysts, ?ruptured ovarian cyst, conservative management • Jan 1993 - Admission for pamidronate therapy, causalgia dorsolateral right foot secondary to common peroneal lesion after right leg osteotomy noted - no specific analgaesic regime

  18. Now the Fun Starts:July to Sept 1993 • 9/7/93 - Admitted JHH with fractured left femur (recurrent) • Transferring with crutches, fell, painful left hip and thigh • Fracture diagnosed ? on clinical grounds (grossly dysmorphic femur) • Initially IM pethidine - 19 injections in 3 days, H-R traction • 13/7 - APS involved - PCA (pethidine, morphine, fentanyl) • 15/7 - 21/7 Femoral nerve catheter - Burstal - (persistent lateral thigh pain) • 23/7 - Methadone commenced • Relaxation tapes and meditation techniques noted to significant component of pain management techniques • 10/8 - Mood lability with incident pain noted • 10/8 - Traction removed, out in chair 25/8 • Off to hydrotherapy, up in FSF, discharged 1/9

  19. More Fun: Late 1993 - 1994 • Craniotomy Nov 1993 - Decompression right optic nerve • Admitted 2/1/1994 - 10/1/1994 severe intractable migraine • Craniotomy March 1994 - Decompression left optic nerve (visual acuity both eyes 6/18, left lateral upper quadrant blindness)

  20. So Much Fun 1995/96 • 27/12/95 – Significant visual deterioration associated with migraine episode but no recovery of vision with headache resolution • 10/1/96 to 19/1/96 – Booked admission, right optic nerve decompression • Vision: R light/dark (some post-op improvement), L 6/6 • My first contact (PCA manipulation)

  21. Mid 1996: Shit Happens (Again)(Admission 28/5/96 to 6/6/96) • Fall from crutches in supermarket • ?#R radius and ulna, ?#L subcapital NOF • Morphine infusion, PCA • 30/5/96 - Seen by sexual assault service, Psych liaison involvement requested • 2/6/96 – Psych liaison, recurrent nightmares noted • 6/6/96 – Discharged, R arm in cast

  22. Pause for Amusing Picture

  23. 1998: Now Non-Chargeable (But Still Anglican) • 24/4/98 – Admitted with severe headache and deteriorating vision R eye • Neurosurgical review – Visual disturbance settled • Dr S Lord’s first contact with BB • 27/4/98 – Discharged, discharge diagnoses included “anxiety disorder” and H/O sexual assault again noted • Noted to be living with friends, ambulant on crutches and reasonably independent • But…

  24. …“Wait…There’s More”

  25. A Little Less Cryptic:

  26. Readmitted 28/4/98 • Headache, vomiting +++ • Anxiety disorder and depression secondary to chronic illness and sexual assault again noted • 28/4/98 – C/O RIF pain • Enrolled into ‘Appendicitis Study’ • But U/S suggested R ovarian cyst • 29/4/98 – C/O visual loss L eye, neurology review advised against opioids, PCA stopped, regular droperidol and ergotamine • Decreased LOC 2hrs after ceasing PCA and starting droperidol, given naloxone – “feels odd” • 30/4/98 – Bilateral greater occipital nerve blocks, no benefit • 1/5/98 – Physiotherapy input re management of headaches • 2/5/98 – Hot packs, neck pillow, encouraged with mobilisation, simple analgaesics, gradual improvement • 7/5/98 - Discharged

  27. Somewhat Less Than a Thousand Words:

  28. Another Excremental Event: • 13/9/99 - Admitted JHH after fall onto L hip • Severe pain L hip, unable to weight-bear, syncopal episode asociated with pain • X-Ray - ?new # L hip • Bed-rest, PCA till 30/9/99 • 23/9/99 - Liaison psychiatry contact: • Poor mood and sleep disturbance (nightmares) noted • Current suicidal thoughts denied • History of sexual assault 4 years previously, had subsequently accessed a number of mental health services • Suicide attempts in past, most recently early that year • Noted to be employing various alternate methods of stress management (eg meditation and Reiki) • Assessed as mixed picture of depression and post-traumatic stress response • 2/10/99 - Transferred to RNH and an unavailable set of mouldy medical records

  29. Moving Right Along… • 23/11/00 to 30/11/00 - Craniotomy for L optic nerve decompression - some improvement, now blind in R eye. • 9/12/00 to 17/12/00 - Headache, dysphasia, tinnitus - ?raised post-op ICP / ?epileptiform event • 22/1/01 to 25/1/01 - Headache, worsening visual impairment, steroid therapy • 30/5/01 to 11/6/01 - Elective admission for L optic nerve decompression, now essentially blind, persistent post-operative headache, further psych liaison contact re depression and fears for future, discharged on transdermal fentanyl

  30. More Admissions!(and Buddism) • 30/10/02 - Booked admission, laparoscopic aspiration ovarian cyst • 26/11/04 - Booked admission for uterine curettage (now Buddist) • 11/8/05 - Zometa (zoledronic acid) infusion • 22/11/05 to 25/11/05 - 10 day H/O headache preceeding complete loss of vision L eye and L ptosis, steroid therapy - slight improvement • 15/12/05 - Zometa infusion

  31. Another 1000 Words

  32. What Happens Next?

  33. Oh for a Decent Retrospectoscope… • May 2006 - Biopsy skin lesion L ankle, ‘non-specific dermatitis’…but it didn’t stay that way • 3/8/06 - First mention of bilateral THR’s (performed at RNSH) - in bone scan report • 25/8/06 - 6/10/06 - Under care of Out-and-About team for management of presumed osteomyelitis L tib and fib • 30/10/06 to 27/11/06 - Inpatient in RNC, bed-rest, ulcer dressings (many under sedation / anaesthesia) , oxygen therapy • 8/1/07 to 16/3/07 - Inpatient in RNC, further bed-rest, oxygen therapy, antifungal therapy, sedation and ketamine facilitated dressing changes. Discharged after significant reduction in ulcer size (again)

  34. “And Now for Something Completely Different”… • 20/3/07 to 3/4/07 - 5 day-only admissions for sedation / GA facilitated dressing changes • Unbelievable amount of paperwork, average 40+ pages per admission: • Front sheet • Discharge summary (generally blank) • 10 page RFA (sometimes two), mostly blank • Clinical pathway guidelines / pre-admission checklist • 2 page nicotine dependent care assessment form (blank - non-smoker) • Short stay record • Falls / Patient Risk Assessment - Always completed, but with little consistency • Same Day Follow-up phone call form - sometimes completed • Operating Room Registered Nurses Report (“No count required”) • Peri-operative Report • On one occasion - Operating Room ‘Down-Time’Data Sheet (clearly labeled “DO NOT PLACE IN MEDICAL RECORD”)

  35. Our Problem?

  36. Meanwhile, at St. Elsewhere’s… • 25/6/07 - Admitted RPAH for review of leg ulcer care • Long term severe pain at ulcer site noted with local tenderness and more generalised bony pain (exacerbated by bisphosphonate infusions) • Biopsies inconclusive, pyoderma gangrenosum, infection or vasculitis unlikely • Possibly venous stasis ulcer • Low positive ßHCG, wished to continue viable pregnancy - non-viable on repeat ßHCG, hysteroscopy D&C • Started pregabalin and increasing nortriptyline

  37. HBO - A Cable Television Channel and a Wound Treatment • 18/2/08 to 20/3/08 - 23 hyperbaric oxygen treatments at POWH • Biggest problem - Pain with dressing changes • Pain managed with oral ketamine and temazepam • Minor improvement

  38. Irrelevance or Irreverence?

  39. So Much for the Background…Now the Foreground • 31/2 monthadmission to RNC • Inpatient from Sept to mid-Dec • 4 volumes of mould to add to digital archive • 4 page Discharge Summary • 3 page Coding Summary: • 13 coded diagnoses • 76 coded procedures

  40. Commode-or / Commodore?

  41. ‘Highlights’ [sic] of Admission • 1/9/08 - Admitted under dermatologists for inpatient ulcer management (daily dressings, ultrasound, various Ix) • 2/9/08 - ?Neuropathic pain, Pain Service input requested • 3/9/08 - APS review, O/T for dressing changes arranged • 3/9/08 - HIPS / Hayes review • Continue ketamine / temazepam for dressings • Suggested Liaison Psych input for help applying relaxation techniques and general support

  42. More ‘Highlights’ • 5/9/08 - O/T for dressings, oxycodone added • 8/9/08, 10/9, 12/9, 15/9, 17/9, 19/9 - O/T for dressings • 22/9 - O/T for uterine curette (endometrial polyp) and leg dressing • 22/9 to 24/10 - continued with 3rd to 4th daily O/T dressing changes

  43. So Now We VAC (That Sucks) • 27/10/08 - VAC dressing applied • Detailed regime of downward suction adjustment steps if not tolerated • 27/10 evening • VAC not tolerated despite PCA • Suction reduced, Anaesthetic registrar contacted, ketamine infusion

  44. This Also Sucks:

  45. 28/10 - APS / Complex Pain review (Lord) • Noted non-medical strategies: eg meditation • Medical strategies: including methadone and ketamine • Management through RPAH pain clinic (HIPS waiting list) • Failed trials of gabapentin, pregabalin, nortriptyline • Recommended increases in ketamine, oxycodone and PCA doses • Consultation regarding regional anaesthesia options

  46. HIPS Consult Davies4th HIPS Consultant:

  47. Meanwhile… • 28/10/08 pm - MET call, “bizarre behaviour”, ?ketamine SFX, BP 175/105, HR 130 (sinus) • Troponin normal, ECG unremarkable • VAC now removed • Ketamine reduced then ceased on 29/10 after further “dissociative episode” • 30/10 - Further episodes of panic off ketamine - described phenomena of PTSD related to sexual assault and separate panic attacks, PCA off, oral oxycodone, option of lignocaine infusion discussed, BB reluctant as would involve move to monitored bed • 1/11 - Opioid withdrawal episode (dose error)

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