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The Glasgow Neurosociety
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in association with SI, or Surgical Neurology International, and SI Digital are happy to present
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the abstracts and discussion of the 10th anniversary Glasgow Neurosociety meeting held in November of 2022 in Glasgow, Scotland.
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Hassan Ishmael is president of the Glasgow Neurosociety at that time. He's from the Wolfson School of Medicine at the University of Glasgow in Scotland and the United Kingdom
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Faculty commentators are Likith L. Akhandi, who's the consultant neurosurgeon at the Queen Elizabeth University Hospital in Glasgow
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And Amy Davidson, a neurologist, also at the University of Glasgow, also at the Institute of Infection, Immunity, and Inflammation in Glasgow, Scotland.
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Other Glasgow neuro hosts were Alidith Middleton, Vice President of Glasgow neuro, and Edica Choudry, another Vice President of Glasgow neuro. Hi everyone, welcome back to our session. Our next
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speaker is Marty Hunter, who will be talking us through perioperative pain assessment and management in the Institute of Neurological Science and audit. I'll hand over to you, Marty. Hi everybody,
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I'm Mary. Thank you so much for the opportunity to do this today. So I'll just talk to you briefly about my audit. It was a small study conducted in the Institute of Neurosciences of September of
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this year. It was a prospective audit, including just 13 patients was quite a small population. I did look at sort of analgesic prescriptions of these patients, their PRN breakthrough requirements,
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the levels of anxiety they had pre and post-op and their sort of guideline compliance overall. And to do this, I looked at the Royal College of Anisthetist guidelines and the NHS, GDC guidelines,
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so looking at their prescriptions and whether they were compliant and also their news charts and how they how they match guidelines.
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So sort of overall headline figures where the deadlines
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were maintained in the vast majority of patients who I spoke to. So two thirds, not perfect, but
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they were maintained quite quite well. And those who did have compliance, it was found that they had reduced levels of postoperative pain so they had reduced average NRS pain scores and they also
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had a reduced PRN requirement so they had just sort of an average of 24 doses required per day versus four for the non-compliant groups. I forgot to mention but the main non-compliance as I find were
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sort of co-prescriptions of opiates so somebody being on a weak opiate and a strong opiate which obviously reduces the efficacy and also having sort of errors in their pain scores recorded. So while
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every single patient did regularly have a pain score taken which is appropriate and sometimes they were noted zero when the patient was reported severe pain so things that could be worked on.
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Interestingly I found that in patients who had chronic pain or more complex pain requirements and guidelines were sort of more often than not followed. So of the five patients who didn't have
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guidelines followed in their care, 80 of them were chronic pain patients. I think this is probably to be expected due to their sort of higher complexity and their increased needs. So it was
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something that was noted and that can be worked on. Pro-optive anxiety also seems to have a bit of a role
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in sort of more severe pain after surgery. So patients who said they were anxious or very anxious, pre-optatively had higher NRS pain scores post-optively on day one and day three. And this was
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quite consistent, actually, and I found that if they'd had a discussion about their pain prior, it was sort of useful in reducing anxiety and also pain scores afterwards. And sort really
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reassuringly. 100 of patients who I spoke to said that their care was either good or excellent so really overall promising for the INS. The sort of main things that I found for this and the
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importance of this study is that up to 40 of surgical patients can have really severe pain after surgery and I'm sure it's well understood that purely controlled post-operative pain is associated with
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things like hyperalgesia and higher levels of chronic pain post-op so it's quite important to know
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when pain can be better controlled and some really promising changes were discussed and I think implemented after this audit as well so the main sort of big thing that's changed is that the
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anaesthetists are now giving people leaflets about their pain control prior to their surgeries so and it gives them a chance to ask questions and read patients a chance to sort of read about their
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analgesic options. It can help increase the quality of their care because they know what to expect post-hopatively and it might help reduce anxiety levels afterwards as well. So hopefully increasing
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quality of care while sort of reducing errors if possible. There was also a discussion on re-education of documentation, so letting ward staff know about the importance of accurate documentation.
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And while the regular documentation is being done, which is really promising, just making sure that every pain score is actually asked and recorded properly so we can sort of have patients who are
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having severe requirements or increasing requirements flagged up quicker. And also, sort of earlier, refers to the acute pain service was discussed as well. patients, especially those with
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chronic pain and complex needs getting sort of spoken to earlier by those who are professionals and experts in it. Of the three patients of the 13 who are referred to the acute pain service, only
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two of them had chronic pain, so it's a way to easily help manage these patient's complex requirements and ensuring that they're getting treated properly as well for their level
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of pain. So I think that's a pretty good summary of what I did, so thank you so much for listening to me. Go on there.
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I mean thank you for that, that was really great. Can I just ask, so I mean I know this is kind of a perioperative pain stuff, obviously as a neurologist, you know, repain is something I deal
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with a lot. But just to contextualise, so
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didn't matter what they were getting an operation for, like, was brain surgery different from spinal surgery? I know that, you know, just 13 patients were involved, but was there a sense that,
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you know, some operations led to more postoperative pain, or do you feel that it was more patient-driven factors? I think it might be the reason for that. No, I definitely agree. I think because
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of the patients that were sort of available to discuss and this with most of my patients were neurosurgery patients and it was more, it was more sort of the longer procedures were definitely
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associated with more pain and max facts patients. They made up just, I think it's four of my patients were max facts and they had really high levels of pain. So I think, yeah, there was an
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element of how
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sort of severe the surgery was that contributed, but also I think I think. there were patients who sort of had higher levels of pain pre-work, who statistically, not statistically sorry, and they
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still had higher levels of pain post-work as well, I'm trying to say. That's, yeah, I'm trying to stand there. And so, just think, oh, I'm sorry, I just have another question, I just popped
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right in my head there, be making notes, let me go back to it.
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Yes, when you talked about the level of anxiety and anxiety, just made me think of it kind of comorbidities, and was there any kind of pattern? Was it people who had more comorbidities? Was it a
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kind of, we know that mental health can play a role in pain? So was it an anxiety related to their surgery or was it people that perhaps had history of anxiety that had more pain? Was there a way
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of teasing that out? I mean, naturally, I guess everyone getting an operation will be a bit anxious, but was it a kind of an unexpected anxiety where you struck by the anxiety, their level of it,
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like, kind of, and keep. And that had a role in the pain, or is it just anyone with any anxiety? I think, you know, that's definitely fair enough. I didn't actually look at sort of chronic or
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sort of diagnosed anxiety, but it was a sort of sliding scale. So I asked people just sort of generally, how are you feeling? And then sort of if they could say they were not anxious at all,
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which would obviously nobody said, um, quite anxious. Um, sort of fairly anxious or very anxious and sort of, um, um, use that. And obviously the patients who said they were very anxious, did
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have the higher pain scores afterwards. And I think that was almost to be expected, but, um, the patients who'd had the discussions about pain. So even if they said they were very anxious and
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they had a nurse or a doctor speak to them about their sort of pain control options and the things that were to come, they said it made them feel better afterwards So, and, and. You'd mentioned
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some interventions, so they need to test how we're given leaflets and the nurses who are gonna do some education around
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the kind of pain skills and things like that. What do you think we could do for the doctors? How can we help more, you know, like the kind of clinicians on the ward? What can we do to help out of
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the pain? So I think the other sort of main thing that was picked up was that there's quite a lot of co-prescription of sort of weak opiates and strong opiates. So just making sure that if you are
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prescribing analgesia, making sure that you're doing it in line with the who you pain matter is probably really good. And then also co-prescribing opiates with paracetamol can reduce the dose you
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need so it can help sort of minimize symptoms for patients, but also maximize their analgesic control. So I think just making sure people regularly sort of think back as well because I'm I know
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personally, I didn't know any of this until I done this project and I find it really useful. So, okay, thank you very much.
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My, that's very, very, can I speak over here? That's very good. And I was going to ask the same question about the nature of the procedure, but doing a prospective study is quite difficult, you
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know, and to stratify them based on creating a whole new spinal and, you know, max factors will be very much more difficult. Yeah, but the pain requirement, the pain relief requirements for
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cranial surgery is very different from a spine surgery. And if you look at the anterior neck, even less than a posterior neck, I think like that. But my question is, with regards to what the
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doctors can do, how have you considered whether these patients had pre-emptive in Well, this year. The two things we normally use are one, but the next thing is to give a pain killer even before
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the patient comes out of an operation. Or as a surgeon, we inject local anesthetic and block the pain from manifesting and the patient wakes up. So that is known. So what are your thoughts on that?
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And have you had any of those factors included in this assessment? Yeah, absolutely. So one of the questions that I sort of checked in the performer was about local anaesthetic use. But there
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wasn't quite enough patients to sort of look at the effect it had on
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pain afterwards. But I would imagine it would reduce it as well. But again, the patients who were having the sort of bigger procedures were the ones who had the local anaesthetic. So I suppose it
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goes hand in hand almost. And as far as the
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other aspect of sort of having sort of having. immediate control. And I think most patients actually had IV paracetamol while in recovery. So it was something that it was 90 or something of
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patients had that done. And I think for those that didn't need it, or for those that didn't get it, they required to get pure endosis as well. That's sort of why noticed. But it wasn't something
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I sort of looked at specifically Yeah, so from your in your study, with the law, any patients on
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patient control analysis here, and how effective do you think them are they are they useful in
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the situation? Probably not in cranial patients, but in at least spinal patients.
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I didn't actually see any on PCA. I've seen, I've seen how effective they are since, especially in patients who are like cancer patients, I think quite a lot of that is very valuable. I think
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letting the patient choose when get their pain controls is for the best because they know their own body and they know what
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they need and I think it's probably quite useful and it's maybe something that could be used a little bit more but again I think most of my patients were cranial patients as well so thinking back and
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how it's probably it would have been better to stratify them Anyway, I think that's all I have, thank you rooms. Thank you. Just got another, just when we're thinking, I mean we're and rightly
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so and kind of petty occupations might be limited what we can do but we're thinking a lot about the medications. Can there ever be a role for kind of adjunct kind of, you know, things that aren't
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tablets or injections, do you think there'd be a role for other ways of trying to cope with pain? I don't know getting the psychologists involved or any other kind of, you know, tens machines,
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anything like that, like we could do anything to reduce the the need for painkillers, so to say. I really think that would be, I think it would be useful, definitely. There's sort of studies
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I've seen that, especially the Royal College of Annesa test, they suggest that using the pre-operative and post-operative periods to make sure the patients are, especially the levels of anxiety,
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make sure there is low as possible, make sure they're understanding what's going on, and it's been shown that if a patient's well-informed of their sort of control and their options, they're more
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likely to have well-managed pains is what I find. So I
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think, yeah, having patients be able to talk about it with somebody's probably really useful. And I suppose that's where the sort of introspective
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personality's coming a little bit as well. So yeah, probably useful.
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Thank you very much Was it?
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Lovely, and I think in that case, Mary, do you have any final comments or anything on your end? No, I don't think so, thank you so much. I know it's quite small compared to some of the other
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ones that pop through, but enjoy
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doing it. No, I think there's any type of respect 'cause that is really hard to do and you've done well, you know. Thanks. Lovely, I'm not - We hope you enjoy these presentations
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