ABM (Art-based medicine)

PONV has been described as "the big little problem" and only until recently the evidence for its prophylaxis and treatment seemed largely confined to poster presentations and small studies conducted by trainees in teaching hospital departments.

But there are a lot of "little problems" in clinical anesthesia which do not gain the attention of our eggheads but can mean a lot to our patients. The little things like the conduct of venepuncture, the application of a mask for preoxygenation, the conduct of regional blockade, and patient position for epidural in labour.

These sort things rarely get the attention of the editorialists but they can certainly be the talk and memories of our patients. Quality of care outcomes usually rank "'patient satisfaction" prominently, and contrary satisfaction scores can vex investigators who otherwise find improved outcomes from an intervention under study. For example, potential satisfaction from a painless postoperative course as a result of a nerve blockade can be lost if the the placement of the block was insufferable. Another example is the pruritis of neuraxial morphine antagonising any satisfaction of lower pain scores after surgery. Instead, the little things become "pearls" conveyed by experienced pratitioners or found in the mullock heaps that are meeting abstract books and journal correspondence sections.

In April 2008 IJOA there is correspondence about what do put down the Tuohey needle before passing the epidural catheter in the labouring parturient. A curious little schism between academics (who would only dare put local anaesthetic through the catheter) and the the workhorse private practitioners who prime the epidural space with 8 - 10 ml of 0.1% bupivacaine. The argument for the latter is an earlier onset of analgesia and a facilitated insertion of the catheter, and ultimately a patient who has sooner analgesia.The contrary academics'view is that the LA through the needle may mask the misplacement of the catheter, placing the patient at risk of inadvertant intrathecal injection, though I think it is more likely to mask an ineffective catheter.

I favour the "private practitioner" approach and usually administer 10ml of 0.08% bupivacaine with fentanyl through the needle prior to the passage of the catheter. Sometimes, such as the parturient with a prohibitive airway risk and a high risk for cesarean I reserve the LA for the catheter only to ensure the catheter is indeed providing bilateral epidural blockade.

In the same edition, there is a transcript of a debate between Tsen and another about the merits of lateral versus sitting positions for neuraxial blockade in labour. This is a topic which can mean so much in practice, but has been little studied so it is a nice one for debate. The points made by the debaters are predictable but nicely succinct and are worth a read. I favour the lateral position.