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EDUCATION AND DEBATE: Claire Ripouteau, Ornella Conort, Jean Paul Lamas, Guy-Robert Auleley, Georges Hazebroucq, and Pierre Durieux Quality improvement report: Effect of multifaceted intervention promoting early switch from intravenous to oral acetaminophen for postoperative pain: controlled, prospective, before and after study BMJ 2000; 321: 1460-1463 [Abstract] [Full text]

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Rapid Responses published:

Improving Post-op Analgesia

Trevor Jenkins   (8 December 2000)

It should be Paracetamol, not Acetaminophen

L F Prescott   (6 January 2001)

Learning from outside is about adopt and adapt

Michael Bergström   (15 January 2001)

quality improvement report- acitominophen

Srinivasan Sampathkumar, David Lowe   (16 January 2001)

Efficacy not Cost is the Key

Gary Heyburn   (17 January 2001)

Improving Post-op Analgesia 8 December 2000
Trevor Jenkins, Pharmaceutical Adviser Milton Keynes Primary Care Trust Send response to journal: Re: Improving Post-op Analgesia	This is a good example of how improvements in hospital prescribing practice in post-op care can be achieved. There are a number of flaws in the evidence basis of the medicines used: - there is no mention of use of NSAIDs - There is no benefit to adding dextropropxyphene to paracetamol, in the form of Co-proxamol. These together with non-availability of IV paracetamol limit the article's applicability in the UK. We attempted a similar strategy (1) based on a BMJ article (2) and the Oxford Analgesic League Table (3). Our experiences and lessons learnt were very similar. The fundamental question to ask is "what is the best post-operative analgesic regimen?" rather than "what is usually prescribed for post-op pain?". The mission is to substiute the latter with the former. Once an evidence based framework has been agreed the article shows an effective multi-professional method of implementing guidance that answers that question. References 1. http://www.jr2.ox.ac.uk/bandolier/ImpAct/imp08/i8-4.html 2. http://www.bmj.com/cgi/content/full/314/7093/1531 3. http://www.jr2.ox.ac.uk/bandolier/painres/painpag/Acutrev/Analgesics/Leagtab.html
It should be Paracetamol, not Acetaminophen 6 January 2001
L F Prescott, Emeritus Professor of Clinical Pharmacology University of Edinburgh Send response to journal: Re: It should be Paracetamol, not Acetaminophen	Editor- It was gratifying to see that with the use of an educational programme and local guidelines, Ripouteau et al1 were able to reduce the use of expensive intravenous propacetamol in favour of the cheaper oral combination of paracetamol with d-propoxyphene for postoperative pain relief. However, it is regrettable that paracetamol was referred to by its American name "acetaminophen". It was not stated anywhere in their article that paracetamol and acetaminophen are the same drug (N-acetyl-p-aminophenol, 4-hydroxyacetanilide), or that propacetamol is a prodrug of paracetamol. It is likely that the central issue of this report will have been missed by most readers who will not have been aware that paracetamol and acetaminophen are one and the same. It is difficult to see why the authors preferred "acetaminophen" to paracetamol when the latter name is used exclusively in France, the UK and other European countries. It is even more difficult to understand why the British Medical Journal allowed this confusing substitution, especially since paracetamol is now the International Approved Name for the drug. The use of different names for the same compound is confusing and potentially dangerous. At least in the countries where is known as such, paracetamol should be referred to as paracetamol and not "acetaminophen". Laurie Prescott emeritus professor of Clinical Pharmacology Edinburgh EH10 5EQ laurie.prescott@ed.ac.uk 1 Ripouteau C, Conort C, Lamas,JP, Auleley G-R, Hazebroucq G, Durieux P. Effect of multifaceted intervention promoting early switch from intravenous to oral acetaminophen for postoperative pain: controlled, prospective, before and after study. BMJ 2000;321:1460-3.
Learning from outside is about adopt and adapt 15 January 2001
Michael Bergström Send response to journal: Re: Learning from outside is about adopt and adapt	Editor - I wish to thank BMJ for the first quality improvement report (1) and the editorial (2). In the editorial - your editor Richard Smith wrote; "One of the best ways to improve your journal - or anything- is to keep scanning your environment for good ideas and then copy them". Well beeing a Global Knowledge Explorer and a MD, I agree with the scanning part, although the idea of copying is not what I consider learning is about. Learning is more about - adopt and adapt. This means adjusting it and making it a part of your context. If you believe that learning is about copying , you will be surprised how many times good ideas will fail to work and also surprised about the resistance it will provoke. So Dr Smith, keep on scanning but please be careful with your learning ! Michael Bergström Global Knowledge Explorer, Change Agent, MD Department of Healthcare Improvement, Federation of the Swedish County Councils, Sweden 1. Ripoteau C, Conort O, Lamas JP, Auleley G-R, Hazebrougq G, Durieux P. Effect of multifaceted intervention promoting early switch from intravenous to oral aminophen for postoperative pain; controlled,prospected, before and after satudy. BMJ 2000;321:1460-3 2. Smith R, Quality Improvement reports: a new kind of article. Editorial. BMJ 2000;321:1428 Change Agent, Global Knowledge Explorer, MD Avdelningen för hälso- och sjukvårdens utveckling,LANDSTINGSFÖRBUNDET Landstingsförbundet , SE-118 82 STOCKHOLM
quality improvement report- acitominophen 16 January 2001
Srinivasan Sampathkumar , David Lowe Send response to journal: Re: quality improvement report- acitominophen	Dear Sir - Ripouteau's study1 to improve the cost effectiveness of postoperative pain management is interesting. Though their aim is to improve the implementation of local guidelines, we can not ignore the fact that one of the important routes for drug administration is ignored. They initially used intravenous pro-paracetamol to treat postoperative pain and switched over to oral paracetamol when the patients were able to take oral feeds. Paracetamol can be administered safely as suppositories and it is used widely. The drug can be given after induction of anaesthesia so that it is effective in the immediate postoperative period. It can be given on a regular basis and the problem of postoperative nausea and vomiting does not affect its administration. Rectal paracetamol has wide acceptance in all the age groups. It is safe and easy to administer. The pain on injection and the contact dermatitis to health care personnel could be avoided totally by adopting this route of administration. In this study the nature of the operation was not mentioned but it appears that full control of pain was achieved with paracetamol alone, which is a level one analgesic (WHO). This raises the question - Is a parenteral analgesic required at all and could oral aracetamol- dextropropoxyphene have been started immediately after surgery. Within our unit virtually all-orthopaedic procedures, which do not require postoperative opiates, are treated as day cases and eat and drink within one hour of surgery Srinivasan Sampathkumar Specialist Registrar Anaesthetics David Lowe Consultant Anaesthetist Basildon Hospital, Essex, SS16 5NL 1. Claire Ripouteau, Ornella Conort, Jean Paul Lamas, Guy-Robert Auleley, Georges Hazebroucq, Pierre Durieux. BMJ 2000; 321:1460-3
Efficacy not Cost is the Key 17 January 2001
Gary Heyburn, staff grade orthogeriatrician Royal Victoria Hospital, Belfast Send response to journal: Re: Efficacy not Cost is the Key	EDITOR – We read with interest the paper of Ripouteau et al1 concerning the early switch from intravenous to oral acetaminophen for postoperative pain in an orthopaedic unit in which the authors state that they “evaluated the impact of implementing guidelines on the process of care rather than patient outcome” and that such guidelines reduced costs. However is it logical to separate process from outcome when dealing with analgesia and possible cost benefits? One tablet might be cheaper than two but this is of no interest to the patient if he is in twice as much pain. This is of particular relevence to orthopaedic patients where inadequate pain relief may delay early mobilisation, increase perioperative morbidity and thereby increase costs due to longer hospital stays. We have previously outlined the inadequate levels of analgesia in elderly hip fracture patients treated in an acute orthopaedic ward2 We would contend that this quality improvement report should have included details regarding the patients’ orthopaedic diagnoses and the efficacy of the analgesia, using recognized outcomes, both before and after the interventions. A more complete overall picture would then allow a thorough assessment of the true benefits to patients of early substitution from intravenous to oral acetaminophen. G Heyburn staff grade orthogeriatrician TRO Beringer consultant geriatrician Royal Victoria Hospital , Belfast BT 12 6BA, N. Ireland 1 Ripouteau C, Conort O, Lamas JP, Auley GR, Hazebroucq G, Durieux P. Effect of multifaceted intervention promoting early switch from intravenous to oral acetaminophen for postoperative pain: controlled, prospective, before and after study. BMJ 2000;321:1460-3 ( 9 December) 2 Heyburn G, Jenkinson M, Beringer TRO, Atkinson S. The efficacy of analgesia in the elderly hip fracture patient. Age and Ageing, 2000; 29: ( supplement 1) 26.