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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evaluation and outcome. Journal of

Trauma 2001; 50: 457–63.

2 Demetriades D, Charalambides K,

Chahwan S et al. Nonskeletal cervical

spine injuries: epidemiology and

diagnostic pitfalls. Journal of Trauma

2000; 48: 724–7.

3 Hills MW, Deane SA. Head injury

and facial injury: is there an increased

risk of cervical injury? Journal of

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4 Holly LT, Kelly DF, Counelis GJ,

Blinman T, McArthur DL, Cryer HG.

Cervical spine trauma associated with

moderate and severe head injury:

incidence, risk factors and injury

characteristics. Journal of Neurosurgery

2002; 96 (Suppl.): 285–91.

5 Veale P, Lamb J. Anaesthesia and

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of Anaesthesia CEPD Reviews 2002; 2:

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Miller JD. Etiology and clinical course

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Trauma 1987; 27: 980–6.

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American College of Surgeons 1997.

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tions of the cervical spine: an end

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Surgery 1957; 39A: 341.

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bilization before admission to hos-

pital. Neurosurgery 2002; 50: S7–17.

11 http://www.lasunofficial.co.uk

12 Lockey AS, Handley R, Willett K.

Clearance of cervical injury in the

obtunded patient. Injury 1998; 29:

493–7.

13 Velhamos GC, Theodoru D, Tate-

vossian R et al. Radiographic cervical

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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17 EAST Ad Hoc Committee on Practice

Management Guideline Development.

Practice management guidelines for

trauma from the Eastern Association

for The Surgery of Trauma. Journal of

Trauma 1998; 44: 941–6.

18 Determination of cervical spine sta-

bility in trauma patients 2000 EAST.

http://www.east.org.

19 Harris MB, Kronlage SC, Carboni PA

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

cervical spine in head-injured patients

with dynamic fluoroscopy: a reap-

praisal. Journal of Trauma 2001; 50:

1044–7.

23 Davis JW, Phreaner DL, Hoyt DB,

Mackersie RC. The etiology of

missed cervical spine injuries. Journal

of Trauma 1993; 34: 342–6.

24 Mower WR, Hoffman JR, Pollack

CV Jr, Zucker MI, Browne BJ,

Wolfson AB, The NEXUS Group.

Use of plain radiography to screen for

cervical spine injuries. Annals of

Emergency Medicine 2001; 38: 1–7.

25 Ajani AE, Cooper DJ, SceinKestel

CD et al. Optimal assessment of

cervical spine trauma in severe

nonpenetrating closed head injury: a

prospective study. Anaesthesia and

Intensive Care 1998; 26: 487–91.

26 Watts D, Abrahams E, MacMillan C

et al. Insult after injury: pressure ulcers

in trauma patients. Orthopaedic Nurse

1998; 17: 84–91.

27 Davies G, Deakin C, Wilson A. The

effect of a rigid collar on intracranial

pressure. Injury 1996; 27: 647–9.

28 Hunt K, Hallsworth S, Smith M.

The effect of rigid collar placement

on intracranial and cerebral perfu-

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29 Raphael JH, Chotai R. Effects of the

cervical collar on cerebrospinal fluid

pressure.Anaesthesia1994;49: 437–19.

30 Kuhnigk H, Bomke S, Sefrin P. Effect

of external cervical spine immobil-

ization on intracranial pressure.

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350–3.

31 Kreisler NS, Durieux ME, Spieker-

mann BF. Airway obstruction due to a

rigid collar. Journal of Neurosurgical

Anaesthesiology 2000; 12: 118–19.

32 Gabbott DA. Laryngoscopy using the

McCoy Laryngoscope after applica-

tion of a cervical collar. Anaesthesia

1996; 51: 812–14.

33 Lieberman IH, Webb JK. Cervical

injuries in the elderly. Journal of Bone

and Joint Surgery of Britain 1994; 76:

877–81.

34 Heyland DK, Cook DJ, Griffith L et al.

The attributable morbidity and mor-

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Critical Care Medicine 1999; 159:

1249–56.

35 Corona ML, Peters SG, Narr BJ et al.

Infections related to central venous

catheters. Mayo Clinical Proceedings

1990; 65: 979–80.

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et al. Central venous catheter infec-

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Daschner FD. An epidemiological

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units – a prospective 2 Year analysis.

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39 Hughes SJ. How effective is the

Newport ⁄ Aspen Collar? A pros-

pective radiographic evaluation in

healthy adult volunteers. Journal of

Trauma 1998; 45: 374–8.

40 Sandler AJ, Dvorak J, Humke T,

Grob D, Daniels W. The effectiveness

of various cervical orthoses. An in

vivo comparison of the mechanical

stability provided by several widely

used models. Spine 1996; 15: 1624–9.

41 Alberts LR, Mahoney CR, Neff JR.

Comparison of the Nebraska Collar,

a new prototype immobilisation

collar, with three standard models.

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42 Podolsky S, Baraff LJ, Simon RR,

Hoffman JR, Larmon B, Ablon W.

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ization methods. Journal of Trauma

1983; 23: 461–5.

43 Krock N. Immobilizing the cervical

spine using a collar. Complications

and nursing management. Axone

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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

Anaesthesia, 2003, 58, pages 1051–1055 Editorial......................................................................................................................................................................................................................

� 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

Editorial Anaesthesia, 2003, 58, pages 1051–1055......................................................................................................................................................................................................................

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

Episode Statistics 2000–01.

3 Department of Health. NHS Refer-

ence Costs, 1998–2002.

4 Elliott RA, Payne K, Moore JK et al.

Clinical and economic choices in

anaesthesia for day surgery: a pros-

pective randomised controlled trial.

Anaesthesia 2003; 58: 412–21.

5 Shakir AAK, Ramachandra V, Hasan

MA. Day surgery postoperative nausea

and vomiting at home related to

peroperative fentanyl. Journal of

One-Day Surgery 1997; 6: 10–1.

6 Smith I. PONV associated with

VIMA may be due to opioids; A

prospective audit. Journal of One-Day

Surgery 2000; 10: 12.

7 Department of Health. The NHS Plan

2000.

8 NHS Modernisation Agency. National

Good Practice Guidelines on Pre-Opera-

tive Assessment for Day Surgery 2002.

9 Thwaites A, Edmends S, Smith I.

Inhalation induction with sevoflura-

ne: a double-blind comparison with

propofol. British Journal of Anaesthesia

1997; 78: 356–61.

10 Kirkbride DA, Parker JL, Williams

GD, Buggy DJ. Induction of

anesthesia in the elderly ambulatory

patient: a double-blind comparison of

propofol and sevoflurane. Anesthesia

and Analgesia 2001; 93: 1185–7.

11 Song D, Whitten CW, White PF.

Remifentanil infusion facilitates early

recovery for obese outpatients

undergoing laparoscopic cholecys-

tectomy. Anesthesia and Analgesia

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-

ness analysis of antiemetic therapy for

ambulatory surgery. Journal of Clinical

Anesthesia 1994; 6: 370–7.

14 Jakobsson J. Postoperative Pain and

Emesis: a Systematic Approach. In:

Smith, I, eds. Day Care Anaesthesia.

London: BMJ Books 2000, 155–79.

15 Moynihan R. Drug company spon-

sorship of education could be re-

placed at a fraction of its cost. British

Medical Journal 2003; 326: 1163.

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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