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Pain Rounds February 2010

Pain Rounds February 2010. A convergence of pain and morbid obesity. Chris Hayes John Hambridge Debbie Harper. 26 years female: persistent pain in the context of morbid obesity. A tale of 2 admissions related to obesity April – June 2009 (discharge against medical advice)

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Pain Rounds February 2010

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  1. Pain RoundsFebruary 2010 A convergence of pain and morbid obesity Chris Hayes John Hambridge Debbie Harper

  2. 26 years female: persistent pain in the context of morbid obesity • A tale of 2 admissions related to obesity • April – June 2009 (discharge against medical advice) • July 2009 – ongoing • The preceding chapters • Difficult developmental history and adolescence • A complex story • Multiple medical and psychosocial problems • Input from multiple health care professionals

  3. PSYCHOLOGICAL ASPECTS OF MORBID OBESITY It’s no laughing matter…….

  4. Morbid obesity: brief overview • BMI ≥ 40 (or ≥ 35 with serious co-morbidities) • 180cm, 129kg, BMI=40 • 160cm, 102kg, BMI=40 • 2.4% Australian adults morbidly obese • ≈275,000 people, more women than men • 25% of population obese (BMI 30-40) • Prevalence doubling every 5-10 years • Pre-pubescent onset • Associated with socioeconomic disadvantage

  5. PEOPLE OVERWEIGHT OR OBESE ≥ 18 YRS Australian National Health Survey, 2007-8

  6. Health consequences • Obesity vs. morbid obesity? • Increased all cause mortality • Morbidity • CVD; type 2 diabetes; musculoskeletal disorders; endometrial, breast & colon cancers; respiratory disorders • Risks of chronic conditions increases progressively with BMI

  7. What’s it like being morbidly obese? • Survey of formerly morbidly obese who had undergone surgery • Given forced choices between obesity & variety of other conditions • 42% preferred blindness to obesity • 40% preferred BKA • Negative stereotypes held by children, adults, medics, employers etc • Mixed findings regarding psychopathology

  8. Binge eating • 32%-49% BED in surgery presenters

  9. Issues faced by morbidly obese in hospital and community • Stigma • “Freak show” • One of few remaining “safe” prejudices • Made worse by number of staff required for care needs • “Chinese whispers” • Lack of dignity • Difficulty in getting weighed • Morgue only option in JHH • Patients are often weighed at vet’s or weighbridge when home

  10. Multiple levels of overt and covert discrimination • Ultrasound, CT & MRI impossible • Even BP difficult • Lack of appropriate bariatric equipment • Door width! • Special equipment can also add to stigma e.g. throne-like appearance of special chairs • Transport issues (within & outside hospital) • Clothing

  11. Morbid obesity - treatment • No current good evidence for psychological interventions • No current good evidence for pharmacotherapy • Appetite suppressants • Reduced nutrient absorption (orlistat) • Bariatric surgery is recommended treatment

  12. Surgery outcomes • Dramatic reduction in medical co-morbidities in Swedish study (n > 4000) Sjöström et al., 2007 • At two years • 32x reduction in diabetes • 2.6 – 10x reduction for others • At eight years • 5x reduction in diabetes • Weight loss typically 40kg

  13. Does surgery improve psychosocial functioning? • Improved QoL • Decreased depression • Decreased psychopathological symptoms • Binge eating impact depends on type of surgery • Vomiting seems to increase though • Improvements in social/vocational/sexual domains • Generally, improvements are dose dependent • Herpertz, 2003

  14. The early years • No information regarding early childhood • 1995 aged 12 years – admission for a weight reduction program (paediatric endocrinologist and psychiatrist) • Obesity (150 kg) • Obstructive sleep apnoea (OSA): mild – moderate (Camperdown Children's Hospital). CPAP recommended but not accepted. • Skin infection (intertrigo) • School non-attendance • Dysfunctional family

  15. The initial outcomes Weight loss 150 to 135 kg over 6 week admission Non-attendance at F/U appointments with dietician, physiotherapist DOCS notification

  16. Usual themes • Dysfunctional relationship with mother • Sabotage of medical treatment • Restricted social milieu • Eating to regulate all types of emotions • Adolescent intervention • School refusal / bullying • Genetics

  17. Ongoing Problems Depression Agoraphobia – not left home since age 17 years Period of high alcohol use Asthma Worsening OSA, pulmonary hypertension, right heart failure, leg oedema Increasing weight (340 kg)

  18. Admission 1: April-June 2009 • Presenting problem • Fall at home • Ambulance transport after help from fire brigade and ambulance officers • Precipitating problem - Community acquired pneumonia • Initial treatment • BiPAP • Antibiotics

  19. Admission 1: Other problems • Morbid obesity • Poor mobility • Depression, agoraphobia • OSA, pulmonary hypertension, right heart failure • Asthma • Fe deficiency anaemia (menorrhagia)

  20. Admission 1: More other problems • Abnormal LFTs (cholelithiasis, hepatosplenomegaly) • Cellulitis of legs • Heparin induced thrombocytopaenia syndrome (HITS) • Hypothyroidism

  21. Admission 1: Progress • Weight loss of 80 kg (340 to 260 kg) • Some gains in mobility and other problems • Transferred to rehabilitation ward to address broader goals • Discharged home against medical advice

  22. One month later: July 2009 • Re-admitted with cellulitis of left leg and abdominal wall

  23. Broad themes • Ulceration/infection over hip region bilaterally • Antibiotics • Unsuitable for debridement under general anaesthetic • Maggot therapy • Nutrition • Nasogastric and oral feeds • Now down to 160 kg • Albumin 13 up to 29 g/l (33-41)

  24. Broad themes • Respiratory status • Variable compliance with CPAP • Mobility and posture • Physiotherapy • Slings, beds and other specialised equipment • Psychology • Social aspects • Mother’s presence • Co-ordination of care

  25. “A Sizeable Issue” The J3 Experience Physical Mental Emotional Dysfunctional Spiritual Dignity Challenging the Senses Beliefs

  26. Pain issues • Pain sites • Areas of ulceration • Surrounding areas • Related to postural factors • Dressing changes • Focus on external layers and external solutions • Balance of medication V meditation

  27. Pain treatment • Entonox (nitrous oxide, laughing gas) • Escalating requirements • Ketamine infusion • Escalating requirements • The power of the case conference • Limit setting

  28. More pain treatment • Gabapentin • Escitalopram, venlafaxine • Lorazepam • Oral opioids (oral morphine equivalent 240mg) • Oxycontin 20 mg bd • Endone 15 mg q 3 hours • Trialled rotation (hydromorphone, methadone)

  29. Medication adverse effects • Constipation • Sedation • Tolerance • Opioid induced hyperalgesia ?

  30. Where to next ? • Which battles to fight • Balancing empathy with boundaries

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