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An Age Old Problem: Insights from Anaesthesia

This publication discusses the challenges and opportunities in implementing effective analgesia strategies in various surgical specialties. It delves into the importance of pain relief, different analgesic methods, and the impact on patient outcomes, particularly in elderly and high-risk populations. The text explores the use of opioids, non-opioid methods, and regional techniques, highlighting the need for careful assessment and consideration of individual patient needs. The implications of changing hospital practices, such as enhanced recovery protocols and day case target rates, are also analyzed. Overall, this resource provides valuable insights into optimizing surgical analgesia for improved patient care.

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An Age Old Problem: Insights from Anaesthesia

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  1. An Age Old Problem:Insights from Anaesthesia Chair Acute Pain Special Interest Group – British Pain Society Chief of Staff, Anaesthetics, Critical Care, Pain & Resuscitation CPG. BCUHB, North Wales Dr David Counsell MB ChB FRCA FFPMRCA PhD

  2. Give me a Challengeand I’ll show you an Opportunity. D.J Counsell 2010???

  3. Changing Hospital Practice • Implications of:- • Day case target rates of 85%. • Eyes 100% but rarely GAs, minimal analgesia. • Appropriate in elderly? • Enhanced recovery (hip, knee, colorectal etc.) • 100% Elective admission on day of surgery. • Less opportunity to go daft? • Increase risk to elderly patients? • Reduced bed numbers but ‘sicker’ patients.

  4. Why Give Pain Relief? • Humanitarian

  5. Pillars Of Analgesia • Pain Assessment • Multi modal Analgesia • Opioids, NSAIDS, Paracetamol, Local, Other. • Patient Controlled Analgesia • Humanitarian but doesn’t reduce morbidity. • Relies on Dexterity and Understanding Often Difficult • Careful Assessment • May Precipitate Confusion

  6. Post operative Analgesia • Dilemma • Opioids • confusion, • no reduction in morbidity • Regional techniques • Hypotension (spinal/epidural), • Immobility (nerve blocks) • But do lower morbidity/mortality • Hypotension easily managed on HDU • resource issues. Opium Poppies – Andalucia, Spain Circa 4500 BC

  7. 4 Clinical Groups • Report conclusions very ‘generalised’. • Unscheduled Admissions • Orthopaedic Trauma – mainly #NOF. • Other Surgery – mainly abdominal. • Scheduled Admissions • Orthopaedic – mainly arthroplasty • Other Surgery • Very different groups. • Very different challenges.

  8. Analgesia – Trauma #NOF • Difficult challenge –opioid aversion, NSAID risk • Opioids – confusion, sleepy, impair self caring with dehydration and poor nutrition. • Non opioid methods including regional blocks done on admission have significant advantages (by Nurses) pre and post op. • Logistics and Issues over who can safely perform/top up blocks limit their use. (ESRA).

  9. Surgical Analgesia • Surgical Emergencies • Assessment/resuscitation ‘delays’ surgery often NBM • Direct Pain Team input mainly daytime, post op. • Opioids less of an issue. • Surgeons will give opioids to acute abdomen patients. • Could use PCA, not just remit of pain team/anaesthetist. Opium poppies; tomb of Psamtek, Saqqara circa 550BC

  10. Analgesia - Arthroplasty • Big reliance on femoral/sciatic blocks. • Limit attempts at early mobilisation. • Adverse effects in Enhanced Recovery • Solutions - Knees • Stop using blocks • Multi-modal, local infiltration. • No drains, Tranexamic acid • No (minimal) opioids • Mobilise on day 0, Home day 2-3

  11. Analgesia Elective Abdominal • High risk patient group. • Epidural Analgesia improves outcome. • Hypotension common - 30% • Failure is common - 30% • Require careful supervision – pain team • Commonly need vasoconstrictors • HDU care if possible 1st 24 Hours

  12. Analgesia – Pain Teams • 25% of hospitals have no pain service. • Does private sector offer same care? • Concerned some are NHS Hospitals (NIPPS) • Those that do are limited hours (not 24/7). • Fully support pain as ‘5th Vital Sign’ but not just a surgical issue in the elderly. • Report underlines need for pain teams. • Under threat due to funding cuts.

  13. Critical Care • Ageism - not rife or not admitted? • Beds at a premium. • Denied epidurals due to lack of HDU bed? • UK ‘poor neighbour’ of Western World in terms of Critical Care beds per capita. • Activity thus far – ‘Damage limitation’

  14. Medicine for Care of Older People. • Agree we need more input. • Many examples of good practice • Orthogeriatricians • 1 only in many trusts (?annual leave) • Often trauma (# NOF) focussed. • Involved in analgesia/pre op blocks. • What about other surgery? • How do we get early involvement? • Do we follow paediatrics model???

  15. Anaesthesia – POAC • Pre Assessment for Scheduled Surgery. • Nurse/Pharmacist led (2 consultant sessions/wk) • Massive opportunity for liaison with MCOP clinicians. • Automatic referral protocol based upon:- • Polypharmacy (4+ medicines) • Frailty (could introduce score) • Asses nutrition, analgesia etc • Identify those ‘at risk’ pre admission to MOCP • Better optimisation. • Focussed care during admission.

  16. Elective Surgery v Palliation • Not ageist to ask if surgery was appropriate. • Die in post-op period or live months/years. • CPET (CPEX) Valuable investigation • Measures anaerobic threshold. • Allows improved risk assessment. • Informed joint decision by patients and clinicians. • Relatively inexpensive. • Cheap kit – labour intensive interpretation. • Technicians currently at a premium • ‘Owned’ by Cardio/Resp medicine. • Limited access for pre op assessment.

  17. Anaesthesia – Delays #NOF • Often our fault. • Does ‘Not Fit’ mean ‘I’m too junior’ • Better consultant Trauma input. • Surgical convenience. • More interesting cases go first. • Left late on list – multiple cancellations. • Systematic • Trauma list provision variable (every day)

  18. Anaesthesia - Intraoperative • Anaesthesia comes out well. • Generally agree with conclusions. • Monitoring – non invasive CVS easily available needs more investment/use. • Hypothermia easily avoidable. • National anaesthetic chart ??? Not deliverable by CDs but something the RCoA might tackle. • Hypotension • Simple strategies exist – bread & butter. • Broader appreciation of risks in Elderly. • Is spinal anaesthesia as safe as we think (NAP 3).

  19. Summary Deaths = Tip of Pyramid. • Other poor outcomes. • Challenging on many fronts. • Underlines importance of pain teams. • Implement 5th Vital Sign. • Introduce appropriate scoring systems. • Support use of high tech analgesia. • Ammunition to defend teams from budget cuts. • Do we need to reconsider the UK provision of Level 2 Critical Care Beds?

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