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Improving Pain Treatment in Obese Patients: Challenges and Recommendations

This study explores the inadequate pain treatment in obese patients post-surgery, identifying the reasons behind it and providing recommendations for improvement. It addresses the specific challenges faced in different populations such as the elderly and children. The study also examines the impact of obesity on drug dosage and suggests strategies for individualized pain management. Overall, this research highlights the need for better pain treatment protocols in obese patients.

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Improving Pain Treatment in Obese Patients: Challenges and Recommendations

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  1. Trattamento del dolore postoperatorio nel paziente grande obesoJ P Mulier MD PhDDavid Blacoe, MD Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier JPMulier Pordenone 19 09 2009

  2. Pain is not treated sufficient in obese patients • Obesity is an independent risk factor for having post operative pain and need for extra intervention early after awakening. • retrospective study in 1736 patients under general anaesthesia. • Mei W. et al Eur J Pain. 2009 • Large gaps remains in peri operative pain treatment of obese patients. • Best practice recommendation on peri operative care and pain treatment for weight loss surgery. • Schumann R Obesity 2009 P Rubens JPMulier Pordenone 19 09 2009

  3. Post operative pain is a weighty problem. but more frequent in children, elderly and also in overweight patients WHY ? JPMulier Pordenone 19 09 2009

  4. Insufficient pain treatment in • Elderly Paediatric Obese Because of • Drug studies performed on healthy adults • Dosage difficulty, • Afraid of hypoventilation, sleep apnoea • Access difficulty, • Physician not familiar with • Basic scientific knowledge is missing JPMulier Pordenone 19 09 2009

  5. Pain treatment in elderly is different but need attention • Frequent underreporting of pain tend to under treating pain. • Pergolezi 2008 consensus meeting elderly and pain • Response to mild pain is reduced, but elderly are more sensitive to severe pain. • The elderly respond better to Opiods treatment. • Likar et al. 2009 • However we are more afraid of overdose and sedation. JPMulier Pordenone 19 09 2009

  6. Dosage in geriatrics • Based on pharmacokinetics • Give less in mg/kg body weight to achieve the same plasma level • Based on pharmacodynamics • Give less as effect and side effects are stronger. • Based on metabolism and elimination • Give less frequent as elimination is slower We tend to lower too much and pain is insufficient treated JPMulier Pordenone 19 09 2009

  7. Paediatrics: Not one group • Neonates • Infants • Children • Young adults • Differences in • Body water content • Serum protein composition • Capacity for hepatic biotransformation JPMulier Pordenone 19 09 2009

  8. Children • Based on pharmacokinetics • Hydrophilic drugs with a • high V(d) should be normalised to bodyweight • Low V(d) should be normalised to body surface area (BSA) • Based on developmental physiology • Give less when liver or renal function is not mature. • Individual adapted therapy JPMulier Pordenone 19 09 2009

  9. Pain treatment in children • lack of knowledge, • a deficiency of standardized protocols • the lack of administrative responsibility. Approach: • The prevention • The algorithm for analgesic treatment • The evaluation of the efficiency and give extra pain medication. Peri operative pain therapy in children H Heinrich 2002 JPMulier Pordenone 19 09 2009

  10. What do we know of pain treatment in morbid obese patients? • Frequent under treatment • Stronger reaction to mild pain • Putting an infusion line is more painful • Reaction more like a child • Need more pain killers • Not one group: • Obese – severe obese - morbid obese – super obese – super super obese. • Still a lot to investigate! JPMulier Pordenone 19 09 2009

  11. Obesity: body composition Dosage based on ? • Ideal body weight is not enough - total body weight is too much • Increased blood volume and CO • Increased extra cellular water but not according to body weight (relative more fat ) Increased renal clearance, increased hepatic clearance. • Increased protein binding Chumlea W body water status in obese J nutr Health Aging 2007 JPMulier Pordenone 19 09 2009

  12. Local anaesthetics • Local infiltration: • Growing interest for wound infiltration and use of elastomer pumps. • However not efficient in laparoscopic surgery • Loco regional anaesthesia • Great value but difficult to puncture? • Larger loading dose, but increased spread, prolonged effects. JPMulier Pordenone 19 09 2009

  13. NSAIDs • We tend to underdose • Margarson M 2008 • 1 gr paracetamol vs 3 gr paracetamol • Repeat every 2 hours Our practice: • 2 gr paracetamol per op • 1 gr every 4 hours post op • Combine with diclofenac >10 g and Opiods JPMulier Pordenone 19 09 2009

  14. Opiods • Morphine consumption is less after Sufentanil vs Remifentanil per operative • L Debaerdemaeker BJA 2007 JPMulier Pordenone 19 09 2009

  15. Opiods • Use high dose of Sufentanil at start of operation (25 ug) • Use Remifentanil infusion on top to improve hemodynamic stability • Use post op morphine 25 % more than in non obese according to patients need. • Formula? • Opiods are Part of a Multimodal therapy • PCIA is preferable JPMulier Pordenone 19 09 2009

  16. Our Results in lap RNY • 260 revision from prev RNY JPMulier Pordenone 19 09 2009

  17. Conclusion • Work multimodal • Use ideal body weight +25 % to calculate dose Opiods • Double NSAIDs dose • Start per operative your pain management • Combine with local infiltration and loco regional if possible • Adapt individual JPMulier Pordenone 19 09 2009

  18. Food consumption inhibits pain • Mason P Ann N Y Acad Sci. 2009 • Eating analgesia does not depend on energy-depletion • sucrose is not a necessary component of analgesia-evoking ingestates early oral feeding: new pain therapy? Pieter Breughel Farmers festivity: 1500 JPMulier Pordenone 19 09 2009

  19. ESPCOP President Jan P Mulier Secretary Luc De baerdemaeker Treasurer Nick Kennedy Vice-President Yigal Leykin www.publicationslsit.org/ESPCOP www.espcop.org JPMulier Pordenone 19 09 2009

  20. Attend first ESPCOP meeting14 nov 2009 Ostend Belgium • “The sea” from Georges Grard • Better known as “fat Mathilde of Ostend” JPMulier Pordenone 19 09 2009

  21. Scientific meeting JPMulier Pordenone 19 09 2009

  22. Pieter Paul Rubens • 1577 – 1640 Antwerp Belgium • Flemish baroque painter with Italian influence • Venetia, Florence, Rome • Morbid obese was the ideal body shape of the rich class • Naked obese woman as a sign of wealth • More info: • jan.mulier@azbrugge.be • www.publicationslist.org/jan.mulier JPMulier Pordenone 19 09 2009

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