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
Give me a Challengeand I’ll show you an Opportunity. D.J Counsell 2010???
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.
Why Give Pain Relief? • Humanitarian
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
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
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.
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).
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
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
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
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.
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’
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???
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.
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.
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)
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).
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?