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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.

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an age old problem insights from anaesthesia

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

changing hospital practice
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.
pillars of analgesia
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
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
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
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 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
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
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
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
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
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
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
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
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 - 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
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?