David Counsell - National Confidential Enquiry into Patient

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An Age Old Problem:

Insights from Anaesthesia

Dr David Counsell

MB ChB FRCA FFPMRCA PhD

Chair Acute Pain Special Interest

Group – British Pain Society

Chief of Staff, Anaesthetics, Critical

Care, Pain & Resuscitation CPG.

BCUHB, North Wales

Give me a

Challenge and 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

Pain on Movement

Impaired Mobilisation

Pain

Poor Cough/Expectoration

Deep Breathing

Slow Return Of

Lung Function / FRC

Risk of DVT

Increased BP/ Heart Rate

Increased O2 requirements

Global ? Myocardial

Pneumonia

Hypoxia Organ Failure

Organ Ischaemia

MI Gut/Sepsis

Pillars Of Analgesia

 Pain Assessment

Often Difficult

 Multi modal Analgesia

Opioids, NSAIDS, Paracetamol, Local, Other.

 Patient Controlled Analgesia

Humanitarian but doesn’t reduce morbidity.

Relies on Dexterity and Understanding

- 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

Opium Poppies – Andalucia, Spain Circa 4500 BC

Hypotension easily managed on HDU

• resource issues.

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 1 st 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 ‘5 th 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 5 th 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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