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

D.J Counsell 2010???

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

 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

 Pain Assessment
 Multi modal Analgesia
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Opioids, NSAIDS, Paracetamol, Local, Other.
 Patient Controlled Analgesia
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Humanitarian but doesn’t reduce morbidity.
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Relies on Dexterity and Understanding

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

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

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

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

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

 25% of hospitals have no pain service.
 Does private sector offer same care?
 Concerned some are NHS Hospitals (NIPPS)
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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.

 Ageism - not rife or not admitted?
 Beds at a premium.
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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.
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Many examples of good practice
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Orthogeriatricians
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1 only in many trusts (?annual leave)
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Often trauma (# NOF) focussed.
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Involved in analgesia/pre op blocks.
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What about other surgery?
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How do we get early involvement?
Do we follow paediatrics model???

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

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

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

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

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