Pain Management Geriatric Batam Dr Ike

8/12/2019 Pain Management Geriatric Batam Dr Ike

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Pain Management

inPostsurgical Geriatric Patients

CPD

Pain ManangementIDSAI


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Objectives

Problem in post-operative geriatric

patients

Pain pathway

Pain management in postoperative

geriatric patients


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Definition of Pain(International Association for the Study of Pain)

An unpleasant sensoryandemotional experienceassociated

with actual or potential tissuedamage, or described in terms ofsuch damage

From the Latin root poena whichmeans punishment


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Physiological effects of Pain Increased catabolic demands:

poor wound healing Weakness

muscle breakdown

Decreased limb movement : increased risk of DVT/PE

Respiratory effects: shallow breathing

Tachypnea

cough suppression increasing risk of

pneumonia and atelectasis Increased sodium and water retention (renal)

Decreased gastrointestinal mobility

Tachycardia and elevated blood pressure


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Psychological effects of Pain

Negative emotions:

Anxiety

Depression

Sleep deprivation

Existential suffering:

May lead to patients seeking active end of life.


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Immunological effects of Pain

Decrease natural killer cell counts

Effects on other lymphocytes not yet defined.

Increase the possibility of infection


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Potensial problems of geriatric patients

Aging is associated with decliningphysiologic reservesand an increasedsusceptibility to disease

In the eldery : physiologic reserve used tomaintain homeostasis

Increase demands of surgical stress or

acute illness

reserve no longer presentimbalance between demands andreserves organ failure may result


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Cardiac : Progressive decrease in the number of myocyte and

increase in collagen content decrease inventricular compliance

Autonomic tissue is replaced by conective tissue, fat,and fibrosis caused abnormalities of conductionsystem( sick sinus syndrome, atrial arrhythmia,bundle branch block )

Progressive stiffening of the outflow tract and greatvessels increase systolic BP, increasedresistance to ventricular emptying, andcompensatory ventricular hypertrophy


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Cardiac : Resting cardiac output, and ejection fraction are

maintained

Maximal heart rate, maximal aerobic capacity, peak

exercise cardiac output, and peak ejection fraction decrease with increasing age

In young age during exercise CO maintained byincreasing HR caused by sympathetic outflow

In elderly hyposympathetic statein exercise

CO maintained by increasing ventricular filling( preload ) and stroke volume

Minor hypovolemia can result in significantcompromise in cardiac function


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Cardiac disease is the most commoncomorbid condition

In the Framingham Heart Study:

In the age 7584years myocardialinfarction was unrecognized ( silent ) in >40%of patients compare to < 20% in theage 4554 years

In the elderly MI frequently present with thesymptoms of shortness of breath, acuteconfusion, stroke ( and not chest pain )


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Respiratory Progressive decrease in :

Chest wall compliance( structural changes andkyphosis and vertebral collapse )

Strength of respiratory muscle cause Maximum

Inspiratory and Expiratory force decrease by 50% Loss of elasticity of the lungincrease alveolarcompliance and collaps of small airway

Leads to ventilationperfusion mismatch decline inPaO2 0.30.4 mmHg/per year

The control of ventilation ventilatory responses tohypoxia and hypercapnia fall by 50% and 40%

The loss of cough reflexes predisposed toaspiration

Progerssive decrease in Tcell function leads to

infections


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Renal

Between 2585 years old 40% of the

nephrons become sclerotic

The remaining functional unit become

hypertrophy in a compensatory manner

RBF falls by 50%

Decline in GFR ; 45%in the age 80 years Creatinin clearance decline 0.75cc/min per

year


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PAIN THRESHOLD WITH AGING

Author Stimulus Threshold

Shumacher, 1940 Thermal No Change

Birren, 1950 Thermal No ChangeSherman, 1964 Electric/Tooth Higher

Collins, 1968 Electric/Skin Lower

Harkins, 1977 Electric/Tooth No Change

Tucker, 1989 Electric/Skin Higher


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Age Related Differences in SensoryReceptor Function

Encapsulated end organs

50% reduction in Pacinis

10-30% reduction Meissners/Merkels

Disks

Free nerve endings

no age change


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Age Related Differences in

Peripheral Nerve Function

Myelinated nerves

Reduction in density (all sizes including small)

Increase in abnormal/degenerating fibres Decrease in action potential/slower

conduction velocity

Unmyelinated nerves

Reduction in number(1.2-1.6un) not (.4un)

Substance P, CGRP content decreased

Neurogenic inflammation reduced


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Age Related Differences in

Central Nervous System Function

Loss of dorsal horn spinal neurons

Altered endogenous inhibition, hyperalgesia.

Loss of neurons in cortex, midbrain, brain stem (18% reduction in thalamus, no change

cingulum cortex)

Altered cerebral evoked responses (increased

latency, reduced amplitude)

Reduced catecholamines, acetylcholine, GABA,5HT, not neuropeptides


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NOCICEPTION

PAIN

SUFFERING

PAIN BEHAVIORPostoperative

pain


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Pain has several detrimental effects in older

persons

Physical / functional Increase morbidity and worsen

the existing comorbidity

CVS morbidity

Delayed wound healing

Increase risk of infection sleep disruption

appetite disturbance

weight loss

cognitive impairment

limitations in performance ofdaily activities

Global quality of life

poorer health status

use health care services

Psychosocial

depression

suicide risk anxiety

social isolation


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Sensitization of Pain Transmission

Pain transmission system can be sensitized

by noxious stimuli.

Explains many chronic pain syndromes

where pain perception is distorted

Allodynia- lowering of pain thresholds tonormally non-noxious stimuli

Hyperalgesia- lowering of pain thresholds tonoxious stimuli

Secondary hyperalgesia- spread of pain andhyperalgesia to uninjured areas

Spontaneous pain- pain in absence ofnoxious stimulation, pain memory


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Peripheral

sensitization

to pain:

Hyperalgesia

increased sensitivity to

an already painful

stimulus

Allodynia

normally non painful

stimuli are felt aspainful


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Strategy in Postoperative Pain Management

Preemptive strategy

Balance analgesia multimodal approach

Consider pharmacodynamics and

pharmacokinetics of the drugs used in painmanagement

Assessment and evaluation of the treatment

effect Early intervention to under-treatment and side

effect


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Narcotics

Sustained Release

ATC

Immediate Release

PRN

Nonsteroidal

anti-inflammatory

Non-narcotic

analgesic

Multi-modalapproach


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The Concept of post operative acute pain

treatment and rehabilitation.

From Kehlet H : Modification of responses to surgery by neural blockade : Clinical implication

( Critical care clinics 1999)

Pre-Op Education, Preparation,Planning

Pre and Intra-Op Analgesia and Physiological

Stabilization

Post-Op

Analgesia

Acute

Rehabilization

Drug Modalities

Spinal Route first 24-48 hrsEarly deletion of Opioids

Non Drug Modalities

Surgical care

Local (eg. Wound, avoidance of tubes )

General ( eg. CVS, respiratory, metabolic,

nutrition - early use of oral route )

Physical and mental Reactivation

Emphasis on spinal/epidural

Regional where appropriate

1) Geriatric


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Postoperative Pain Management in Elderly

Evaluation requires multifaceted andcomprehensive assessment

- pain characteristics

- other medical illnesses

- pain impacts

- cognitive functions

- utilization of coping strategies

- functional status- beliefs and attitudes toward pain

- social situation and support


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The most reliable indicator of

the existence pain and its

intensity is the patients

description.

Assessment and

Evaluation of Pain

intensity


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MISCONCEPTIONS ABOUT PAIN

Myth: If they dont complain, they dont have pain

Fact: There are many reasons patients may be

reluctant to complain, despite pain that

significantly effects their functional status and

mood.


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REASONS PATIENTS MAY NOT

REPORT PAIN

Fear of diagnostic tests

Fear of medications

Fear meaning of pain

Perceive physicians and nurses too busy

Complaining may effect quality of care

Believe nothing can or will be done


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Postoperative management in the elderly

Existing of multiple medical andnutritional problems, and take severaldifferent medications

treatment with analgesics limiteddue to

risk of adverse effects and problems withcomplex drug interactions

Older persons with dementia or

communication problems are even moreat risk


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Postoperative management in the elderly

likelihood of atypical pain presentationsdue neurologic degeneration Under-report of pain

Misinterpretation of physical sensations

Difficulty using standard pain assessment scales

False beliefs about pain and its management

Lack of scientific evidence to support treatment

approaches


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Local

Anesthetic /

regional block,epidural

Transmision

Modulation

Opioid


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Presynaptic fiber

Substance P, glutamat, neurokininA,

peptide,CGRP

NMDA

AMPA

Wind Up allodynia

hyperalgesia

Dorsal Horn

medula spinalis


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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

12.00 16.00 20.00 24.00

Sedation/side

effect

Analgesia

Pain

T i m e (hour)

Analgesicdrug

concen-tration in blood

THEORETICAL THERAPEUTICWINDOW


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PHARMACOKINETIC GOALS

HOURS

PAIN

NO PAIN

SIDE EFECTS


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Epidural analgesia local anesthetic and

opiat

Epidural analgesi local anesthetic and opiat Limiting the dose of opiat to provide analgesia

Excelent analgesia

Long lasting

Minimal stress responseSide effect :

Local anesthetic :

Sympatethic respons

Diastolic dysfunction preload dependent

Volume maldistribution

Opiat :

Respiratory depression


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The Ten Basic Principles of

Pain Management

5. Do not use the analgetic PRN forcontinuous pain, but ATC (around the clock)

6. Reassure the patient and family that risk of

opioid addiction is rare7. Provide support for the whole family

8. Do not limit modality of approach simply tothe use of analgesics, but also adjuvant

drugs and mind-body techniques.


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The Ten Basic Principles of

Pain Management

9. Prevent or treat side effects of opioids

10.Do not be afraid to ask colleagues advice.

References


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References

Rosenthal RA,Kavics SM. Assessment and management of the geriatricpatients. Critical Care Medicine 2004;32:S92S105

Bandolier Extra. Evidenebased health care. February 2003

Beilin B, et al. The effects of Postoperative pain Management on ImmuneResponse to Surgery. Anaesthesia Analgesia 2003;97:822827

Rabah DM, et al. Postoperative Pain Current management concepts.Contemporary Urology Archive; August 2003: 111

Karani R, et al. Systemic Pharmacologic postoperative pain management inthe geridatric orthopaedic patients. Clinical Orthopaedics and relatedresearch, 2004: 425; 2634.

Vaurio LE, et al. Postoperative Delirium : The Importance of pain and painmanagement. Anaesthesia and Analgesia 2006; 102: 12671273.

Levine WC, et al. Anesthesia for the elderly: selected topics. Currentopinion in Anaesthesiology. 2006;19:320324

Wu CL, et al. Postoperative pain and quality of recovery. Current opinion inAnaesthesiology. 2004; 17: 455460

Auburn F, et al. Presictive factors of severe postoperative pain in the

postanaesthesia care unit. Anaesthesia Analgesia 2008; 106:15351541 Chia YY. Et al. Does postoperative pain induce emesis ?. The clinical

Journal of pain 2002; 18: 317323.

Atanassoff P. Effect of regional/ epidural anaesthesia on perioperativeoutcome in high risk patients. contemporary surgery @doedenhealth.com

Modified from Twycross, R: Practical Palliative Care Today. Spring 2000, Vol. 2. Center forPalliative Studies at San Diego Hospice, San Diego.


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Pain Management Geriatric Batam Dr Ike

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