2023.1 Day 2 VIVA 4

It is 9pm in Scenarioville and you are called by the surgical registrar to provide anaesthesia for an emergency laparotomy for a presumed bowel obstruction. The patient is Clive, a 70 year old, BMI 33 (weight 100kg) male with a past history of well controlled hypertension, hypercholesterolaemia, obstructive sleep apnoea and chronic back pain. His regular medications are:

• Targin 10/5mg BD (Oxycodone 10/ Naloxone 5)

• Perindopril 4mg OD

• Rosuvastatin 20mg OD

What features in this patient’s history would influence your choice of analgesia and why?

• Chronic opioid use:

  • The patient’s use of Targin (Oxycodone/Naloxone) will likely result in opioid tolerance, requiring higher doses of opioids for adequate analgesia.

  • Consider opioid-induced hyperalgesia, which may require multimodal analgesia strategies to avoid excessive opioid dosing.

• Obstructive sleep apnoea (OSA):

  • Increased risk of respiratory depression with opioids, necessitating careful titration and consideration for non-opioid analgesia.

  • Postoperative monitoring in high-dependency care for continuous oxygen saturation monitoring.

• Bowel obstruction:

  • Oral analgesics (including Targin) may be poorly absorbed due to bowel dysfunction, so consider IV opioids or regional anaesthesia (e.g., nerve blocks, epidural).

• Age and comorbidities:

  • Elderly patient with comorbidities (hypertension, hypercholesterolemia) may have reduced physiological reserves, requiring cautious anaesthetic management and multimodal analgesia to avoid hypotension and cardiac complications

What is your approach to multimodal analgesia for this patient?

Intraoperative:

• Opioids (Fentanyl or Remifentanil) for analgesia, considering lower doses to avoid excessive respiratory depression.

• Paracetamol (1g IV) and NSAIDs (e.g., ketorolac) if no contraindications for additional analgesia.

• Regional anaesthesia (e.g., epidural or fascia iliaca block) to reduce opioid requirements and improve post-op analgesia.

Postoperative:

• PCA (patient-controlled analgesia) with opioids for breakthrough pain, considering the patient’s opioid tolerance.

• Ketamine (low-dose) as a rescue analgesic for opioid-sparing, especially in patients with chronic pain.

• Paracetamol regularly and consider NSAIDs (unless contraindicated) for inflammatory pain.

• Monitor for respiratory depression closely due to OSA and opioid use.

What is your approach to the patient’s pain management in PACU 30 minutes post-op?

Attend to the patient:

• Assess pain (Numerical Rating Scale – NRS) and check if any additional analgesia has been administered.

• Check sedation levels (using Ramsay sedation scale) to assess for opioid side effects (e.g., sedation, respiratory depression).

• Assess for any signs of complications (e.g., bleeding, infection, or an undiagnosed bowel issue).

Opioid assessment:

• Review previous opioid administration (PCA, nurse-administered doses).

• Consider increased opioid requirements in patients with chronic opioid use, but balance with risk of respiratory depression.

Multimodal analgesia plan:

• Increase opioid doses cautiously (adjust PCA settings if needed).

• Consider adding IV paracetamol (1g IV), NSAIDs (e.g., ketorolac), and low-dose ketamine if breakthrough pain persists.

• Check for opioid side effects and ensure close monitoring of oxygen saturation due to OSA risk.

• Continuous monitoring in PACU, with specific attention to respiratory function.

How would you manage the transition to the ward for pain control?

• PCA weaning: Gradually decrease the PCA settings as the patient’s pain reduces and oral analgesia is initiated.

• Regular oral analgesia: Start with oral Targin, continuing from their baseline dose, and consider adding paracetamol and NSAIDs for additional pain control.

Transition plan:

• Monitor for breakthrough pain and adjust oral analgesics accordingly.

• Preventive analgesia with regular paracetamol (1g every 6 hours).

• Avoid NSAIDs if renal dysfunction or GI issues are a concern.

• Ensure adequate hydration and renal function (especially with the patient’s chronic conditions).

How would you manage ongoing analgesia on the ward 3 days post-op?

Oral analgesia:

• Continue oral Targin at their regular dose (10/5 mg BD), adjusting as needed for breakthrough pain.

• If pain persists, consider adding NSAIDs or a short-acting opioid like tramadol for flare-ups.

Non-opioid options:

• Paracetamol (1g TDS) for ongoing inflammatory pain.

• Gabapentin (if neuropathic pain is suspected) or duloxetine if pain persists.

Opioid reduction plan:

• Start a tapering plan for opioid use once pain levels improve. Reduce Targin over weeks, transitioning to short-acting analgesics like tramadol or codeine for breakthrough pain.

Discontinuation of NSAIDs:

• If NSAIDs have been used for perioperative pain, consider discontinuation on discharge due to risk of renal impairment and gastric irritation, especially given the patient’s chronic conditions.

How would you address opioid dependence on discharge?

Opioid tapering:

• Slow tapering of opioids to reduce the risk of opioid withdrawal or opioid use disorder.

• If the patient is on high doses, gradual reduction of Targin by 10-20% weekly until a suitable low dose is reached.

Multidisciplinary support:

• Provide education on pain management and opioid risks.

• Refer to a pain management clinic if opioids are required long-term or if pain persists.

What is your plan for the patient’s post-discharge pain management?

• Weaning opioids: Continue to taper Targin gradually and consider transitioning to tramadol or paracetamol for mild pain.

• Non-opioid options: Consider NSAIDs (if safe) or gabapentin for ongoing pain management, especially if there’s neuropathic pain.

• Follow-up: Ensure proper follow-up care for pain management and assess for any long-term opioid use needs.

• Refer to a pain clinic if opioid dependency or chronic pain is identified.