Download Treatment of Acute Postoperative Pain Christopher Wu, MD

Mai Nguyen
Mercer University COPHS
Doctor of Pharmacy Candidate 2012
November 8, 2011
Preceptor: Dr. Ali Rahimi
Thomas R. Hornick, MD.
Clinics in Geriatric Medicine. 2006;22: 499-513.

In the past, major surgery was rare in the elderly
population.

But now, indications for surgery are being extended to
include older patients for many major operations that
were limited to younger patients not long ago.

In 1996, people >65 yo accounted for 35% of all
operations in the US

In 2002-2003, there were 4.2 million hospital stays with
at least one procedure done in those older than 75 years.

Multiple chronic diseases

Susceptible to common in-hospital complications:
 Adverse drug events
 Delirium
 Functional decline
 Falls
 Incontinence
 Pressure ulcers

Patients’ resultant comfort or sense of well
being

Extent to which they were able to maintain
reasonable physical, emotional, and
intellectual function

Degree to which they retain their ability to
participate in valued activities with the family,
in the workplace and in the community

Measured by questionnaires
 Short-form-36 (SF-36) or its shortened version, shortform-12 (SF-12)

These scales measure areas of mental and physical
health.
 Physical health: physical functioning, problems with
work or other daily activities as a result of physical
problems, bodily pain, and general health perception.
 Mental health: perceived mental health, problems
with work or other daily activities as a result of
emotional problems, social function, and vitality.

HRQOL and joint replacements have been well
studied.

Older individuals who have severe OA have poor
SF-36 scores for pain, physical function, and
problems with work or other daily activities as a
result of physical health.

These scores improve remarkably after joint
replacement, often reaching or exceeding scores
of normal population after 6 months.

Valve replacement surgery has greater risks and
benefits in the elderly.

Rates for short-term mortality range from 8% to
20%, depending on valve and comorbidities.

QOL in those surviving valve replacement is
greatly improved, with improvement in SF-36.
 SF-36 improvement at 18 months was significant in
almost all QOL areas and the mean scores were
comparable to the scores of healthy elderly patients.

Removal of cataracts improves vision and
vision-related QOL with low risk.
 72% to 92% of patients reporting
improvement in visual function after surgery
 89% of patients showing improvement on
vision-specific HRQOL scales

Morbidity and mortality are low despite
its use in the very elderly.

As surgery has been extended into the elderly
population, HRQOL has been added as a
parameter to evaluate surgical success.

Surgery remains of significant risk in older
patients
 Estimate of the type of outcome, including
morbidity, mortality, and HRQOL can aid in that
decision.
Selvon F. St. Clair, et al.
Clinics in Geriatric Medicine. 2006;22: 515-533.

OA is a chronic widespread form of arthritis that affects
all joint structures and commonly manifested in hip and
knee.

Risk factors for OA: genetic origins, microtrauma,
increased cytokine activity, lack of nutrients
(antioxidants), and obesity.

Approximately 68% of total hip arthroplasties and 74% of
total knee arthroplasties are performed on people over
age 65.

THA was developed in the 1960s and is considered the
standard of care for severe end-stage OA of the hip in
elderly patients

Typically takes approximately 1.5 hours to complete

Involves the surgical excision of the head and proximal
neck of the femur and removal of the acetabular
cartilage and subchondral bone
 Replacement of hip joint with prosthetic implant.

TKA is the treatment of choice in patients over 55 years
who have progressive and painful OA and who have failed
nonsurgical and less invasive treatments.

Replacement of diseased or damaged joint surfaces of the
knee with different type of metals, polyethylene, or
ceramics prosthesis.
Intraoperative
Complications (rare)
 Fat embolism
 Nerve injury (sciatic
nerve) with resultant foot
drop
 Vascular injury
 Fractures
Postoperative
Complications
 Infections
Staphylococcus aureus
Prophylactic antibiotic given
within 1 hour of skin incision
and continued for 24 hours
after surgery
 Dislocation after THA due to
implant loosening
 DVT and PE
 Fractures

Minimally Invasive Surgery TKA
 Involves using a limited incision (4-7 in.) down the
midline of knee
▪ Standard TKA involves 8-14 in. skin incision
 Early retrospective results from other centers indicate
positive results with this technique.

Computer-Assisted Navigation TKA
 Increases the accuracy of implantation
 Results in improved outcomes and faster return to
normal functions
Vincent Conti, MD, and Scott D. Lick, MD
Clinics in Geriatric Medicine. 2006;22: 559-574.

Cardiovascular disease remains the most
common cause of morbidity and mortality
in the US
 CAD and CHF most common in the elderly

Surgical procedures (CABG and cardiac
valve repair and replacement) are the best
options for many older patients to
improve their QOL.

Primary Indication: Presence of symptoms
that compromise the QOL when these
symptoms are the result of the cardiac lesion
to be corrected and likely to resolve or
improve with successful operation

Other considerations:






Limited life expectancy
Dementia
Multisystem organ failure
Chronic liver failure
Severe pulmonary disease
Severe malnutrition

Coronary artery bypass operations
traditionally have been performed using a
median sternotomy incision.

Although recovery after median sternotomy
in most patients is rapid and complete, the
elderly tend to have more difficulties and
recover more slowly.
 Development of coronary artery
bypass operations using a small
anterolateral thoracotomy incision
 Some studies showed did not
improve outcomes and associated
with more early postoperative
pain

Valve replacement and repair have been done
through smaller incisions
 Aortic valve replacement  partial sternotomy
incisions
 Mitral valve procedures right parasternal incisions
 Mitral valve repair or replacement  robotic
techniques for minimal incisions
 Transcatheter heart valve replacement
 Valve replacement without open heart surgery
 More studies needed

Aortic dissection occurs when a tear in the inner wall of the
aorta causes blood to flow between the layers of the wall of the
aorta and force the layers apart.

Patients who have acute ascending (type A) aortic dissection
involving the ascending aorta should undergo urgent operation.

Patients who have dissections involving only the descending aorta
(type B) are managed medically initially.

Operative risk increases with age in patients with Type A dissection
and survival with medical therapy have improved.
 More elderly patients are treated medically

Occasionally is 0ffered to patients >70yo but rarely to
those >75yo

Recipient age adversely affects 1-year survival after heart
transplant
 OR = 1 at age 55
(P<0.0001)
 OR = 1.3 at age 65 (P<0.0001)
 No valid data beyond 65

All solid-organ transplants require lifelong medications to
suppress the immune system
 But they can cause neuropathy, osteoporosis, HTN, worsening DM,
and renal dysfunction.

Recipient must not only survive the operation but also
tolerate the side effects of postoperative medications.
Rishi P. Singh, MD, Hilel Lewis, MD
Clinics in Geriatric Medicine. 2006;22: 659-675.

Prevalence and disabling effects of eyerelated illness increases as the population
ages.

Recent research shows that vision
impairment is associated with:
 Decline in QOL
 2 or more falls in the elderly
 Increased rate of hip fractures and decreased
mobility

Clouding of the lens caused by
clumping of proteins due to inadequate
delivery of nutrients to deeper lens
fibers

Results in blurry vision

Primary Goal of Surgery:
 To remove clouded lens
Innovation
Impact
Limitations
Microincision
Phacoemulsification Surgery
• Uses ultrasound and allows surgeon to
operate through 1.4mm or smaller incision
wounds to dissolve and remove damaged
lens
• Theoretically faster recovery, less
postoperative astigmatism, and safer
• No randomized studies
available
Phaco Chop
Technique
• Uses ultrasound and a fine instrument,
“cracker” or “chopper” - fragment cloudy
lens into smaller pieces
• Reduction in total ultrasound usage,
faster surgical times, and safer
• Steep learning curve for
surgeons to master
• Requires use of
nondominant hand
Multifocal
Intraocular
Lens
Implantation
• Implantation of intraocular lens
• Allows near and distance vision without
glasses
• Increased patient satisfaction after
surgery
• Some patients require
glasses after surgery
• Increased halo perception
and decreased contrast
sensitivity
• Additional cost for lens

Condition that causes damage to the optic nerve
due to increased intraocular pressure
 Caused by decreased or no drainage of aqueous
humor

Glaucoma causes irreversible loss of peripheral
vision early and central vision later in the disease
development.

Primary goal of surgery:
 To reduce intraocular pressure
Innovation
Impact
Limitations
Antifibrotics in
Trabeculectomy
• Trabeculectomy: reduce intraocular pressure
by shunting the aqueous fluid directly through
the sclera and conjunctiva fistula
• Antifibrotic therapies: mitomycin C and 5fluorouracil
• Use of antifibrotic injection after surgery
showed greater surgical success
• Less need for glaucoma medications
• Decreased need for reoperations
• Increased risk for
postoperative infection
and damaging hypotony
(an intraocular pressure
of 5 mm Hg or less)
Glaucoma
Drainage
Device
• Intraocular fluid passes through a tube placed
into the anterior or posterior chamber to a
footplate sewed to the exterior scleral tissue.
•Provides a surgical option for those with
previous failure trabeculectomies and those at
high risk for failures.
• High rates of
postoperative hypotony
• Diplopia can occur
after implantation
• Problems with longterm biocompatibility

Disease associated with aging that
gradually destroys sharp, central vision.
 Affects the macula, the part of the eye that
allow you to see fine detail

Wet AMD
 Occurs when abnormal blood vessels
behind the retina start to grow under
the macula
 Loss of central vision occurs quickly
 Early symptom: straight lines appear
wavy

Dry AMD
 Occurs when the light-sensitive cells in the macula slowly break
down
 Loss of central vision occurs gradually
 Early symptom: slightly blurred vision
Innovation
Macular
Translocation
Retinal
Prosthesis
Implantation
Impact
Limitations
• Surgical procedure which
involves detachment of the retina
and relocation of it to a healthier
spot in the eye
• Restores vision and improves
quality of life
• Only meant to treat wet AMD
• Steep surgeon learning
curve.
• Diplopia is common.
• High rate of retinal
complications.
• Implantation of a retinal
prosthesis that restores “useful”
vision in those with profound
retinal disorders and blindness.
• Implantation is technically
challenging.
• Only crude shape
recognition is possible
currently.
• Feasibility of device
mimicking the retina is
doubtful in the near future.

Diabetic retinopathy is a complication of diabetes that
results from damage to the blood vessels of the retina.

Symptoms: blurred vision, floaters, trouble seeing at
night, blindness eventually.

Many with early diabetic retinopathy have no
symptoms before major bleeding occurs in the eye.

Surgical procedures for treatment:
 Laser eye surgery (photocoagulation)
▪ Creates small burns in the retina where there are
abnormal blood vessels in order to stop or slow the
leakage of blood and fluid in the eye
 Vitrectomy
▪ Removes some or all of the vitreous humor from the
eye
Innovation
Impact
Pars plana
• Pars plana vitrectomy: vitrectomy that is
vitrectomy for accomplished in the deeper part of the eye
•Successful in decreasing
persistent
macular edema macular edema refractory to
Limitations
• Can accelerate cataract
formation and risk of
significant retinal
complications.
laser therapy and steroids.
Vitrectomy for
diabetic
vitreous
hemorrhage
• Restores retinal anatomy
quickly and allows treatment of
proliferative retinal disease
with laser.
Vitrectomy for • Useful in the restoration of
retinal
vision in cases of retinal
detachments in detachments.
diabetes
• Despite anatomic
success, visual outcomes
may be poor because of
long-standing ischemia.
• Despite anatomic
success, visual outcomes
may be poor because of
long-standing ischemia.
1.
Hornick TR. Surgical Innovations: Impact on the Quality of Life of the
Older Patient. Clinics in Geriatric Medicine. 2006;22: 499-513.
2.
St. Clair SF, et al. Hip and Knee Arthroplasty in the Geriatric Population.
Clinics in Geriatric Medicine. 2006;22: 515-533.
3.
Conti V. and Lick SD. Cardiac Surgery in the Elderly: Indications and
Management Options to Optimize Outcomes. Clinics in Geriatric
Medicine. 2006;22: 559-574.
4.
Singh RP and Lewis H. Innovations in Eye Surgery. Clinics in Geriatric
Medicine. 2006;22: 659-675.
5.
www.ncbi.nlm.nih.gov