The aggregation of marginal gains: Analgesia for Rectal Cancer - PowerPoint PPT Presentation

The aggregation of marginal gains: Analgesia for Rectal Cancer Resections Dr Cat Williams Dr Vinay Ratnaliker Professor Umesh Khot Morriston Hospital, Swansea

Rectal Cancer • Colorectal cancer = 4th commonest • 40,000 new cases per year • 14,000 = rectal cancer Cancer research UK

The problem • Older patients • Multiple co-morbidities • Burden of surgery is considerable

Perioperative Mortality • 30-day post-op mortality 6.7% • Significant increase with age National Cancer Intelligence Network

Perioperative Morbidity • Substantial morbidity following major abdominal surgery • 78% at day 5 • 50% at day 8 • Negative impact on patient and service provider Ann Surg 2011;254(6):907-913

ERAS

Aggregation of marginal gains

Audit • Retrospective audit • Rectal cancer resections with intrathecal diamorphine • Jan 2012 - Dec 2016

• Does the dose of intrathecal diamorphine make a difference to: • Post-operative pain scores • Incidence of nausea and vomiting • PCA usage post-operatively

Data collected • Dose of intrathecal diamorphine • Pain scores on rest and with moving for 3 days post-op • Pain scores: 0,1,2,3 • Total PCA dose used • Presence of nausea & vomiting or respiratory depression

Results Final number of patients = 103

Analysis • Divided into laparoscopic and open cases • Intrathecal dose of <1.5mg/>1.5mg • Chi2 test/Fisher’s exact test

ITO dose & Sex Distribution 45 40 35 30 25 Male 20 15 Female 10 5 0 Laparoscopic Open Laparoscopic Open <1.5mg ≥1.5mg

Pain Scores • No significant difference between pain scores at rest or on moving for open or laparoscopic procedures regardless of ITO dose • EXCEPT………

Laparoscopic Procedure - Day 1 Pain Scores 30 25 20 0 15 1 2 10 3 5 0 <1.5mg ≥1.5mg <1.5mg ≥1.5mg Day 1 Rest Day 1 Moving p=0.0117

Nausea & Vomiting/Resp Depression • Total 7 patients recorded as having N&V (6.8%) • No patients had respiratory depression

PCA Doses (Fentanyl mcg) 2000 1800 1600 1400 1200 <1.5mg 1000 ≥1.5mg 800 ITO & Block 600 400 200 0 All Patients Laparoscopic Open Open & Block

DREAMing • Lower pain scores on day 1 moving in laparoscopic procedures in >1.5mg group Anaesthesia 2016;71(9):1008-1012

Limitations • Retrospective audit • Pain scores not VAS • Small sample size

Recommendations • Higher dose opioids: • Appears to improve pain score on moving for laparoscopic procedures • Do not have increased N&V or resp depression

Recommendations • Optimise pain management protocols by examining procedure-specific data?

Recommendations • Further studies needed looking at the relationship of intrathecal opioid dose and pain scores

We acknowledge the work done by the acute pain team in collecting the patient data Questions?