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

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

Sep 05, 2023 28 likes •260 views

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

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The aggregation of marginal gains:

Analgesia for Rectal Cancer Resections

Dr Cat Williams Dr Vinay Ratnaliker Professor Umesh Khot

Morriston Hospital, Swansea

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Rectal Cancer

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

Cancer research UK

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The problem

  • Older patients
  • Multiple co-morbidities
  • Burden of surgery is

considerable

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Perioperative Mortality

  • 30-day post-op

mortality 6.7%

  • Significant

increase with age

National Cancer Intelligence Network

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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

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ERAS

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Aggregation of marginal gains

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Audit

  • Retrospective audit
  • Rectal cancer resections with intrathecal

diamorphine

  • Jan 2012 - Dec 2016
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  • Does the dose of intrathecal diamorphine make a

difference to:

  • Post-operative pain scores
  • Incidence of nausea and vomiting
  • PCA usage post-operatively
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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

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Results

Final number of patients = 103

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Analysis

  • Divided into laparoscopic and open cases
  • Intrathecal dose of <1.5mg/>1.5mg
  • Chi2 test/Fisher’s exact test
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5 10 15 20 25 30 35 40 45

Laparoscopic Open Laparoscopic Open <1.5mg ≥1.5mg

ITO dose & Sex Distribution

Male Female

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Pain Scores

  • No significant difference between pain scores at

rest or on moving for open or laparoscopic procedures regardless of ITO dose

  • EXCEPT………
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5 10 15 20 25 30

<1.5mg ≥1.5mg <1.5mg ≥1.5mg Day 1 Rest Day 1 Moving

Laparoscopic Procedure - Day 1 Pain Scores

1 2 3

p=0.0117

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Nausea & Vomiting/Resp Depression

  • Total 7 patients recorded as having N&V (6.8%)
  • No patients had respiratory depression
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200 400 600 800 1000 1200 1400 1600 1800 2000 All Patients Laparoscopic Open Open & Block

PCA Doses (Fentanyl mcg)

<1.5mg ≥1.5mg ITO & Block

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DREAMing

  • Lower pain scores on

day 1 moving in laparoscopic procedures in >1.5mg group

Anaesthesia 2016;71(9):1008-1012

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Limitations

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

  • Higher dose opioids:
  • Appears to improve pain score on moving for

laparoscopic procedures

  • Do not have increased N&V or resp depression
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Recommendations

  • Optimise pain management protocols by

examining procedure-specific data?

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Recommendations

  • Further studies needed looking at the relationship of

intrathecal opioid dose and pain scores

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