Pain management in the elderly and cognitively impaired patient: the role of regional anesthesia and analgesia

Random forest algorithm for predicting postoperative delirium in older patients

Objective

In this study, we were aimed to identify important variables via machine learning algorithms and predict postoperative delirium (POD) occurrence in older patients.

Methods

This study was to make the secondary analysis of data from a randomized controlled trial. The Boruta function was used to screen relevant basic characteristic variables. Four models including Logistic Regression (LR), K-Nearest Neighbor (KNN), the Classification and Regression Tree (CART), and Random Forest (RF) were established from the data set using repeated cross validation, hyper-parameter optimization, and Smote technique (Synthetic minority over-sampling technique, Smote), with the calculation of confusion matrix parameters and the plotting of Receiver operating characteristic curve (ROC), Precision recall curve (PRC), and partial dependence graph for further analysis and evaluation.

Results

The basic characteristic variables resulting from Boruta screening included grouping, preoperative Mini-Mental State Examination(MMSE), CHARLSON score, preoperative HCT, preoperative serum creatinine, intraoperative bleeding volume, intraoperative urine volume, anesthesia duration, operation duration, postoperative morphine dosage, intensive care unit (ICU) duration, tracheal intubation duration, and 7-day postoperative rest and move pain score (median and max; VAS-Rest-M, VAS-Move-M, VAS-Rest-Max, and VAS-Move-Max). And Random Forest (RF) showed the best performance in the testing set among the 4 models with Accuracy: 0.9878; Matthews correlation coefficient (MCC): 0.8763; Area under ROC curve (AUC-ROC): 1.0; Area under the PRC Curve (AUC-PRC): 1.0.

Conclusion

A high-performance algorithm was established and verified in this study demonstrating the degree of POD risk changes in perioperative elderly patients. And the major risk factors for the development of POD were CREA and VAS-Move-Max.

Opioid-Free Segmental Thoracic Spinal Anesthesia with Intrathecal Sedation for Breast and Axillary Surgery: Report of Four Cases

Purpose

Few studies have described segmental thoracic spinal anesthesia (STSA) as primary anesthesiologic method in breast and axillary surgery, documenting the association of intrathecal local anesthetics and opioids. This case series reports an opioid-free scheme of STSA in four elderly patients undergoing major breast and axillary oncological surgery.

Patients and Methods

STSA was performed in three female patients undergoing unilateral mastectomy ± axillary lymph node dissection (ALND) or sentinel lymph node biopsy for invasive ductal carcinoma and in one male patient undergoing ALND for melanoma metastases. The level of needle insertion was included between T6-8, via a median or paramedian approach. Midazolam (2 mg) and ketamine (20 mg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 8 mg. The level of sensory blockade achieved was comprised between C2-3 and T11-12. Postoperative analgesia was maintained through continuous intravenous administration of Ketorolac by an elastomeric pump (90 mg over 24 hrs.).

Results

Spinal anesthesia was completed without complications in all patients. Conversion to general anesthesia (GA) and perioperative intravenous sedation were not required. No major postoperative complications and no episodes of postoperative nausea and vomiting (PONV) were reported. No rescue analgesic was administered. All patients were discharged in postoperative day 2 and are alive at 30, 29, 27 and 13 months after surgery, respectively. High grade of satisfaction on the anesthesiologic method was expressed by all cases.

Conclusion

STSA with local anesthetic plus midazolam and ketamine might be considered a safe and effective alternative to GA, even in surgeries involving the breast and axillary region, particularly in elderly and frail patients. Larger prospective studies are required to validate these findings.

Effects of pericapsular nerve group (PENG) block on postoperative recovery in elderly patients with hip fracture: study protocol for a randomised, parallel controlled, double-blind trial

INTRODUCTION

Hip fracture is a common and serious emergency in the elderly, and it is associated with severe pain, significant morbidity and mortality. The use of peripheral nerve block can relieve pain effectively and reduce opioid requirements, which may accelerate patient's recovery. The pericapsular nerve group (PENG) block has been found to provide an effective blockade to the hip joint with a potential motor-sparing effect, so we hypothesised that the PENG block may be an effective tool to enhance the recovery in elderly patients after hip fracture surgery.

METHODS AND ANALYSIS

This study is a single-centred, randomised, parallel controlled, double-blind trial. A total of 92 elderly patients scheduled for hip fracture surgery will be divided into two groups at random to receive either ultrasound-guided femoral nerve block or ultrasound-guided PENG block. The primary outcome will be to compare the Quality of Recovery-15 scores at 24 hours postoperatively between the two groups. The secondary outcomes will include measuring and comparing the strength of the quadriceps, the visual analogue scale at rest and on movement, the total morphine consumption, the rescue analgesic, the first time of postoperative out-of-bed mobilisation and complications.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine on 15 December 2020 (reference K2020-110). The results of this study will be published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100042341.

Electroacupuncture for the Prevention of Postoperative Cognitive Dysfunction Among Older Adults Undergoing Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Postoperative cognitive dysfunction (POCD) is a common surgical complication in elderly patients undergoing hip and knee replacement. Electroacupuncture (EA) may have a protective effect on postoperative cognitive function, but relevant evidence remains uncertain. Objective: To systematically evaluate the evidence of EA for the prevention of POCD after total joint arthroplasty. Methods: PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP, and Chinese Biomedical Literature Database (CBM) databases were searched until May 1, 2021. Randomized controlled trials (RCTs) in which patients undergoing hip and knee replacement pretreated with EA for preventing POCD were included. The risk of bias was assessed by the Cochrane Collaboration tool. Meta-analysis was performed using Review Manager version 5.4. Results: A total of 11 RCTs with 949 patients were identified. Meta-analysis showed that compared with controls, EA pretreatment significantly reduced the incidence of POCD at 1, 3, and 7 days and 3 and 6 months after the operation. EA was also superior in improving the Mini-Mental State Examination (MMSE) scores on the third postoperative day, but not on the first postoperative day. Neuron-specific enolase (NSE) and interleukin-1β (IL-1β) in the EA group were significantly lower than that in the control group. There was no difference in S100β between the EA group and the control group. Compared to the control group, tumor necrosis factor-α (TNF-α) levels were not significantly lower in the EA group at postoperative hour 0, while significantly decreased at postoperative hours 24 and 48. Conclusion: Our results suggest that EA pretreatment is an effective adjunctive therapy for reducing the incidence of POCD for patients receiving total joint replacement surgery. Its effect was embodied in improving the MMSE scores and NSE, IL-1β, and TNF-α levels, whereas it had no significant effect on S100β levels. Meanwhile, the benefits of EA for improving POCD need further strengthening and support from more large-scale, high-quality, and good-homogeneity RCTs. Systematic Review Registration: https://osf.io/xb3e8.

Ultrasound-guided femoral nerve block and intravenous fentanyl in pain management of the patients with hip fracture: a prospective, randomized, single blinded clinical trial

Aim

Proximal femoral fracture is a painful condition. Pain alleviation is a treatment cornerstone to both comfort the patient and reduce adverse effects. This study aimed to evaluate and compare ultrasound-guided femoral nerve block and intravenous fentanyl administration in relieving the pain of patients with hip fractures.

Methods

The present interventional clinical trial was conducted on 40 patients referred to Shahid-Bahonar Hospital with unilateral isolated proximal femur fracture and American Society of Anesthesiologists I and II. The patients were randomly divided into two groups: intravenous fentanyl and ultrasound-guided femoral nerve block for pain management. Pain severity was assessed by a numerical rating scale before and after the intervention in both groups and the groups were then compared.

Results

Forty patients were enrolled in to study; 27 (67.5%) were male. There was no significant difference in demographic variables between the two groups. Fourteen (35%) were older than 80 years. Pain significantly decreased three scores compared to the pre-intervention level in both groups (95% confidence interval, 2-4). This was slightly higher in the femoral nerve block group. The largest strength of association for age and numerical rating scale of pain was found in the differences between the pre-intervention and after-intervention in femoral nerve block group (r = -0.775, P < 0.001).

Conclusion

We found similar pain severity between the two groups. Considering the possible side effects of fentanyl, an ultrasound-guided femoral nerve block shows may provide safer pain control and may be particularly suitable for patients with opioid dependence.

Hemodynamic changes in patients undergoing office-based sinus procedures under local anesthesia

BACKGROUND

The objective of this study is to characterize changes in hemodynamics, pain, and anxiety during office-based endoscopic sinus procedures performed under local anesthesia.

METHODS

We conducted a prospective study of adults undergoing in-office endoscopic sinus procedures under local anesthesia. Patients with American Society of Anesthesiologists (ASA) Physical Status Classification System class 1 or 2 were included. Anesthesia was administered by topical 4% lidocaine/oxymetazoline and submucosal injection of 1% lidocaine/1:200,000 epinephrine. Vital signs and pain were measured at baseline, postinjection, and 5-minute intervals throughout the procedure. Anxiety levels were scored using the State-Trait Anxiety Inventory (STAI). Univariate and multivariate regression analyses were performed to identify factors significantly associated with changes in each hemodynamic metric.

RESULTS

Twenty-five patients were studied. This cohort was 52% male, mean age of 57.8 ± 14.4 years, and Charlson Comorbidity Index (CCI) median of 2. Mean procedure duration was 25.0 ± 10.3 minutes. Mean maximal increase in systolic blood pressure (SBP) was 24.6 ± 17.8 mmHg from baseline. Mean maximal heart rate increase was 22.8 ± 10.8 beats per minute (bpm) from baseline. In multivariate regression analysis, when accounting for patient age, cardiac comorbidity, CCI, and ASA, older age was significantly associated with an increase of >20 mmHg in SBP (p = 0.043). Mean pain score during procedures was 1.5 ± 1.3 with a mean maximum of 4.0 ± 2.6. STAI anxiety scores did not change significantly from preprocedure to postprocedure (32.8 ± 11.6 to 31.0 ± 12.6, p = 0.46). No medical complications occurred.

CONCLUSION

Although patients appear to tolerate office procedures well, providers should recognize the potential for significant fluctuations in blood pressure during the procedure, especially in older patients.

Acute Pain in Older Adults: Recommendations for Assessment and Treatment

The management of acute pain in older adults (age 65 or greater) requires special attention due to various physiologic, cognitive, functional, and social issues that may change with aging. Especially in the postoperative setting, there are significant complications that can occur if pain is not treated adequately for elderly patients. In this article, the authors describe these changes in detail and discuss how pain should be assessed appropriately in older patients. In addition, the authors detail the unique risks and benefits of several mainstream analgesic medications as well as interventional treatments for elderly patients. The authors' goal is to provide recommendations for health care providers on appropriately recognizing and treating pain in a safe, effective manner for aging patients.

Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients: a randomized controlled preliminary trial

Background:

Postoperative cognitive dysfunction (POCD) is a serious complication after surgery, especially in elderly patients. The anesthesia technique is a potentially modifiable risk factor for POCD. This study assessed the effects of dexmedetomidine, propofol or midazolam sedation on POCD in elderly patients who underwent hip or knee replacement under spinal anesthesia.

Methods:

The present study was a prospective randomized controlled preliminary trial. From July 2013 and December 2014, a total of 164 patients aged 65 years or older who underwent hip or knee arthroplasty at China-Japan Friendship Hospital and 41 non-surgical controls were included in this study. Patients were randomized in a 1:1:1 ratio to 3 sedative groups. All the patients received combined spinal-epidural anesthesia (CSEA) with midazolam, dexmedetomidine or propofol sedation. The sedative dose was adjusted to achieve light sedation (bispectral index[BIS] score between 70 and 85). All study participants and controls completed a battery of 5 neuropsychological tests before and 7 days after surgery. One year postoperatively, the patients and controls were interviewed over the telephone using the Montreal cognitive assessment 5-minute protocol.

Results:

In all, 60 of 164 patients (36.6%) were diagnosed with POCD 7 days postoperatively, POCD incidence in propofol group was significantly lower than that in dexmedetomidine and midazolam groups (18.2% vs. 40.0%, 51.9%, χ² = 6.342 and 13.603, P = 0.012 and < 0.001). When the patients were re-tested 1 year postoperatively, the incidence of POCD was not significantly different among the 3 groups (14.0%, 10.6% vs. 14.9%, χ² = 0.016 and 0.382, P = 0.899 and 0.536).

Conclusion:

Among dexmedetomidine, propofol and midazolam sedation in elderly patients, propofol sedation shows a significant advantage in term of short-term POCD incidence.

Preventive Effects of Pre- and Intra-operative Marcaine, Lidocaine, and Marcaine Plus Lidocaine on Pain Relief in Lumbar Disc Herination Open Surgery

BACKGROUND

As marcaine is administered to a great extent due to minor complications and reasonable expenses and as discectomy is prevalently used in Iran, this study makes a comparison between effect of marcaine alone, lidocaine alone, and marcaine plus lidocaine on pain relief of patients undergoing lumbar disc open surgery.

MATERIALS AND METHODS

In a clinical trial study, 192 patients were selected and randomly divided into four groups. Patients in Groups 1-4 received 0.5 ml marcaine during surgery, 5 ml lidocaine 2% before incision, 5 ml lidocaine 2% before incision plus 5 ml marcaine during surgey and normal saline, respectively. After patients gained knowledge of visual analog scale (VAS) criteria, their severity of pain was measured and was recorded in their profiles, along with demographic details and history of diseases. After surgery and their transfer to their rooms, their severity of pain was measured and recorded again by using VAS criteria. Finally, difference between the four groups was compared by SPSS software.

RESULTS

The mean (±standard deviation) of postoperative pain in marcaine + lidocaine, marcaine, lidocaine, and normal saline was 3.5 ± 1.3, 3.5 ± 1.6, 36.1.9, and 4.2 ± 1.8, respectively, and we did not observe any significant difference in severity of pain after surgery in these groups (P = 0.15). The highest and lowest degree of satisfaction occurred in marcaine-lidocaine group and control group, respectively, (40 patients [83.3%] vs. 25 patients [52.1%]).

CONCLUSION

Lidocaine-marcaine treatment reduces the need to opiates in cases of postoperative pain relief of discectomy and provides patients with great satisfaction.

Economic Considerations of Acute Pain Medicine Programs

Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.

An update on pain management for elderly patients undergoing ambulatory surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting.

RECENT FINDINGS

Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h.

SUMMARY

The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.

[Perioperative patient management in orthogeriatrics]

The management of major orthopedic surgery in the elderly prototypically reflects the perioperative risks of geriatric, often very frail patients reflecting an aging population. To improve outcome, the risks of anesthesia and surgery as well as of patient comorbidities must be thoroughly assessed and balanced using a multidisciplinary approach. Particular risks include cardiopulmonary morbidity, anemia, risk of hemorrhage and the management by anticoagulation, cerebral impairments as well as frailty and limited physiological reserves in general. Accordingly, an optimized therapy prior to, during, and after surgery will likely influence not only the immediate postoperative course but also hospital mortality and long-term outcome. Publications on the topic of perioperative management of geriatric patients are fortunately gaining in quality and quantity, not least against the background of the demographic developments. Accordingly, specific influencing factors relevant for perioperative management can be increasingly more identified. This short review summarizes the current state of knowledge to provide an overview and rationale for clinical decision making.

Postoperative analgesia in patients older than 75 years undergoing intervention for per-trochanteric hip fracture: a single centre retrospective cohort study

The aim of this study was to compare the efficacy of four analgesia techniques on postoperative pain after per-trochanteric femur fracture. A retrospective cohort study was conducted on 131 consecutive patients older than 75 years enrolled in an 18-month period and who underwent per-trochanteric fracture repair under spinal analgesia. Patients received postoperative analgesia from: G1 (n = 36), intravenous analgesia on demand only; G2 (n = 28) administration of acetaminophen at fixed hours; G3 (n = 50) continuous morphine infusion; G4 (n = 17), preoperative echo-graphic guided femoral nerve block. Continuous opioid infusion failed to prevent the onset of pain at the end of the effects of subarachnoid anesthesia (rescue dose of analgesic in 48 % of patients in G3 vs. 22 % in G2 in the first day; p < 0.05). The greater effectiveness was achieved by preventing the onset of pain with drugs administered at time intervals (rescue dose of analgesic in 48 % of patients in G3, 58 % in G1 and 48 % in G4 vs. 22 % in G2 in the first day and rescue dose of analgesic in 32 % of patients in G3, 67 % in G1 and 76 % in G4 vs. 18 % in G2 in the second day; p < 0.05). Our study does not confirm the effectiveness of a single shot femoral nerve block on postoperative pain in per-trochanteric femur fracture (PAIN VAS score > 3 at t1 in 23 % of patients in G1 and 19 % in G4 vs. 10 % in G2 and G3; p < 0.05).

Developing a strategy to identify and treat older patients with postoperative delirium

Postoperative delirium is one of the most common adverse outcomes in elderly patients undergoing surgery and is associated with increased morbidity, length of stay, and patient care costs. The purpose of this quality improvement project was to evaluate the effectiveness of a multicomponent strategy to identify and treat general surgical patients 65 years of age or older at risk for and who develop postoperative delirium at Cape Cod Hospital, a community hospital in southern New England. We evaluated 96 patients using the Mini-Cog assessment tool preoperatively and the Confusion Assessment Method (CAM) delirium screening tool or CAM-Intensive Care Unit (CAM-ICU) assessment tool postoperatively. Patients who tested positive during preoperative assessment underwent a postoperative delirium management protocol. We summarized data using descriptive statistics. The results showed an association between compliance and outcomes. High compliance with implementation of CAM and CAM-ICU assessment tools resulted in increased identification of postoperative delirium in the older surgical population. The use of screening tools helped facilitate early identification of postoperative delirium in elderly surgical patients.

[Postoperative cognitive dysfunction (POCD): strategy of prevention, assessment and management]

The femoral neck fracture is a major cause of morbidity and mortality in the elderly. The etiology of cognitive impairment observed in this population of aged patient seems to be multifactorial. In the strategy of prevention, elderly patient must have the clearer information dealing with the postoperative cognitive dysfunction. This would reduce the incidence of POCD and some cognitive complaints, which often reflect the anxiety of the elderly patient facing the possibility of cognitive impairment. During the anaesthesia consultation, it seems important to assess the cognitive function of this elderly patient (like using neuropsycholgical scale as the MMSE) and to identify associated risk factors of cognitive dysfunction. The management of cognitive disorders should be multidisciplinary, the anesthesiologist being the main referent, in collaboration with the geriatrician and the surgeon. In the clinical setting of femoral neck fracture in the elderly, this multimodal management (pain, nutrition, functional rehabilitation to make these patients autonomous as quickly as possible), seems to improve the functional prognosis and to have the observed POCD decreased.

Parathyroid surgery in the elderly

The prevalence of primary hyperparathyroidism (PHPT) will increase with the growth of the elderly population. Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in elderly patients with PHPT, the majority of them reporting increased fracture-free survival and symptomatic relief postoperatively and thus experiencing improved quality of life.

Introduction.

The prevalence of primary hyperparathyroidism (PHPT) is expected to increase in developed nations as the aged population grows. This review discusses issues related to PHPT in the elderly population with a focus on differences in disease presentation, medical and surgical management, and outcomes.

Methods.

Literature review of English-language studies of PHPT or parathyroidectomy (PTx) in the elderly was performed. Surgical literature reviewed included original clinical studies published after 1990. Priority was given to studies with >30 patients where institutional practice and outcomes have not changed significantly over time.

Results.

Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. They have equivalent surgical outcomes, including morbidity, mortality, and cure rates, compared with younger patients, although their length of hospital stay is significantly longer. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in an elderly population. Patients are referred for PTx less frequently with each advancing decade, although surgical referral patterns have increased over time in centers that offer minimally invasive parathyroidectomy. Elderly patients experience increased fracture-free survival after PTx. The majority of elderly patients report symptomatic relief postoperatively.

Conclusion.

PTx can offer elderly patients with PHPT improved quality of life. PTx is safe and effective in elderly patients, and advanced age alone should not deter surgical referral.