Chinese expert consensus on perioperative multimodal analgesia and low opioid regimen for elderly patients (2021 edition) (1)

Chinese Medical Association Anesthesiology Branch Elderly Anesthesia and Perioperative Management Group Chinese Medical Association Anesthesiology Branch Pain Group National Clinical Research Center for Geriatric Diseases National Geriatric Anesthesia Alliance SUMMER Accelerated Postoperative Rehabilitation (ERAS) is a perioperative medical clinic Important developments in practice and route management
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Early post-operative movement and early food and drink intake are important outcome goals, and the premise of this goal needs to ensure the early recovery of postoperative intestinal function and effective analgesic management
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Due to aging and disease-related fragile bowel function and serious adverse reactions related to opioid analgesia in elderly patients, relying solely on opioids to control intraoperative pain and postoperative pain stress in the perioperative period will significantly affect the course of postoperative ERAS.

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Therefore, the following measures should be implemented in elderly patients: (1) local anesthesia (local anesthesia) drug-based intraspinal and peripheral nerve blocks and wound infiltration analgesia to control incision pain; (2) non-steroidal Anti-inflammatory drugs control inflammatory pain associated with perioperative inflammation; (3) opioids control perioperative pain stress, especially the use of kappa receptor agonists to control visceral pain associated with visceral surgery, so as to achieve perioperative pain relief.
Under the premise of controlling pain stress, the use of opioids can be minimized; and preventive multimodal analgesia is more beneficial to the realization of this goal
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The Chinese Expert Consensus on Perioperative Multimodal Analgesia and Low Opioid Protocol for Elderly Patients (2021 Edition) was formulated based on this clinical concept and the characteristics of elderly patients
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01 The epidemiology and status of postoperative acute pain in elderly patients The proportion of all surgical patients is as high as 50% (2005 statistics)
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Elderly patients are difficult to objectively assess pain due to their decreased organ function, reduced physiological reserve, age-related changes in pharmacokinetics and pharmacodynamics, vision, hearing, and coexisting neuropsychiatric diseases.
The pain medication management of patients has become a difficult problem, and the rate of poor postoperative acute pain control in elderly patients is as high as 50% to 75%
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Poor postoperative acute pain control significantly increases the incidence of perioperative complications and increases the incidence of long-term chronic pain in elderly patients
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02 Effects of aging-related physiological changes on perioperative pain management SUMMER Significant age-related changes in central and peripheral nerve structure, function, and neurotransmitter levels occur during aging Decreased thalamic β-endorphin and γ-aminobutyric acid (GABA) synthesis, decreased central GABA and serotonin (5-HT) receptor densities, and decreased opioid receptor densities
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The age-related changes of the spinal cord are manifested as degeneration of sensory neurons in the dorsal horn, slowed nerve conduction, decreased noradrenergic and 5-HT neurons in the dorsal horn, and decreased opioid receptor affinity; the content of dorsal root ganglion neuropeptides Increased calmodulin gene-related peptide and substance P decreased, normal somatostatin, decreased expression of high-affinity tyrosine kinase receptors (TrkA, TrkB, and TrkC)
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Peripheral nerve changes include reduced and demyelinated myelinated and unmyelinated fibers, dysfunctional C and Aδ fibers, decreased conductivity, motor nerve fiber conduction velocity decreased at a rate of 0.
15 m/s per year, nerve regeneration and vasa vasorum self-regulation drop
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The pain behavior and placebo treatment effects disappeared, and the descending inhibitory mechanism of pain was weakened
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Dementia does not reduce central perception of pain signals, and pain stimuli cause more significant changes in brain fMRI signals in dementia patients than in age-matched normal controls
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Due to the reduced self-recovery ability of the nervous system, elderly patients are more likely to develop hyperalgesia and even develop chronic pain.
In general, postoperative pain in elderly patients does not decrease with age, but shows decreased sensitivity to visceral pain and thermal pain.
, mechanical pain and electrical stimulation pain thresholds remain unchanged, the descending inhibitory mechanism is weakened, the time summation effect is unchanged, pain tolerance is reduced, hyperalgesia relief is slowed down, and pain-induced sympathetic responses are weakened
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The effects of physiological changes in older adults on perioperative pain management are shown in Table 1
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 Gastrointestinal function changes in elderly patients are mainly due to weakened protective mechanisms, decreased intestinal regulatory function, and prone to constipation and intestinal obstruction.
Therefore, it is more difficult to maintain self-balance under stress.
Therefore, how to protect the fragile intestinal function during the perioperative period and restore the elderly patients' postoperative food and drink as soon as possible are the problems that ERAS needs to solve
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Recommendations for pain management in elderly patients, it is necessary to understand the changes in pain perception related to aging, according to the characteristics of aging-related physiological and pathophysiological changes in the heart, lung, liver, kidney, gastrointestinal tract, past medication history and perioperative analgesic drugs.
Based on the interaction of factors such as the ERAS principle, an appropriate individualized multimodal low-opioid analgesia regimen was selected
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03 Sources of nociceptive stimuli, pain classification and analgesia principles in the perioperative period SUMMER The sources of nociceptive stimuli in the perioperative period mainly come from three aspects: (1) Pre-operative pain; (2) Injury caused by surgery: ① Local tissue damage releases endogenous pain-causing factors, which activate peripheral nociceptors; ② Surgery directly damages peripheral nerve endings, and the damaged nerve fibers themselves can also release pain-causing factors (such as substance P, calcitonin gene-related Peptide), leading to acute neuropathic pain, and poor repair of damaged peripheral nerve endings (such as formation of neuroma) is also the root cause of chronic pain; ③ Intraoperative and postoperative inflammatory response and repair, the inflammatory factors prostaglandins, prostaglandins, and prostaglandins are synthesized and released immediately after injury.
Activated nociceptors such as bradykinin persist until tissue healing, or even exist for a long time; (3) Intraoperative visceral ischemia, hollow organ expansion, stretch and other factors can lead to visceral pain, which is characterized by inability to accurately locate, Pain and discomfort
etc.

The sources of perioperative pain include preoperative acute and chronic pain, as well as residual incisional pain, visceral pain, inflammatory pain, and neuropathic pain due to improper pain management during surgery
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Incision pain can be effectively controlled by epidural block analgesia, peripheral nerve block analgesia, local anesthetic infiltration analgesia, etc.
mainly based on local anesthesia (local anesthesia); visceral pain can be stimulated by κ opioid receptors Medications or epidural analgesia can be used to control pain; inflammatory pain can be managed with nonsteroidal anti-inflammatory drugs (NSAIDs)
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 Recommendations suggest that the corresponding analgesic drugs or methods should be selected according to different pain sources and classifications in the perioperative period
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