Chinese expert consensus on perioperative multimodal analgesia and low opioid regimen for elderly patients (2021 edition) (3)

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
.

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
.

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.

.

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
.

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
.

05 Pain management SUMMER Elderly patients have fragile physiology, decreased functional reserve of vital organs, narrow safety window of drug treatment, large individual differences in response to drug treatment, and increased adverse drug reactions
.

A special acute pain service (APS) team should be established to be responsible for the management of perioperative pain in the elderly.
Its management goals are: effective pain relief, reduction of adverse drug reactions, accelerated postoperative functional recovery, and overall improvement of patients' quality of life and satisfaction, At the same time reduce the cost-effectiveness ratio
.

Multimodal analgesia refers to the combined application of analgesic drugs or analgesic methods that act on different targets and different mechanisms of action in the pain conduction pathway to obtain additive or synergistic analgesic effects, reduce drug doses, and reduce related adverse reactions.
The maximum effect/hazard ratio is achieved
.

Preventive analgesia refers to the use of multimodal analgesia during the entire perioperative period (including preoperative, intraoperative and postoperative) to block the transmission of noxious stimuli, enhance postoperative analgesic efficacy, and reduce postoperative analgesia.
Drug use to prevent central and peripheral nerve sensitization and reduce the occurrence of long-term chronic pain
.

[Recommendation] It is recommended that elderly patients should give priority to the use of non-opioid and regional nerve block analgesia techniques, minimize or not use opioid analgesics, and actively adopt a low-opioid, multimodal, preventive, individualized analgesia program (OSMPIA).
) to achieve maximum analgesia, minimum adverse effects, optimal physical and psychological function, best quality of life and patient satisfaction
.

 1.
Non-drug therapy Non-drug therapy mainly includes ice compress, acupuncture, transcutaneous electrical nerve stimulation (TENS), physical therapy (massage, etc.
), psychological and cognitive behavioral intervention, etc.
part of the pain [35]
.

Combined with TENS, postoperative analgesic drug consumption can be reduced by 25%
.

 【Recommendations】 It is recommended to use TENS technology as the basic solution of OSMPIA
.

 2.
Principles of analgesic drug therapy Drug therapy is the most commonly used and effective intervention for postoperative analgesia in elderly patients
.

However, as the age increases, various organs of elderly patients age and function declines, which affects drug metabolism and drug efficacy (Table 7)
.

The principles of using analgesics in elderly patients include: (1) Titration principle: It is the basic principle of pain management in elderly patients.
When using, it needs to start with a small dose, and after evaluation, it is slowly administered for dose titration; (2) According to the specific situation of the patient Appropriate route of administration: Patient-controlled intravenous analgesia (PCIA) is the first choice for those who cannot eat.
After eating resumes, oral administration is preferred, and intramuscular injection is not recommended; (3) Analgesics with active metabolites are not recommended; (4) In elderly patients, the proportion of muscle decreases, the proportion of fat increases, and the volume of drug distribution changes.
Lipophilic drugs are prone to fat accumulation, and their half-life is prolonged.
and other adverse reactions, adjust the dose in time to minimize adverse reactions; (6) When choosing analgesic drugs, comorbidities and other drugs should be considered to minimize drug-disease and drug-drug interactions; (7) Not recommended Long-acting opioids are used for postoperative analgesia, and opioids are not the first choice for preoperative analgesia (except for those who take opioids for a long time before surgery); (8) The principle of multimodal analgesia: intravenous patient-controlled analgesia combined with regional obstruction The multimodal combination of analgesic techniques is the most common; (9) PCIA in elderly patients: try to use PCIA analgesia without background dose, and the lowest effective dose should be set according to age and other relevant factors for each dose setting; (10) Patients undergoing visceral surgery , κ receptor agonists can be used instead of μ receptor agonists to effectively control visceral pain, and reduce intestinal obstruction and nausea and vomiting adverse reactions; (11) Implement multidisciplinary comprehensive assessment (basic disease assessment, quality of life assessment, social psychological assessment, etc.
), adhere to the principles of individualized treatment and stepped treatment
.

 (1) Paracetamol and NSAIDs Paracetamol and NSAIDs are the basic drugs for multimodal analgesia
.

The use of NSAIDs in elderly patients should follow the following principles: careful selection (eg, patients with risk factors should be carefully considered for such drugs); start at the lowest dose, and use the shortest duration; use proton pump inhibitors to protect the gastrointestinal tract; Adverse drug reactions
.

1.
Acetaminophen: In addition to indirect central cyclooxygenase (COX) inhibition, acetaminophen also regulates the endocannabinoid system, inhibits the descending serotonergic pathway and inhibits central monoxide The role of nitrogen synthesis
.

Its analgesic efficacy is 20% to 30% weaker than NSAIDs, has no peripheral effects, less adverse reactions, does not cause gastrointestinal bleeding, and is safer than NSAIDs
.

Acetaminophen is used for the treatment of mild to moderate pain, either alone or in combination with other drugs or methods, with significant opioid-sparing effects, or in combination with regional anesthesia to reduce rebound pain
.

Although there is some controversy, there is evidence that acetaminophen before skin incision is more beneficial to improve postoperative analgesia than administration after skin incision
.

The maximum daily dose should not exceed 3 g/d, and the daily dose of combined administration or compound preparation should not exceed 1.
5 g, otherwise it may cause severe liver damage and acute renal tubular necrosis
.

In general, there is no significant difference in analgesic effects between oral and intravenous preparations, but the absorption of oral dosage forms is affected by many factors
.

Acetaminophen is well tolerated and generally does not require dose reduction
.

For those with a history of liver disease or heavy drinkers, the dose should be reduced by 50% to 75%
.

Combined use with anticoagulants can increase its anticoagulant effect, and it is necessary to adjust the dosage of anticoagulants
.

Many compound preparations contain acetaminophen (such as Tylenin is a compound preparation of acetaminophen and oxycodone, compound cold preparations, antipyretics, etc.
), at this time, the total amount of the drug should be calculated to avoid excess
.

[Recommendation] For patients without contraindications, it is recommended to use paracetamol as the first-line basic drug for OSMPIA.
For those with normal gastrointestinal absorption, oral paracetamol can be used for preoperative analgesia.
It is recommended to start intravenous infusion 30 minutes before skin incision.
Note
.

 2.
NSAIDs: The main mechanism of action of NSAIDs is the inhibition of central and peripheral COX and prostaglandin (PGs) synthesis
.

NSAIDs can be divided into non-selective NSAIDs and selective COX-2 inhibitors according to their effects on COX
.

It is mainly used to relieve mild to moderate pain, or as a basic drug for multimodal analgesia.
It can be used in combination with opioids to save the amount of opioids and reduce the adverse reactions of opioids.
It can be combined with regional block analgesia to reduce adverse reactions.
throbbing pain
.

NSAIDs are more effective than acetaminophen in the treatment of inflammatory pain
.

The usage and dosage of common injectable NSAIDs are shown in Table 8
.

NSAIDs have a "cap" effect, so they should not be overdose
.

The plasma protein binding rate of NSAIDs is high, so two NSAIDs cannot be used at the same time
.

The common adverse reactions of NSAIDs are gastrointestinal, cardiovascular and renal adverse reactions
.

The adverse reactions of non-selective NSAIDs causing peptic ulcer or bleeding and inhibiting platelet function are more obvious
.

The incidence of NSAIDs-related gastrointestinal bleeding in elderly patients over 65 years of age is approximately twice that of younger patients
.

The risk of serious complications of peptic ulcer (such as bleeding or perforation) caused by non-selective NSAIDs is 2- to 5-fold increased in elderly patients, especially elderly women
.

NSAIDs should be avoided in elderly patients who cannot tolerate proton pump inhibitors or misoprostol
.

In addition, we should be alert to the hepatotoxicity, renal toxicity, platelet function, and adverse reactions of the nervous system and skin caused by non-selective NSAIDs
.

In addition, we need to be alert to the following high-risk factors: combined use of aspirin, glucocorticoids, digestive tract diseases, anticoagulant and antiplatelet drugs,
etc.

The nephrotoxic effect of NSAIDs is more pronounced in the elderly, and patients with renal damage, heart failure or taking nephrotoxic drugs (aminoglycoside antibiotics, vancomycin, diuretics and angiotensin-converting enzyme inhibitors, etc.
) use NSAIDs.
Risk of renal failure
.

Avoidance of NSAIDs is recommended in patients with creatinine clearance less than 50 ml/min
.

Among elderly patients hospitalized for adverse drug events, 23.
5% were caused by NSAIDs
.

If NSAIDs are used in elderly patients, the lowest dose should be used for the shortest period of time (25% to 50% reduction), and gastrointestinal, renal, and cardiovascular adverse reactions should be monitored
.

Selective COX‑2 inhibitors have fewer adverse effects in the digestive tract and inhibit platelet function, and have similar adverse renal effects as nonselective NSAIDs, but increase the risk of cardiovascular thrombotic events, including myocardial infarction and stroke, coronary artery bypass grafting Selective COX-2 inhibitors are contraindicated in surgical patients and patients with severe heart failure
.

Preoperative initiation is still controversial
.

Whether NSAIDs can improve analgesia in patients undergoing non-cardiac surgery Currently, preoperative use of COX-2 inhibitors can effectively reduce postoperative pain scores, reduce opioid consumption, reduce the incidence of nausea and vomiting, and increase patient satisfaction
.

Compared with administration after skin incision, preoperative administration of celecoxib is beneficial to reduce inflammatory response and reduce the incidence of postoperative cognitive dysfunction in elderly patients
.

The dosage of celecoxib is 200-400 mg orally 30-60 minutes before surgery
.

 【Recommendations】 For those without contraindications, it is recommended to use NSAIDs as the basic drug for postoperative OSMPIA, especially for the treatment of inflammatory pain, strictly control the use time and dose, and monitor gastrointestinal, renal and cardiovascular adverse reactions
.

Oral celecoxib is recommended before non-cardiac surgery
.

(2) Opioids Opioids are the first-line drugs for the management of moderate or more postoperative pain
.

The opioid needs of elderly patients vary greatly from individual to individual.
Dose titration should be carried out, starting from a low dose and increasing the dose slowly to ensure adequate analgesia and reduce adverse reactions as much as possible
.

Elderly patients often take multiple drugs due to comorbidities, and interactions with opioids should be noted (Table 9)
.

In high-risk groups [the elderly, those with poor liver and kidney function, chronic respiratory failure, obstructive sleep apnea syndrome (OSAS), and those who use central nervous system depressants at the same time], if opioid analgesics are used, the dose must be reduced and strict monitoring should be performed
.

Rapid-acting, short- and medium-acting formulations are recommended for postoperative analgesia, and long-acting/sustained-release formulations or skin patch formulations are not recommended
.

Oral dosage forms are preferred for those who can eat, and intravenous dosage forms are recommended for those who cannot eat or who need titration to quickly control burst pain
.

Common adverse reactions and treatment of opioids: (1) Nausea and vomiting: It is the most common adverse reaction.
For specific prevention and treatment methods, please refer to the Expert Opinions on Prevention and Treatment of Postoperative Nausea and Vomiting (PONV) by Chinese Society of Anesthesiology; (2) Breathing Suppression: opioids lead to slow breathing, treatment methods include immediate discontinuation of opioids, oxygen inhalation, strong pain stimulation, establishment of artificial airway or mechanical ventilation if necessary, and intravenous naloxone; (3) tolerance, physical Dependence and mental dependence: tolerance refers to the reduction of drug efficacy during constant dose administration, often with shortening of the action time of analgesics as the primary manifestation; for patients with regular administration, drug withdrawal or sudden dose reduction results in withdrawal reactions; Mental dependence is compulsive drug-seeking willingness and behavior; (4) pruritus: low-dose opioid agonist antagonists butorphanol, dezocine, nalbuphine and ondansetron are often used to treat pruritus; (5) muscle Stiffness, myoclonus and convulsions: use the central relaxant baclofen, or opioid receptor antagonists to eliminate them; (6) sedation and cognitive dysfunction: mild sedation often occurs, and long-term high-dose use Opioids may lead to cognitive decline; (7) Miotic: mu and κ receptor agonists excite the parasympathetic nucleus of the ophthalmic nerve leading to miosis; (8) hypothermia: opioids can cause vasodilation, changing the The hypothermia is caused by the thalamic thermoregulatory mechanism; (9) immunosuppression: strong opioids can cause immunosuppression; (10) constipation: a common adverse reaction
.

 [Recommendation] It is recommended to use low-dose opioids, combined with NSAIDs and other drugs, and weak opioids are preferred when the analgesic needs can be met.
It is recommended to routinely combine non-opioid drugs and/or regional analgesia to save money.
Opioid dosage and efficacy in reducing adverse drug reactions
.

Reliance on opioids alone for postoperative analgesia is not recommended
.

For those who have used long-acting opioids before surgery, it is not recommended to interrupt the original treatment regimen during the perioperative period, unless there are obvious contraindications or due to obvious drug interactions
.

Long-acting opioids are not recommended for perioperative analgesia
.

 (3) It is recommended to use 0.
25%-0.
5% ropivacaine as the drug of choice for wound infiltration, peripheral nerve block or continuous epidural analgesia in elderly patients
.

Long-acting bupivacaine can also be used as the preferred drug for wound local infiltration analgesia
.

Bupivacaine is not recommended for peripheral nerve block or continuous epidural analgesia in elderly patients
.

For acute post-traumatic pain in the limbs, the implementation of a single or continuous peripheral nerve block with local anesthetics, or the application of local anesthetic infiltration analgesia or local anesthetic peripheral nerve block analgesia before surgery can help improve intraoperative and postoperative analgesia.
Analgesic effect, accelerate postoperative recovery process
.

 (4) For patients with no contraindications to analgesic adjuvant drugs, intraoperative infusion of dexmedetomidine or clonidine is recommended as part of OSMPIA for major head, face and spine surgery or major thoracic and abdominal surgery without epidural analgesia.
the person
.

Routine preoperative use of gabapentin or pregabalin is not recommended.
It is recommended to use gabapentin or pregabalin as part of OSMPIA for patients with severe pain after partial thoracotomy or laparotomy, those prone to neuropathic pain, or patients with opioid tolerance
.

Ketamine is recommended as an alternative to OSMPIA, mainly for moderate to severe pain, especially in opioid-tolerant, or intolerant patients with opioid analgesia
.

Intravenous lidocaine infusion is recommended as an alternative to OSMPIA during open or laparoscopic abdominal surgery and spinal surgery, which can shorten the time of intestinal paralysis and improve the analgesic effect
.

When there is no contraindication, a single preoperative intravenous injection of dexamethasone (8 mg) can be considered as a component of OSMPIA, especially for patients with high risk of postoperative nausea and vomiting
.

 3.
Perioperative analgesia program (1) PCIA When postoperative analgesia requires intravenous administration, it is recommended to use PCIA
.

PCIA can provide continuous analgesia, and can significantly reduce the incidence of postoperative delirium and pulmonary complications.
It is suitable for elderly patients with certain cognitive ability and high degree of cooperation.
It is not recommended for elderly patients with severe weakness or cognitive impairment.

.

For elderly patients with renal dysfunction, opioids with inactive metabolites should be selected for PCIA
.

The main analgesics used in PCIA are opioids, and the recommended regimens of commonly used PCIA drugs are shown in Table 10
.

The use of fentanyl and other drugs with high lipid solubility and strong accumulation effect is not recommended for elderly patients during PCIA, and continuous infusion of opioids at background doses is not recommended.
Using background doses not only fails to achieve better analgesic effect, but also increases respiration.
Inhibition and other adverse reactions
.

When elderly patients use PCIA, oxygen inhalation and intensive monitoring are recommended to prevent the occurrence of hypoxemia
.

 [Recommendation] For elderly patients with certain cognitive ability and high degree of cooperation who need to use intravenous opioid analgesics, PCIA analgesia is recommended.
Background-dose continuous infusion of opioids is not recommended.
Oxygen and continuous monitoring
.

 (2) Regional block analgesia Regional block analgesia can reduce the patient's surgical stress response, reduce the dosage of opioids, and accelerate the postoperative recovery of patients
.

Commonly used methods include wound topical drug infiltration analgesia, patient-controlled epidural analgesia (PCEA), peripheral nerve block analgesia, or patient-controlled peripheral nerve block analgesia (PCNB)
.

Multimodal analgesia based on local anesthetics is the basis and premise of low-opioid analgesia
.

1.
Wound local anesthetic infiltration or pleural infiltration analgesia: subcutaneous or intra-articular injection of long-acting local anesthetic, as a component of multimodal analgesia, is commonly used in total knee replacement, knee arthroscopy, cesarean section, Laparoscopic surgery and hemorrhoid surgery,
etc.

 [Recommendation] It is recommended that local anesthetic wound infiltration analgesia be used as the first-line regimen for OSMPIA in surgeries with sufficient clinical evidence (total knee replacement, arthroscopy, laparoscopy, cesarean section, open surgery, and hemorrhoid surgery, etc.
)
.

 2.
Epidural analgesia: Physiological changes in elderly patients can affect the effect and metabolism of local anesthetics.
The reduction in the volume of the spinal canal can lead to a higher analgesic level with the same volume of local anesthetics; myelinated nerve fibers are reduced or myelinated Increased permeability leads to increased sensitivity to local anesthetics, and low concentrations of local anesthetics can produce motor block; the decrease in clearance rate in elderly patients leads to prolonged drug half-life and prolonged blocking time; due to anatomical changes, epidural analgesic nerves in elderly patients The injury rate is higher than in adults
.

Appropriate reduction of local anesthetic concentration and dose is recommended
.

In major thoracic and abdominal surgery, especially in patients at high risk of cardiopulmonary complications and intestinal obstruction, the benefit of epidural analgesia is more pronounced
.

Combined use of local anesthetics and opioids can reduce the concentration of local anesthetics, reduce the risk of hypotension or motor block, and also reduce the risk of adverse reactions to opioids (such as respiratory depression).
Commonly used drugs are Sufentanil
.

Compared with continuous epidural analgesia, PCEA can not only reduce the amount of analgesic drugs, but also reduce the incidence of adverse events and accelerate postoperative recovery of patients
.

In elderly patients, changes in respiratory rate and sedation status should be observed hourly within the first 24 hours of PCEA
.

Vital signs should be monitored routinely in patients using epidural analgesia
.

 【Recommendations】 In major thoracic and abdominal surgery, especially those with high risk of cardiopulmonary complications and long expected postoperative intestinal paralysis, it is recommended to use intraspinal analgesia as the first-line solution for multimodal analgesia
.

It is recommended that sufentanil be routinely added to local anesthetics for epidural analgesia
.

Close monitoring and follow-up of patients during neuraxial analgesia is recommended
.

3.
Peripheral nerve block: Peripheral nerve block has the same efficacy as epidural analgesia, but the incidence of adverse reactions is lower
.

Due to the physiological changes of elderly patients, it is easier for anesthetics to penetrate and block; and the sensitivity of elderly patients to local anesthetics increases, and the clearance force decreases.
When performing peripheral nerve block, the concentration of local anesthetics should be appropriately reduced.
Total local anesthetic dose
.

After peripheral plexus block, elderly patients may experience prolonged sensory and motor block, which is significantly related to age
.

When a single injection cannot meet the needs of postoperative analgesia, continuous peripheral nerve block analgesia is recommended
.

Ultrasound-guided peripheral nerve block can improve the blocking and analgesic effects and reduce damage, and it is recommended to actively use it
.

【Recommendations】 For those without obvious contraindications, peripheral nerve block is recommended as the first-line solution for multimodal analgesia, especially for upper and lower extremity surgery and thoraco-abdominal surgery
.

When a single block cannot meet the analgesic needs, continuous peripheral nerve block techniques can be considered
.

Recommended reading [Wednesday] Chinese Expert Consensus on Perioperative Multimodal Analgesia and Low Opioid Protocol for Elderly Patients (2021 Edition) (1) [Wednesday] Chinese Expert Consensus on Perioperative Multimodal Analgesia and Low Opioid Protocol for Elderly Patients (2021 Edition) ( 2) [Wednesday] Guidelines Consensus: Interpretation of Guiding Opinions on Perioperative Anesthesia Management in Chinese Elderly Patients with Knee Surgery (2020 Edition) (1) [Wednesday] Guidelines Consensus: Interpretation of Guiding Opinions on Perioperative Anesthesia Management in Chinese Elderly Patients with Knee Surgery (2) 2020 Edition) (2) [Wednesday] Guidelines Consensus: Interpretation of Guidance for Perioperative Anesthesia Management in Chinese Elderly Patients with Knee Surgery (2020 Edition) (3) [Wednesday] Guidelines Consensus: Experts on Perioperative Management of Chinese Elderly Colorectal Tumor Patients Consensus (2020 Edition) (1) [Wednesday] Guidelines Consensus Expert Consensus on Perioperative Management of Chinese Elderly Colorectal Cancer Patients (2020 Edition) (2) [Wednesday] Perioperative Guidelines for the Elderly (2020 Edition) (14) Guidelines Consensus summary and notes of anesthesia book series "Thinking of Anesthesia Dispute Cases" is over.
Looking forward to the next chapter "Challenges of Peri-Anesthesia Emergencies".
Scan the code to follow us.
Selected ArticlesLatest GuidelinesConsensusDisputesCase NotesClassic BooksNotesOnline LessonsSuper NotesExcellent CoursewareFull SharingCase DiscussionsSparksPolynerve BlocksLearn Up Literature ReadingTall AnesthesiaNewsI would have known it before,recommendation,watching,enjoying,living,wallpapers,Junjia, and post it here! ! Anesthesia knowledge, we are intimately prepared in the public account of anesthesia Q & A.
Join the community WeChat and wait for you