TATALAKSANA PASCA OPERATIF GERIATRI

(MAJEMEN NYERI AKUT PASCA BEDAH,

MANAJEMEN KOMPLIKASI, LAMBAT
BANGUN, POCD)
ALI-FAW-ASH-ERU-MII-AIL-JAT-RAP-TIM-OKI
MANAJEMEN NYERI AKUT PASCA BEDAH

Pain in elderly patients follows one of three scenarios:

1. Acute pain results from surgery, cancer, fractures, medical conditions such as vascular
ischemia, herpes zoster, etc.
2. Chronic pain results from various persistent medical and physical conditions. Specific
chronic pain syndromes that are known to affect the geriatric population disproportionately
include arthritis which may affect 80% of patients over 65, cancer, herpes zoster and
postherpetic neuralgia, temporal arteritis, polymyalgia rheumatica, atherosclerotic peripheral
vascular disease, diabetic neuropathy, and back pain syndromes.
3. Finally, there are those who are suffering from persistent pain who then experience a new
acute injury or exacerba_x0002_tion of their primary condition that is superimposed on their
primary pain state.
Pathophysiology of Types of Pain

Somatic Pain
• A noxious stimulus in the periphery activates nociceptors. This results in a release of pain-producing
substances, e.g., prostaglandins, leukotrienes, and substance P. Impulses travel via Aδ and C fibers
to the dorsal horn of the spinal cord. Somatic pain is well localized and gnawing. There is also often
the presence of associated tenderness and swelling.
• Examples include fractures, bone metastasis, and postoperative pain. This type of pain is usually
opioid-responsive.

Visceral Pain
• When viscera are stretched, compressed, invaded, or distended, pain will result. The pain is poorly
localized and may be referred to seemingly somatic areas distant from the vis_x0002_cera of origin.
It is described as deep, squeezing, cramplike, or colicky. It is frequently associated with sympathetic
and parasympathetic symptoms: nausea, diaphoresis, and hypotension.
• Examples include bowel obstruction and pancreatic cancer. This type of pain is also usually opioid-
responsive.
Neuropathic Pain
• Injury to neural tissues or dysfunctional changes of the nervous system from trauma,
compression, tumor invasion, or cancer therapies result in this form of pain. The pain may
be associated with sensory and motor deficits, but not always. The quality of the pain is
often described as burning, squeezing, lancinating, or electrical. There can be associated
sleep and eating disturbances, and significant patient emotional suffering. Examples include
brachial and lumbosacral plexopathy, postherpetic neuralgia, neuromas, complex regional
pain syndrome, diabetic neuropathy, and radiculopathies. Neuropathic pain is associated
with opi_x0002_oid tolerance, termed “apparent opioid resistance.” That is, patients with
neuropathic pain often require higher than expected doses of opioids to obtain pain relief,
and the pain relief is usually not complete.
Postsurgical Analgesia

• The importance of adequate postop_x0002_erative analgesia for reducing morbidity, and

mortality in the elderly patients is undisputed. Epidural analgesia and IV PCA are both
excellent postoperative techniques. Physicians are often reluctant to use PCA in older
patients

• In a study of elderly patients after abdominal surgery, IV PCA versus patient-controlled

epidural analgesia (PCEA), the authors concluded that PCEA with local anesthetic and
opioid provided better pain control, improved mental status, and better bowel function
return than did traditional IV PCA morphine after general anesthesia. Orthostatic and
mobility deficits were not a problem with the PCEA adjustments.
Postoperative cognitive dysfunction

• Postoperative cognitive dysfunction (POCD) is diagnosed by neurobehavioral testing. Unlike

delirium, which is a clinical diagnosis, cognitive dysfunction must be sought by using evaluative
techniques.
• Up to 30% of elderly patients can demonstrate abnormal neurobehavioral testing within the first
week after an operation
• A 2014 clinical trial that included 200 elderly patients with mild cognitive impairment showed that
there is no difference in the incidence of POCD at 7 days after radical rectal resection under
sevoflurane (33.3%) or propofol-based (29.7%)
• GA, even though sevoflurane had more severe impact on cognitive function than propofol.
• POCD was higher in sevoflurane than propofol anesthesia using the Mini Mental State Examination
(MMSE) and the Montreal cognitive assessment (MoCA) scores
• The etiology of POCD is likely multifactorial and includes drug effects, pain, underlying dysfunction,
hypothermia, and metabolic disturbances.
• Elderly patients are particularly sensitive to centrally acting anticholinergic agents, such as
scopolamine and atropine.
Diagnosing POCD

• Generally a group of neurocognitive tests

have been combined and administered as
a battery, with verbal learning and working
memory, episodic memory, processing
speed, and set shifting emerging as the
most sensitive cognitive testing domains.
Some examples of these tests include the
logical memory test, CERAD word list
memory, Boston Naming Test, category
fluency test, digit span test, trail-making
test, and digit symbol substitution
Postoperative Delirium

• Delirium is perhaps the most significant age-related postoperative complication. It is

characterized by an acute decline in cognitive function and attention, with evidence from the
history that this is due to physiologic derangement, a medication, or multi-factorial.

• Postoperative delirium (PD) is characterized by fluctuating disturbance of consciousness

hallmarked by inattention and disorganized thinking.

• Incidence of PD varies widely from 4% to 7% after elective outpatient surgery, to excess of

65% after hip fracture repair or cardiothoracic surgery

• All postoperative patients who develop delirium for possible precipitating conditions. These
include: Uncontrolled pain, Hypoxia, Pneumonia, Infection (wound, indwelling catheter and
blood stream, urinary tract, sepsis), Electrolyte abnormalities, Urinary retention, Fecal
impaction, Medication, Hypoglycemia
Faktor Resiko
 Diagnosis

The most common delirium

assessments include the
Diagnostic and Statistical Manual
of Mental Disorders (DSM V),
International Classification of
Diseases tenth revision (ICD-10),
and the Confusion Assessment
Method (CAM).
 Prevention and treatment
• Up to 30 to 40 percent of cases of delirium are preventable. Consequently, the best
treatment for delirium is prevention