Pain Rounds February 2010
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Pain Rounds
February 2010
A convergence of pain and morbid obesity
Chris Hayes John HambridgeDebbie Harper
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26 years female: persistent pain in the context of morbid obesity
A tale of 2 admissions related to obesity April – June 2009 (discharge against medical
advice) July 2009 – ongoing
The preceding chapters Difficult developmental history and adolescence
A complex story Multiple medical and psychosocial problems Input from multiple health care professionals
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PSYCHOLOGICAL ASPECTS OF MORBID OBESITY
It’s no laughing matter…….
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Morbid obesity: brief overview
BMI ≥ 40 (or ≥ 35 with serious co-morbidities) 180cm, 129kg, BMI=40 160cm, 102kg, BMI=40
2.4% Australian adults morbidly obese ≈275,000 people, more women than men
25% of population obese (BMI 30-40) Prevalence doubling every 5-10 years Pre-pubescent onset Associated with socioeconomic
disadvantage
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PEOPLE OVERWEIGHT OR OBESE ≥ 18 YRS
Australian National Health Survey, 2007-8
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Health consequences
Obesity vs. morbid obesity? Increased all cause mortality Morbidity
CVD; type 2 diabetes; musculoskeletal disorders; endometrial, breast & colon cancers; respiratory disorders
Risks of chronic conditions increases progressively with BMI
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What’s it like being morbidly obese?
Survey of formerly morbidly obese who had undergone surgery
Given forced choices between obesity & variety of other conditions 42% preferred blindness to obesity 40% preferred BKA
Negative stereotypes held by children, adults, medics, employers etc
Mixed findings regarding psychopathology
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Binge eating
32%-49% BED in surgery presenters
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Issues faced by morbidly obese in hospital and community
Stigma “Freak show” One of few remaining “safe” prejudices Made worse by number of staff required for
care needs “Chinese whispers”
Lack of dignity Difficulty in getting weighed
Morgue only option in JHH Patients are often weighed at vet’s or
weighbridge when home
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Multiple levels of overt and covert discrimination Ultrasound, CT & MRI impossible Even BP difficult Lack of appropriate bariatric equipment Door width! Special equipment can also add to stigma e.g.
throne-like appearance of special chairs Transport issues (within & outside hospital) Clothing
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Morbid obesity - treatment
No current good evidence for psychological interventions
No current good evidence for pharmacotherapy Appetite suppressants Reduced nutrient absorption (orlistat)
Bariatric surgery is recommended treatment
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Surgery outcomes
Dramatic reduction in medical co-morbidities in Swedish study (n > 4000)
Sjöström et al., 2007
At two years 32x reduction in diabetes 2.6 – 10x reduction for others
At eight years 5x reduction in diabetes
Weight loss typically 40kg
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Does surgery improve psychosocial functioning?
Improved QoL Decreased depression Decreased psychopathological
symptoms Binge eating impact depends on type of
surgery Vomiting seems to increase though
Improvements in social/vocational/sexual domains
Generally, improvements are dose dependent
Herpertz, 2003
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The early years
No information regarding early childhood 1995 aged 12 years – admission for a weight
reduction program (paediatric endocrinologist and psychiatrist) Obesity (150 kg) Obstructive sleep apnoea (OSA): mild – moderate
(Camperdown Children's Hospital). CPAP recommended but not accepted.
Skin infection (intertrigo) School non-attendance Dysfunctional family
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The initial outcomesThe initial outcomes
Weight loss 150 to 135 kg over 6 week admission
Non-attendance at F/U appointments with dietician, physiotherapist
DOCS notification
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Usual themes
Dysfunctional relationship with mother Sabotage of medical treatment Restricted social milieu Eating to regulate all types of emotions Adolescent intervention School refusal / bullying Genetics
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Ongoing ProblemsOngoing Problems
Depression Agoraphobia – not left home since age 17
years Period of high alcohol use Asthma Worsening OSA, pulmonary hypertension,
right heart failure, leg oedema Increasing weight (340 kg)
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Admission 1: April-June 2009
Presenting problem Fall at home Ambulance transport after help from fire brigade
and ambulance officers Precipitating problem - Community acquired
pneumonia Initial treatment
BiPAP Antibiotics
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Admission 1: Other problems
Morbid obesity Poor mobility Depression, agoraphobia OSA, pulmonary hypertension, right heart
failure Asthma Fe deficiency anaemia (menorrhagia)
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Admission 1: More other problems
Abnormal LFTs (cholelithiasis, hepatosplenomegaly)
Cellulitis of legs Heparin induced thrombocytopaenia
syndrome (HITS) Hypothyroidism
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Admission 1: Progress
Weight loss of 80 kg (340 to 260 kg) Some gains in mobility and other problems Transferred to rehabilitation ward to address
broader goals Discharged home against medical advice
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One month later: July 2009
Re-admitted with cellulitis of left leg and abdominal wall
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Broad themes
Ulceration/infection over hip region bilaterally Antibiotics Unsuitable for debridement under general
anaesthetic Maggot therapy
Nutrition Nasogastric and oral feeds Now down to 160 kg Albumin 13 up to 29 g/l (33-41)
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Broad themes
Respiratory status Variable compliance with CPAP
Mobility and posture Physiotherapy Slings, beds and other specialised equipment
Psychology Social aspects
Mother’s presence Co-ordination of care
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PhysicalMental
EmotionalDysfunctional
SpiritualDignity
Challenging the SensesBeliefs
“A Sizeable Issue” The J3 Experience
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Pain issues
Pain sites Areas of ulceration Surrounding areas Related to postural factors Dressing changes
Focus on external layers and external solutions
Balance of medication V meditation
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Pain treatment
Entonox (nitrous oxide, laughing gas) Escalating requirements
Ketamine infusion Escalating requirements
The power of the case conference Limit setting
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More pain treatment
Gabapentin Escitalopram, venlafaxine Lorazepam Oral opioids (oral morphine equivalent
240mg) Oxycontin 20 mg bd Endone 15 mg q 3 hours Trialled rotation (hydromorphone, methadone)
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Medication adverse effects
Constipation Sedation Tolerance Opioid induced hyperalgesia ?
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Where to next ?
Which battles to fight Balancing empathy with boundaries