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High-Tech Methods for Management of Post-Operative Pain

Explore the current issues and available high-tech methods for post-operative pain management, including PCA methods and hi-tech regional anesthesia/analgesia techniques. Learn about the equipment and approaches used in this field.

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High-Tech Methods for Management of Post-Operative Pain

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  1. high technology treatment methods Management of post-operative pain Type in your name Type in the name of your institution

  2. Lecture outline • Postoperative pain management – what are the current issues? • Which hi-tech methods are available? • PCA methods • Hi-tech regional anesthesia / analgesia techniques • Equipment • Summary

  3. 1. Postoperative pain - current issues • Major advances in knowledge of physiology & pharmacology over last 40 yrs. • Introduction of new drugs “incredibly slow” (nothing new in 50 yrs). • “Old” non-opioids becoming mainstream (gabapentinoids, ketamine). • Challenge of persistent postoperative pain. • Special groups: elderly, opioid dependent / opioid tolerant, ambulatory surgery, children. • Role of audits, organisation of staff (e.g. Acute Pain Services) more important than ever. • Opioids remain mainstay but new delivery systems, high-tech methods • Regional techniques best but remain underused; the trend is to “go peripheral” topics covered by this talk

  4. 2. Which hi-tech methods are available for management of postoperative pain? • Systemic analgesic techniques: • I.V. opioid PCA technique • Transdermal PCA • Transmucosal PCA (sublingual, intranasal,inhalational) • Continuous (catheter) regional anaesthesia techniques: • Central blocks (epidural, Combined Spinal-Epidural) • Perineural techniques (in hospital, at home) • Wound catheter techniques • Local Infiltration Analgesia (LIA) technique for hip and knee replacement

  5. 2. Which hi-tech methods are available for management of postoperative pain? • Non-pharmacological techniques: • TENS (Transcutaneous Electrical Nerve Stimulation)

  6. 2. Which hi-tech methods are available for management of postoperative pain? • Equipment: • Pumps (Electronic, elastomeric, battery-driven) • Ultrasound devices to improve success rates of regional anaesthesia techniques • Catheters (multiple-hole, stimulating, kink-free)

  7. 3. PCA methods for management of postoperative pain Systemic methods for analgesia: Intravenous Patient Controlled Analgesia (IV-PCA)

  8. The Pain Cycle – PRN vs PCA dosing • Patients recovering from surgery are often treated with IM or IV analgesics given on a PRN basis. • This is inefficient and labor intensive as it requires screening, preparing and nurse administration and that might delay administration of the analgesics by up to 40 minutes. • Onset of analgesia can be delayed further by variables related to absorption.

  9. The Pain Cycle – PRN vs PCA dosing • Patients finally receive relief and some degree of sedation only to experience pain several hours later. • This cycle can be repeated every 3-4 hours during the post operative period. • PCA administration eliminates the pain cycle by allowing more frequent patient directed dosing.

  10. The Pain Cycle – PRN vs PCA dosing Patient need (pain) Sedation Nurse call < PCA boluses Relief (analgesia) Nurse response screening Absorption from site < < 35- 40 minutes < Give injection Sign out medication < Prepare injection

  11. Relationship between opioid plasma levels, in PRN dosing vs PCA PCA enables patients to remain in the analgesic window for a greater proportion of the time compared to conventional PRN administration Analgesic Window Aim to stop using IM, SC routes; encourage administration by IV boluses or oral route. Caution: IV route dependson availability of staff for observation. Ferrante et al, Anesth Analg, 1988;67:457-461

  12. Technical schematic of a typical Patient Controlled Analgesia (=PCA) device. Microprocessors allow caregivers to program drug, dose and lockout interval (=time between doses). A dose is administered to the patient when he presses on the ‘patient activation button’. The cumulative dose is displayed on a small screen. The syringe or bag containing drug is placed in a locked, tamper-resistant portion of the device. Physician prescribed settings

  13. Patient-Controlled Analgesia Principles • Demand dosing • Lock-out interval • Constant-rate infusion (optional) plus demand dosing • Variable-rate infusion plus demand dosing • Loading dose (titrated to effect) • Routes of administration • IV; • ALSO: subcutaneous, oral, epidural, intrathecal, transdermal, nasal

  14. Potential advantages of PCA • Minimizes intervals between analgesic request & pain relief. • Rapid onset of effect (5-10 min). • Breaks the pain cycle. • Accommodates for inter-individual differences in analgesic requirements. • High degree of patient acceptance • and satisfaction? –evidence is mixed.

  15. Potential disadvantages of (IV)-PCA • Requires expensive devices & tubing. • Requires IV access and dedicated line. • Over-dosage may occur due to programming errors. • Over-dosage may occur when relatives/parents/nurses administer doses for patient (“PCA by proxy”).

  16. PCA overdose reports • The database of the Institute of Safe Medical Practice received information about 425 incidents involving opioid infusion pumps during 1987 – 2003. • The incidents were associated with 135 injuries, 23 deaths and 127 potential deaths requiring pump deactivation and naloxone administration. • Methods to reduce PCA and analgesic infusion pump injuries and death include: • Adequate training of nurses and refresher courses. • ‘High alert’ medication labeling. • Two nurses must program the pump. • Safeguards against use of pump by ‘concerned proxy’. • Programming safeguards (smart pumps). • Ref: http://www.ismp-canada.org/index.htm

  17. PCA – contraindications • Patient rejection or inability to comprehend technique • Lack of trained nursing staff • Severe chronic obstructive lung disease • Sleep apnea

  18. PCA can be used by all ages ... • …provided that: • Patients receive adequate explanations how to use the technique. • Sufficient nursing staff to enable follow-up of effectiveness, adverse effects.

  19. PCA for postoperative pain - a systematic review • Randomized Contolled Trials (RCTs) up to Jan 2000 comparing i.v. PCA vs same opioid s.c., i.m. or i.v. • 32 trials: 22 morphine (n=1139), 5 pethidine (n=682), 3 piritramide (n=184), 1 nalbuphine (n=47), 1 tramadol (n=20) • Main findings: • No major difference in analgesia, amount of opioid consumed or opioid related adverse effects • Patients prefer PCA (not necessarily more satisfied) • Limited evidence of decreased pulmonary complications • Lack of data on cost-effectiveness Walder B et al Acta Anesth Scand 2001;45:795-804

  20. PCA for postoperative pain - a systematic review (cont) These differences are not significant Bottom line: If carried out correctly, analgesia can be effective with conventional administration of analgesics, without use of expensive pumps. Walder B et al Acta Anesth Scand 2001;45:795-804

  21. Patient controlled transdermal system Pre-programmed, self-contained, non-invasive alternative to i.v. PCA Operates for 24 h after 1st dose is delivered or delivers a maximum of 80 doses and shuts off Dose (controlled by current) is fixed at 40 µg.

  22. Intranasal PCA • Hallett A et al Anaesthesia 2000;55:532-9

  23. Perioperative epidural analgeisa and outcome after major surgery Advantages of epidural analgesia: • Excellent analgesia - the best technique. • Shorter duration of postoperative ilieus. • Reduced risk of pulmonary complications (Ballantyne 1998). • Reduced risk of postoperative myocardial infarction (Beattie 2001). • Reduced risk of persistent postoperative pain. • Some evidence of reduced risk of cancer recurrence.

  24. Patient controlled epidural analgeisa (PCEA) vs. continuousinfusion for labor analgesia • 9 RCTs, 1980-2001, n = 641 (ropivacaine n = 96) • PCEA (no background infusion) is associated with:- fewer anesthetic interventions- significantly less local anesthetic- less motor block • No difference in pain scores, patient satisfaction or other outcomes (maternal, fetal, block level, hypotension, pruritus etc). • Both techniques are safe. newer meta analysis 2012 cochrane Van der Vyer et al, Br. J. Anaesth. 2002;89:459-65

  25. ”… ”

  26. cont. 299 RCT’s • Epidural (CEI or PCEA) is superior to IV-PCA for pain at rest and activity • Compared with IV-PCA, epidural analgesia is associated with: - lower incidence of PONV, sedation - higher incidence of pruritus, urinary retention, motor block • PCEA ( vs CEI) is associated with: - inferior analgesia ( at rest and activity) - lower incidence of PONV, motor block - higher incidence of pruritus ”In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared with intravenous patient-controlled analgesia”

  27. Prospective. • PCEA (n = 14,223), iv PCA (n = 1591), brachial plexus cath. interscalene or axillary (n = 1737), femoral/ sciatic catheter (n = 1374) • pain scores significantly better for regional techniques • Complications : - epidural haematoma 1:4741 (0.02 %), risk greater with lumbar (vs thoracic) - epidural abscess 1:7142 (0.01 %) - severe neurological complications of perineural catheters 2: 3111 (0.06 %) - infection (perineural catheter) 3.7 % (no abscess) - respiratory depression PCEA 1.1 %, iv PCA 0.7 % PCEA, IV PCA and perineural catheter techniques "--- are safe and efficient, --- close supervision of all these techniques by an acute pain service in the postoperative period is mandatory"

  28. ‘Walking epidurals’

  29. Patient Controlled Epidural Analgesia - current status Summary • Both epidural techniques (CEI and PCEA) provide excellent analgesia • PCEA is superior to CEI for labour analgesia, conflicting evidence for postoperative analgesia • PCEA allows dose reduction of local anaesthetics - less motor block (”walking epidural”) - lower risk of adverse effects (PONV) • Routine use of epidural analgeisa is decreasing (multiple reasons), but when indicated PCEA seems to be the best choice.

  30. Anesth Analg 2005;100:1822-33 • Strong evidence for improved postoperative analgesia, sleep quality, patient satisfaction • Decreased need for opioids (& reduced opioid side effects) • Further studies necessary: selection of appropriate patients and surgical procedures optimal LA concentration, adjuvants safest frequency of patient contact?, method of catheter removal

  31. 4. Hi-tech regional anesthesia / analgesia techniques

  32. J Am Coll Surg2006;203:914-932 39 RCT’s (n = 1761) qualitative analysis, 45 RCT’s (n = 2031), qualitative analysis Surgical subgroups: abdominal, cardiothoracic, gynecologic, orthopedic, minor Benefits of wound catheters:decreased pain scores at rest and activity (32 % reduction)decreased need for opioids (25 % reduction)decreased risk of PONV (16 % reduction)increased patient satisfaction (30 % increase)decreased LOS in hospitalized patients (limited data, 1 day, p = 0.01) no increase in adverse effects ”Continuous wound catheters appear to be an effective modality for management of postoperative pain.”

  33. Wound catheter infusions - the evidence ”Continuous local anaesthetic infusions lead to reductions in pain scores (at rest and activity), opioid consumption, postoperative nausea and vomiting, and length of hospital stay; patient satisfaction is higher and there is no difference in the incidence of wound infections” (S) (level 1) Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine.3rd edition 2010. www.anzca.edu.au <http://www.anzca.edu.au>

  34. LIA technique (knee, hip replacement) • Intraoperative infiltration of surgical area • ropivacaine 0.2 % 150 mL (300 mg) • ketolorac 30 mg • adrenaline 0.5 mg • Intraarticular catheter (withdrawn morning after surgery) • Pressure bandage + icepack for 4-6 h (to prolong analgesia)

  35. LIA technique (knee, hip replacement) • Anaesthesia: spinal with high GA? • Surgical technique: conventional • Early mobilization within 3-5 h ~ 50 % discharged day after surgery (almost all others on day 2) • Pain management: paracetamol, NSAID’s, weak opioids • Antithrombotic treatment: only aspirin!

  36. Perioperative injection during total hip resurfacing. • Injection around acetabulum after insertion of the component. • Injection of the rotators and the gluteal muscles. • The epidural catheter is place in the joint. • Perioperative injection during total knee arthroplasty. • Injection of the posterior capsule, shown with multiple needles. • Injection of the capsule. • The epidural catheter places behind the medial condyle. • Injection of the subcutaneous layer

  37. LIA technique for TKA and THA - summary • Emerging technique for total hip and knee replacement surgery • Has changed orthopaedic practice in many institutions (75% TKA in Sweden) • Promising results- better for TKA • Need for good, comparative studies with pre-defined outcome criteria to: • identify essential components • reduce inappropriate and unnecessary interventions • establish if technique is cost-effective

  38. 5. Disposable infusion devices • Non-electrically powered disposable infusion devices • in clinical practice for more than 30 years • Indications • chemotherapy, antimicrobials, pain management (acute and chronic) • Types of pumps: - Elastomeric - Spring powered - Gas pressure pumps - PCA devices (with and without background infusion)

  39. Portable, disposable basal- & bolus-capable infusion pumps need to have two slides for this?If only one, which do you prefer?

  40. Portable, reusable basal- & bolus-capable infusion pumps

  41. Elastomeric pump, PCA device elastomeric pump, pca device

  42. Ambulatory surgery • Elastomeric disposable pump • Continuous infusion & boluses • Patient can be at home pt button

  43. PCA techniques for postoperative analgesia • IV-opioid : well-established worldwide, high patient satisfaction, unimpressive effects on outcome • Epidural : excellent dynamic pain relief, cost-effective with good APS. Superior to continuous infusion technique. • Perineural : excellent alternative to PCEA in appropriate patients • Incisional/intraarticular : simpler, safer, less expensive than other regional techniques • Transdermal : as good as i.v.. Further studies necessary • Intranasal, buccal : interesting concepts. Further studies necessary

  44. PCA - key messages (1) IV-opioid-PCA – if property administered - provides better analgesia than conventional parenteral regimens. Analgesia effectiveness can be as good with conventional parenteral opioids if administered appropriately (=e.g. titrated, combined with non-opioids). points 1 & 2 somewhat contradict each other; would think #2 more accurate? IV-opioid-PCA leads to higher opioid consumption, higher incidence of pruritus but no difference in length of stay. compared with traditional intermittent opioid administration Patient preference for IV-PCA is higher vs conventional regimens.

  45. PCA – key messages (2) The provision of epidural analgesia by continuous infusion or patient-controlled administration of local anesthetic-opioid mixtures is safe on general hospital wards, as long as supervised by anesthesia-based service with 24-hour medical staff cover and monitored by well-trained nursing staff.

  46. Summary Many opioid-based, regional anesthetic and even non-pharmacological hi-tech methods are available for treating postoperative pain. In general most hi-tech methods are patient-controlled techniques. A variety of pump devices provide patient-activated boluses, continuous infusions or both for opioid-based or regional anesthesia techniques.

  47. Summary Operator error remains a relatively common safety problem with IV-opioid-PCA methods Minimal-invasive surgical methods can play an important role in reducing postoperative pain There is no evidence of better analgesic effectiveness with hi-tech PCA if conventional methods are used optimally.

  48. This talk was originally prepared by: Narinder Rawal, M.D. PhD, FRCA (Hon) Orebro, Sweden

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