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Postoperative pain management strategies Dienst Anesthesie & Intensieve Zorgen OLV-Hospital Aalst, Belgium

Postoperative pain management strategies Dienst Anesthesie & Intensieve Zorgen OLV-Hospital Aalst, Belgium. Jan De Witte, M.D. Koen Suy, M.D. Loïc Delplanque, M.D. Topics. Stepwise introduction of new techniques Ultrasound-guided blocks TAP block Data management client-based software

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Postoperative pain management strategies Dienst Anesthesie & Intensieve Zorgen OLV-Hospital Aalst, Belgium

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  1. Postoperative pain management strategiesDienst Anesthesie & Intensieve ZorgenOLV-Hospital Aalst, Belgium Jan De Witte, M.D. Koen Suy, M.D. Loïc Delplanque, M.D.

  2. Topics • Stepwise introduction of new techniques • Ultrasound-guided blocks • TAP block • Data management • client-based software • Pain armentarium • tramadol

  3. Stepwise introduction of techniquesgain a surgeon’s confidence

  4. Ultrasound guided blocks e.g. TAP block

  5. TAP Block Dr. Koen Suy Onze-Lieve-Vrouwziekenhuis Campus Aalst

  6. ‘Transverse Abdominis Plane’ ‘TAP’ Block • ‘Old blocks, new tricks … ‘ under ultrasound !!!!!! • Wat is een TAP block? = Regionale anesthesie van de abdominale buikwand dmv (bilaterale) infiltratie met langwerkende lokale anesthetica in deneurovasculaire ‘TAP’ (= tussen de M. obliquus internus abdominis en de M. transversus abdominis) • Sensorisch blok T6-L1 • Deel van ‘multimodale postoperatieve analgesie’

  7. Anatomie buikwand

  8. Anatomie buikwand

  9. Wat?

  10. Hoe?

  11. Hoe?

  12. Indicaties-Contraindicaties Indicaties: • Laag abdominale ingrepen: appendix, sectio, abdominale hysterectomie, retropubische prostatectomie, colectomie, liesbreuk, abdominoplastie … • Hoog abdominale ingrepen: variante techniek (‘sub-costal oblique’ TAP block) cholecystectomie, gastric bypass, umbilicale hernia, … Contraindicaties: geen Laparoscopie: cfr letter to the editor BJA januari 2009

  13. Voordelen TAP-block • Eenvoudig, snel, veilig, ruime doelgroep • Succesratio is hoog (mbv ultrasound) • Lange werkingsduur (> 20 u met 1 single shot langwerkend LA (20 cc)) • Catheter versus repetitief prikken (zo nodig) • TAP block is een goed alternatief voor epidurale analgesie: • Geen beinvloeding autonoom zenuwstelsel (hemodynamiek, blaassonde,…) • Geen motorisch blok • Geen invloed anticoagulantia (cfr fraxi, …) • Opvolging eenvoudiger • Bruikbaarheid in dagziekenhuis • Mobielere patient • Plaatsing onder narcose (  comfort patient) • …

  14. Referentie ‘The Transversus Abdominis Plane (TAP) block: Abdominal plane regional anaesthesia’ Katrina Webstar, MD ‘Update in Anaesthesia’ p 24-29 www.worldanaesthesia.org

  15. WELKOM koen.suy@olvz-aalst.be

  16. Pain Management Program Dr Loïc Delplanque

  17. Situering • Dienst Acute Pijn • Oprichting: april 2003 • Doel: reduceren post-operatieve pijn door aanpassingen pre-, per- en postop • Werkwijze: • Registreren • Analyseren

  18. Situering • Dienst Acute Pijn OLV Aalst: • 1 staflid anesthesie • 1 assistent anesthesie • 2 verpleegkundigen • Situatie tot 2006: • Overdracht • Registreren

  19. Software • Administratieve vereenvoudiging • Digitale formulieren • Keuzelijsten • Elektronisch medisch dossier • Digitaal archief • Automatische registratie • Vereenvoudigde analyse • Facturatie

  20. Software • Mogelijkheden: • Commerciële software • Kostprijs • Service • Flexibiliteit • Eigen database • Tijdrovend • Betrouwbaarheid

  21. Demonstratie

  22. Besides catheter techniquesJ. De Witte, M.D. • Gabapentine • Ketamine, Mg2+ • Sufentanil • Remifentanil • Tramadol

  23. Dalende pijnbanen

  24. Tramadol: not just another analgesic • No ceiling effect • Antitussive potency • Lowers shivering threshold (De Witte 1997, 1998, 2002) • High safety profile • Minor side effects • nausea: 5-30% • more frequently after IV injection • dose dependency • antiemetic prophylaxis • prevention by slow injection

  25. Tramadol: loading dose and maintenance doses • loading dose: tramadol 3 mg/kg IV (max. 250 mg) • intermittent dose regimen: tramadol 50-100 mg 4/d IV • continuous infusion: tramadol 12-25 mg/h IV • patient-controlled analgesia: demand 25 mg; lock-out 10 min (Lehmann 1990: 5 min) • PCA + concurrent infusion: demand 25 mg, lock-out 30 min, infusion 12.5 mg/h  max 4h dose 250 mg (Lehmann 1990: 500 mg)

  26. De Witte J, Rietman W, Deloof T, Vandenbroucke G. Postoperative effects of tramadol administered at wound closure. European Journal of Anaesthesiology 1998; 15: 190-195 Tramadol 3 mg kg−1 (n=20) was administered intravenously at the beginning of wound closure, and was compared with saline (n=20). Post-anaesthetic shivering did not occur in any patient who received tramadol, whereas it occurred in 60% of the control group (P<0.001). There were no adverse effects on time to extubation and sedation, and discharge-ready time was shorter in the tramadol group (P<0.05). Pain scores in the post-anaesthesia care unit (PACU) were statistically not different between the two groups, but significantly more supplemental medication was administered in the control group. PONV occurred in one patient of the tramadol group (5%) (antiemetic prophylaxis: droperidol 1.25 mg IV)

  27. De Witte J, Schoenmaekers B, Sessler DI, Deloof T.The analgesic efficacy of tramadol is impaired by concurrent ondansetron administration Anesthesia and Analgesia, 2001; 92: 1319-21

  28. Special patient groups • children > 1 y: tramadol 2 mg/kg IV 4/d tramadol 10 mg/kg/24h IV ( adults) • elderly: dose reduction is not necessary (if hepatic and renal function are within normal limits) • parturients: tramadol has a superior safety profile (Viegas, 1993)

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