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Post operative pain management. Jutarat Luanpholcharoenchai. Learning objects. Pain pathway Physiologic response to pain Pain evaluation & assessment Pain management & monitoring Complication. Pain.

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post operative pain management

Post operative pain management

Jutarat Luanpholcharoenchai

learning objects
Learning objects
  • Pain pathway
  • Physiologic response to pain
  • Pain evaluation & assessment
  • Pain management & monitoring
  • Complication
slide3
Pain
  • unpleasant sensory & emotional experience that is associated with actual or potential tissue damage.
pain pathway5
Pain pathway
  • Peripheral sensitization

: mechanical, thermal, chemical stimuli

: PGE2 ↓nociceptor threshold

↑response to noxious stimuli

pain pathway7
Pain pathway
  • Lateral pain system
  • Lateral thalamic nuclei
  • Location, duration, intensity

Medial pain system

central, medial thalamus &limbic system

unpleasant, defense response

pain pathway8
Pain pathway
  • Central sensitization

: C- fibers release glutamate binding to NMDA receptor

: second messenger cascade

 hyperexcitable spinal cord neuron

 ↑ response from injuries region & adjacent region

“secondary hyperalgesia”

“hyperalgesia” & “allodynia”

physiologic response
Physiologic response
  • Cardiovascular

:  HR,  BP ,PVR, ↑myocardial O2 consumption

MI, DVT, pulmonary embolism

  • Respiratory

:⇩ lung volume  atelectasis

:⇩cough, sputum retention infection, hypoxemia

  • Gastrointestinal

: ⇩gastric & bowel motility,

:risk of bacterial transgression of bowel wall

physiologic response10
Physiologic response
  • Musculoskeletal

:muscle spasm, immobility risk DVT

:muscle wasting prolong recovery

  • Central nervous

: central sensitization  chronic pain

  • Psychological

: anxiety, fear, sleep deprivation, leading to  pain

physiologic response11
Physiologic response
  • Neuroendocrine

: catabolic hormone

(glucagon, growth hormone, vasopressin, aldosterone, renin angiotensin)

 hyperglycemia, impaired wound healing

: ⇩anabolic hormone(insulin, testosterone)

surgical pain
Surgical pain

ReviewMultimodal strategies to improve surgical outcome

The American Journal of Surgery 183 (2002) 630–641

surgical pain13
Surgical pain

Major surgery

Thoracotomy

Major abdominal surgery

Knee surgery

Surgical procedure

Moderate surgery

Hip replacement

Hysterectomy

maxillofacial

Minor surgery

Herniotomy

Varicose vein

Gynecological laparotomy

Paracetamol /NSIADs Epidural anesthesia systemic opioids

PCA

Paracetamol /NSIADs +Wound infiltration

Peripheral nerve block

Systemic opioids

PCA

Paracetamol /NSIADs / weak opiods

Wound infiltration

Peripheral nerve block

Treatment modality

surgical outcome
Surgical outcome

ReviewMultimodal strategies to improve surgical outcome

The American Journal of Surgery 183 (2002) 630–641

pain management
Pain management

1. Patient education

2. Drugs & non drugs treatment

3. Monitoring requirement

4.Treatment of side effects

pain management16
Pain management
  • Preemptive analgesia & Multimodal analgesia
    • ⇩ doses of each analgesic
    • Improved actinociception due to synergistic/additive effects
    • may⇩ reduce severity of side effect of each drugs
multimodal analgesia
Multimodal analgesia

Opioid

Anti inflammatory agents

Alpha 2 agonist

Local anesthetics

Opioid

Anti inflammatory agents

Alpha 2 agonist

Local anesthetics

Opioid

Anti inflammatory agents

pain evaluation assessment
Pain evaluation & assessment

Nociceptive / Inflammatory pain

:Somatic; sharp, hot, sting

well localized

:Visceral; dull, cramping, colicky

poorly localized, referred pain

pain evaluation assessment20
Pain evaluation & assessment

Non- nociceptive pain

:Neuropathic

Hx of nerve damage, burning, shooting,

stabbing, allodynia, hyperalgesia,

dysesthesias

: Psychogenic pain

pain evaluation
Pain evaluation
  • Pain history
    • Site of pain
    • Conditions associated with pain onset
    • Character :intensity , associated symptoms
    • Current & prior treatment
    • Relevant medical history
    • Other patient factors
pain evaluation22
Pain evaluation
  • Physical examination
  • Psychological examination
pain management guideline
Pain management guideline

Pain symptom

Mild

Moderate

severe

intensity

Drug selection

Constant moderate to severe pain

Intermittent pain

prn short acting analgesics

Long acting analgesics +prn short acting analgesics

factors influencing analgesic requirements
Factors influencing analgesic requirements
  • Age : elderly request smaller doses
  • Pre-operative analgesic use.
  • Coexisting medical conditions
  • Preoperative patient education
  • Site of operation
treatment
Treatment …
  • Pharmacologic
  • Opioid
  • Non opioid
  • Adjuvant
opioids
Opioids
  • Essential element of pain management
  • Mechanism
    • Action on opioid receptor
    • Located mainly in spinal cord& brain stem, some in peripheral tissue
opioids receptors
Opioids receptors

Clinical effect

Analgesia, sedation, euphoria

Resp. depression, physical dependence

Spinal analgesia, resp. depression

Analgesia, resp. depression

Dysphoria, hallucination, tachycardia

hypertension

Receptors

Mu (μ or OP3)

μ1

μ2

Kappa (κ or OP2)

Delta (δ orOP1)

Sigma(σ)

opioids30
Opioids

1.Agonists

: stimulate receptor

: no ceiling effect ( no limit mg/kg)

: moderate to severe pain

: Codiene, morphine, pethidine, fentanyl, methadone

opioids31
Opioids

2.Partial agonists

: ceiling effects eg.buprenorphine

opioids32
Opioids

3. Agonists-antagonists

: agonist-κ or σ receptor

but antagonist to μ receptor

: can used in mild to moderate pain

: ceiling effects

: precipitate withdrawal in opioids dependent

: pentazocine, nalbuphine

opioids33
Opioids

4. Antagonists

: competitive antagonist to all opioid receptors

eg. naloxone

morphine
Morphine

:standard treatment

: metabolism : liver

M-3-G : no analgesic property

M-6-G : more potent than morphine(2X)

: histamine release

meperidine
Meperidine

:atropine like effect : tachycardia ,dry mouth

: metabolism liver

Normeperidine  CNS excitation

: shivering treatment

: interaction with MAOI  hyperpyrexia, convulsion ,hypertension ,coma

fentanyl
Fentanyl

: rapid onset & short duration

: inactive metabolite

: no histamine release

:100X potent than morphine

codeine
Codeine

: weak opioids

: orally plus with paracetamol “ TWC”

: mild to moderate pain.

:Doses 15-60 mg 4 hourly

(with a maximum of 300 mg daily)

naloxone
Naloxone

: Px opioid intoxication

: dilute to 10 ml. titration

: side effect : withdrawal symptoms, hypertension, tachycardia, pain, pulmonary edema

naloxone39
Naloxone

Respiratory depression & somnolence

: 1-4 mcg/kg repeat q 2-3 min

: 3-5 mcg/kg/hr continuous infusion

Urinary retention & Pruritus

: 1-2 mcg/kg

Nausea vomitting

: 0.5-1 mcg/kg

basic requirement for opioid
Basic requirement for opioid

Route of administration

: safe, effective titration

Initial prescription

: appropriated dose

: used of dose interval

: monitoring of pain & sedation score

: alteration of subsequence dose

Aim : patient comfort, sedation score <3

goal treatment
Goal! treatment

: Right opioids

: Right route

: Right dose

: Right interval

opioids administration
Opioids Administration

Analgesic corridor

opioids administration43
Opioids Administration

Around the clock

opioids dose
Opioids dose

Breakthrough pain

Promt

Short action

easy to give

opioids administration45
Opioids Administration

prn for pain q …

opioids administration46
Opioids Administration

1.Intravenous continuous drip

Side effects

Analgesic corridor

PAIN

opioids administration47
Opioids Administration

2.Intravenous q 4 hr

3.Intramuscular q 4 hr

opioids administration48
Opioids Administration

4. IM prn q 6 hr

5. IM prn q 2 hr

intrathecal opioids

Opioids

Morphine

Meperidine

fentanyl

Opioids

Morphine

Meperidine

fentanyl

Dose (mg)

0.1-0.5

10-25

0.006-0.05

Dose (mg)

1-5

20-150

0.025-0.1

Duration(h)

8-24

6-12

3-6

Duration(h)

6-24

4-8

2-4

Intrathecal opioids

Onset(min)

15-30

5-10

5

Epidural opioids

Onset(min)

30

5

5

opioids52
Opioids
  • Tolerance
  • Physical dependence

- withdrawal symptom

  • Addiction /psychological dependence
  • pseudotolerance
tramadol
Tramadol
  • Multiple mechanism
    • Weak µ-receptor agonist
    • Inhibit serotonin & NE reuptake
  • Application: neuropathic component
  • Dose : 50-100 mg PO q 4-6 hr.
  • Max. 400 mg/d
potential side effects of opioids
Potential side effects of Opioids
  • -Respiratory & cardiovascular depression
  • - Nausea, vomiting, ileus , Constipation
  • - Urinary hesitency & retention
  • - Pruritus
  • Sedation dizziness ,delirium
  • -Myoclonus/seizure
  • - Tolerance dependence

REVIEW ARTICLE WHITE ANESTH ANALG

NON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–S22

treatment opioid adverse effects
Treatment opioid adverse effects
  • Respiratory depression:most serious

Sedation score

0 : wide awake

1 : easy to rouse

2 : easy to rouse but unable to stay awake

early respiratory depression

3 : somnolent, difficult to rouse

severe respiratory depression

adverse effects
Adverse effects
  • Indicators of respiratory depression

- Respiratory rate

> 10 breaths/min

treatment opioid adverse effects57
Treatment opioid adverse effects
  • Nausea: tolerance within 7–10 days

Pxhaloperidol , ondansetron or domperidone

  • Vomiting:

Pxdomperidone or metoclopramide

  • Constipation: not tolerance

Px laxativeand stool-softeners

treatment opioid adverse effects58
Treatment opioid adverse effects
  • Drowsiness: tolerance over 5–7 daysoxycodone or meperidine
  • Itching:

antihistamine

non opioids
Non opioids
  • Acetaminophen
  • Local anesthetic drugs
  • Nonsteroidal anti-inflammatory drugs

No physical dependence

No tolerance

Ceiling effect

acetaminophen
Acetaminophen
  • Effective analgesic
  • Action
    • Analgesic
    • Antipyretic
    • Anti-inflammatory agent
  • Relative safety
  • Effective for the musculoskeletal aches, joint stiffness
acetaminophen61
Acetaminophen
  • Disadvantage
    • Dose-dependent hepatotoxicity, GI upset
    • Agranulocytosis
  • Dosage
    • 650-1000 mg PO q 4 hr.
    • Max. 4 g/d
  • Reduce dose 50-70% in patient with significant hepatic impairment
nsaid
NSAID

PGI2

PGI2

PGE2

TXA2

Side effects

Therapeutic effects

contraindication of nsiad
Contraindication of NSIAD
  • Pre-existing renal impairment (Cr)
  • Cardiac failure
  • Severe liver dysfunction
  • Uncontrolled hypertension
  • Aspirin-induced asthma
  • History of GI bleeding
  • Known hypersensitivity
nsiad used with caution
NSIAD used with caution
  • High risk of intraoperative hemorrhage eg. Cardiac, major vascular, hepatobiliary surgery
  • Impaired hepatic function, diabetes, bleeding or coagulation disorders, vascular disease.
  • Pregnant and lactating woman
  • Children < 16 or advanced age
  • Concurrent used other NSIAD ,ACEI , cyclosporin, methotrexate
potential side effects of nsaid
Potential side effects of NSAID
  • Operative site bleeding
  • GI bleeding
  • Renal tubular dysfunction
  • Allergic reaction
  • Bronchospasm
  • Hypertension
  • Pedal edema

REVIEW ARTICLE WHITE ANESTH ANALG

NON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–S22

local anesthetic
Local anesthetic
  • Block generation & conduction of nerve impulse in peripheral & central nervous systems

Myelinated fibers

A-alpha(Aα)

A- beta(Aβ)

A-gamma(Aγ)

A-delta(Aδ)

B

Myelinated fibers

C

Function

Motor, proprioception

Touch, pressure

Muscle spindle tone

Pain, temperature, touch

Sympathetic (preganglion)

Pain, temperature

technique for administering local anesthesia
Technique for administering local anesthesia

Peripheral nerve blocks

Ilioinguinal/hypogastric : herniorrhaphy

Paracervical : F&C, D&C, cone biopsy

Penile : circumcision

Brachial plexus : arm, hand

Intercostal/paravertebral : breast

Peribulbar/retrobulbar :eye

REVIEW ARTICLE WHITE ANESTH ANALG

NON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–S22

technique for administering local anesthesia69
Technique for administering local anesthesia

Tissue infiltration wound instillation

Topical analgesia

EMLA : skin lesion

Lidocaine spray : bronchoscopy, endoscopy

Lidocaine gel /cream: uro,oral surgery

Cocaine paste : nasal ,endosinus surgery

REVIEW ARTICLE WHITE ANESTH ANALG

NON-OPIOID ANALGESICS AND ACUTE POSTOPERATIVE PAIN 2005;101:S5–S22

local anesthetic70
Local anesthetic

Agents

Lidocaine

-infiltration

-epidural

-plexus or nerve

Bupivacaine

-infiltrate

-epidural

-plexus or nerve

% solution

0.5-1

1-2

0.75-1.5

0.125-0.25

0.25-0.75

0.25-0.5

Duration(h)

1-2

1-2

1-3

1.5-6

1.5-6

8-24+

Max dose

7mg/kg

3.5mg/kg

potential side effects of local anesthetic
Potential side effects of Local anesthetic
  • - Residual motor weakness
  • - Peripheral nerve irritation
  • - Cardiac arrhythmias
  • - Allergic reactions
  • Sympathomimetic effects (due to vasoconstrictors)
sign symptoms of local anesthetic intoxication
Sign &symptoms of Local anesthetic intoxication
  • Cardiovascular depression
  • Respiratory arrest
  • Coma
  • Convulsion
  • Drowsiness  Unconscious
  • Muscle twitching
  • Tinnitus, visual disturbance
  • Circumoral , tongue numbness
  • Lightheadedness

 Blood concentration

corticosteroid
Corticosteroid
  • Reduce pain in several ways
    • Reduce inflammation
    • Relieve nerve compression
    • Decrease spontaneous firing of sodium channels in neuromas
  • Effective in
    • Pain secondary to edema (CNS ds.)
    • Prostglandin-mediated pain (arthritis, bone metastasis)
  • Not recommend for long term