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Post operative pain management

Post operative pain management

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Post operative pain management

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  1. Post operative pain management Jutarat Luanpholcharoenchai

  2. Learning objects • Pain pathway • Physiologic response to pain • Pain evaluation & assessment • Pain management & monitoring • Complication

  3. Pain • unpleasant sensory & emotional experience that is associated with actual or potential tissue damage.

  4. Pain pathway

  5. Pain pathway • Peripheral sensitization : mechanical, thermal, chemical stimuli : PGE2 ↓nociceptor threshold ↑response to noxious stimuli

  6. Pain pathway • Lateral pain system • Lateral thalamic nuclei • Location, duration, intensity Medial pain system central, medial thalamus &limbic system unpleasant, defense response

  7. 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”

  8. 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

  9. 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

  10. Physiologic response • Neuroendocrine : catabolic hormone (glucagon, growth hormone, vasopressin, aldosterone, renin angiotensin)  hyperglycemia, impaired wound healing : ⇩anabolic hormone(insulin, testosterone)

  11. Surgical pain ReviewMultimodal strategies to improve surgical outcome The American Journal of Surgery 183 (2002) 630–641

  12. 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

  13. Surgical outcome ReviewMultimodal strategies to improve surgical outcome The American Journal of Surgery 183 (2002) 630–641

  14. Pain management 1. Patient education 2. Drugs & non drugs treatment 3. Monitoring requirement 4.Treatment of side effects

  15. 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

  16. Preemptive analgesia

  17. Multimodal analgesia Opioid Anti inflammatory agents Alpha 2 agonist Local anesthetics Opioid Anti inflammatory agents Alpha 2 agonist Local anesthetics Opioid Anti inflammatory agents

  18. Pain evaluation & assessment Nociceptive / Inflammatory pain :Somatic; sharp, hot, sting well localized :Visceral; dull, cramping, colicky poorly localized, referred pain

  19. Pain evaluation & assessment Non- nociceptive pain :Neuropathic Hx of nerve damage, burning, shooting, stabbing, allodynia, hyperalgesia, dysesthesias : Psychogenic pain

  20. 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

  21. Pain evaluation • Physical examination • Psychological examination

  22. Pain assessment tools

  23. Pain Assessment tools

  24. 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

  25. Factors influencing analgesic requirements • Age : elderly request smaller doses • Pre-operative analgesic use. • Coexisting medical conditions • Preoperative patient education • Site of operation

  26. Treatment … • Pharmacologic • Opioid • Non opioid • Adjuvant

  27. Opioids • Essential element of pain management • Mechanism • Action on opioid receptor • Located mainly in spinal cord& brain stem, some in peripheral tissue

  28. 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)

  29. Opioids 1.Agonists : stimulate receptor : no ceiling effect ( no limit mg/kg) : moderate to severe pain : Codiene, morphine, pethidine, fentanyl, methadone

  30. Opioids 2.Partial agonists : ceiling effects eg.buprenorphine

  31. 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

  32. Opioids 4. Antagonists : competitive antagonist to all opioid receptors eg. naloxone

  33. Morphine :standard treatment : metabolism : liver M-3-G : no analgesic property M-6-G : more potent than morphine(2X) : histamine release

  34. Meperidine :atropine like effect : tachycardia ,dry mouth : metabolism liver Normeperidine  CNS excitation : shivering treatment : interaction with MAOI  hyperpyrexia, convulsion ,hypertension ,coma

  35. Fentanyl : rapid onset & short duration : inactive metabolite : no histamine release :100X potent than morphine

  36. 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)

  37. Naloxone : Px opioid intoxication : dilute to 10 ml. titration : side effect : withdrawal symptoms, hypertension, tachycardia, pain, pulmonary edema

  38. 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

  39. 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

  40. Goal! treatment : Right opioids : Right route : Right dose : Right interval

  41. Opioids Administration Analgesic corridor

  42. Opioids Administration Around the clock

  43. Opioids dose Breakthrough pain Promt Short action easy to give

  44. Opioids Administration prn for pain q …

  45. Opioids Administration 1.Intravenous continuous drip Side effects Analgesic corridor PAIN

  46. Opioids Administration 2.Intravenous q 4 hr 3.Intramuscular q 4 hr

  47. Opioids Administration 4. IM prn q 6 hr 5. IM prn q 2 hr

  48. Patient controlled analgesia

  49. Opioids