pain relief after major oncologic surgery l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Pain relief after major oncologic surgery PowerPoint Presentation
Download Presentation
Pain relief after major oncologic surgery

Loading in 2 Seconds...

play fullscreen
1 / 23

Pain relief after major oncologic surgery - PowerPoint PPT Presentation


  • 96 Views
  • Uploaded on

Pain relief after major oncologic surgery. Ksenija Mahkovic Hergouth Onkološki inštitut. GIT carcinomas. Urologic,gynec.carcin. Retroperitoneal sark. Surgical procedures for. Sarkomas of thoracic/ abdominal wall with reconstruction. Liver metastases. Peritonectomies, cyto-

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Pain relief after major oncologic surgery' - dusty


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
pain relief after major oncologic surgery

Pain relief after major oncologic surgery

Ksenija Mahkovic Hergouth

Onkološki inštitut

slide2

GIT carcinomas

Urologic,gynec.carcin.

Retroperitoneal sark.

Surgical procedures for

Sarkomas of thoracic/

abdominal wall with

reconstruction

Liver metastases

Peritonectomies, cyto-

reductive surgery

postoperative pain is due to
Postoperative pain is due to
  • Surgical wound (laparatomy – somatic pain; organ resections – visceral, sympatic pain)
  • Analgesia during operation (opioid, LA consumption
  • Genetic determination of analgesic requirements (gene polymorphism for opioid receptors)

Havashida M, Pharmacogenomics 2008

slide4

Good pain relief after surgery is important part of quick and successfull recovery

It diminishes perioperative stress response to surgery

pain relief after major oncologic surgery5
Pain relief after major oncologic surgery
  • Continuous/PCEA epidural analgesia – based on long acting local anesthetics
  • Continuous/PCA intravenous analgesia – based on opioids
  • Continuous drip of local anesthetics by the catheter in the surgical wound ?

All ways effective when proper used and with PCA technick

Mann C et all, Anesthesiology 2000

slide6

Epidural analgesia – golden standard, insertion of epidural catether (EK) in the thoracic region

(most of the abdominal wall and organs are inervated from Th6–Th12)

physiologic effects of epidural analgesia
Physiologic effects of epidural analgesia
  • Blocade of aferent pain impulses
  • Blokade of aferent sypmatic impulses from intestine
  •  of pain and  sympatic nerves activity in GIT
  • ↓ stress and inflammatory response to surgery
  •  of postoperative ileus, shortens time to passing stools
  • Improves mobilisation after surgery

Clemante A,Carli F. Minerva Anesthesiol 2008

slide8

Stress response I

Hormonal and inflammat.response and recovery after radical cystectomy

  • group.:general anesthesia + piritramid i.v. postoperatively
  • group.: general + toracic epidural anesth. + piritramid i.v. postoperatively
  • group.: general + toracic epidural anesth.+ epidur. analgesia postoperatively

Results

↑Cortisol and epinephrin: no difference among groups

group 3 ↓less inflammatory response (↓CRP, ↑albumini)

group 3 ↓less fatigue

group 3↓less postoperative pain

group 3 ↑better enteral feeding and passing stools sooner

Brodner G et al. Multimodal perioperative management- combining thoracic epidural

analgesia, forced mobilisation and oralnutrition-reduces hormonal and metabolic

stress after major urologic surgery.AnesthAnalg 2001;92:1594-1600.

stress response ii
Stress response II
  • study of 45 patients on hormonal and inflammatory stress responce to major abdominal surgery

1st group: epidural analgesia during surgery

2nd group: i.v. opioid analgesia during surgery

Results

Epidural group: lower plasma epinephrine and cortisol

higher lymphocyte number and T-helper cells

no difference in IL 12 and clinical course

Ahlers O et al. Intraoperative thoracic epidural anesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-7.

advantages of epidural analgesia to systemic analgesia
Advantages of epidural analgesia to systemic analgesia
  • Better analgesia (still and moving) than with systemic opioids (1,2,3)
  • Less adverse events than with opioids –↓ nausea,vomiting, sedation (2,3,4)
  • Less paralytic ileus, less respiratory complications (5)
  • But no difference in mortality compared to systemic opioid analgesia (3)
  • Low incidence of motor block with thoracic epidurals compared to lumbal epidurals(2)
  • Importance of the LA dose compared to volume or concentration (6)

1.Nishimori M et al. Cochrane Data Base Rev 2006

2.Flisberg P et al..Acta Anaesthesiol Scand 2003;47:457-65

3.Rudin A et al. J Cardiothorac Vasc Anesth 2005;19:350-7

4.Saeki H et al. Surgery Today 2009.

5..Popping DM et al .Arch Surg 2008

6..Dernedde M et al. Anaesth Intensive Care 2008

slide11

Random group of our patients after abdominal surgery in year 2006 with epidural analgesia

Dg.: 6 colon carcinoma,7 carcinoma of sygmoid colon, 9 rectum carcinoma, 5 stomac carcinoma, 7 retroperitoneal sarcoma

postoperative pain relief by epidural analgesia we practice
Postoperative pain relief by epidural analgesia (we practice)

48h after surgery: continuous epidural infusion of local anesthetic (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, LO 30 – 60 min. Sometimes combined with low dose opioid epiduraly or in i.v. infusion (< 30%)

Metamizol 2,5g/12 h i.v.

Piritramid 3 – 5mg i.v. when VAS>4

3.-5. day: 10 ml boluses of 0,25% levobupivacain /6–8h into EK ±opioids p.os (oksicodon)

after 5th day removal of epidural catheter.

from 5th day on: analgesic drugs p.o. (oksicodon, tramadol, NSAID,

paracetamol)

complications with epidural catheters
Complications with epidural catheters
  • Punction of dura (incidence 0,3 – 1,2%)
  • Transitory neropathy (0,01 – 0,02%)
  • Punction of epidural vein (3 – 12%), epidural hemmatoma very rare (1:150 000)
  • Infection: local on insertion site 4%,epidural absscess: 0,05 – 0,1% (perioperative epidural catheters)
  • Migration of the catheter into spinal space (0,18%)
postoperative pain relief by systemic opioid analgesia we practice
Postoperative pain relief by systemic opioid analgesia (we practice)

Systemic opioid analgesia – when epidural analgesia is containdicated, technically not possible or refused by the patient. Pump needed.

  • Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses
  • Sufentanil 50–100 μg/24h in continuous i.v. infusion + PCA boluses
  • Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses s.c./i.v.

I.v.analgesia up to 3 days+metamizol/neodolpasse

After 2-3-days analgetic drugs in tablets by mouth (oxicodon,

tramadol, paracetamol, NSAID)

Monitoring pain (VAS) and side effects

monitoring of the patient
Monitoring of the patient
  • Day of surg.: pulse oximetry, blood pressure, VAS. Broader monitoring according to patient’s state.
  • Next days: blood pressure /1-2 h, pulse oximetry, VAS. 50 – 100 μg/24 h. Broader monitoring according to patient’s state.
  • Patient can be moved to the ward when cont.epidural infusion is stopped and regular epidural boluses given. Time of epidural catheter removal should be planned.
slide17

94 bolnik

Dg: Ca cekuma,eksulceriran. Op: desna hemikolektomija3. dan po operaciji

vloga sester in tehnikov
Vloga sester in tehnikov
  • poznati morajo delovanje EK kot tudi kontinuirano i.v. analgezijo
  • Redno morajo spremljati pooperativno bolečino z merjenjem bolečine po VAS
  • Redno meriti bolnikove vitalne znake.
  • Pomembna je tudi tudi odzivnost na bolnikovo bolečino ali neželjene učinke in ukrepanje v okviru možnosti in navodil.
multimodalno perioperativno okrevanje
Multimodalno perioperativno okrevanje
  • Predoperativno informiranje in priprava bolnika na op
  • ↓ kirurškega stresa (krg. tehnika, anestezija)
  • Optimalna pooperativna epidural. analgezija z LA (torakalni EK)
  • Hitra mobilizacija
  • Zgodnje enteralno hranjenje
pooperativni problemi po operacijah v trebuhu
Pooperativni problemi po operacijah v trebuhu
  • Bolečina
  • Pooperativni ileus
  • Okužbe kirurške rane & druge okužbe
  • intraabdomin.pritisk
  • Motnje v delovanju organov