Postoperative Pain Management Is it a Luxury or Necessity? KHALED ABDEL HAMEED,MD PROFESSOR AND HEAD OF ANAESTHESIA AND PAIN MEDICINE DEPARTMENT NCI,CAIRO UNIVERISTY
Key Points from the JCAHO Pain Management Standards • Patients have a right to pain management. • Pain must be assessed at regular intervals. Pain should be reassessed soon following an intervention to treat pain to ensure a response. • Institutions are required to have policies and procedures for pain assessment and treatment. • Patient education for pain management is mandated. • Staff education concerning pain management is required. • Pain assessments are required as a discharge criterion
WHY PAIN IS UNDERTREATED? 1- Lack of formal education in pain management among health care professional. 2- Attitude and misconceptions of health care professionals and patients. 3- Lack of formal pain assessment, documentation of pain intensity, pain relief and patient satisfaction after pain therapy 4-Deficiency associated with traditional analgesic delivery.
POSTOPERATIVE PAINPOP Stress response to surgical stimulation and pain cascade leads to alteration in hypothalamic-adrenal function with increased plasma level of cortisol, glucagon and epinephrine. Hyperglycemia and hypermetabolic state with negative nitrogen balance. Prolonged stress response lead to prolonged catabolic sate which lead to adverse effect on post surgical outcome. Several studies showed that adequate pain relief significantly reduce the stress response and improve the patient outcome.
WHY ANALGESIA IT IS IMPORTANT? Adequate post operative analgesia significantly reduced both peri-operative tachycardia and ischemic episodes. Also, there will besignificant reductions in CVS morbidity, mechanical ventilation, pulmonary infection, ICU stay and total hospital stay. The immune suppression could be attenuated by adequate control of pain Adequate analgesia intra and post operative has been associated with decrease in DVT and decrease the incidence of post-operative clotting of vascular graft Pre,intra and postoperative analgesia reduce the incidence of CPSP in susciptiple patients
MULTIMODAL OR BALANCED ANALGESIA • • A combination regimen using two or more medications or interventional techniques • • May include more than one route of administration • • The synergistic effects between different drug classes can enhance the analgesic effects of each drug • • Using different agents allows for reduced doses of each medication and subsequent reduced side effects • • Especially effective in patients who are at risk for the side effects of large doses of opioids: -frail elderly -obstructive sleep apnea -chronic pain patients
Post-op pain...!Pharmacological options Nociceptive: SomaticVisceral Mix Pain:Neuropathic and nociceptive elements Neuropathic: PeripheralCentral NASAID’sCOXIB’sAcetaminopheneTramadolOpioids NMDA antagonist TCAsPrégabalineGabapentinTramadolOpioids NMDA antagonist TramadolOpioids NMDA antagonist
PRE-EMPTIVE ANALGESIA • Recent advances in pain management havesupported ideas proposed 70 years ago that blockade of pain transmission prior to surgical injury reduce post operative morbidity and mortality. • Wall in the late 1980 suggested that analgesic intervention is most effective when made in advance of pain stimulus rather than in reaction to it. • It is well recognized that peripheral injury triggers state of neuro-excitability which outlast surgical inflammation. This could be prevented by pre-emptive neural blockade and administration of analgesics. Such treatment is much less effective following the injury.
Pain Nurse variables Sedation Call for Nurse Pain Relief PCA Nurse Responds Patient Variables Absorption from site Screening Sign out Medication Administer Med. Prepare Medication
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