Management of acute postoperative pain r

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Management of acute postoperative pain r

  1. 1. What is Pain? “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” International Association for the Study of Pain, 1979
  2. 2. ACUTE PAIN Most common forms: • Posttraumatic • Postoperative • Obstetric pain • Pain associated with acute medical illnesses
  3. 3. Pain: The 5th Vital Sign 1. Temperature 2. Blood Pressure 3. Pulse 4. Respiratory Rate American Pain Society. 1998 5. Pain Assessment
  4. 4. Assessment and Education Keys to Proper Pain Management:
  5. 5. SELF-REPORT SCALES “GOLD STANDARD” Manne et al Pain 1992 McGrath et al Pain 1996 Chambers et al Pain 1999 Soetenga et al Pediatric Nursing 1999 Voepel-Lewis et al Anesthesia and Analgesia 2002 Willis et al Pediatric Nursing 2003
  6. 6. Numeric Pain Intensity Scale SELF-REPORT SCALES
  7. 7. Categorical Scale No pain “walang kirot” Mild pain “konting kirot” Moderate pain “katamtamang kirot” Severe pain “malubhang kirot” SELF-REPORT SCALES
  8. 8. Visual Analogue Scale (VAS) SELF-REPORT SCALES
  9. 9. Categorical Scale SELF-REPORT SCALES
  10. 10. FLACC Behavioral Scale
  11. 11. Wong-Baker Faces Pain Scale 0 2 4 6 8 10 SELF-REPORT SCALES
  12. 12. BASIC PRINCIPLES • PREEMPTIVE ANALGESIA • OPIOID SPARING
  13. 13. PREEMPTIVE ANALGESIA ”An antinociceptive therapy that prevents establishment of altered processing of afferent input, which amplifies postoperative pain” Kissin, I. Preemptive Analgesia. Anesthesiology 2000;93(4):1138-1143)
  14. 14. Preemptive analgesia aims to stop pain before even it begins preemptive analgesia receptor sensitization pain stimulus
  15. 15. PREEMPTIVE ANALGESIA • fundamental principles: (a) that the central nervous system is capable of changing so that pain becomes either improved or worsened via central processes such as desensitization and sensitization (b) that alterations in sensory and pain transmission can effect such changes
  16. 16. OPIOID SPARING & MULTIMODAL ANALGESIA Current teaching states that good pain relief during and after surgery, using opioids whenever necessary, can improve surgical recovery. Carr DB, Goudas LC. Acute pain. Lancet. 1999; 362(9169):2051-2058 Pain relief is an important component of accelerated recovery programs that aim to achieve early return of mobility, coughing, and bowel and bladder function, and to restore normal physiologic functioning as rapidly as possible, thereby reducing complication rates. Brennan TJ, Kehlet H. Preventive analgesia to reduce wound hyperalgersia and persistent postsurgical pain. Not an easy path. Anesthesiology 2005;103:681-683
  17. 17. OPIOID SPARING AND MULTIMODAL ANALGESIA OPIOIDS most effective analgesics sedating nauseating slows bowel activity delay recovery
  18. 18. OPIOID SPARING and Opioid-sparing interventions using several analgesic modes together  opioid reduce requirements adjunctive medications Epidurals nerve blocks nondrug interventions MULTIMODAL ANALGESIA
  19. 19. TREATMENT OPTIONS Opioids • mainstay of acute pain treatment • used alone or in combination with other analgesics • higher doses of parenteral opioids are given during the first 24-48 hours after surgery • IV route is preferred SYSTEMIC TREATMENTS
  20. 20. Choice of opioids Commonly used opioids • Morphine – Morphine SR – Oxycodone • Codeine – Fentanyl patch – Fentanyl oralet • Hydromorphone • Levophanol • Meperidine • Methadone • Tramadol
  21. 21. Choice of opioids Morphine • the standard, most widely used • least lipophilic opioid – delayed peak effect (occurs at 20 minutes after IV injection) • highly metabolized – morphine-6-glucoronide – morphine-3-glucoronide • induces histamine release • duration of a standard dose (10mg) = 3-4 hrs • poor oral bioavailability, (oral dose is 3x parenteral dose) • may cause biliary and urinary tract spasm
  22. 22. Opioid Adverse effects • Respiratory depression • Nausea and vomiting • Sedation • Direct bowel effects • Dizziness • Pruritus • Meiosis • Euphoria • Dysphoria • Biliary spasm
  23. 23. NSAIDs and ACETAMINOPHEN
  24. 24. NSAIDs and ACETAMINOPHEN Acetaminophen • not strictly an anti-inflammatory drug, but shares many of the properties of NSAIDs • acidic and crosses the blood-brain barrier • action resides mainly in the central nervous system – prostaglandin inhibition produces analgesia and antipyresis
  25. 25. NSAIDs and ACETAMINOPHEN Ketorolac • first injectable NSAID approved for use surgical patients • potent NSAID • side-effect profile reflects its potency
  26. 26. NSAIDs and ACETAMINOPHEN
  27. 27. Adverse Effects and Limitations on Perioperative Use of NSAIDs • GI hemorrhage • Renal dysfunction • Decreased hemostasis • Asthma (in susceptible individuals) • Anaphylaxis
  28. 28. Adverse Effects and Limitations on Perioperative Use of NSAIDs Contraindications to NSAID use: –History of peptic ulcer disease –History of intolerance to NSAIDs –Renal failure, renal dysfunction –Old age
  29. 29. Acetaminophen – relatively safe – not associated with the adverse effects listed for standard NSAIDs. COX-2 inhibitors – less likely to cause bleeding – b carry the same risk as standard NSAIDs of the other listed adverse effects – cardiovascular and thrombotic risks
  30. 30. NSAIDs safe for perioperative use? used for a short period most adverse effects associated with prolonged use
  31. 31. Use of NSAIDs and ACETAMINOPHEN for POSTOPERATIVE PAIN • for mild postoperative pain • as adjuncts in multimodal analgesia – 30-50% opioid-sparing effect – 30% reduction in nausea – 29% reduction in sedation
  32. 32. PATIENT-CONTROLLED ANALGESIA • Computer-controlled pumps • satisfies the needs of patients to receive pain medication easily and quickly, when needed
  33. 33. The Inherent Safety of PCA • dosing regiments == small frequent doses • avoid the large swings between peaks and lows associated with less frequent and larger doses • a single dose is too small to produce overt sedation or respiratory depression • less need for monitoring
  34. 34. Benefits of PCA Meta-analyses of PCA vs conventional analgesia: • slightly better analgesia associated with PCA use • large difference in patient satisfaction favoring PCA, • no difference in opioid usage, side effects, or surgical outcome
  35. 35. Patient-Controlled Epidural Analgesia • PCA technology can also be used for epidural analgesia • main advantage is that patients like the sense of control offered by the patient triggered pump
  36. 36. SPECIAL POPULATIONS • tolerate opioid poorly – prone to apnea – slow conjugation by liver • smaller, more frequent dosing • opioids  mainstay for treating severe pain – reduce opioid requirements – use adjunctive treatments such as NSAIDs and acetaminophen • dosing is calculated on a per-kilogram basis • frequent checking of vital signs mandatory • use respiratory rate and oxygen saturation monitors Neonates, Infants, and Children
  37. 37. The Elderly • sensitive to opioids – respiratory depressant effects – central dysphoric and euphoric effects • opioid-induced confusion is common • sensitive to NSAID side effects SPECIAL POPULATIONS

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