Multimodal analgesia Al Razi hospital Kuwait

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This is was part of series of lectures presented at the department before starting or modifying pain protocols.

This is was part of series of lectures presented at the department before starting or modifying pain protocols.

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  • 1. Multimodal Analgesia Farah Jafri
  • 2. INTRODUCTION DEFINATION A multimodal approach to Acute Pain Management entails combining several pain relieving techniques with different mechanisms of action. The net result is usually better than if a single technique is relied upon.
  • 3. Pain pathway  Tissue injury activate nociceptors pain impulse A-delta & C fibers dorsal horn spinothalamic tract thalamuscerebral cortex cerebellum
  • 4. Multimodal analgesia AIMS-  ⇩ doses of each analgesic  Improved antinociception due to synergistic/additive effects  may⇩ reduce severity of side effect of each drugs
  • 5. Endorsed by 1)Faculty of Pain Medicine, Royal College of Anaesthetists, United Kingdom 2)Royal College of Anaesthetists, United Kingdom 3) Australian Pain Society 4) Faculty of Pain Medicine, College of Anaesthetist of Ireland 5) Recommended to American Academy of Pain Medicine
  • 6. MULTIMODAL APPROACH TO PAIN MANAGEMENT DRUGS- 1) PARACETAMOL 2) NSAIDS 3) OPIOIDS- PCA, 'around the clock', prn 4) ANTIDEPRESSANTS 5)ANTI-EPILEPTICS NERVE BLOCKS- LOCAL ANESTHETICS- I.V, CNB, PNB - OPIOIDS
  • 7. PARACETAMOL Mechanism of Action (MOA) -  Direct and indirect inhibition of central cyclo-oxygenases  Activation of the endocannabinoid system and spinal serotonergic pathways  Prevent prostaglandin production at the cellular transcriptional level, independent of cyclo-oxygenase activity
  • 8. KEY MESSAGES- PARACETAMOL Paracetamol - effective adjunct to opioid analgesia, opioid requirements being reduced by 20% to 30% In the same doses, Oral paracetamol less effective; slower onset than IV Paracetamol injection,
  • 9. NSAID Refer to both nsNSAIDs and coxibs (COX-2 selective inhibitors). Analgesic, Anti-inflammatory and Antipyretic MOA- NsNSAIDs are ‘non- selective’ cyclo-oxygenase inhibitors that inhibit both COX-1 and COX-2. COXIBS inhibit only the inducible COX -2
  • 10. KEY MESSAGES- NSAIDS Opioids + nsNSAIDs = better analgesia, reduced opioid consumption ↓ PONV and sedation Perioperative non-selective NSAIDs ↑risk of severe bleeding
  • 11. KEY MESSAGE- COXIBS - Effective analgesics - adverse effects on renal function - do not impair platelet function - GI complications are less. - do not produce bronchospasm.
  • 12. KEY MESSAGE - NSAIDS CARDIOVASCULAR CONCERNS.... FDA concluded that ‘Short-term use of NSAIDs to relieve acute pain, particularly at low doses, does not appear to confer an increased risk of serious adverse CV events (with the exception of valdecoxib in hospitalized patients immediately postoperative from coronary artery bypass surgery)’ (FDA, 2005).
  • 13. Opioids Control moderate to severe pain and do not interfere with clotting. MOA: 1)Attach to opioid receptors and “modulate” impulse transmission in cord 2) CNS effects alter pain perception
  • 14. KEY MESSAGES -OPIOIDS Opioids in high doses can induce hyperalgesia (N) (Level I). Tramadol is an effective treatment for neuropathic pain (Level I [Cochrane Review]). Opioid-sparing medications like--Gabapentin, non-steroidal NSAIDs and ketamine reduce opioid-related side effects (N) (Level I).
  • 15. KEY MESSAGES Tramadol has a lower risk of respiratory depression and impairs GI function less than other opioids at equianalgesic doses. The use of pethidine and dextropropoxyphene should be discouraged in favour of other opioids. Pethidine is not superior to morphine in treatment of pain of renal or biliary colic
  • 16. ADJUVANTS TO PAIN CONTROL Ketamine Adrenaline Neostigmine Midazolam Magnesium Alpha 2 agonists
  • 17. ADJUVANTS KETAMINE- Non-competitive antagonist of the NMDA receptor,in the peripheral and central nervous systems Principal effect of ketamine at these doses is as an ‘antihyperalgesic’, ‘antiallodynic’ and ‘antitolerance’ agent and not as a primary analgesic per se.
  • 18. KEY MESSAGE - ADJUVANTS Intrathecal clonidine improves duration of analgesia and anaesthesia Epidural ketamine (without preservative) + opioid-based epidural analgesia regimens improves pain relief Intrathecal midazolam + local anaesthetic prolongs the time to first analgesia and reduces postoperative nausea and vomiting Epidural adrenaline (epinephrine) in combination with a local anaesthetic improves the quality of analgesia (2 mcg/ml + bupivacaine 0.1% + inj
  • 19. Antidepressants  Amitriptyline, imipramine, doxepin, trazodone  Benefits: Help control paresthesias and burning sensations from damaged nerves. They also improve sleep.  MOA: Prevent reuptake of serotonin into neuronal fibers making more serotonin available to inhibit nociception in the dorsal horn
  • 20. Antidepressant Side Effects Adverse Effects  Dry mouth, drowsiness, and constipation. Some cause postural dizziness and vertigo.  Most positive studies report on older cyclic compounds (IMI, AMI, DOX) or MAOIs  Tricyclic doses lower than “antidepressant” doses frequently produce analgesic augmentation  Onset of analgesic benefit occurs early (days-weeks)
  • 21. KEY MESSAGE ANTI DEPRESSANTS Tricyclic antidepressants and SSRI are effective in the management of acute neuropathic pain Tricyclic antidepressants are more effective than SSRI .
  • 22. ANTIEPILEPTICS  Gabapentin and Pregabalin  Benefits: Antiepileptics help control paresthesias or burning sensations from nerve injury.  Risks: Common-Drowsiness, dizziness, somnolence, weight gain and edema. Infrequent-hepatotoxicity, anemia, thrombocytopenia  MOA: Direct stimulation of GABAergic receptors or Ca++ channel blockade
  • 23. KEY MESSAGE ANTI EPILEPTICS Perioperative gabapentinoids (gabapentin/ pregabalin) reduce postoperative pain and opioid requirements and reduce the incidence of vomiting, pruritus and urinary retention, but increase the risk of sedation (N) (Level I). Effective in management of acute neuropathic pain
  • 24. MEMBRANE STABILIZERS MOA- Local anaesthetics exert their effect as analgesics by the blockade of sodium channels and hence impeding neuronal excitation and/or conduction. XYLOCAINE- Lignocaine (intravenous or subcutaneous) may be a useful agent to treat acute neuropathic pain
  • 25. LOCAL ANESTHETICS KEY MESSAGE The quality of epidural analgesia with local anaesthetics is improved with the addition of opioids Analgesia and motor block from ropivacaine= levobupivacaine = bupivacaine for regional analgesia (epidural and peripheral nerve blockade)
  • 26. LOCAL ANESTHETICS KEY MESSAGE Compared with opioid analgesia, continuous PNB (regardless of catheter location) provides better postoperative analgesia and leads to reductions in opioid use as well as nausea, vomiting, pruritus and sedation (N) (Level I) Perioperative epidural analgesia reduces the incidence of severe phantom limb pain
  • 27. LOCAL ANESTHETICS KEY MESSAGE Continuous femoral nerve analgesia = epidural analgesia but with fewer side effects following total knee joint replacement surgery Continuous local anaesthetic wound infusions ↓in pain scores (at rest and with activity), ↓opioid consumption, postoperative nausea and vomiting, ↓Length of hospital stay patient satisfaction and there is no difference in
  • 28. Neuroaxial opioids The absence of consistent dose- responsiveness to the efficacy of intrathecal opioids or the adverse event rate, suggests that the lowest effective dose should be used in all circumstance
  • 29. Non pharmacological  Non pharmacologic - psychologic approach - physical therapy - education - neurostimulation - neuroablative techniques
  • 30. KEY MESSAGE NON PHARMACOLOGICAL APPROACH Distraction is effective in procedure-related pain in children (Level I). Training in coping methods or behavioural instruction prior to surgery reduces pain, negative affect and analgesic use (Level I). Acupuncture reduces postoperative pain as well as opioid-related adverse effects
  • 31. Acute pain step Ladder SEVERE PAIN ? Epidural analgesia or morphine PCA or im protocol plus diclofenac 100-150mg / OTHER NSAID ) plus paracetamol 1g QDS regularly MODERATE PAIN ? tramadol 400mg in 24hrs plus diclofenac 75-150mg in 24 hrs / OTHER NSAID plus paracetamol 1g x 6hrly regularly
  • 32. HOW TO USE MULTIMODAL ANALGESIA ? EXAMPLES-  IN AMBULATORY SURGERY CASES  TOTAL HIP REPLACEMENT  TOTAL KNEE REPLACEMENT  ACUTE NEUROPATHIC PAIN
  • 33. AMBULATORY SURGERY MAIN AIM- EARLY PAIN FREE, NAUSEA FREE DISCHARGE KEY MODES OF PAIN RELIEF- 1.Infiltration of the wound with local anaesthetic 2.Peripheral nerve blocks with long-acting local anaesthetic agents, single shot/ infusions 3.Regular paracetamol, NSAIDS, 4.AVOID OPIOIDS
  • 34. ACUTE NEUROPATHIC PAIN Tramadol +/- OPIOIDS IV/ PO/ SC Ketamine IV lignocaine (bolus dose between 1-5 mg/kg I.v over 15 to 60 minutes depending on the dose.) Amitriptyline improved neuropathic pain in patients with depression Anticonvulsants reduced central pain and improved sleep and reduced anxiety
  • 35. CONCLUSION Multimodal analgesia offers many benefits to patients Opioids remain an integral part of most analgesic plans. Techniques that reduce opioid requirements typically improve pain control both at rest and with motion, reduce opioid related side effects, provide better patient satisfaction