Post operative pain management

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Post operative pain management has no specific criteria. Lots of methods and procedures are suggested with various types of drugs. It is just a guideline for management of pain after surgery.

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Post operative pain management

  1. 1. Postoperative Pain Management Dr. Hriday Ranjan Roy Assistant Professor, Surgery, Rangpur Medical College, Rangpur, Bangladesh
  2. 2. What’s the definition of pain?
  3. 3. Pain is a Sensory and Emotional experience associated with tissue damage or described in terms of such damage (I.A.S.P) (The International Association for the Study of Pain)
  4. 4. Pain is Always Subjective and Can Never be Proved or TOTAL RECALL
  5. 5. The Pain Pathways and Mechanisms
  6. 6. How Pain Occurs Tissue damage prostaglandins, releases bradykinin and which activate or sensitize nociceptors. Activation of nociceptors leads to the release of substance P and calcitonin gene related peptide (CGRP). Substance P acts on mast cells in the vicinity of sensory endings and release of histamine, which directly excites nociceptors. Substance P and CGRP produces dilation of peripheral blood vessels. The resultant edema causes additional liberation of bradykinin. Thus Nociceptors activate and cause pain.
  7. 7. Pain Pathways Frenchman Rene Descartes, De humine textbook
  8. 8. Axon Reflex Np : Neuro-peptides, BV : Blood Vessels
  9. 9. Pathophysiology • The generation of pain involves interaction between all parts of the nervous system. Pain ultimately transmitted to: • Thalamus • Medulla oblongata • Cerebral cortex.
  10. 10. Types of Pain Fast Pain: Felt within 0.1 second after painful stimulus. Also called: sharp pain, pricking pain, electric pain and acute pain. Slow Pain: Felt within 1.0 second or more after painful stimulus. Also called: dull pain and chronic pain.
  11. 11. Types of Pain 1. Nociceptive pain- Direct stimulation of intact nociceptors • Transmission along normal nerves • Sharp, aching, throbbing – somatic • easy to describe, localize – visceral • difficult to describe, localize
  12. 12. 2. Neuropathic pain . . . • Disordered peripheral or central nerves • Compression, transection, infiltration, ischemia, metabolic injury • Varied types – peripheral, deafferentation, complex regional syndromes • Pain may exceed observable injury • Described as burning, tingling, shooting, stabbing, electrical • Mx: opioids, adjuvant / coanalgesics often req.
  13. 13. Assessment of Pain How do You Quantify pain?
  14. 14. Pain rating scales Categorical scale 1 Mild 0 No pain 2 3 Discomforting Distressing 4 Intense 5 Excruciating Visual analogue scale (VAS) No pain Most pain Numeric rating scale 0 1 2 3 4 5 6 7 ( 0 = No pain, 10 = Worst pain imaginable ) “Ten Scale” most common: 11 point scale – 0 = No pain – 10 = Worst pain imaginable 8 9 10
  15. 15. •PAIN MANAGEMENT
  16. 16. Pain Management in the late 18 th century Barker M.D.
  17. 17. Pain Management
  18. 18. Different Pain management Modalities
  19. 19. Pre-emptive Analgesia • • • • • Pre-emptive analgesia can be achieved by: local anesthetic infiltration of the skin Effective dose of systemic opioids Systemic nonsteroidal anti-inflammatory drugs (NSAIDs) Neuroaxial opioids or local anesthetic Peripheral nerve blocks
  20. 20. Patient Controlled Analgesia PCA 1. Increase patient satisfaction 2. Decrease side effects and complications 3. Decrease sedation 4. Decrease total amount of daily opioids 5. Avoid Basal rate in the Elderly 6. PCA Flowsheets
  21. 21. Regional analgesia
  22. 22. Isolated Extremity Injury
  23. 23. Brachial plexus Anatomy
  24. 24. Infraclavicular Approach
  25. 25. Infraclavicular Approach
  26. 26. Lower Extremity Injury
  27. 27. Paravertebral Lumbar Somatic Nerve Block
  28. 28. Femoral Nerve Block
  29. 29. Sciatic Nerve Block
  30. 30. Neuroaxial Blocks
  31. 31. Opioid Spread after Epidural injection
  32. 32. Adjuvant Therapy
  33. 33. Nonsteroidals
  34. 34. Conformational structure of COX-1 and COX-2 isozymes COX-1 (A) COX-2 (B)
  35. 35. NSAID's • Blocks the production of Prostaglandin • Very effective in pain control, Alone or in Combination with Narcotics • Ketorolac is My drug of choice as an adjunct therapy in acute pain • Use p.o. forms “Cox2 inhibitors” when possible in combination with Epidural, IV,or oral narcotics
  36. 36. Practical guide for NSAID’s Usage • Pre-op administration significantly decreases • • • • • post-op pain and cramps Toradol 30mg, IV or Celebrex 400mg, P.O. preop For sever acute pain Celebrex 400mg, P.O. bid X one week the 200 P.O., bid. Bextra 20mg, bid X one week the 20mg, QD PPI are the drugs of choice to treat gastric complications. H2 blockers only mask the disease Please check the patient renal function routinely prior to administration COX2 inhibitors doesn’t affect the platelet
  37. 37. Practical guide for NSAID’s Usage (Continuum) All specific or non-specific NSAID’s may cause: • water retention and edema • Hypertension • Renal dysfunction • May delay bony fusion in chronic usage ?
  38. 38. Clonidine • Alpha2 agonist with outstanding • • • • • properties when administered intrathecally: Pain control properties by itself Decrease the requirement of narcotics Decrease tolerance Great for neuropathic pain control Adding 1mcg/kg for children caudal block will extend pain relief up to 24h
  39. 39. Clonidine Oral or transdermal Clonidine:  Enhance the effect of narcotics  Decreases the daily narcotic requirement  Excellent Adjuvant therapy for narcotic dependent patients  Effective for neuropathic pain
  40. 40. Coanalgesic Agents • • • • Anxiolytic drugs Anticonvulsants Antidepressants Ketamine
  41. 41. Ketamine • NMDA receptors antagonist → Neuropathic pain • Potent analgesic effect • Small doses in combination of opioids substantially improve pain control • Bolus dose of 100 mcg/kg followed by a continuous drip of 1-3 mcg/kg/min is ideal for chronic opioid users postoperatively
  42. 42. Mechanisms of Anti-Epileptic Drugs in Pain
  43. 43. Usage of Anti-Epileptic Drugs in Acute Pain • Every surgical incisional pain has Neuropathic • • • component Studies showed giving 1200 mg of Gabapentin 1 h prior to surgery decreases the opioids requirement post-op and results in better pain control without increased sedation Combining Gabapentin with opioids is ideal for re-do back surgery cases with chronic opioids usage These class of drugs are also mode stabilizers
  44. 44. Non Chemical Techniques • Psychological treatments: Relaxation, hypnosis Cognitive therapy etc.. • TENS Units • Physiotherapy
  45. 45. The W.H.O 3-step Pain “Ladder” • Step 1 (mild): – non opioid + adjuvant • Step 2 (moderate): ASA Acetaminophen NSAIDs ± Adjuvants • Step 3 (severe) : – ‘strong’ opioid+step 1 meds Hydrocodone Oxycodone Dihydrocodeine Tramadol – “weak” opioid + step 1 meds Codeine ± Adjuvants Nalbuphine Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants
  46. 46. Physiological vs clinical pain • Physiological pain has a biological function • Pathological pain has no biological function Woolf
  47. 47. Multidisciplinary Approach Surgeon Pharmacist Nurse Acute Pain Team Physiotherapist Anaesthetist Psychologist
  48. 48. Pain after surgery Inflammatory pain • • • Inflammatory pain Nociceptive painpain Nociceptive Neuropathic pain Neuropathic pain
  49. 49. Chronic post surgical pain • • • Pain developed after a surgical procedure At least 2 month duration Other causes excluded (malignancy, chronic infection) • Possibility of continuous pain of pre-existing problem Macrae 2001
  50. 50. Principles of analgesic Plan • • • • • Balanced analgesia Opioids: First line morphine Regional analgesia Actual dose of analgesics will not be discussed Regular and breakthrough prescription including night-time
  51. 51. Analgesic ladder
  52. 52. Non-opioid Analgesics • Paracetamol: Acetaminophen centrally acting 500mg-1g 6h or 1520mg/kg for children • Diclofenac sodium: 50mg TDS orally • Aspirin: 300-900mg 4h • NSAIDs: Analgesic, antipyretic,antiinflam matory • Opioid sparing • SE: Prostaglandin and prostacyclin effect • Ibuprofen, diclofenac, naproxen, piroxicam
  53. 53. Opioid Analgesics • Weak opioids Codeine phosphate 3060mg 4h Dihydrocodeine 30mg 4-6h po or 50mg 4-6h im Buprenorphine 200400mcg sl 4-6h Tramadol weak agonist 50100mg 4h • Strong opioids Nalbuphine Morphine Diamorphine Pethidine: max 1.2g daily
  54. 54. Prevalence of chronic pain following surgery Surgery Perkins & Kehlet Macrae Breast 11-49% 23-49% Thoracotomy 22-67% 5-67% Cholecystectomy 3-56% 3.4-27% Inguinal Hernia 0-37% 15-63% N/A 0-37% Vasectomy
  55. 55. Neuropathic pain can become established extremely quickly after trauma and surgery and remain unchanged after 6 months

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