2. Anesthesia for the area to be operated
Spinal, Epidural, Caudal
Plexus Blocks(e.g.) - Brachial plexus block
Peripheral Nerve blocks
What is Regional Anesthesia?
3. Instructions
Equipment
Choice of anesthetic
Positioning the patient
Preparation of area to be blocked
Choosing the nerves to block
Preparation
4. Suitability for the type of surgery being performed
Surgeon’s preference
Experience in performing the block
Physiological/mental state of the patient
General Considerations
5. Improved patient satisfaction
Less immunosuppression
Less nausea and vomiting
Non-general anesthetic option for patient with
malignant hyperthermia
Patient who is hemodynamically unstable or too ill to
tolerate a general anesthetic
Advantages of Peripheral Nerve Blocks
7. In addition to some of the peripheral nerve block
indications…
Patient mentally prepared to accept neuraxial
blockade
No contraindications
No need for routine labs unless meds or conditions
dictate this
Indications for Neuraxial Blockade
8. Patient refusal
Infection at the site of injection
Coagulopathy
Severe hypovolemia
Increased Intracranial pressure
Severe Aortic Stenosis
Severe Mitral Stenosis
Ischemic Hypertrophic Sub-aortic Stenosis
Absolute Contraindications for Neuraxial
Blockade
10. Superior analgesia to IV PCA in open abdominal procedures &
specifically in colorectal surgery
Reduce incidence of paralytic ileus
Blunt surgical stress response
Improves dynamic pain relief
Reduces systemic opiate requirements
Facilitates early oral intake, mobilization and return of bowel fx
when part of fast track protocols
Benefits of
Epidural Analgesia
11. Involves blockade of nerve impulses using local
anesthetics (LA)
LA bind sodium channels preventing propagation of
action potentials along nerves
Wide variety of LA with different characteristics:
ie. Lidocaine – fast onset, short duration of action
ie. Bupivacaine (Marcaine) – slow onset, longer duration
Regional Anesthesia
15. Pain is perfect miserie,
The worst of all Evils,
And if excessive,
Overturns all patience!
Milton
16. “It is important what you have,
What is more important is what you do
With what you have”
17. Multi modal analgesia
Individualized therapy
New modalities----
Transdermal patches of opioids,NSAIDS etc
analgesia in low dose & less side-effects
Sustained-release epidural morphine ‘Depodur’- microcapsules
epidurally --single-dose extended-release epidural morphine
Tapentadol -an interesting new molecule that activates opioid receptors
and inhibits norepinephrine uptake
Basic research is in the inhibition of breakdown of endogenous opioids
with opiorphin, targeting of the endocannabinoid system, and the use of
ampakines to obtund opioid-induced side-effects
Availability of infusion pumps and syringe pumps-for continuous
infusions
Acute pain
18. “Pain is all in the mind”
“Surgery will be associated with pain”
Does it have to???
19. ROLE OF PAIN
1. Focus attention and empathy
2. Protect body from further damage
3. Gives rest to the part - helps healing
4. Immediate benefit to patient/caregiver
5. Disposition to care for people in pain
20. “Unpleasant sensory or emotional experience associated
with actual or potential damage
or described in terms of such damage!”
IASP definition of PAIN
21. Most common annoying complaint
Most inadequately assessed & treated symptom
Most difficult sensation to define - protopathic
Subjective, but not personal & is of vital importance
Most important person is the observer
- hears beyond the words
- sees behind the picture
PAIN
22. Post - operative
Trauma
Burns
Medical procedures
Signals organic disease,easy to diagnose
Disappears with Rx
Opioids are specifically effective
WHAT IS ACUTE PAIN?
23. Lack of awareness - surgery is assoc. with pain
“Pain not visible”- not assessed
Understaffed anaesthesia dept.( freelancing)
Myths & fears assoc. with opiates/ underprescription,
Unavailability of opiates and preservative free drugs
Patient expenditure when using sophisticated equip
WHY IS ACUTE PAIN BADLY MANAGED?
24. • Surgery--> tissue damage/ release of mediators
• CNS stimulation and pain perception
• CVS - Increase BP, HR, Workload
• RS - Increase work of breathing
• Renal /GIT - decreased function
• Inadequate --- cause of 30% chronic pain
WHY TREAT ACUTE PAIN?
31. Every patient different, Multimodal therapy
All pain protocols not suitable for all patients
If one protocol fails, choose another
Rescue analgesics mandatory
No IM opiates when already on other opiates
Discuss with the surgeons / assure safety
EMPHASISE AND STRESS
32. Medical Reasons:
Improved respiratory function
Earlier ambulation --> DVT
Shorter post - op hospitalisation
Cost to patient and hospital less
Comfortable and pain- free patient
NEED FOR ADEQUATE PAIN RELIEF
33. • Traditional I/M route disliked by all
• Big prn doses ---> sedation, analgesia, pain
• Underprescription due to myths & fears
• Relies on another person for pain relief
• Multiple needle sticks --> infection
• Variability in absorption ---- peak time & conc:
NEED FOR NEWER METHODS
34.
35. ANY PAIN THERAPY
not
“One size fits all
or
Set and forget therapy.
Is essentially a
maintenance therapy”
36. GOALS OF ACUTE PAIN SERVICES
“NO MAGIC BULLETS”
Ensure all patients pain-free at rest, on movt.
Discourage IM analgesics and prn orders
Switch to S/C routes wherever possible
Standard protocols to avoid confusion
Prevent pain – round the clock drugs
37. Posters
Make “PAIN” visible
APS Sheets
Free services initially and contactable any time
Equipment technician-maintenance/record of equip.
Anaesthesia technician –adequate supply of epi.cocktail
IMMEDIATE back up and advice whenever required.
Encouragement / acknowledgement in plenty
38. “Any drug is valueless if it remains in the ampoule, bottle
on infusion pump.”
It has to be give in adequate doses at adequate time
intervals to be effective, whatever technique you use.
42. • .
Improves controllability through any route
Prevents fluctuating analgesic concs:
Does not have to rely on others
Rate adjustments may be required
Post-op pain intensity not the same thru
CONTINUOUS INFUSIONS
43. Continuous I/V, S/C, epidurally
Morphine-1mg/ml: pethidine10mg/ml:
Initially 1 ml/hr with naloxone I/V or S/C
Ensure pumps functioning well
Most common causes of patient mishaps
- pump
dysfunction
- errors in programming
OPIATE INFUSIONS
44. Infusions set at 5-10 ml / hr for 72 hrs
0.1%bupivacaine + 2-5ug/ml fentanyl
Monitor pulse, BP, respiration closely
PCEA - bolus 5-8ml: LOI-15-20 mins
Catheter migration - I/V or dural space
Premixed syringes - LA + opioids
EPIDURAL INFUSIONS
47. •Analgesia on demand
• Patients can regulate analgesic to MEAC
•Sense of control over his pain
• High acceptance and popular
•Decreased drug usage via any route
•Trained staff, back up, education
PATIENT - CONTROLLED ANALGESIA
(PCA)
48. Must understand the concept of PCA
Must be willing to use it
Must be able to perceive pain intensity
Must be able to respond
Must be relieved of all doubts
Must not be an `Opiate-abuser’
THE PATIENT IN PCA
49. Pumps with patient demand button
Ensure pump is locked, key kept safe
Set 1 ml boluses, no background infusion
Lockout interval - 5-10 mins 1/V, S/C
Disposable PCA pumps available
Note total dose consumed by the patients
PCA PUMPS
50.
51. Demand made only by the patient
Lock- out interval for full effect of drug
Negative feed- back and dose limits
Demand/infusion modes/computer integrated PCEA
Fail-proof designing of pumps (max.dose limits)
Lockable, monitor incorporated pumps (O2,BP)
SAFETY ASPECTS OF PCA
59. Resp depression/ sedation/ pruritis
Hypotension/ bradycardia/ urine retention
Have mephentine & naloxone in the ward
Call the Pain physician
Meanwhile treat with O2,vasopressors & fluids
Instructions on the APS sheets
COMPLICATIONS WITH OPIATES
63. All patients pain-free entire post-op period
Standard protocols to avoid confusion
Discourage IM analgesics/ use other techniques
Switch to other routes whenever one fails
Routine patient observation charts/ audits
Create Awareness among Surgeons/ Nurses
Better relationship between Nursing staff & pts
APS IS TO ENSURE
64. Origin of Pain
Acute Pain
ie. Incisional pain, acute appendicitis
Chronic Pain
ie. Chronic back pain
Acute on Chronic Pain
Acute and chronic causes may or may not be related to each
other
Pain Assessment
66. Current Pain Medications
Accuracy and detail are very important!
Name, dose, frequency, route
ie. Oxycontin 10mg PO TID
Don’t forget to re-order or factor in patient’s pre-existing
pain Rx usage when writing orders
Conflicts with HPI / PMH
Renal disease → avoid morphine, NSAID’s
Vomiting → avoid oral forms of medication
Short gut/high output stomas → avoid CR formulations
Pain Assessment
67. Allergies / Intolerances
Drug allergies
Document drug, adverse reaction and severity
Intolerances
Nausea / vomiting, hallucinations, disorientation, etc.
Very important to differentiate between an allergy and an
intolerance!
Pain Assessment
68. Pharmacologic
Medications (po, iv, im, sc, pr, transdermal)
Acetaminophen
NSAIDs
Opioids
Gabapentin
NMDA antagonists
Alpha-2 agonists
Procedures
Regional Anesthesia
LA infiltration at incision site
Surgical Intervention
Non-Pharmacologic / Non-Surgical
Methods to Treat Pain
70. Using more than one drug for pain control
Different drugs with different mechanisms/sites of action
along pain pathway
Each with a lower dose than if used alone
Can provide additive or synergistic effects
Provides better analgesia with less side effects (mainly
opiate related S/E)
Always consider multimodal analgesia when treating pain
Multimodal Analgesia
71. First-line treatment if no contraindication
Mechanism: thought to inhibit prostaglandin
synthesis in CNS → analgesia, antipyretic
Only available in po form in Canada
Typical dose: 650 to 1000 mg PO Q6H
Max dose: 4 g / 24 hrs from all sources
Warning: ↓ dose / avoid in those with liver damage
Acetaminophen
75. Key Points:
Centrally acting on opioid receptors
No ceiling effect
High dose/response variability in non-opiate users
Previous dependence creates a challenge in acute on chronic pain
management cases
Balancing safety and efficacy can be difficult (OSA patients)
Side effects may limit reaching effective dose
Opioids
77. Morphine
Most commonly prescribed opioid in hospital
Metabolism:
Conjugation with glucuronic acid in liver and kidney
Morphine-3-glucuronide (inactive)
Morphine-6-glucuronide (active)
Impaired morphine glucuronide elimination in renal failure
Prolonged respiratory depression with small doses
Due to metabolite build-up (morphine-6-glucuronide)
Opioids
78. Hydromorphone (Dilaudid)
Better tolerated by elderly, better S/E profile
Preferred over morphine for renal disease patients
Low cost, IV and PO forms available
Oxycodone
Good S/E profile, but $$
PO form only
Percocet (oxycodone + acetaminophen)
Opioids
79. Codeine
1/10th Potency of morphine
Metabolized into morphine by body
Ineffective in 10% of Caucasian patents
Challenge with combination formulations
Meperidine (Demerol)
Not very potent
Decreases seizure threshold, dystonic reactions
Neurotoxic metabolite (normeperidine)
Avoid in renal disease
Opioids
80. Short acting forms
Need to be dosed frequently to maintain consistent analgesia
Controlled Release forms
Provides more consistent steady state level
Helpful for severe pain or chronic pain situations
Never crush / split / chew controlled release pills
Opioids - Formulations
83. Allows patient to reach their own minimum effective
analgesic concentration (MEAC)
Rapid titration (Morphine 1mg IV every 5 min)
Better analgesia and less side effects than IM prn
Opioids – PCA
84. Anti-epileptic drug, also useful in:
Neuropathic pain, Postherpetic neuralgia, CRPS
Blocks voltage-gated Ca channels in CNS
Additive effect with NSAIDs
Reduces opioid consumption by 16-67%
Reduces opioid related side effects
Drowsiness if dose increased too fast
Gabapentin
87. Accurate pain assessment
Make sure to continue or account for patient’s pre-
hospital pain regimen
Use Multimodal pain management
Discharge pain management plan
Acute Pain Service available 24 hrs/day
Summary
88. Superior analgesia, ↓ side effects means:
Improved patient satisfaction
Better rehabilitation
Earlier functional return
Earlier discharge from hospital
↓ likelihood of chronic pain
Reduced health care costs
Summary
89. Nerve Blocks of the Digits
Anatomy
Technique
Dorsal approach
90. Nerve Blocks of the Digits
Anatomy
Technique
Dorsal approach
Ring block
Palm approach