Dr. Sudheer Dhara

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  • Be sure to ask about pre-existing pain scores (ie. Pre-hospital)
  • Be sure to ask about pre-existing pain scores (ie. Pre-hospital)
  • Dr. Sudheer Dhara

    1. 1. Dr Sudheer Dara • Consultant Anaesthesiologist & Pain specialist, Yashoda Hospital Secunderabad. • Hon. Treasurer of ISSP (AP Chapter) • Faculty for “Traveling pain school” started by ISSP (AP Chapter) • Founder of YAPM (Yashoda Academy of Pain Medicine) • Special Interests: Interventional Pain Management Ultrasound Regional Anaesthesia
    2. 2. Post operative pain & acute pain services DR.SUDHEER DARA ANAESTHESIOLOGIST PAIN SPECIALIST YASHODA HOSPITAL SECUNDERABAD
    3. 3. Drugs (oral & injectable)
    4. 4. Epidural analgesia
    5. 5. Periphral nerve blocks
    6. 6. Where are we ?
    7. 7. Questionnaire 1)The % of your patients comfortable in post operative ward? 2)Are you satisfied with your post operative rounds? 3)How frequently you use opioids in postoperative period? 4) Do you have acute pain services?
    8. 8. Sub optimal analgesia ? lack of knowledge about drugs ? ? many myths associate with pain ? pain is not harmful to patient ? pain relief obscures signs of complications ? ? patient will become addicted to opioids ? risk of respiratory depression is high ? PRN: means ? give as infrequently as possible’
    9. 9. Sources of postoperative pain •Acute nociceptive pain from incision. • Musculoskeletal pain from abnormal body positioning and immobility during and after surgery • Neuropathic pain from excessive stretching or direct trauma to peripheral nerves
    10. 10. Postoperative pain is nociceptive Perception Modulation Is responsive to NSAID’s,coxibs, paracetamol and opiates Transmission Transduction Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.
    11. 11. Pain pathway and modulation1 Ascending nociceptive pathways Interpretation in cerebral cortex: pain Stimulation of nociceptors (A and C fibers) / Release of neurotransmitters and neuromodulators (i.e. PG) Descending inhibitory controls / Diffuse noxious inhibitory controls Activation of serotoninergic and noradrenergic pathways Release of serotonin, noradrenalin and enkephalins at spinal level Injury 1. Adapted from: Bonica JJ. Postoperative pain. In Bonica JJ, ed. The management of pain. Philadelphia: Lea and Febiger;1990:461-80.
    12. 12. Post operative pain- effects
    13. 13. Adverse Effects of Poor Pain Control “… it remains a common misconception amongst clinicians that acute postoperative pain is a transient condition involving physiological nociceptive stimulation, with a variable affective component, that differs markedly in its pathophysiological basis from chronic pain syndromes.” Cousins MJ, Power I, and Smith G. Regional Analgesia and Pain Medicine, 25 (2000) 6-21
    14. 14. No one likes it
    15. 15. Consequences of Unrelieved Pain Acute Pain Increased sympathetic activity GI effects Splinting, shallow breathing Increased catabolic demands Anxiety and fear Peripheral/ central sensitization Myocardial O2 consumption GI motility Atelectasis, hypoxemia, hypercarbia Poor wound healing/muscle breakdown Sleeplessness, helplessness Available drugs Myocardial ischemia Delayed recovery Pneumonia Weakness and impaired rehabilitation Psychological Chronic pain Courtesy of Sunil J Panchal, MD
    16. 16. Pain is subjective Pain is subjective
    17. 17. Pain Assessment Visual Analogue Scale
    18. 18. Different modalities of pain control      Drugs- oral,intramuscular,intravenous,rectal, Epiduralanalgesia Nerve blocks Skin infiltration Accessory methods: TENS, ACUPUNCTURE COGNITVE THERAPIES
    19. 19. Modes of action of analgesics1,2,3,4 Paracetamol  Inhibition of central Cox-3 (?) (Inhibition of PG synthesis) Opioids  Activation of opioid receptors Paracetamol  Interaction with serotoninergic descending inhibitory pathway NSAIDs / Coxibs  Inhibition of peripheral and central Cox-1 / Cox-2 (Inhibition of PG synthesis) 1. D’Amours RH et al. JOSPT 1996;24(4):227-36. 2. Piguet V et al. Eur J Clin Pharmacol 1998;53:321-4. 3. Pini LA et al. JPET 1997;280(2):934-40. 4. Chandrasekharan NV et al. PNAS 2002;99(21):13926-31.
    20. 20.  How much we are successful?
    21. 21. Where is the problem?
    22. 22. First contact (PAC)  Explaining about the nature of surgery  Explaining about the expected amount of     pain Explaining the self assessment of pain Explaining about the management offered Explaining about the reassessment Clearing the faulty thoughts (spiritual)
    23. 23. Operation theatre  Preemptive analgesia  Pre incision infiltration  Epidural analgesia (continous)  Parentral medication continuing into post operative period (dosing)  Peripheral nerve blocks (technique ?)  Neuropathic pain  Patches ( fancy but questionable)
    24. 24. Epidural analgesia(failures)  Technical difficulties
    25. 25. Epidural analgesia (failures)
    26. 26. Epidural failures (guess?)
    27. 27. Epidural failures  Loss of resistance
    28. 28. Catheter placement  Cervical – 1cm  Thoracic-1.5 cm  Lumbar – 2 cm
    29. 29.  Dermatomal involvement  Calculation
    30. 30. Drug concentration & dosages (epidural)  Bupivacaine hydrochloride ( 0.125% to 0.5%)  Ropivacaine ( 0.2%) Additives : fentanyl citrate, morphine,clonidine Precise and strict monitoring Bolus dosage:
    31. 31. Post operative room Pain assessment: rarely done
    32. 32. Pain Assessment Visual Analogue Scale
    33. 33. Principles of assessment of pain        At rest and on movement Evaluate before and after therapy Character of the pain Severe the pain more the evaluation Document the response and adverse effects Attention towards those unable to express Family members are involved
    34. 34. Post operative pain (guess??)
    35. 35.  Isolated
    36. 36. Be compassionate  Pp 
    37. 37. Assurance  Done by a nurse or the physician  Explain the measures and administer  Reassess the pain  Multimodal approach
    38. 38. Treat according to the scale  Upto 4/10 ---- NSAID AND PARACETOMOL  4/10 and above ---- NSAID AND OPIOID
    39. 39. Epidural is not the sole saviour Combination therapy WHO LADDER
    40. 40. Combination analgesia  Epidural drug(opioid) + Nsaid  Nsaid and paracetomol  Nsaid and opioid  Do not add opioid to opioid  Paracetomol--- ?????( alone)
    41. 41. “Real World”: Multimodal Analgesia  Reduced doses Opioids  Improved pain relief Potentiation  Reduce severity of AEs  Earlier discharge NSAIDs, coxibs, paracetamol, nerve blocks Kehlet et al. Anesth Analg. 1993;77:1048-1056 (B).  Decreased costs
    42. 42. BJA 2002 Comparative effect of paracetomol(pct),NSAID,or their combination Systematic review of literature in medline 1996 to 2001
    43. 43. Bja 2002 Major abdominal surgeries: Nsaid are superior to pct Gynaecological : Nsaid superior to pct ENT: pct = Nsaid Dental: Nsaid superior to pct
    44. 44. Result Paracetomol is additive to nsaids and opioids
    45. 45. Assessment of pain in critically ill ( non verbal)  Critical care pain observation tool (CPOT)  Adult non verbal pain scale(NVPS)  Faces legs activity cry consolibility scale(FLACC)
    46. 46. Assessment CPOT . Facial description . Body movements .muscle tension . Compliance with ventilator .vocalization
    47. 47. Assessment  NVPS . Face . Activity . Guarding . Physiology . Respiration
    48. 48. Precise dosing and timing
    49. 49. PRN based monotherapy  Analgesic gaps  Break through pains
    50. 50.  Failure of NSAID and paracetomol  Failure of epidural analgesia
    51. 51. Opioids!!!!!!!!!!!
    52. 52. Opioid !!!!  Gold standard  Needs understanding  Side effects  Antidote
    53. 53. Opioid intravenous infusions  Morphine sulphate infusions 30 to 50 mics per kg per hour  Fentanyl citrate infusions 1 mic/kg/hour
    54. 54. Yashoda opioid infusion protocol Opioid infusion protocol in post-operative pain Morphine : 30 µg/kg/hour Add 2.5 cc(2.5 amp)- inj morphine in 50 ml N.S 1cc = 0.5 mg 50 kg ----------------1.5mg/hour--------------3cc/hour 60kg -----------------1.8mg/hour--------------3.6cc/hour 70kg -----------------2.1mg/hour---------------4.3cc/hour 80kg ---------------- 2.4mg/hour---------------4.8cc/hour 90kg-----------------2.7mg/hour---------------5.6cc/hour 100kg---------------3.0mg/hour----------------6cc/hour Initial bolus: Dose: 50 µg/kg 50 kg----------------------2.5 mg---------------5cc 60kg----------------------3.0 mg---------------6cc 70kg---------------------3.5 mg----------------7cc 80 kg--------------------4.0 mg----------------8cc 90 kg--------------------4.5 mg----------------9cc
    55. 55.                Painful procedures: Physiotherapy,dressing,shifting: Dose: 20 µg/kg 50 kg----------------1.0mg----------------2cc 60 kg----------------1.2mg----------------2.4cc 70 kg----------------1.4mg----------------2.8cc 80 kg---------------1.6mg-----------------3.2cc 90 kg---------------1.8mg---------------- 3.8cc 100kg--------------2.0 mg---------------4.0 cc Keep Nalaxone ready Dilute: NALAXONE 0.4 mg (1 amp) + 20 cc N.S 1cc = 20µg Pruritis Excess sedation C.P ARREST 1µg/kg 2µg/kg(5 dose) 10µg/kg(5 dose) Rpt after 2 hours Rpt after 1-2 min rpt 1-2 min
    56. 56. Transdermal patches??  Buprigesic patches  Fentanyl patches
    57. 57. Patches for acute pain????  Delayed onset  Respiratory complications
    58. 58. Transdermal fentanyl. A review of its pharmacological properties and therapeutic efficacy in pain control. Jeal W, Benfield P. Source Adis International Limited, Auckland, New Zealand. demail@adis.co.nz
    59. 59. Initially, much of the clinical experience with fentanyl TTS was obtained in patients with acute postoperative pain. However, because of the increased risk of respiratory complications, fentanyl TTS is contraindicated in this setting.  The most serious adverse event was hypoventilation, which occurred more frequently in postoperative (4%) than in cancer patients (2%).
    60. 60. Opioid adverse effects Common Uncommon Constipation Bad dreams / hallucination Dry mouth Dysphoria / delirium Nausea / vomiting Myoclonus / seizures Sedation Pruritus / urticaria Sweats Respiratory depression Urinary retention
    61. 61. POST OP ANALGESIA????
    62. 62.  Opioid infusion  Combination with others
    63. 63. Peripheral nerve blocks
    64. 64. Anatomy
    65. 65. CONTINOUS CATHETER TECHNIQUE
    66. 66. patient-controlled analgesia (PCA) negative feed back loop microprocessor-controlled pump basal (infusion) rate incremental (bolus) dose lockout interval 4-hour limit monitoring: pain score, sedation score, RR, other side effects
    67. 67. SO!!!!!  WHAT’S THE SOLUTION
    68. 68. Acute pain services
    69. 69. The important components of APS are as follows: (a) Multidisciplinary committee comprising anesthetists, surgeons, nurses and pharmacists, supported by the secretarial staff. The committee should define the needs and suggest the equipments and infrastructure besides providing guidance to develop and manage the APS. (b) Acute pain management protocols and modalities of APS. (c) Regular pain assessment methods and guidelines to control pain within a defined time scale. (d) Continuous professional development and teaching programs. (e) Regular meetings, cooperation and networking amongst the members
    70. 70. Guidelines for optimising POP management1,2,3,4,5,6  Adequate and thorough patient information2,3,4,5,6  Use of written protocols1,3,4,5,6  Regular assessment of pain intensity1,2,3,4,5,6  Adequate medical and nursing staff training1,3,4,5,6 Use of balanced analgesia, PCA, and epidural drug administration1,2,3,4,5,6  1. The Royal College of Surgeons of England and the College of Anaesthetists. Commission on the provision of surgical services, report of the working party on pain after surgery. London, UK, HMSO.1990. 2. Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. Acute Pain Management in Adults: Operative Procedures. Quick Reference Guide for Clinicians. AHCPR Pub. No. 92-0019. Rockville, MD.1992. 3. International Association for the Study of Pain, Management of acute pain: a practical guide. In: Ready LB, Edwards WT, eds. Seattle, 1992. 4. Wulf H et al. Die Behandlung akuter perioperativer und posttraumatischer Schmerzen Empfehlungen einer interdisziplinaeren Expertenkommision. G. Thieme, Stuttgart, New York. 1997. 5. EuroPain. European Minimum Standards for the Management of Postoperative Pain.1998. 6. SFAR. Conférence de consensus. Prise en charge de la douleur postopératoire chez l’adulte et l’enfant. Ann Fr Anesth Réanim 1998;17:445-61.
    71. 71. Thanks for your patient hearing DR.SUDHEER DARA ANAESTHESIOLOGIST & PAIN SPECIALIST YASHODA HOSPITAL SECUNDERABAD

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