postoperative pain assessment and management


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  • This table summarizes some of the adverse physiological consequences of unrelieved acute pain
  • Along with elevated levels of catecholamines Cortisol, growth hormone, adrenocorticotropic
  • postoperative pain assessment and management

    1. 1. Acute postoperative Pain Assessment and Management PRESENTED BY Dr. MAHMOUD A. KAFY MD Anesthesia & ICU MINISTRY OF HEALTH FUJAIRAH HOSPITAL
    2. 2. Objectives • Be able to provide a definition for pain • Have an understanding of pain assessment and pain assessment tools • Have a knowledge of analgesic drugs and side effects of drugs • Have an understanding of routes of drug administration
    4. 4. “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” IASP (1979) Definition of pain • Implies emotional component. • Pain can exist without tissue damage.
    5. 5. PATHOPHYSIOLOGY OF PAIN • Involves four physiological processes: - Transduction - Transmission - Modulation - Perception
    6. 6. Pain Language • Acute pain: lasts less than 6 months, subsides once the healing process is accomplished. • Chronic pain: involves complex processes and pathology. Usually involves altered anatomy and neural pathways. It is constant and prolonged, lasting longer than 6 months, and sometimes, for life.
    7. 7. Why Treat Pain? • Basic human right! • ↓ pain and suffering • ↓ complications of unreleived pain • ↓ chronic pain development • ↑ patient satisfaction • ↑ speed of recovery → ↓ length of stay → ↓ cost • ↑ productivity and quality of life
    8. 8. Barriers to Effective Pain Management ● Multidisciplinary factors - lack of knowledge - failure to recognize multi - faceted nature of pain - poor interpretation of information ● Patient factors - unwillingness to report pain - non compliance with treatment - lack of knowledge / information
    10. 10. Pain may be undertreated Physicians may have concern that pain medications will: - worsen hemodynamic instability - produce harmful or long-lasting metabolites in the setting of multiple organ dysfunction - Impair the ability to examine a patient’s mental status. However, these concerns must be balanced against harmful effects of undertreatment of pain.
    11. 11. Adverse effects of unrelieved PainAdverse effects of unrelieved Pain CardiovascularCardiovascular Heart Rate Blood Pressure Increased myocardial o2 demand Hypercoagulation Unstable angina Myocardial infarction DVT PE RespiratoryRespiratory Lung Volumes Decreased cough Retension of secretion Atelectasis Pneumonia Hypoxemia GIGI Gastric Emptying  Bowel Motility Constipation Anorexia Ileus National Pharmaceutical Council (2001). Macintyre & Schug (2007).Cohen et al (2004)
    12. 12. Adverse effects of unrelieved PainAdverse effects of unrelieved Pain NeuroendocrineNeuroendocrine Altered release of multiple hormones Hyperglycemia Wt loss/ muscle wasting Impaired wound healing Impaired immune function MSKMSK Muscle spasm Impaired muscle mobility & function Immobility Weakness Fatigue PsychologicalPsychological Anxiety Fear Sleep deprivation Post traumatic stress disorder
    13. 13. PAIN PATHWAY
    14. 14. Pain Pathway – Pain Management Tricyclic Antidepressants Opioids SSRI Anticonvulsants
    16. 16. Pain Assessment “One of the most important functions of the nurse is to alleviate the suffering of people who are experiencing pain” Schofield P(1995)
    17. 17. Why we assess pain ? • To establish degree and nature of pain • To ensure patient comfort • To evaluate effectiveness of analgesia • To help alleviate anxiety • To decide on type of analgesia • To aid recovery and prevent complications
    18. 18. When should pain be measured • Usually asked when pt. are resting . • Better indicator is assessment of pain during coughing , deep breathing or movement . • Regular reassessment .
    19. 19. How to assess pain • Communication with patient is essential • Observe for changes in physiological signs • Consider pain as 5th vital sign • Use a pain scoring system
    20. 20. pain Assessment in Critical Care
    21. 21. In patients who are unable to self-report and in whom motor function is intact and behaviors are observable. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for monitoring pain in • Medical ICU • Postoperative, • Trauma (except for brain injury) In patients who are unable to self-report and in whom motor function is intact and behaviors are observable. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for monitoring pain in • Medical ICU • Postoperative, • Trauma (except for brain injury) Identifying and Treating PainIdentifying and Treating Pain Patients who can self report Numerical scale Guideline do not suggest that vital signs be used alone for pain assessment in adult ICU patients. Guideline suggest that vital signs may be used as a cue to begin further assessment of pain in these patients, Assess pain ≥ 4 times per shift & as needed
    22. 22. Pain is a more terrible lord of mankind than even death
    23. 23. DO:301DO:301 Pain in the ICU
    24. 24. *CPOT range = 0 – 8, CPOT > 3 is significant Critical Care Pain Observation Tool* (CPOT)
    25. 25. post operative pain management
    26. 26. Management of acute pain Analgesic drugs are used to treat acute pain, the choice of drug dependent on the intensity of pain being experienced.
    27. 27. Analgesic Ladder
    28. 28. What is the “Best Way” to manage acute pain? • FIRST , DO NO HARM Therefore , the “best way” is a BALANCE Patient Safety Effective Analgesic Modalities
    29. 29. How do we do it? • Multimodal analgesia : Several analgesics with different mechanisms of action , each working at different sites in the nervous system • Acetaminophen • Non-steroidal anti-inflammatory drugs (NSAIDs) • Opioids • NMDA Antagonists • Local anaesthetics • Non-pharmacologic methods
    30. 30. Methods of administration • Epidural Analgesia • Patient Controlled Analgesia [ intra - venous ] • Intra Muscular Injection • Sub Cutaneous • Oral • Rectal [ suppositories ] • Transdermal • Inhalation [ gas ] • Regional Nerve Blocks e.g. Paravertebral, Brachial Plexus block. • Wound Infiltration
    31. 31. Opioid Opioid is a blanket term used for any drug which binds to the opioid receptors in the CNS.
    32. 32. Opioids for acute pain (ARI) • Morphine • Diamorphine • Fentanyl • Oxycodone • Tramadol • MST continus • Hydormorphone • Codeine • Dihydrocodeine
    33. 33. Adverse effects of opioids • Respiratory Depression • Sedation • Nausea and Vomiting • Pruritus • Urinary retention • Hallucinations
    34. 34. PARACETAMOL  Mechanism of action: ? Selective inhibition of prostaglandin synthesis in CNS  Analgesic and antipyretic  Oral , rectal and intravenous prep  Useful adjunct
    35. 35. NSAIDS • Work at site of tissue injury to prevent the formation of the nociceptive mediators Prostaglandins. • Can decrease opioid use ~30% therefore decreasing opioid-related side effects • NSAIDs should be the first-line drug for treatment of mild to moderate pain & should be used in combination with opioids for more severe pain . • Adv. : no sedation , resp. depression , N&V. – Side effects : GI upset , gastric ulcers , decrease renal medullary blood flow , reversible inhibition of platelet function
    36. 36. NSAIDS • Newer NSAIDS selectively (primarily) inhibit cyclooxygenase-2 (COX-2) which is induced by surgical trauma with minimal effect on COX-1 which is responsible for GI and platelet side effects • Equivalent analgesic efficacy with non-selective COX-inhibitors • No effects on platelets! • Much reduced incidence of upper GI S/E compared to non-selective • Duration of action about 24 hr.
    37. 37. NMDA Receptor Antagonists • Ketamine : - Ketamine 0.15 - 0.3 mg/kg IV with induction of general anesthesia has pre-emptive analgesic effects - less pain and less opioid use post-op - Low dose (0.25-0.5 mg/kg) IV bolus followed by infusion of 2-4 µg/kg/min , can provide significant analgesia. - Ketamine as co-analgesic , combined 1:1 with morphine IV PCA . Better analgesia , less S/E
    38. 38. Dexmedetomidine : - Highly selective- Highly selective αα22 agonist.agonist. - Does not depress the respiratory drive.- Does not depress the respiratory drive. - Causes- Analgesia dose-dependent , sedation- Causes- Analgesia dose-dependent , sedation (“(“Cooperative sedationCooperative sedation”), anxiolysis.”), anxiolysis. - Reduction in Sympathetic tone.- Reduction in Sympathetic tone. - Useful adjunct to both opioid & non-opioidUseful adjunct to both opioid & non-opioid analgesicanalgesic. - Side effects : Bradycardia , Hypotension - Dose : Loading dose – 1 µg/kg i.v. over 10 min , followed by infusion of 0.2-0.7 µg/kg/hr.
    40. 40. THANK YOU