A talk by Stephan Schug at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All of the conference content can be found here: https://scanfoam.org/ssai2017/

1. Acute Pain after Surgery:
Lessons Learned from the Last Decade
Stephan A Schug
Anaesthesiology & Pain Medicine
University of Western Australia
Royal Perth Hospital

2. Disclosure
The Anaesthesiology Unit of the University of
Western Australia, but not Professor Schug
personally, has received research and travel funding
and speaking and consulting honoraria from Eli Lilly,
bioCSL/Seqirus, Grunenthal, Indivior, Janssen,
Mundipharma, Pfizer, Phosphagenics and
iXBiopharma within the last 5 years.

3. http://www.iasp-pain.org/GlobalYear

4. http://fpm.anzca.edu.au/
Resources/Publications

5. APM:SE 4th edition
Endnote library: 8,598 references
Pages: 647
Key Messages: 669
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

6. Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

7. Opioids – the Good
 Opioids are very effective analgesics
 Opioids are necessary to provide pain relief in many
situations linked to severe pain:
– postoperative
– after severe trauma
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

8. Opioids – the Bad
 Opioids are often associated with adverse events including:
– Opioid-Induced Ventilatory Impairment
– Nausea and vomiting
– Constipation
– Urinary retention
– Sedation
– Confusion or agitation
– Rash, itching, hives
– Opioid-Induced Hyperalgesia
Opioid-related AEs increase length of stay and costs
Oderda GM, et al. J Pain Symptom Manage. 2003;25:276-83. TJ et al. Anesth Analg. 2004;98:1665-73.

9. What Can We Do About
Adverse Effects of Postoperative Opioids?
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

10. Acute Pain Management:
Scientific Evidence 4th edition 2015
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

11. Effects of Parecoxib/Valdecoxib with PCA
Morphine in Laparoscopic Cholecystectomy
Gan TJ, et al. Acta Anaesthesiol Scand 2004;48:1194
Risk of
1 CME*
p<0.01 for all results
*Clinically meaningful events caused by opioid symptom distress
–29.2%
–32.7% –34.4%
–31.0%
0
–5
–10
–15
–20
–25
–30
–35
Opioid
dose
Mean brief
pain inventory
severity
Opioid
symptom
distress score
Change(%)

12. 12
American Pain Society,
American Society of Regional Anesthesia and Pain Medicine,
and the American Society of Anesthesiologists
“The panel recommends that clinicians
offer multimodal analgesia,
or the use of a variety of analgesic
medications and techniques combined
with nonpharmacological interventions,
for the treatment of postoperative pain
in children and adults
(strong recommendation, high-quality
evidence).”
Note: Exact components of effective multimodal care will vary depending on the
patient, setting, and surgical procedure.
Chou R, et al. J Pain. 2016;17:131-57.

13. Multimodal Analgesia
Adapted from Julius D, Basbaum A. Nature
2001;413:203-10.

14. Peripheral and Central Sensitisation
Leads to Pain Amplification
Normal
pain response
Sensitised
pain response
Injury
X
HYPERALGESIA
Stimulus intensity
Pain intensity
for stimulus X
normal pain
response
Pain intensity
for stimulus X
sensitised
pain response
ALLODYNIA
Painintensity
10
8
6
4
2
0
14Adapted from: Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84.

15. Anti-hyperalgesic Therapy:
Opioid-Sparing
~30%
reduction
Opioid
Opioid
Painintensity
10
8
6
4
2
0
X
Stimulus intensity
Anti-
hyper
algesic
Normal
pain
response
Sensitised
pain response
Partially desensitised
pain response
15
Adapted from: Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-84.
Zhao et al, J Pain Symp Manag 2004;28:35

16. Scientific Evidence:
Multimodal Analgesia*
 There is Level I evidence for the effectiveness of the following
components of multimodal analgesia:
– Regional anaesthesia (peripheral and epidural)
– Paracetamol
– NSAIDs/Coxibs
– Alpha-2-Delta Ligands
– Systemic Local Anaesthetics (lignocaine)
– NMDA Receptor antagonists (ketamine, magnesium)
– Alpha-2 Agonists (clonidine/dexmedetomidine)
– [Corticosteroids (dexamethasone)]
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

17. Practical Conclusions:
Multimodal Analgesia*
 Regional anaesthesia techniques should be used whenever possible
 In practical terms current routine use for systemic analgesia should
include:
– Paracetamol
– COX-2 inhibitors/nsNSAIDs (if no renal contraindications)
– Alpha-2-Delta Agonists (single preoperative dose)
 In selected patients
– Low-dose ketamine (opioid tolerant, neuropathic pain)
– Systemic local anaesthetics (bowel surgery?)
– Alpha-2 agonists (agitation? withdrawal?)
17Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

18. Chronification of Pain
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

19. Chronification of Pain
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

20. Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

22. Acute Pain Management:
Scientific Evidence 4th edition 2015
22.Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

23. Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.

24. Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.

25. Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.

26.  Initiate multimodal analgesic techniques
– Minimise use of opioids
– Maximise use of non-opioid agents
– Use regional anaesthesia whenever possible
• Superior to opioids, especially in orthopaedic
patients
 Use evidence-based, procedure-specific pain management
guidelines where available
– http://fpm.anzca.edu.au/Resources/Publications
– http://www.jpain.org/article/S1526-5900(15)00995-5/pdf
– http://www.postoppain.org
Conclusions
26