This document summarizes a presentation on anaesthesia and pain relief given by Dr. Annush Tha. It covers various topics including: - Types of anaesthesia such as general, local, and regional anaesthesia along with their techniques and monitoring. - Pre-anaesthetic evaluation and selection of anaesthetic technique based on factors like operative site and patient risk. - Acute and chronic pain management with a focus on multimodal approaches using analgesics like opioids, NSAIDs, and local anaesthetics. - Special considerations for pain control in malignant diseases and chronic pain conditions. The key messages are that anaesthesia selection should be tailored per patient and surgery with cost in mind, multimodal pain

1. ANAESTHESIA AND PAIN RELIEF
• Presenter : Dr. Annush Tha
• Moderator: Dr. Devendra Shrestha/ Dr. Puspa raj koirala
• Department of Surgery
• Pokhara Academy of Health Sciences
• 2077-06-19

2. Learning objectives
• Technique of anaesthesia
• Local and regional anaesthesia
• Methods of providing pain relief
• Management of chronic pain and pain from malignant disease

3. Anaesthesia
• Greek “an” – without “aesthesis” – no sensation
• Hippocratic corpus – anesthesia–reversible loss of sensation and
unconsciousness
• 16th October 1846 Ether day – 1st time ether used by William Morton
for operation on a vascular tumor on neck
• THE ETHER DOME
• 1853- John snow used chloroform on Queen Victoria for labour pain
• 1926- Jhon Lundy – “Balanced anaestheisa”

4. Pre anaesthetic evaluation

5. Mouth opening ( 6-8 cm)
Cervical spine mobility
Mallampati classification
Thyromental distance (6-8
cm)
Assacement for disease
associated airway
abnormalities

6. • Cardiovascular assessment ( for perioperative ischemia and infarction)
• Wait for 4-6 weeks after MI
• METs >4
• 1MET- 3.5ml/kg/min
• resting/basal oxygen consumption (VO2) of 70kg, 40yr old man in resting state
• Pulmonary
• Age >60
• COPD /CHD
• Se. albumin 3.5g/dL- strong predictor of pulmonary complication
• Renal and hepatic
• Dialysis (18-24 hours prior to surgery)

7. • Fasting before surgery
Clear liquid 2 hour
Breast milk 4 hour
Infant formula
Non human milk
Solid food
6 hour

8. Selection of the anaesthetic technique
• Operative site
• Patient position
• Duration of surgery
• Pt expected to return home or anticipated for admission
• Cost
• Risk of anaesthiesia

9. Types of anaesthesia

10. General anaesthesia
• Pre-medication-
• Anxiolys/Amnesia/Sedation- BZDs
• Analgesia: opoids
• Antiautonomic: Anticholinergics/antiadrenergis
• Antisecretory
• Antiemetics

11. General anaesthesia
analgesia
Muscle
relaxaion
Amnesia
Triad of GA

12. • Induction – (administration inducing agent to loss of consciousness)
• Done with iv agents
• Eg: propofol, thiopentone sodium, etomidate, ketamine
Muscle relaxation (depolarisng/non depolarizing muscle relaxants)
Mechanical ventilation
• Maintainence – inhalational agents
(isoflurane/desflurane/sevoflurane)

13. Monitoring
• Pulse oximetry
• ECG – (II-Arrhythymia, V2, V3, V4, V5- ischemia)
• Blood pressure
• Capnography
• Temperature
•
Reversal and post anaesthetic care

14. Local anaesthesia
• Moa: binds to voltage gated Na channels(open)prevents the entry
of Na no depolarization no transmission of impulses

15. Regional anaesthesia
• Neuroaxial or peripheral nerve or plexus block
• Effective where general anaesthesia has higher risk of morbidity and
mortality
• Obstetrics, debilitiating respiratory and cardiovascular dz
• Excellent pain relief in postop period
• Decreases the need of analgesia

16. Nerve blocks
• Interscalene – shoulder surgery( horner syndrome/phrenic nerve block)
• Axillary brachial plexus block
• Femoral and sciatic block
• Transverse abdominis plane (TAP)block—
• T6-L1 segment block
• LA in fascial plane in between Int. Oblique and
Transverse abdominis
• Intravenous regional anaesthisia(Bier’s )

17. SPINAL ANAESTHESIA EPIDURAL ANAESTHESIA

18. PAIN
• An unpleasant sensory and emotional experience a/w actual
Tissue damage or potential tissue damage
Acute pain:
Relatively of short duration and resolves with tissue healing or withdrawal of
noxious stimuli
Resolves within minutes/hours or days
Chronic pain:
Persists for at least 1 month beyond the usual course of an acute disease or beyond
a reasonable time in which an injury is expected to heal
Cancer pain or chronic pain syndrome

19. PAIN PATHWAY
TRANSDUCTION
TRANSMISSION
MODULATION
PERCEPTION

20. • More than 80% of surgical patients experience acute postoperative
pain
• Approx. 75% report the severity as moderate, severe or extreme
• Inadequately controlled pain negatively affects
• quality of life
• function and functional recovery
• Risk of post surgical complications
• Risk of persistent postsurgical pain

22. Why should we treat pain??
• To provide good quality patient care
• To reduce post operative complication:
• Respiratory : retention of secretion  pneumonia & atelectasis
• Cardiovascular : pain increases sympathetic drive causing increased
• myocardial oxygen demand risk of post operative myocardial ischemia
• Neuroendocrine effects: increased secretion of catecholamines and cortisols
promoting water and Na retention
• Mobilisation : risk of DVTdue to delayed mobilization coz of pain

23. How to treat post operative pain??
• Multimodal pain management is recommended
• Includes non pharmacological and pharmacological methods
• Preoperative counselling
• About the nature of surgery and post operative pain to patient and caregivers
• Helps to educate patient about post operative pain and devise the treatment
plans
• TENS( Transcutaneous electrical nerve stimulation)
• Acupuncture

24. Pharmacological treatment
• Methods of analgesia
• Oral route is preferred
• Parenteral for moderate to severe pain –requiring rapid control
• IV route preferred over IM and SC
• IM – painful and erratic absorption

25. Opioids
• Strong opioids  moderate to severe pain
• Weak opioids  mild to moderate pain
• Tramadol :
• Non opioid
• Centrally acting analgesic for mild to moderate pain
• A/E: nausea, pruritus, sedation , urinary retention, respiratory
depression, decrease gastric motility
STRONG WEAK
Morphine Codeine and hydrocodone
Fentanyl ( suitable in renal impairment) Used in combination with aspirin or PCM
Meperidine( decreases seizure threshold)

26. NSAIDs
• Inhibits COX enzyme and decreases prostaglandins( potent mediators of
pain acting at nociceptors and increases its sensitivity )
• Part of analgesia regimen that reduces opioid need
• Ketorolac – mild to moderate pain (iv 30 mg)
• Ketorolac + opioid moderate to severe pain
• A/e: gastric ulceration , renal injury and bleeding
• Avoid in platelet dysfunction, thrombocytopenia , renal dysfunction
• Others celecoxib, rofecoxib, valdecoib COX2 inhibitors

27. Local anaesthesia
• Local infiltration of anaesthetic prior to incision– reduces
sensitization of nociceptors and decreases pain conduction to CNS
• Local infiltration on wound closure may be helpful
• Local anaesthetics via epidural infusion, peripheral nerve infusion
• Decreases postop pain and opioid requirement

28. Combination of analgesic therapy
• NSAIDs + OPIOIDS
• NSAIDs + OPIOIDS + Local Anaesthesia based regional analgesia
• Acetaminophen + NSAIDs more effective when used together
• Preoperative dose of oral celecoxib in adult patients (200-400 mg – 30-1
hour preoperatively lowers post operative pain score)
• Gabapentin (600-1200 mg) or pregabalin (150-300 mg)preoperatively
1-2 hours preoperative or after 12 hours post operatively – effective
• Neuraxial and peripheral analgesia highly advocated
• Guidelines on Management of postoperative pain
• Management of postoperative pain : a Clinical practice guideline..Roger chou et al. The journal
of pain, 2016

29. Chronic pain management
• Acute pain after surgery may progress to chronic pain if inadequately
managed
• Types
• Nociceptive pain from musculoskeletal disorders or cancer (cutaneous
nociceptors sensitization and exaggerated response in dorsal horn )
• Neuropathic paindysfunction in peripheral or central nerves
• Burning, shooting or stabbing type
• Poorly responsive to opioids  give gabapentine, tricyclic antidepressants
• Eg: trigeminal neuralgia, diabetic neuropathy, postherpetic neuralgia
• Psychogenic paina/w depressive illness

30. Chronic pain control in benign dz
• Chronic persistent pain (>3 months duration):
• spontaneous Firing of pain signals at NMDA receptors in ascending
pathway
• Postoperative neuropathic pain
• Nerve injury
• Sympathetic dystrophy
• Phantom limb pain( provide preoperative and post op pain relief to avoid)
• Neuropathic pain management
• Local anaesthetic + steroid injections
• Nerve stimulation procedures (TENS, Accupunture, dorsal column stimulation
with epidural electrodes )

31. Pain control in malignant disease
Simple analgesics : Aspirin, paracetamol,
NSAIDs, TCA, Anticonvulsants
Intermediate opioids: codeine,
tramadol
strong opioids: morphine,
fentanyl, mepiridine

32. Breakthrough pain
• Acute excruciating and incapacitating pain occurring spontaneously or
specific predictable or unpredictable trigger in pt with controlled pain
• Experienced by some cancer patients
• Managed with morphine or fentanyl

33. Infusions
• Subcutaneous , intravenous , intrathecal or epidual opiates infusions
in patient controlled analgesia via infusion pumps may be required
Neurolytic techniques in cancer pain
• Used only if limited life expectancy and diagnosis is certain
• For intractable pain
• Subcostal phenol inj. For rib metastasis
• Coeliac plexus neurolytic block with alcohol for – pancreatic , gastric Ca pain
• Percutaneous anterolateral cordotomy - divides the spinothalamic ascending
pain pathway

34. Take home message
• Anaesthesia techniques must be patient and surgery specific keeping
on mind of the cost
• Pain management should begin preoperatively and continue
postoperatively for quality patient care and avoid complications
• Pain management requires multimodal approach and effective when
combined
• Pain management in malignant condition should follow pain
stepladder

35. References
• Short practice of surgery, 27 edition , Bailey and love
• Sabiston Textbook of surgey ,19th edition
• Management of the postoperative pain: A clinical practice guideline
from the American pain society,.. Roger chou, et al. The journal of
pain , vol 17.

36. Thank you