This document provides information on multimodal regiments for acute pain management. It discusses the goals of multimodal analgesia including reducing opioid use through additive or synergistic effects. Key points:
- Multimodal analgesia involves using two or more analgesics with different mechanisms to better treat multiple pain sources and reduce side effects.
- Postoperative pain involves peripheral and central sensitization, so multimodal regiments target both levels.
- Common regiments discussed include paracetamol, NSAIDs, COXIBs, ketamine, gabapentinoids, clonidine and opioids. Low dose ketamine and gabapentinoids are highlighted for their anti-hyperalgesic effects.
- Combining
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
The transversus abdominis plane, more commonly referred to as the TAP block,
Places local anesthetic in the lateral abdominal wall in a plane between the internal oblique and the transversus abdominis muscles.
Here, the local anesthetic block can block many of the abdominal nerves as they pass to the abdominal structures.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
The transversus abdominis plane, more commonly referred to as the TAP block,
Places local anesthetic in the lateral abdominal wall in a plane between the internal oblique and the transversus abdominis muscles.
Here, the local anesthetic block can block many of the abdominal nerves as they pass to the abdominal structures.
A powerpoint explaining in detail about all the intravenous induction agents and their clinical uses, pharmacokinetics & pharmacodynamics, adverse effects and complications.
Ropivacaine is a recently launched local anesthetic in Iran. Because of its more safety profile, it would be an appropriate substitution for routinely used LA, Bupivacaine.
A powerpoint explaining in detail about all the intravenous induction agents and their clinical uses, pharmacokinetics & pharmacodynamics, adverse effects and complications.
Ropivacaine is a recently launched local anesthetic in Iran. Because of its more safety profile, it would be an appropriate substitution for routinely used LA, Bupivacaine.
SpAn harus memberi waktu untuk pengelolaan nyeri
SpAn harus mampu mengelola nyeri dengan memilih cara yang paling aman, paling efektif dan paling ekonomis
Berperan aktif pada acute pain
Berperan, minimal partisipatif, dalam chronic pain
Berperan utama pada interventional pain management
APS : The Chance for Anaesthesiology
“Anaesthesiologist now have a golden opportunity to expand their services into a field where we easily can get many satisfied customers, something very different from the operating room or the intensive care unit, where our patients are asleep or too sick to appreciate our efforts.”
(Breivik. Pain Digest 1993;3:27)
This pain service manual was written to assist the anesthesiologists and nursing
staff in implementing and monitoring the various pain control modalities
available at Al Razi hospital in Kuwait. The manual contains advice and tips on managing patients from immediate post operative period in the recovery to care and monitoring in the wards. This manual was based on extensive research of the standard pain control
guidelines available in texts and online. Certain protocols are based on the
local experience of patient response to narcotics. Highest care was taken t o
research the doses and the reader is advised to exercise their discretion is
choosing the best possible technique and doses for their patients.
Regional Blocks of the Upper Limb and Thorax RRTRanjith Thampi
Blocks of the UL and Thorax made easy. Most methods mentioned here are modifications and not classical methods used that maybe be required for examination writing purpose.
The key to a successful Acute Pain Service is not so much the use of sophisticated drugs and high technology equipment, but an excellent organisational structure and well trained medical and nursing personnel.
Paracetamol iv as a single analgesic is very safe analgesic, but only for mild and moderate pain.
It can be combined with many analgesic or adjuvan drugs to provide strong analgesic for postoperative pain.
So, it can be the basic regiment for Multimodal Analgesia.
Because of its safety it can be the choice for high risk surgical patient
To improving postoperative pain management, we need to;
- Always applies multi-modal analgesia. (get the advantages of multimodal analgesia)
- Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
- Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
Topical Specialist & Compound Pharmacy Study in Jacksonville FL Dr Manish Bansal MD explains the quality of life effects of various transdermal pain therapies. A multicenter prospective cohort study.
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
HISTORY OF 3-STEP LADDER WHO
1980 – WHO establishes Cancer Control Programme
Cancer prevention
Early diagnosis with curative treatment
Pain relief and palliative care
1986 – ” Cancer Pain Relief “ published by WHO
Step Ladder WHO
Updated on 1996
Worldwide acceptance protocol
Today, worldwide consensus favouring its used for management of all pain associated with serious illness
INADEQUATE PAIN TREATMENT STILL A FACT IN INDONESIA HEALTH SERVICES
PAIN AS A COMPLEX PROBLEM NEED MULTIDISCIPLINARY APPROACH FOR BETTER RESULT BASED INDIVIDUALLY PATIENT NEEDED
THERE IS A BIG ROLE OF PHYSICIAN AND HOSPITAL FOR BETTER PAIN MANAGEMENT
CHANGE PARADIGM TO MULTIDISCIPLINARY PAIN TREATMENT IS AN OBLIGATE FOR ALL PHYSICIAN
Pain is a common yet complex biopsychosocial phenomenon that affects every aspect of a patient’s life
Optimal management often requires good assessment, formulation of the problem in the patient, and combining pharmacological and non-pharmacological (psychological and social) interventions
Through palliative care, we change the role of a patient into a whole human being.
Through palliative care, we transform the stages leading to death into times filled with life
Pain is the production (out put ) of the brain.
Pain is invisible disease, we can’t see it like other disease, such as struma, fracture or blind.
What you have to do is to believe what ever the patient says.
Pain is what ever the patient says it is
Pain is invisible diseases, but is real for patient.
NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS
However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation.
Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding.
The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored
Solution of inadequate postoperative pain relief lies in developing Acute Pain Service.
APS has been shown to reduced morbidity and
mortality, increased out put and out come of
postoperative pain patients
Increased stisfaction of the patients
Shorten LOS in ICU and Hopital low cost
Nyeri adalah penggabungan perasaan sensorik dan emosional yang dipengaruhi oleh berbagai faktor.
Nyeri memiliki dua dimensi yg jelas, dimensi inderawi dan emosional
Peran dimensi emosional lebih dominan dibanding inderawi utamanya pada nyeri kronik.
History taking
Adequate time
Listen carefully
Empathetic
Trust building
Do not intervere
Pschosocioeconomic & spiritual codition
- quantity: VAS
- quality: nociceptive
- mode of onset and location
- duration & chronicity
- provocating & relieving factors
- special character
- timing of pain
- relation with posture
- associated complaints
Take home message
Acute pain is a symptom, tell us that there is something wrong in our body.
Chronic pain is a disease entity and that must be treated differently to acute pain.
Since chronic pain is biopsychosocial phenomenon it must be treated by multidisciplinary team with multidisiplinary approach.
Clossing
By 3 step ladder WHO cancer pain management, 90 % of cancer pain can be relief.
Since cancer patients cannot be cured, our main task is to let them die free of pain with Iman
Ideal pain clinic
Promoting multidisciplinary team approach
Coordinating all specialist effort
Measuring the outcome of treatment offered
Promoting palliative model rather than curative models of pain treatments
Identifying complications of IPM and promoting safe and base-evidence intervention
PiCCO tidak hanya memberikan informasi tentang curah jantung (CO) tapi bisa memberi pengukuran untuk menilai preload, kontraktilitas, afterload, dan air paru ekstravaskular (ELWI)
Role of the thalamus in propofol-induced unconsciousness relates primarily to the functional connections of nonspecific nuclei to the cortex (i.e., mediating multimodal integration of information)
The Anesthetized Brain is less Vulnerable to ischemic injury than the awake brain.
EEG changes suggestive of severe ischemia are present.
Basic Methode Brain Protection are “ Corner Stone “
CPP, CBF, CBV maintained in “Normal Range”, MAP may increased up to 10 – 20 %.
Anesthetics Drugs may have Brain Protectection effect.
Volatile anesthetics do provide some Transient Protection (< 1,5 MAC)
Barbiturates, although long considered to be the gold standard.
Hypothermic methode are controversial, Hyperthermia should be avoided.
Insulin is Administered if glucose values exceed 180 mg/dl.
Close monitoring of BSL to ensure that Hypoglycemia does not develop
Anesthesiologists should concern about the risk of POCD by making prevention and attentive to the potential risk factors.
It should be remembered that research in animal models which represent the specific characteristics of POCD in human remains unclear.
With many factors still unknown, there is still a chance for sinchronized preclinical and clinical research on POCD.
a better understanding of sleep and coma may lead to new approaches to general anesthesia based on new ways to alter consciousness,29,97,98 provide analgesia,99,100 induce amnesia, and provide muscle relaxation.66
More from Department of Anesthesiology, Faculty of Medicine Hasanuddin University (20)
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. Multimodal Regiments for Acute
Pain Management
A. Husni Tanra
Department of Anesthesiology IC and Pain Management
Faculty of Medicine Hasanuddin University
Makassar Indonesia
3. What is multimodal analgesia?
Is a combination of two or more
analgesics that act at different
mechanisms, produce additive or
synergistic analgesia
Main goals of Multimodal Analgsia is to reduce the amount of Opioid
5. Why we need multimodal analgesia
for posoperative pain?
No single analgesic is perfect and no
single analgesic can treat all types of pain.
Multimodal Analgesia potentiating in
efficacy, reduced doses, minimal adverse
effect. Improve the outcome.
Most of the pain is a multifaceted and
multiple-sources.
7. Different types
of pain
Different pain
intensity
Different
location of
pain
Different risks
and benefits of
analgesic
techniques
Different surgical procedures have characteristic
pain profiles
Different
procedures
11. So, after the surgery there is a
change in NS
what we called:
“Neuro-Plasticity of the
Nervous System”
12. Neuro-Plasticity of the NS
Primary hyperalgesiaPeripheral sensitization
Secondary
hyperalgesia
Spinal “wind-up”
Central sensitization
Histamine, Leukotrienes,
Norepinephrine, Cytokines,
Bradykinin, Prostaglandins,
Neuropeptides, 5-HT,
Purines, H+/K+ions
Modify by AHTAfter the injury the NS will changed neuro-plasticity
13. After surgery Pain Sensitization:
Hyperalgesia and Allodynia
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
15. Basic Principle of Postop Pain
Management is
preemptive
analgesia
Peripheral
and
Central sanitization
prevent the occurrence of
reduced the process of Neuroplasticity
By Giving
Anti-hyperalgesic &
Anti-allodynia
16. Antihyperalgesic Drugs
• NSAIDs (Nonsteroidal anti-inflammatory drugs)
• COXIBs (Selective COX-2 inhibitors)
• lidocaine (iv and topical)
• Ketamine (low-dose) and other NMDA antagonist
• Clonidine (iv and Intrathecal)
• Gabapentinoid (Gabapentin and Pregabalin)
• Amitriptyline
• TENS
• Midazolam (Intratheca
17. Antiallodynic Drugs
• Lidocaine iv
• Ketamine (low-dose) & other NMDA antagonist
• Gabapentin (Oral and intrathecal)
• Clonidine (iv and intrathecal)
• Propofol (low dose)
• Midazolam (intrathecal)
19. Philosophy of Multimodal Analgesia
Not only just giving 2 or more drugs which different
mechanism, but;
• One drug should be effective at peripheral
sensitization and other at central sensitization.
• Combine drugs must be synergetic or addictive.
• Must be proven by laboratory or clinical data.
• Some drugs may act at several point at nociceptive
pathway.
21. WHAT IS THE MOST REGIMENTS
There are many regiments for multimodal analgesia,
but the most popular are:
Opioid Local Anesthetic
Paracetamol
NSAIDs and Coxibs
NMDA Antagonist
(Ketamin)
-2 antagonist
(Clonidine)
2 (subunit of Ca
Channel) agonist
(Gabapentinoid)
23. Central Antinociceptive Effect
Bertolini et al, 2006; Botting, 2006; Pickering et al, 2006; Mallet et al, 2008; Pickering et al, 2008; Mancini et al, 2003
Mechanism Of Action
Central COX (Cyclooxygenase) Inhibition
Activation of the endocannabinoid system
and serotonergic pathways)
prevent prostaglandin
production at the
cellular level.
24. Paracetamol is very safe drug as long as it is
given within recommended doses
(Adult < 4 gr/day, Infant and children 20-40 mg/kgBW)
1. All Age – from Infant to Elderly
2. From pregnant to Lactating Woman
3. Can be used for patients with renal and
hepatic impairment.
Paracetamol
25. Guidelines line for postoperative pain management
state that:
“Unless contraindication, all patients
should receive an around-the clock(ATC)
regiment on NSAIDs, COXIBs, or
Paracetamol”.
American Society of Anesthesiologists Task Force on Acute Pain Management
2004;100:1573-1581
26. Hyllested M, Jones S, Pedersen JL et al (2002) Comparative effect of paracetamol, NSAIDs or their combination in
postoperative pain management: a qualitative review. Br J Anaesth 88(2): 199–214.
Paracetamol can be the best alternative to
NSAID especially for high risk patients
It is appropriate to administer acetaminophen
with NSAID, or COXIBs additive or synergistic effects
Intravenous form of paracetamol has more
predictable onset and duration of actions
Qualitative Review of Paracetamol
and NSAIDs
27. 1.Sindet-Pedersen S.1997. Data on file.
* I.V. paracetamol was administered as a bio-equivalent dose of propacetamol.
Fast onset of action *
1
Sindet-Pedersen S, 1997
Rapid onset: 5min
Peak at ideal time: 30min
IV paracetamol for dental
Good residual effect at >6hrs
28. Paracetamol has Opioid Sparing Effects
I.V. paracetamol in these studies
was administered as a bio-
equivalent dose of propacetamol.
29. Quantitative Systemic Review 2010
Paracetamol and NSAIDs (cox1 and cox2)
Combination of paracetamol and an NSAIDs may offer
superior analgesia compared with either drug alone
(Anesth Analg 2010)
30. Combination of paracetamol and parecoxib may useful in
patients
who are susceptible to haemorrhagic complications of
NSAIDs
Parecoxib and Acetominophen
31. A combination of 1000 mg paracetamol and 30mg codeine was significantly more
effective in controlling pain for 12 hours following third molar removal, with no
significant difference of side effects during the 12 hour period studied
Paracetamol vs Paracetamol + Codeine
In post-operative dental pain
32. Tramadol/paracetamol combination tablets provided
analgesic efficacy with a better safety profile to
tramadol capsules in patients postoperative pain
following ambulatory hand surgery.
Paracetamol + Tramadol
33. Advantages of Multimodal Analgesia
Elia N, Lysakowski C & Tramer MR (2005) Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2
inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology 103(6): 1296–304.
Acetaminophen,
NSAIDs, or
COXIBs
Added To
PCA Morphine
All of analgesic agent provided an opioid-
sparing effect
However, the decrease in morphine use
did not consistently result in a decrease
in opioid-releted adverse effects
NSAIDs + Morphine was associated with
a decrease in the incidence of PONV and
sedation
34. NSAIDs vs COXIBs For Postoperative Pain
Romsing J & Moiniche S (2004) A systematic review of COX-2 inhibitors compared with traditional NSAIDs, or different COX-2 inhibitors for post-operative
pain. Acta Anaesthesiol Scand 48(5): 525–46.
Demonstrate Equipotent Analgesic Efficacy After
Minor and Major Surgical Procedure
NSAIDs COXIBs
COXIBs Better Alternative TO
NSAIDs in the perioperative
setting
COXIBs associated with:
Reduce gastrointestinal side
effects
Absence of anti-platelet activity
35. Limitation of Traditional NSAIDS:
(Aspirin/NSAID) sensitive asthma
• The COX-2 selective inhibitors
celecoxib1,2 and rofecoxib3,4 given
orally do not cause bronchospasm
in patients with
aspirin/conventional NSAID-
sensitive asthma
1. Gyllfors et al. Allergy Clin Immunol 2003;111:1116;
2. Martin-Garcia et al. J Investig Allergol Clin Immunol 2003;13:20;
3. Stevenson et al. J Allergy Clin Immunol 2001;108:47;
4. Martin-Garcia et al. Chest 2002;121:1812
36. Anesthesia Dose more than 2 mg/kg (iv) anesthesia + produce side effects such us
Psychomimetic effect
• Excessive sedation
• Cognitive Dysfunction
• Hallucination
• Nightmares
Subanesthesia Dose (Low Dose) < 1 mg/kg demonstrated significant
analgesic efficacy without these side effects
Very Low dose (0,15 mg/kg) single intraoperative injection of ketamine 0,15
mg/kg improve analgesia and passive knee mobilization 24 hour after
arthroscopy
37. Ketamin
More Frequently Use in Postorthopedic Surgical Pain
Management
Arthroscopic Anterior
Cruciate Ligament
Surgery
Outpatient Knee
Arthroplasty
Total Knee
Arthroplasty
A Single intraoperative injection of ketamin
(0,15 mg/kg) improved analgesia and passive
knee mobilization 24 hour after surgery
Improved Postoperative Outcome
When combine with epidural or femoral
nerve block, increase postoperative pain
relief for total knee arthroplasty.
•Menigaux C, Guignard B, Fletcher D, Dupont X, Guirimand F, Chauvin M. Anesth Analg. 2000;90:129–135.
•Menigaux C, Guignard B, Fletcher D, Sessler DI, Dupont X, Chauvin M. Anesth Analg. 2001;93:606–612.
•Himmelseher S, Ziegler-Pithamitsis D, Agiriadou H, Martin Jjelen-Esselborn S, Koch E. Anesth Analg. 2001;92: 1290–1295.
•Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Anesth Analg. 2005;100:475–480.
39. progressive increase in
response of second
order neurons to
repetitive C-fiber input
“Wind-Up”
Mendel and Wall, 1965
Now is appreciated that
“wind-up” is a crucial
factor for chronic pain
after surgery
NMDA unblocked
NMDA blocked (AP5)
Stimulus frequency applied to
C-fiber nerve endings
Actionpotentialdischargein
Secondorderspinalneurons
60
50
40
30
20
10
0
2 4 6 8 10 12 14
40. Ongoing activation after injury, the
receptive fields of these neurons
expand, leading to spread of pain.
Recruitment
41.
42.
43.
44.
45.
46.
47.
48. • Low-dose ketamine is not really an ‘analgesic’,
but better described as:
‘anti-hyperalgesic’
‘anti-allodynic’
‘tolerance-protective’ of opioid
Opioid-induced Hyperalgesia
49. Gabapentin and Pregabalin
Eckhardt K, Ammon S, Hofmann U, Riebe A, Gugeler N, Mikus G. Anesth Analg. 2000;91:185–191.
Hurley RW, Chatterjea D, Rose Feng M, Taylor CP, Hammond DL.. Anesthesiology. 2002; 97:1263–1273.
Gilron I, Orr E, Tu D, O’Neill JP, Zamora JE, Bell AC. Pain. 2005;113:191–200.
Reuben SS,Buvanendran A,Kroin JS, Raghunathan. Anesth Analg. 2006;103:1271–1277.
Enhanced Analgesic effects of:Gabapentin
Gabapentin
and
pregabalin
Provide anti-hyperalgesiacan synergically with NSAID
Pregabalin
Superior to either single
drugs for postoperative
pain following spinal
fusion surgery
and Celecoxib
50. Sedation can be interpreted as a negative outcome of gabapentin
,however its can be benefical in the perioperative setting as an
anxiolysis
54. De Kock MF, Pichon G & Scholtes JL (1992) Intraoperative clonidine enhances postoperative morphine patient-controlled analgesia. Can J Anaesth 39(6): 537–44.
Jeffs SA, Hall JE & Morris S (2002) Comparison of morphine alone with morphine plus clonidine for postoperative patient-controlled analgesia. Br J Anaesth 89(3): 424–
7.
Marinangeli F, Ciccozzi A, Donatelli F et al (2002) Clonidine for treatment of postoperative pain: a dose-finding study. Eur J Pain 6(1): 35–42
Clonidine
(intravenous)
REDUCED DOSES
• Opioid postoperative requirements
IMPROVED EFFECACY
• Improved Postoperative Analgesia
REDUCE SIDE EFFECTS
• Nausea and Vomiting
Cautions !!!
• Sedation and Hypotension dose-
dependent
Alpha-2 Agonist
Clonidine
55. Alpha-2 Agonist
Intrathecal (SAB)
De Kock MF, Pichon G & Scholtes JL (1992) Intraoperative clonidine enhances postoperative morphine patient-controlled analgesia. Can J Anaesth 39(6): 537–44.
Jeffs SA, Hall JE & Morris S (2002) Comparison of morphine alone with morphine plus clonidine for postoperative patient-controlled analgesia. Br J Anaesth 89(3): 424–
7.
Marinangeli F, Ciccozzi A, Donatelli F et al (2002) Clonidine for treatment of postoperative pain: a dose-finding study. Eur J Pain 6(1): 35–42
Advantages
Clonidine 15-150 mcg + Local anesthetic
Prolonged time of regression
Prolonged time to analgesic request
Increased speed of onset and duration.
Improved early analgesia
Prolonged analgesia
56. Continuous PNB
Chelly JE, Ben-David B,Williams BA,KentorML.. Orthopedics. 2003;26:S865–S871.
Capdevilla X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F.. Anesthesiology. 1999;91:8–15.
Richman JM, Liu SS, Courpas G, et al.. Anesth Analg. 2006;102:248–257.
Advantages
Superior Pain Relief with movement
Reduce Surgical Stress
Improved Rehabilitation
Reduced opioid consumption and
reduced opioid-related side effects
Disadvantages
Required technical skill
Infrastructure to manage catheter,
especially outpatient
Peripheral Nerve Block (PNB)
57. Adams HA, Saatweber P, Schmitz CS, Hecker H. Postoperative pain management in orthopedic patients: no differences in pain score, but improved stress control by
epidural anaesthesia. Eur J Anaesthesiol. 2002;19:658–665.
De Leon-Casasola OA. When it comes to outcome, we need to define what a perioperative epidural technique is. Anesth Analg. 2003;96:315–318.
Advantages
Significant pain relief
Reduced Neuroendocrine Response
Superior to either PNB or PCA in blunting surgical
response
↓ Incidence of pulmonary complications,
myocardial infarction, DVT and Pulmonary
Embolism
Epidural Blockade
58. Reuben SS, Buvanendran A, Kroin JS, et al. Postoperative modulation of central nervous system prostaglandins E2 by cyclooxygenase inhibitors after vascular surgery.
Anesthesiology. 2006;104:411–416.
Samad TA, Sapirstein A,Woolf CJ. Prostanoids and pain: unraveling mechanisms and revealing therapeutic targets. Trends Mol Med. 2002;8:390–396.
Limitation
Has no effects on humoral cytokine
proinflammatory response (it may be
blocked only by COXIBs).
Epidural Blockade
Epidural can only block pain tranmissions but not humoral respons
60. From this theory
• We can conclude that epidural with LA
alone, may not able to prevent/block
release cytokines due to tissue injury.
• So combine Epidural with Coxibs may
produce excellent analgesia.
• It can be the future analgesia.
61. Multimodal Analgesia
Using 5 Type of Analgesic Drugs
(a preliminary study)
1. Gabapentin 1200 mg
2. Dexamethasone 8 mg
3. Ketamine 0.15 mg/kgBW
4. Paracetamol 1000 mg
5. Ketorolac 15 mg
1. Paracetamol 1000 mg
2. Ketorolac 15 mg
3. Placebo
superior in pain
control than
Group I Group II
62. PARACETAMOL
• Paracetamol as a single analgesic is
only for mild and moderate pain.
• However it can be combined with
many analgesics to provide strong
effect.
• So, it can be the basic regiment for
Multimodal Analgesia.
64. Multimodal
Analgesia
Lowered Dose Reduced Side
Effects
• Early Mobilization
• Early Enteral Feeding
• Rapid Recovery
• low cost
Aggressive preemtive multimodal including epidural or nerve block
not only produce optimal analgesia but also may prevent the
occurrence of chronic pain after surgical
Conclusion
65. Crile 1913
“Patients Given Inhalation
anesthesia still need to be
protected by regional
anesthesia, otherwise
they might suffer
persistent central nervous
systems changes and
enhanced postoperative
pain ”
Stated That:
This is not new