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Post operative pain management
The document provides an overview of postoperative pain management, defining pain and discussing its pathways and mechanisms. It categorizes pain into nociceptive and neuropathic types, outlines pain assessment scales, and reviews various pain management modalities including opioid and non-opioid treatments, regional analgesia, and adjuvant therapies. It emphasizes a multidisciplinary approach and the importance of tailored analgesic plans for effective pain relief post-surgery.
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Post operative pain management
- 1. Postoperative Pain Management Dr. HridayRanjan Roy Assistant Professor, Surgery, Rangpur Medical College, Rangpur, Bangladesh
- 2. What’s the definitionof pain?
- 3. Pain is aSensory and Emotional experience associated with tissue damage or described in terms of such damage (I.A.S.P) (The International Association for the Study of Pain)
- 6. Pain is Always Subjective and Can Neverbe Proved or TOTAL RECALL
- 7. The Pain Pathwaysand Mechanisms
- 8. How Pain Occurs Tissuedamage prostaglandins, releases bradykinin and which activate or sensitize nociceptors. Activation of nociceptors leads to the release of substance P and calcitonin gene related peptide (CGRP). Substance P acts on mast cells in the vicinity of sensory endings and release of histamine, which directly excites nociceptors. Substance P and CGRP produces dilation of peripheral blood vessels. The resultant edema causes additional liberation of bradykinin. Thus Nociceptors activate and cause pain.
- 9. Pain Pathways Frenchman ReneDescartes, De humine textbook
- 11. Axon Reflex Np :Neuro-peptides, BV : Blood Vessels
- 12. Pathophysiology • The generationof pain involves interaction between all parts of the nervous system. Pain ultimately transmitted to: • Thalamus • Medulla oblongata • Cerebral cortex.
- 13. Types of Pain FastPain: Felt within 0.1 second after painful stimulus. Also called: sharp pain, pricking pain, electric pain and acute pain. Slow Pain: Felt within 1.0 second or more after painful stimulus. Also called: dull pain and chronic pain.
- 14. Types of Pain 1.Nociceptive pain- Direct stimulation of intact nociceptors • Transmission along normal nerves • Sharp, aching, throbbing – somatic • easy to describe, localize – visceral • difficult to describe, localize
- 15. 2. Neuropathic pain. . . • Disordered peripheral or central nerves • Compression, transection, infiltration, ischemia, metabolic injury • Varied types – peripheral, deafferentation, complex regional syndromes • Pain may exceed observable injury • Described as burning, tingling, shooting, stabbing, electrical • Mx: opioids, adjuvant / coanalgesics often req.
- 16. Assessment of Pain Howdo You Quantify pain?
- 17. Pain rating scales Categoricalscale 1 Mild 0 No pain 2 3 Discomforting Distressing 4 Intense 5 Excruciating Visual analogue scale (VAS) No pain Most pain Numeric rating scale 0 1 2 3 4 5 6 7 ( 0 = No pain, 10 = Worst pain imaginable ) “Ten Scale” most common: 11 point scale – 0 = No pain – 10 = Worst pain imaginable 8 9 10
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- 19. Pain Management inthe late 18 th century Barker M.D.
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- 25. Pre-emptive Analgesia • • • • • Pre-emptive analgesiacan be achieved by: local anesthetic infiltration of the skin Effective dose of systemic opioids Systemic nonsteroidal anti-inflammatory drugs (NSAIDs) Neuroaxial opioids or local anesthetic Peripheral nerve blocks
- 26. Patient Controlled Analgesia PCA 1.Increase patient satisfaction 2. Decrease side effects and complications 3. Decrease sedation 4. Decrease total amount of daily opioids 5. Avoid Basal rate in the Elderly 6. PCA Flowsheets
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- 33. Paravertebral Lumbar SomaticNerve Block
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- 37. Opioid Spread afterEpidural injection
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- 40. Conformational structure ofCOX-1 and COX-2 isozymes COX-1 (A) COX-2 (B)
- 41. NSAID's • Blocks theproduction of Prostaglandin • Very effective in pain control, Alone or in Combination with Narcotics • Ketorolac is My drug of choice as an adjunct therapy in acute pain • Use p.o. forms “Cox2 inhibitors” when possible in combination with Epidural, IV,or oral narcotics
- 42. Practical guide forNSAID’s Usage • Pre-op administration significantly decreases • • • • • post-op pain and cramps Toradol 30mg, IV or Celebrex 400mg, P.O. preop For sever acute pain Celebrex 400mg, P.O. bid X one week the 200 P.O., bid. Bextra 20mg, bid X one week the 20mg, QD PPI are the drugs of choice to treat gastric complications. H2 blockers only mask the disease Please check the patient renal function routinely prior to administration COX2 inhibitors doesn’t affect the platelet
- 43. Practical guide forNSAID’s Usage (Continuum) All specific or non-specific NSAID’s may cause: • water retention and edema • Hypertension • Renal dysfunction • May delay bony fusion in chronic usage ?
- 44. Clonidine • Alpha2 agonistwith outstanding • • • • • properties when administered intrathecally: Pain control properties by itself Decrease the requirement of narcotics Decrease tolerance Great for neuropathic pain control Adding 1mcg/kg for children caudal block will extend pain relief up to 24h
- 45. Clonidine Oral or transdermalClonidine: Enhance the effect of narcotics Decreases the daily narcotic requirement Excellent Adjuvant therapy for narcotic dependent patients Effective for neuropathic pain
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- 47. Ketamine • NMDA receptorsantagonist → Neuropathic pain • Potent analgesic effect • Small doses in combination of opioids substantially improve pain control • Bolus dose of 100 mcg/kg followed by a continuous drip of 1-3 mcg/kg/min is ideal for chronic opioid users postoperatively
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- 49. Usage of Anti-EpilepticDrugs in Acute Pain • Every surgical incisional pain has Neuropathic • • • component Studies showed giving 1200 mg of Gabapentin 1 h prior to surgery decreases the opioids requirement post-op and results in better pain control without increased sedation Combining Gabapentin with opioids is ideal for re-do back surgery cases with chronic opioids usage These class of drugs are also mode stabilizers
- 50. Non Chemical Techniques •Psychological treatments: Relaxation, hypnosis Cognitive therapy etc.. • TENS Units • Physiotherapy
- 51. The W.H.O 3-stepPain “Ladder” • Step 1 (mild): – non opioid + adjuvant • Step 2 (moderate): ASA Acetaminophen NSAIDs ± Adjuvants • Step 3 (severe) : – ‘strong’ opioid+step 1 meds Hydrocodone Oxycodone Dihydrocodeine Tramadol – “weak” opioid + step 1 meds Codeine ± Adjuvants Nalbuphine Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants
- 52. Physiological vs clinicalpain • Physiological pain has a biological function • Pathological pain has no biological function Woolf
- 53. Multidisciplinary Approach Surgeon Pharmacist Nurse Acute PainTeam Physiotherapist Anaesthetist Psychologist
- 54. Pain after surgery Inflammatorypain • • • Inflammatory pain Nociceptive painpain Nociceptive Neuropathic pain Neuropathic pain
- 55. Chronic post surgicalpain • • • Pain developed after a surgical procedure At least 2 month duration Other causes excluded (malignancy, chronic infection) • Possibility of continuous pain of pre-existing problem Macrae 2001
- 56. Principles of analgesicPlan • • • • • Balanced analgesia Opioids: First line morphine Regional analgesia Actual dose of analgesics will not be discussed Regular and breakthrough prescription including night-time
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- 58. Non-opioid Analgesics • Paracetamol: Acetaminophen centrallyacting 500mg-1g 6h or 1520mg/kg for children • Diclofenac sodium: 50mg TDS orally • Aspirin: 300-900mg 4h • NSAIDs: Analgesic, antipyretic,antiinflam matory • Opioid sparing • SE: Prostaglandin and prostacyclin effect • Ibuprofen, diclofenac, naproxen, piroxicam
- 59. Opioid Analgesics • Weakopioids Codeine phosphate 3060mg 4h Dihydrocodeine 30mg 4-6h po or 50mg 4-6h im Buprenorphine 200400mcg sl 4-6h Tramadol weak agonist 50100mg 4h • Strong opioids Nalbuphine Morphine Diamorphine Pethidine: max 1.2g daily
- 60. Prevalence of chronicpain following surgery Surgery Perkins & Kehlet Macrae Breast 11-49% 23-49% Thoracotomy 22-67% 5-67% Cholecystectomy 3-56% 3.4-27% Inguinal Hernia 0-37% 15-63% N/A 0-37% Vasectomy
- 61. Neuropathic pain canbecome established extremely quickly after trauma and surgery and remain unchanged after 6 months