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Dr Nilima Afrin Anirban
Anaesthesiologist,
Department of Anaesthesia & ICU,
Shaheed Ziaur Rahman Medical College Hospital
Introduction
• Optimal management of
postoperative pain is
important for early
mobilisation, reduce
morbidity, minimise
long term impact on
function and quality of
life
What is pain?
• According to IASP,
“An unpleasant sensory and
emotional experience associated with
or resembling that associated with,
actual or potential tissue damage.”
• This definition highlights that, pain
that, pain perception is subjective.
subjective.
• Individual’s emotion has a huge impact
huge impact on pain perception.
Factors
influenc
ing
experien
ce of
pain
Pain Pathway
Classific
ation of
Postopera
tive Pain
according
to
duration
Acute pain: Initial pain
following trauma or surgery.
It should resolve within six
weeks of tissue injury
repairing itself.
Chronic pain: pain that
continues beyond typical
healing period
Of 1-2 months following
surgery.
Risk factors for persistent
postsurgical pain
Management of Post Operative Pain: to make doctors conscious about the benefits of multimodal analgesia.
Pain measurement tools
VERBAL RATING SCALES: Mild,moderate,severe
VISUAL ANALOGUE SCALE (VAS):Composed of an unmarked line 10 cm long.
Anchored with no pain at 0 and the worst pain imaginable at 100cm on the
right.
NUMERICAL RATING SCALE
PICTORIAL RATING SYSTEM: for children. Eg,Wong-Baker FACES Pain Rating
Scale
VISUAL
ANALOGUE
SCALE
Wong-
Baker
FACES
Pain
Rating
Scale
Adverse
effects
of
postopera
tive pain
Treatment of
Postoperative
Pain
• WHO designed Modified
Analgesic ladder is
concept in management of
postoperative pain
Multimod
al
Analgesi
a
• Combines different classes of
medications having different
(multimodal) pharmacological
mechanisms of action,resulting in
additive of synergistic effects to
reduce postoperative pain
Effects
of
Analgesi
cs on
Pain
Pathway
Pre-
emptive
analgesia
Preventive
Analgesia
• Interventions during the
perioperative period with the
aim of reducing postoperative
pain and/or analgesic
consumption.
Regional
Anaesthe
sia
Types of Regional
Anaesthesia
Some neuraxial block
techniques
Periphe
ral
nerve
block
techniq
ues
Some
periphera
l block
technique
s..
s of
Regiona
l
Analges
ia
Disadvantages
The Opioid
• The backbone of most
postoperative analgesic
regimens.
• Analgesic requirements
vary according to type of
surgery,fitness of
patients etc.
Common routes of
opioid
administration
Intramuscular: Commonly used. Painful to
administer and results in variable plasma drug
plasma drug levels.
Intravenous: More reliable method. It includes
-Incremental small boluses titrated against effect.
against effect. So, accidental overdose is reduced
overdose is reduced but analgesia may be
be inadequate.
-Continuous infusion
-Patient-controlled analgesia
Subcutaneous
Transdermal(fentanyl, buprenorphine)
Continued…
Subcutaneous: useful if iv access is limiteed
Transdermal: slow- release patches are stuck
to the skin .eg, fentanyl, buprenorphine patches
buprenorphine patches
Oral: use may be restricted by inability to drink,
nausea, vomiting, delayed gastric emptying,
emptying, first-pass metabolism.
Sublingual: avoids injection but suffers the
disadvantages of intermittent administration.
administration.
Rectal: less common
Regional: Spinal, epidural, intra-articular
Patient Controlled
Analgesia
Side effects of
opoids
Non-opioid
Analgesics(NSAID)
• NSAID: analgesic, anti-inflammatory.
Associated with GI upset and acute kidney
acute kidney injury, impairment of platelet
of platelet function .
• Contraindications of NSAID: h/o PUD, GI
bleeding, renal impairment, previous
previous hypersensitivity reactions, asthma,
reactions, asthma, bleeding diathesis
diathesis
• Should be avoided in dehydrated and
and hypovolaemic patient
• Should be used carefully in elderly.
elderly.
• The Salicylates are absolutely
contraindicated under 12 years of age to
age to prevent Reye’s syndrome.
Acetaminophen(Paracetamol)
• A common component of
multimodal analgesia
• Analgesic effect is 20-
30% less than NSAID
• Produce synergistic
effect together with
NSAID
• Routine use of
paracetamol along with
regional technique may
allow NSAID to be
reserved for
breakthrough pain
Continued…
• Gabapentinoids: Use of Oral
gabapentin and pregabalin,
preoperatively as a single dose may
dose may reduce postoperative pain
pain and opioid consumption in first 24
in first 24 hr following surgery.
surgery.
• Common side effects: sedation,
sedation, dizziness, risk of patient fall
patient fall
NMDA Antagonist (Ketamine):
Beneficial in patient on chronic opioid use.
chronic opioid use. But side effects
effects involving CNS & CVS are present
present
Continued…
Magnesium: Reduce
postoperative pain but may
produce hypotension and
potentiate neuromuscular
blockade.
Intravenous lidocaine
infusion: Recently increased
popularity as a component of
multimodal analgesia. In major
abdominal surgery iv lidocaine
helps to return bowel function
faster and it reduces hospital
stay but continuous
cardiovascular monitoring is
essential.
Alpha 2
agonist:Dexmeditomidine,
clonidine. May produce
hypotension and bradycardia.
Inhalational anaesthetic
agent: Entonox
Others: TENS, Acupuncture,
cryoanalgesia etc
Postoperative pain
management in
pediatric patient
• Should follow the same basic
principles as for adults:
• Multimodal technique with
regional anaesthesia
• Care should be taken
regarding dose calculation.
• eg in case of circumcision,
herniotomy: caudal block
under deep sedation which
provide back up in
postoperative period. Then
regular paracetamol/ NSAID
Acute
pain
service
• A multidisciplinary
approach to control
postoperative pain
effectively.
• It involves
Anaesthetists,
specialist nurses,
clinical pharmacist
• They provide regular
patient assessment,
provide training of
medical and nursing
stuff to improve
understanding of
analgesic method and
pain asessment
Some practical examples
IN MAJOR OPEN ABDOMINAL SURGERIES SUCH AS GASTRECTOMY,
HEMICOLECTOMY, ANTERIOR RESECTION ETC THE POSTOPERATIVE
PAIN MANAGEMENT PROTOCOL SHOULD BE:
MULTIMODAL TECHNIQUE:
PRE-EMPTIVE/PREVENTIVE ANALGESIA> NEURAXIAL BLOCKADE
PREOPERATIVELY BY EPIDURAL> POSTOPERATIVELY,
INCREMENTAL DOSE BY EPIDURAL ROUTE WITH COMBINATION OF
LOW DOSE OPIOIDS WITH PARACETAMOL AND NSAID
Continued…
• In laparoscopic procedures:
• Pre-emptive analgesia>
• Administration of local anaesthetics in
anaesthetics in intraperitoneally and port
intraperitoneally and port side –reduces
side –reduces postoperative analgesia
analgesia requirements.
• In major orthopaedic surgeries:
surgeries: neuraxial blocks using
using epidural catheter, other peripheral
peripheral blocks are beneficial for
beneficial for postoperative pain
pain management.
Continued…
• In neck surgeries, Cervical plexus block is very
helpful to manage postoperative pain and it
and it reduces opioid requirement.
• In neurosurgeries, Scalp block is very much
effective for this purpose.
• In obstetric surgeries neuraxial blockade with or
without Cather in situ along with initially opioid
initially opioid then NSAID with paracetamol are
paracetamol are used.
Sono guided
Femoral nerve
block In
Orthopedics OT
by Anaesthesia
Dept in SZMCH
Glimpse of
activities
of our
Anaesthesia
Dept
Postoperative pain
management by epidural
technique by honourable head
sir of Anaesthesia dept
Sono guided rectus sheath block for
postoperative pain management in
cholecystectomy patient
per operative
and
postoperative
pain in
radiology
dept for
brachytherapy
probe
insertion
Part of Anaesthesia Dept of SZMCH
Management of Post Operative Pain: to make doctors conscious about the benefits of multimodal analgesia.
Management of Post Operative Pain: to make doctors conscious about the benefits of multimodal analgesia.

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Management of Post Operative Pain: to make doctors conscious about the benefits of multimodal analgesia.

  • 1. Dr Nilima Afrin Anirban Anaesthesiologist, Department of Anaesthesia & ICU, Shaheed Ziaur Rahman Medical College Hospital
  • 2. Introduction • Optimal management of postoperative pain is important for early mobilisation, reduce morbidity, minimise long term impact on function and quality of life
  • 3. What is pain? • According to IASP, “An unpleasant sensory and emotional experience associated with or resembling that associated with, actual or potential tissue damage.” • This definition highlights that, pain that, pain perception is subjective. subjective. • Individual’s emotion has a huge impact huge impact on pain perception.
  • 6. Classific ation of Postopera tive Pain according to duration Acute pain: Initial pain following trauma or surgery. It should resolve within six weeks of tissue injury repairing itself. Chronic pain: pain that continues beyond typical healing period Of 1-2 months following surgery.
  • 7. Risk factors for persistent postsurgical pain
  • 9. Pain measurement tools VERBAL RATING SCALES: Mild,moderate,severe VISUAL ANALOGUE SCALE (VAS):Composed of an unmarked line 10 cm long. Anchored with no pain at 0 and the worst pain imaginable at 100cm on the right. NUMERICAL RATING SCALE PICTORIAL RATING SYSTEM: for children. Eg,Wong-Baker FACES Pain Rating Scale
  • 13. Treatment of Postoperative Pain • WHO designed Modified Analgesic ladder is concept in management of postoperative pain
  • 14. Multimod al Analgesi a • Combines different classes of medications having different (multimodal) pharmacological mechanisms of action,resulting in additive of synergistic effects to reduce postoperative pain
  • 17. Preventive Analgesia • Interventions during the perioperative period with the aim of reducing postoperative pain and/or analgesic consumption.
  • 25. The Opioid • The backbone of most postoperative analgesic regimens. • Analgesic requirements vary according to type of surgery,fitness of patients etc.
  • 26. Common routes of opioid administration Intramuscular: Commonly used. Painful to administer and results in variable plasma drug plasma drug levels. Intravenous: More reliable method. It includes -Incremental small boluses titrated against effect. against effect. So, accidental overdose is reduced overdose is reduced but analgesia may be be inadequate. -Continuous infusion -Patient-controlled analgesia Subcutaneous Transdermal(fentanyl, buprenorphine)
  • 27. Continued… Subcutaneous: useful if iv access is limiteed Transdermal: slow- release patches are stuck to the skin .eg, fentanyl, buprenorphine patches buprenorphine patches Oral: use may be restricted by inability to drink, nausea, vomiting, delayed gastric emptying, emptying, first-pass metabolism. Sublingual: avoids injection but suffers the disadvantages of intermittent administration. administration. Rectal: less common Regional: Spinal, epidural, intra-articular
  • 30. Non-opioid Analgesics(NSAID) • NSAID: analgesic, anti-inflammatory. Associated with GI upset and acute kidney acute kidney injury, impairment of platelet of platelet function . • Contraindications of NSAID: h/o PUD, GI bleeding, renal impairment, previous previous hypersensitivity reactions, asthma, reactions, asthma, bleeding diathesis diathesis • Should be avoided in dehydrated and and hypovolaemic patient • Should be used carefully in elderly. elderly. • The Salicylates are absolutely contraindicated under 12 years of age to age to prevent Reye’s syndrome.
  • 31. Acetaminophen(Paracetamol) • A common component of multimodal analgesia • Analgesic effect is 20- 30% less than NSAID • Produce synergistic effect together with NSAID • Routine use of paracetamol along with regional technique may allow NSAID to be reserved for breakthrough pain
  • 32. Continued… • Gabapentinoids: Use of Oral gabapentin and pregabalin, preoperatively as a single dose may dose may reduce postoperative pain pain and opioid consumption in first 24 in first 24 hr following surgery. surgery. • Common side effects: sedation, sedation, dizziness, risk of patient fall patient fall NMDA Antagonist (Ketamine): Beneficial in patient on chronic opioid use. chronic opioid use. But side effects effects involving CNS & CVS are present present
  • 33. Continued… Magnesium: Reduce postoperative pain but may produce hypotension and potentiate neuromuscular blockade. Intravenous lidocaine infusion: Recently increased popularity as a component of multimodal analgesia. In major abdominal surgery iv lidocaine helps to return bowel function faster and it reduces hospital stay but continuous cardiovascular monitoring is essential. Alpha 2 agonist:Dexmeditomidine, clonidine. May produce hypotension and bradycardia. Inhalational anaesthetic agent: Entonox Others: TENS, Acupuncture, cryoanalgesia etc
  • 34. Postoperative pain management in pediatric patient • Should follow the same basic principles as for adults: • Multimodal technique with regional anaesthesia • Care should be taken regarding dose calculation. • eg in case of circumcision, herniotomy: caudal block under deep sedation which provide back up in postoperative period. Then regular paracetamol/ NSAID
  • 35. Acute pain service • A multidisciplinary approach to control postoperative pain effectively. • It involves Anaesthetists, specialist nurses, clinical pharmacist • They provide regular patient assessment, provide training of medical and nursing stuff to improve understanding of analgesic method and pain asessment
  • 36. Some practical examples IN MAJOR OPEN ABDOMINAL SURGERIES SUCH AS GASTRECTOMY, HEMICOLECTOMY, ANTERIOR RESECTION ETC THE POSTOPERATIVE PAIN MANAGEMENT PROTOCOL SHOULD BE: MULTIMODAL TECHNIQUE: PRE-EMPTIVE/PREVENTIVE ANALGESIA> NEURAXIAL BLOCKADE PREOPERATIVELY BY EPIDURAL> POSTOPERATIVELY, INCREMENTAL DOSE BY EPIDURAL ROUTE WITH COMBINATION OF LOW DOSE OPIOIDS WITH PARACETAMOL AND NSAID
  • 37. Continued… • In laparoscopic procedures: • Pre-emptive analgesia> • Administration of local anaesthetics in anaesthetics in intraperitoneally and port intraperitoneally and port side –reduces side –reduces postoperative analgesia analgesia requirements. • In major orthopaedic surgeries: surgeries: neuraxial blocks using using epidural catheter, other peripheral peripheral blocks are beneficial for beneficial for postoperative pain pain management.
  • 38. Continued… • In neck surgeries, Cervical plexus block is very helpful to manage postoperative pain and it and it reduces opioid requirement. • In neurosurgeries, Scalp block is very much effective for this purpose. • In obstetric surgeries neuraxial blockade with or without Cather in situ along with initially opioid initially opioid then NSAID with paracetamol are paracetamol are used.
  • 39. Sono guided Femoral nerve block In Orthopedics OT by Anaesthesia Dept in SZMCH
  • 40. Glimpse of activities of our Anaesthesia Dept Postoperative pain management by epidural technique by honourable head sir of Anaesthesia dept
  • 41. Sono guided rectus sheath block for postoperative pain management in cholecystectomy patient
  • 42. per operative and postoperative pain in radiology dept for brachytherapy probe insertion
  • 43. Part of Anaesthesia Dept of SZMCH

Editor's Notes

  1. Two individuals may experience different type of pain despite same insult. Eg postop pain for elective c-sec is relatively lessthan elective myomectomy.