postoperative pain management ima
TRANSCRIPT
8/8/2019 Postoperative Pain Management IMA
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Pain: An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage.
Milton wrote in Paradise Lost: ³Pain is perfect miserie, the
worst /Of evils, and excessive, overturns/All patience.´
³Pain is a more terrible lord of mankind than even deathitself´
- Schweitzer A ( On the edge of primeval forest)
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PAIN
PAIN
PAIN
PAIN
PAIN
Postoperative
PAIN
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U.S.A
Seventy-three million patients undergo
surgical procedures each year in the
United States.
80% experience acute post-operative pain,
50% inadequate relief
20% experience severe pain.
Magnitude !!!!!
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POST-OPERATIVE PAIN MANAGEMENT
Dr. Ashok Jadon MD, DNB, MNAMS
Fellowship in Interventional Pain management
Sr consultant & H.O.D. Anaesthesia
TATA MOTORS HOSPITAL
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Factors for poor pain control
Patients
Doctor Nurse
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Doctors & Nurse Factors
Inadequate Knowledge
± Drug/ dose/ side effects
Fear of Addiction ± False fear
± Tolerance is different
Accountability ± No litigation- Mera Bharat Mahan
± Lack of sympathy/ empathy
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Patients Factors
Age and Sex. Pre-operative analgesic use.
Past history of poor pain management.
Coexisting medical conditions Cultural factors and personality
Preoperative patient education.
Site of operation
Individual variation in response and painthreshold.
Attitude of the ward staff
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Mechanism of Postoperative Pain
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Systemic effects of Post-operative Pain
Cardiovascular Respiratory
Gastrointestinal
Genitourinary Metabolic-endocrinal
Chronic pain
Psychological
Severe postoperative pain and stress response to surgery
causes increased morbidity and mortality
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Physiological effects of Pain
Tachycardia and elevated blood pressure Increased catabolism : poor wound healing
Decreased limb movement: increased risk
of DVT/PE Respiratory effects: shallow breathing,
cough suppression increasing risk of
atelectasis & pneumonia Decreased gastrointestinal mobility PONV
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Psychological effects of Pain
Negative emotions: anxiety, depression
Sleep deprivation
Existential suffering:
± may lead to patients seeking active end of life.
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Immunological effects of Pain
Decrease natural killer cell counts
Patient become host of infection
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Evidence Based Benefits
of Pain control
Improving clinical outcome by reducing
complications such as:
myocardial infarction or ischemia risk of tachycardia and dysrhythmia
impaired wound healing
risk of atelectasis thromboembolic events
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Objective assessment of subjective pain
V AS
VRS
Picture scales
(facial expressions)
Clinical observation
sighing, groaning,
sweating, ability tomove
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Identify High risk patients
Preemptive approach
PROPHYLAXIS
IS
BETTER THAN CURE
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Pre-emptive Analgesic Therapy
Before surgery to attempt to decrease theintensity and duration of postoperative pain.
Controlling the "wind-up" phenomenon
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Non Pharmacological Strategy
Health-care information
±Information in preparation for
surgery ±Timing of procedures
±Self-care actions
±Pain and discomfort information
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Psychosocial support
Identifying and alleviating concerns
Reassurance
Problem-solving
Encouraging questions, and increasing the
frequency of support
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Skills teaching
Coughing, breathing and bed exercises,
Relaxation, hypnosis, cognitive reappraisal
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Non Pharmaco Adjuvant
Acupuncture
Trans-cutaneous Nerve Stimulation
(TENS)
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Trans-cutaneous Nerve Stimulation TENS
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Trans-cutaneous Nerve Stimulation
TENS
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Pharmacological Treatment
Type of Drugs
Modes & Methods of administration
Recent advances
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Drugs for Postoperative Pain
Opioids
± Morphine, Codeine
± Pethidine
± Fentanyl, Sufentanyl, alfentanyl ± Pentazocin, Buprenorphine, Butrophanol
Tramadol / Ketoralac
NSAID¶s ( COX-2 inhibitor) Local anaesthetics and adjuvant
Anaesthetic drugs: Ketamine
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Route of administration
Common
± Oral / Intramuscular / Intravenous
Less common
± Rectal (suppositories)
± Sub mucosal (lolly pops)
± Trans- cutaneous
± Nasal ( drops and sprays)
Local Anaesthetics
± Wound Infiltration / infusion / instillation
± Spinal: single shot & continuous infusion
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Advantage &Disadvantage
Oral Vs Intramuscular Vs Intravenous Rectal and Nasal
Trans cutaneous and Transmucosal
LOC AL ANAESTHETICS
± Less systemic effects
± Combination with Narcotics
MultimodalApproach
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Contraindications to the use of
NSAID¶s
History of peptic ulceration
gastrointestinal bleeding or bleeding
diathesis
Operations with high blood loss
Asthma, Heart diseases
Renal impairment, dehydration
History of hypersensitivity to NSAID¶s or
aspirin.
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The World Federation of Societies of
Anaesthesiologists (WFSA) Analgesic Ladder
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Patient Controlled Analgesia
(PCA)
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PC A
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PC A
Therapeutic level
Time in Hours
Plasma
Level
PCA
IM
IV
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Alternate novel drug delivery systems for
intravenous analgesics
Transmucosal Passive patch
Transdermal Passive patch
Iontophoretic patch
Nasal (Inhaled drops, spray)
Rectal
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Trans-dermal patch
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Trans-dermal patch
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Rectal Suppository
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Wound infiltration, Instillation,
Infusion & spraySafe and effective
method
Long duration of
analgesia with
minimal systemiceffect
Antibacterial
activity of local
anaesthetics
Peripheral Opioid
receptor theory for
combination
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Catheter techniques
Continuous infusion provides prolonged post-operative analgesia as compared to singleinjection
Block can last up to ten times longer than singleinjection
Analgesic effect superior to conventional
treatment with IV
PC A narcotics
Higher patient satisfaction, earlier mobilization
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Catheter techniques
first described in 1946,gained popularity only in
the 1970s
Continuous Plexus Block
Intrapleural Catheter
Continuous woundinfiltration
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Intrathecal and epidural
Local anaesthetics & opioids
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Epidural or Spinal
Many medications that are normally given orally or intravenously can be delivered directly into the spinalcanal.
The advantage of this delivery is that a much smaller
dosages of medication can be used, thereby minimizingmany side effects associated with other oral or intravenous use.
Typically, the intraspinal administration is 300 timesmore effective than the oral dose. Morphine (and other
opioids or narcotics) interacts with opioid receptors in thespinal cord to decrease pain impulses to the brain,thereby decreasing the brain's perception of painfulconditions.
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Epidural contd.
Intraspinal delivery may allow the patientto significantly decrease the amount of oral medications ingested, thereby
decreasing side effects. Because the effectiveness of intraspinal
morphine is many-times the effectivenessof oral morphine, the patient's pain relief may allow resumption of a much moreactive lifestyle.
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C AUTION
It is particularly dangerous to
prescribe other opioids to patients
receiving intrathecal or epiduralopioids as this increases the
likelihood of clinically significant
respiratory depression.
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Current Modalities preferred for
management of the acute postoperative pain
Epidural/ intrathecal analgesia 25%
Intravenous PC A 25%
Oral analgesics 19%
Peripheral nerve block 13%
Intermittent IV bolus analgesics 8%
Continuous wound infusion 6%
Intramuscular analgesics 3%
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At Tata Motors Hospital !!!!!
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Continuous Wound Infiltration
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Continuous Epidural Analgesia
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TAKE HOME MESSAGE
Fears of post-surgical addiction to opioids
are generally groundless
Giving medicine only "as needed" can result
in prolonged delays because patients maydelay asking for help.
Aggressive prevention of pain is better thantreatment because, once established, pain is
more difficult to suppress.
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TAKE HOME MESSAGE
Physicians need to develop pain control
plans before surgery and inform the
patient what to expect in terms of pain
during and after surgery.
Patient-controlled medication via infusion
pumps is safe.
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