Transcript FATMA POST OP PAIN MANEGEMENT

DR FATMA AL DAMMAS
DR FATMA AL DAMMAS
The management of pain is a
multidisciplinary team effort involving
physicians, psychologists, nurses, and
physical therapists.
Copyright © 2003 American Society of Anesthesiologists. All rights
reserved
Anesthesiologists are physicians and
are experts in the diagnosis and
treatment of acute and chronic pain
disorders.
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
Causes of Post-Operative Pain
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incisional
deep
positional
IV site
tubes
respiratory
rehab
surgical
others
skin and subcutaneous tissue
cutting, coagulation, trauma
bed sore, nerve compression & traction
needle trauma, extravasation, venous irritation
drains, nasogastric tube, ETT
from ETT, coughing, deep breathing
physiotherapy, movement, ambulation
complication of surgery
cast, dressing too tight, urinary retention
CAUSES OF VARIATION IN ANALGESIC
REQUIREMENTS
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Site and type of surgery
Age, gender
Psychological factors
Pharmacokinetic variability
Pharmacodynamic variability
Site and type of surgery
• general upper abdominal surgery produces greater pain
than lower abdominal surgery
• operation on the richly innervated digits associated with
severe pain.
• The type of pain differ with different types of surgery.
Age, gender and body weight
• analgesic requirements of males and females are
identical for similar types of surgery.
• There is a reduction in analgesic requirements with
advancing age.
Psychological factors
• The patient’s personality affects pain perception and
response to analgesic drugs.
• Patients with a less anxiety exhibit less postoperative
pain and require smaller doses of opioid than patients who
rate highly on anxiety scales.
TREATMENT OF PAIN
GOALS OF THERAPY
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Decrease the frequency and / or severity of the pain
General sense of feeling better
Increased level of activity
Return to work
Decreased health care utilization
Elimination or reduction in medication usage
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
Pain
• Pain is subjective and
difficult to quantify
PAIN
• An unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage.
( International association of study of pain)
CLASSIFICATION OF PAIN
PAIN
ACUTE
SOMATIC
SUPERFICIAL
CHRONIC
VISCERAL
DEEP
TRUE VISCERAL
DE AFFERENTATION SYMPATHETICALLY
PAIN
MEDIATED PAIN
TRUE PARIETAL REFERED VISCERAL REFERED PARIETAL
TYPES OF PAIN
According to duration
Acute
Chronic
TYPES OF PAIN
According to Pathophysiology
• Nociceptive;
Due to activation, sensitization of peripheral
nociceptors.
• Neuropathic:
Due to injury or acquired abnormalities of
peripheral OR central nervous system.
TYPES OF PAIN
According to Etiology
• Post operative
OR
• cancer pain
TYPES OF PAIN
According to Type of the organ affected
–Toothache
–Earache
–Headache
–Low backache
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PAIN PATHWAY
1.Transduction-changing of the
noxious stimuli in sensory nerve
ending to impulse.
2.Transmission-movement of
impulse from site of transduction.
3.Perception –recognizing, defining
and responding.
4.Modulation-involves activation of
the descending pathway that exert
inhibitory effect on pain
transmission.
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ACUTE PAIN
• Caused by noxious stimulation due to
injury, a disease process or abnormal
function of muscle or viscera
• It is nearly always nociceptive
• Nociceptive pain serves to detect, localize
and limit the tissue damage.
TYPES OF ACUTE PAIN
• Somatic
OR
• Visceral
SOMATIC PAIN
• Superficial
OR
• Deep
SUPERFICIAL SOMATIC PAIN
• Nociceptive input from skin, subcutaneous tissue and mucous membranes
• Well localized and described as sharp,
pricking, burning and throbbing
DEEP SOMATIC PAIN
• Arise from Muscles, Tendons and Bones
• Dull, aching quality and is less well
localized
• Intensity and Duration of stimulus affects
the degree of localization
VISCERAL PAIN
• Due to disease process, abnormal function of
internal organ or its covering e.g Parietal pleura,
Pericardium or Peritoneum
SUBTYPES OF
VISCERAL PAIN
– True localized visceral pain
– Localized parietal pain
– Referred Visceral pain
– Referred parietal pain
TRUE VISCERAL PAIN
• Dull, diffuse and in midline
• Frequently associated with abnormal sympathetic
activity causing nausea, vomiting, sweating and
changes in heart rate and blood pressure.
PARIETAL PAIN
• Sharp, often described as stabbing
sensation either localized to the area
around the organ or referred to a distant
site.
PATTERNS OF REFERRED PAIN
Lungs
T2 – T6
Heart
T1 –T4
Aorta
T1 –L2
Esophagus
T3 – T8
Pancreas & Spleen
T5 –T10
Stomach, liver and gall bladder
T6 –T9
Adrenals
T6 – L1
Small intestine
T6 – T9
Colon
T10 – L1
Ureters
T10 – T12
Uterus
T11 – T12
Bladder and prostate
S2 – S4
Urethra & Rectum
S2 – S4
Kidneys, Ovaries & Testis
T10 – L1
SYSTEMIC RESPONCES TO ACUTE
PAIN
Efferent limb of the pain pathway is
• Sympathetic nervous system
• Endocrine system.
Cardiovascular effects
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Tachycardia
Hypertension
Increased systemic vascular resistance
RESPIRATORY SYSTEM
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Increased oxygen demand and consumption
Increased minute volume
Splinting and decreased chest excursion
Atelactasis, increased shunting, hypoxemia
Reduced vital capacity, retention of secretions
and chest infection
GASTROINTESTINAL AND URINARY EFFECTS
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Increased sympathetic tone
Decreased motility, ileus and urinary retention
Hypersecretion of stomach
Increased chance of aspiration
Abdominal distension leads to decreased chest
expansion
ENDOCRINE EFFECTS
• Increase secretion of Catecholamine, Cartisol and
Glucagon
• Decreased secretion of Insulin and testosterone
HEMATOLOGICAL EFFECTS
1. Increased platelet adhesiveness
2. Reduced fibrinolysis and
hypercoagulatability
IMMUNE EFFECTS
Leukocytosis
Lymphopenia
Depression of reticuloendothetial system
GENERAL SENSE OF WELL-BEING
• Anxiety
• Sleep disturbances
• Depression
There are many different techniques,nonpharmacological &pharmacological , both
regional and non-regional to provide post op
analgesia.
Nonpharmacologic Approaches to
Relieve Pain and Prevent Suffering
hydrotherapy
intradermal water blocks
movement and
Positioning
touch and massage
acupuncture
transcutaneous electrical
nerve stimulation (TENS
aromatherapy
heat and cold
music and
audioanalgesia.
J Midwifery Womens Health 49(6):489-504, 2004. © 2004 Elsevier Science,
Inc.
PHARMACOLEGICAL
WHO Ladder
An essential principle in using medications to
manage pain is to individualize the regimen
to the patient
WHO analgesic guidelines
• Oral medications whenever possible
• Dose “by the clock” – but always have “as
needed”medications for breakthrough pain
• Titrate the dose
• Use appropriate dosing intervals
• Be aware of relative potencies
• Treat side effects
Pharmacological approach
• Acetamenophen
• NSAIDs
• Tramal
• Opioids
• Adjuvents therapy
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Anticonvulsantants
Antideperssants
NMDA antagonists
Muscle relaxants
Clonidine
Corticosteroids
Local Anesthetics
Sedatives
Acetaminophen
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The most widely used analgesic
Non acidic and a phenol derivative
Readily crosses the BBB.
Its action mainly in the CNS, where prostaglandin
inhibition produces analgesia and antipyresis.
• Its peripheral and anti-inflammatory effects are weak.
Acetaminophen
• Doses of 10 to 15 mg/kg every 4 hours up to a
daily maximum of 100 mg/kg
• For the treatment of mild to moderate pain.
Perfalgan
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Making paracetamol (hydrophobic) soluble
 Use of hydrophilic ingredients
(mannitol and disodium phosphate)
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Ensuring its stability in solution
- By controlling hydrolysis
 Use of a pH buffer (disodium phosphate
and sodium hydroxide)
- By preventing oxidation
 Addition of cysteine hydrochloride
 Oxygen-free manufacturing process
Perfalgan 1g indications
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Short-term treatment of moderate pain, especially
following surgery
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Short-term treatment of fever
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Alone or in combination
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In adults or children over 33kg
How to handle Perfalgan
1. Take the cap off
2. Link the bottle to a drip
with an air intake
3. Hook the bottle with the
built-in calliper
How to infuse Perfalgan
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First administration in the
operating theatre
Frequency of administration:
15-minute infusion every 4 to 6 hours
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Dosages
- Adolescents and adults weighing more than 50kg:
1 g / 4 times a day
- Children weighing more than 33kg, adolescents
and adults weighing less than 50kg:
15 mg/kg (4 times a day )
NSAIDs
NSAIDs
• The NSAIDs are weak organic acids (PKa3 to 5.5)
• Act mainly in the periphery
• Bind extensively to plasma albumin (95% to 99%
bound)
• Do not readily cross the BBB
• Extensively metabolized by the liver
• Have low renal clearance «10% .
NSAIDs
NSAIDs are
powerful
inhibitors of
prostaglandin
synthesis
through their
effect on
cyclooxygenase
(COX)
The adverse effects of NSAIDs in surgical patients
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gastrointestinal hemorrhage
renal dysfunction or failure
hematoma formation
asthma in susceptible individuals
anaphylaxis
decreased healing of gastrointestinal
anastomoses
Tramal® (Tramadol)
is a
centrally acting analgesic
with
opioid and non-opioid activity
for
moderate to severe pain associated
with acute and chronic conditions
Dual mode of action of Tramadol
Two complementary mechanisms of action:
Opioid action:
weak µ-receptor agonist
Monoaminergic action:
weak, indirect 2-receptor agonist
Tramal® presentations (I)
Prolonged-release tablets 100 mg, 150 mg, 200 mg
Ampoules
Capsules
Drops
Soluble tablets
Suppositories
Adverse events (AEs)
• Most common reported AEs: headache, nausea,
vomiting, dizziness and somnolence
Moore RA, McQuay HJ. Pain 1997
Opioids
TERMINOLOGY
• Opiates are drugs derived from opium,
• Opioid applies to substances with morphine-like activity
• Endorphin is endogenous opioid peptides.
CLASSIFICATION OF OPIOIDS
• There are alternative classifications
Agonist
A drug that, when bound to the
receptor, stimulates the receptor to the
maximum level; by definition the
intrinsic, .activity of a full agomstis
unity.
Morphine
Antagonist
A drug that, when bound to the
receptor, fails completely to produce
any stimulation of that receptor; by
definition, the intrinsic activity of a pure
antagonist is zero.
Naloxone
Partial agonist
A drug that, when bound to the
receptor, stimulates the receptor to a
level below the maximum level; by
definition the intrinsic, . activity of a
partIal agonist lies between zero and
unity.
Buprenorphine (partial
mu agonist)
Mixed agonistantagonist
A drug that acts simultaneously on
different subtypes, with the potential
for agonist action on one or more
subtypes and antagonist action on one
Nalbuphine (partial mu
or more subtypes
agonist, kappa agonist, delta
antagonist)
Transdermal therapeutic systems
Advantages
– constant blood levels
– long duration of effect
– avoidance of the gastrointestinal tract (no first-pass
effect)
– high patient compliance
 Disadvantages
– risk of dermal irritation
MORPHINE
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Oldest ,safe .
Water soluble , works longer.
No upper limit to dose.
Metabolized by liver and extra hepatic site ,excreted by
kidney.
• Metabolite M6G very potent.
• Causes respiratory depression, nausea, vomiting,pruritus
and urinary retention
Demerol
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Most commonly used opioid
10mg is equal to 1mg of morphine
fat soluble therefore short duration of action.
Metabolite nor meperidine is a potent CNS stimulant.
Side effects same as other opioids.
Therapeutic approaches
Therapeutic approaches in side effects of opioid therapy
Side-effect
Incidence
Tolerance
First step
Second step
Constipation
Ca. 95%
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Laxatives
Change the mode of
administration
Nausea/
vomiting
Ca. 30%
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Anti-emetics
Opioid rotation
Sedation
Ca. 20%
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Opioid rotation
Application close to
the spinal cord
Pruritus
Ca. 2%
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Opioid rotation
Antihistamines
Hallucinations
Ca. 1%
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Opioid rotation
Haloperidol
Co Analgesics
Classification
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Anticonvulsantants
Antideperssants
Muscle relaxants
Clonidine
Corticosteroids
Local Anesthetics
Sedatives
Methods of Acute Postoperaive Pain
Relief
Methods of Acute Postoperaive Pain Relief
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Intramuscular
Intravenous - Intermittent Bolus
Intravenous-Continuous Infusion
Patient Control Analgesia (PCA)
Epidural analgesia
Peripheral Blocks
POSTOPERATIVE PAIN MANAGEMENT
POSTOPERATIVE PAIN MANAGEMENT
• Pain management continues to be a challenge to anaesthetist .
• PCA ; epidural and nerve block are advance in analgesia that may
assist this challenge.
• Post op Pain management can be evaluated in terms of its ability to
meet 2 main goals:
To relieve postoperative pain.
To relieve patient of inhibition of respiratory movement
without sedation.
IMPORTANCE OF POSTOPERATIVE ANALGESIA
• Pain relief is desirable not only for humane and moral reasons,but
also because
pain relief improves the patients physiological and psychological
status
Pain Assessment: the 6 N’s
• 3. Number?: What is the severity of the pain?
Visual analog scale Pain as bad as it
could possibly be
No pain
Descriptive intensity scale No pain Mild pain
Moderate
pain
Severe Worst possible
pain
pain
Numerical intensity scale 0 1 2 3 4 5 6 7 8 9 10
11 of 16
Pain Intensity Rating Scales
• Pain Faces Scale
0
2
4
6
8
10
No
hurt
Hurts
just a
little bit
Hurts a
little bit
more
Hurts
even
more
Hurts a
whole
lot
Hurts as
much as
you can
imagine
• Brief Pain Inventory
Shade areas of worst pain
Put an X on area that hurts most
(Cleeland, 1991; Wong et al, 2001)
Pre-emptive analgesia
The administration of analgesic agents prior to
an injury in order to prevent development of
central nervous system hyperexcitability or
sensitization
PATIENT CONTROLLED ANALGESIA
• PCA is based on the belief that patients are the best
judges of their pain.
• They should be allowed an active role in controlling their
pain.
PCA
• PCA are modified infusion
pumps that allow patient
to self administer a small
dose of opioid when pain
is present , thus allowing
patients to titrate their
level of analgesia against
the amount of pain they
are experiencing.
PCA
• PCA is well tolerated.
• Offer flexibility in dose size and dose interval in individual
patients.
• Therapeutic serum level can be reached relatively quickly
because the drug is administered into the vascular system
directly.
PCA
• Patient can secure an early therapeutic serum level with
repeated doses titrated to individual pain needs.
• A steady state plasma level occurs because the
elimination of the drug from the plasma is balanced by the
patients self administered drug injection.
Relationship of mode of delivery of analgesia to serum
analgesic level
• IM and IV PCA
PCA
• PCA allows patient control over their pain and therefore
gives greater satisfaction.
• PCA also eliminates the lag time between pain sensation
and administration of analgesia.
PAIN CYCLE
I.M PRN ANALGESIA
PATIENT FEELS PAIN
Sedation
Drug Absorbed
I.M Given
Calls
Nurse
Nurse
Screen
Meds Prepared
PAIN CYCLE
I.M PRN ANALGESIA
PATIENT FEELS PAIN
Sedation
Calls Nurse
absorbed
Nurse
screen
I.M Given
Meds prepared
BENEFITS
• Decreased nursing time
• Increased patient satisfaction.
• Used in a variety of medical and post-op surgical
conditions.
• Decreased narcotic usage.
• Decreased level of sedation.
• Earlier ambulation.
BENEFITS
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Decreased overall pain scores reported by patients.
Increased compliance to post op care.
Less anxiety.
More autonomy regarding pain control.
Improved rest and sleep pattern
PCA FEATURES.
• Drug concentration.
• Drug reservoir volume.
• Demand dose-amount patient will receive each time patient self
administer.
• Delay(lockout)-period of time no drug is available to the demand
button.
• Basal-continuous infusion of drug/hour,is optional.
DRUG CONCENTRATIONS
• Morphine =1mg/1ml. (0.1 -0.2 mg/kg).
• Tramadol =10mg/1ml. (1-2 mg/kg ).
• Fentanyl = 10 mcg/1ml. (10 mcg/kg).
• Demerol = 10mg/1ml. (1-2 mg/kg).
Epidural Analgesia
INSERTION OF EPIDURAL CATHETER
• The site is dependent upon the area of pain
• Fixing the catheter
Incision
Level
Thoracic
Upper abdo
Lower abdo
Pelvic
Lower extremity
T4-T6
T6-T8
T8-T10
T8-T10
L1-L4
MEDICATION COMMONLY USED
• OPIOIDS-Fentanyl +Morphine
(affect the pain transmission at the
opioid receptors)
• L.A.-Bupivacaine(marcaine)
(inhibits the pain impulse
transmission in the nerves with
which it comes in contact)
Epidural Analgesia
• Mode of administration
– intermittent opioid bolus
– PCA opioid
– continuous infusion - LA+opioid
• Advantages
– most effective analgesia
– systemic effect of opioid minimal
– pre-empty analgesia
– reduce incidence of thromboembolism
Epidural Analgesia - Side Effects
• From the technique
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dural puncture
epidural haematoma
epidural abscess
nerve root trauma
• From LA
– hypotension
– paraesthesia
– motor weakness
• From opioid
– delay resp depress
– urinary retention
– pruritus
Caudal Anaesthesia
Brachial Plexus Block
IVRA (BIER’S BLOCK)