Transcript acute pain managent

‫بسم هللا الرحمن الرحيم‬
Lecture Title: Acute Pain Management
Lecturer name:
Lecture date:
Lecture Objectives..
Students at the end of the lecture will be able to:
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Learn a common approach to emergency medical problems encountered in the
postoperative period.
Study post-operative respiratory and hemodynamic problems and understand how
to manage these problems.
Learn about the predisposing factors, differential diagnosis and management of
PONV.
Understand the causes and treatments of post-operative agitation and delirium.
Learn about the causes of delayed emergence and know how to deal with this
problem.
Learn about different approaches of post-Operative pain management
Postoperative care
Post Anesthesia Care Unit
“PACU”
PACU
• Design should match function
• Location:
– Close to the OR.
– Access to x-ray, blood bank & clinical labs.
• Monitoring equipment
• Emergency equipment
• Personnel
Admission to PACU
Steps:
• Coordinate prior to arrival,
• Assess airway,
• Administer oxygen,
• Apply monitors,
• Obtain vital signs,
• Receive report from anesthesia personnel.
PACU - ASA Standards
1. Standard I
All patients should receive appropriate care
2. Standard II
All patients will be accompanied by one of anesthesia team
3. Standard III
The patient will be reevaluated & report given to the nurse
4. Standard IV
The patient shall be continually monitored in the PACU
5. Standard V
A physician will signing for the patient out of the PACU
Patient Care in the PACU
• Admission
– Apply oxygen and monitor
– Receive report
• Monitor & Observe & Manage
 To Achieve
• Cardiovascular stability
• Respiratory stability
• Pain control
• Discharge from PACU
Monitoring in the PACU
• Baseline vital signs.
• Respiration
– RR/min, Rythm
– Pulse oximetry
• Circulation
– PR/min & Blood pressure
– ECG
• Level of consciousness
• Pain scores
Initial Assessment
1. Color
2. Respiration
3. Circulation
4. Consciousness
5. Activity
Aldrete Score
Score
2
Activity
Respiration
Circulation
Consciousness
Oxygen
Saturation
Moves all
extremities
Breaths
deeply and
coughs
BP + 20 mm
of
preanesth.
level
Fully awake
Spo2 > 92%
BP + 20-50
mm of
preanesth.
level
Arousable on
calling
With suppl. O2
Not responding
Spo2 <92%
freely.
1
Moves 2
extremities
Dyspneic, or
shallow
breathing
on room air
Spo2 >90%
BP + 50
0
Unable to
move
Apneic
mm of
preanesth.
level
With suppl. O2
Common PACU Problems
• Airway obstruction
• Bleeding
• Hypoxemia
• Agitation
• Hypoventilation
• Delayed recovery
• Hypotension
• “PONV”
• Hypertension
• Pain
• Cardiac dysrhythmias
• Oliguria
• Hypothermia
1. Airway Obstruction
• Most common: tongue fall back
 posterior pharynx
• May be foreign body
• Inadequate relaxant reversal
• Residual anesthesia
Management of Airway Obstruction
• Patient’s stimulation,
• Suction,
• Oral Airway,
• Nasal Airway,
• Others:
– Tracheal intubation
– Cricothyroidotomy
– Tracheotomy
2. Hypoventilation
• Residual anesthesia
– Narcotics
– Inhalation agent
– Muscle Relaxant
• Post oper - Analgesia
– Intravenous
– Epidural
Treatment of Hypoventilation
• Close observation,
• Assess the problem,
• Treatment of the cause:
– Reverse (or Antidote):
• Muscle relaxant  Neostigmine
• Opioids  Naloxone
• Midazolam  Anexate
3. Hypertension
• Common causes: e.g.
– Pain
– Full Bladder
• Hypertensive patients
• Fluid overload
• Excessive use of vasopressors
Treatment of Hypertension
• Effective pain control
• Sedation
• Anti-hypertensives:
– Beta blockers
– Alpha blockers
– Hydralazine (Apresoline)
– Calcium channel blockers
4. Hypotension
• Decreased venous return
– Hypovolemia,
•  fluid intake
•  losses
• Bleeding
– Sympathectomy,
– 3rd space loss,
– Left ventricular dysfunction
Treatment of Hypotension
• Initially treat with fluid bolus,
• + Vasopressors,
• + Correction of the cause
5. Dysrhythmias
• Secondary to
– Hypoxemia
– Hypercarbia
– Hypothermia
– Acidosis
– Catecholamines
– Electrolyte abnormalities.
Treatment of Dysrhythmia
• Identify and treat the cause,
• Assure oxygenation,
• Pharmacological
6. Urine Output
• Oliguria
– Hypovolemia,
– Surgical trauma,
– Impaired renal function,
– Mechanical blocking of catheter.
• Treatment:
– Assess catheter patency
– Fluid bolus
– Diuretics e.g. Lasix
7. Post op Bleeding
Causes:
• Usually Surgical
Problem,
• Coagulopathy,
• Drug induced
Treatment of Post op Bleeding
Treatment:
• Start i.v. lines  push fluids
• Blood sample,
- CBC,
- Cross matching,
- Coagulopathy
• Notify the surgeon,
• Correction of the cause
8. Hypothermia
• Most of patients will arrive cold
• Treatment:
– Get baseline temperature
– Actively rewarm
– Administer oxygen if shivering
– Take care for:
• Pediatric,
• Geriatric.
9. Altered Mental Status
• Reaction to drugs?
– Drugs e.g. sedatives, anticholinergics
– Intoxication / Drug abusers
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•
•
•
•
Pain
Full bladder
Hypoventilation
Low COP
CVA
Treatment of Altered Mental Status
• Reassurances,
• Always protect the patient,
• Evaluate the cause,
• Treatment of symptoms,
• Sedatives / Opioids if necessary.
10. Delayed Recovery
• Systematic evaluation
– Pre-op status
– Intraoperative events
– Ventilation
– Response to Stimulation
– Cardiovascular status
Delayed Recovery
• The most common cause:
– Residual anesthesia  Consider reversal
• Hypothermia,
• Metabolic e.g. diabetic coma,
• Underlying psychiatric problem
• CVA
11. Postoperative Nausea & Vomiting
“PONV”
• Risk factors
– Type & duration of surgery,
– Type of anesthesia,
– Drugs,
– Hormone levels,
– Medical problems,
– Autonomic involvement.
Prevention of PONV
• NPO status
• Dexamothasone,
• Droperidol,
• Metoclopramide,
• H2 blockers,
• Ondansetron,
• Acupuncture
12. Postoperative Pain
 Causes:

Incisional

Laparoscopy

Others:
Skin and subcutaneous tissue
Insuflation of Co2

Deep
cutting, coagulation, trauma

Positional
nerve compression, traction & bed sore.

IV site
needle trauma, extravasation, venous irritation

Tubes
drains, nasogastric tube, ETT

Surgical
complication of surgery

Others
cast, dressing too tight, urinary retention
PAIN MEASUREMENTS
Subjective
Uni-Dimensional
Multidimentional
Objective
 Behavioral.

VRS, VAS & NRS.
 McGill P Q,
 Physiological.

Facial expression.
 Pain Inventory.
 Neuro-endocrinal.
 Algometry.

ACUTE PAIN
 Chronic Pain
 Both
Pain Scores
Visual Analogue Scale (VAS)
0
10
Numeric Rating Scale (NRS)
Verbal scale
No
Pain
Mild
Moderate
Severe
Pain
Wong-Baker “Faces Scale”
ACUTE POSTOPERATIVE MANAGEMENT TOOLS
Regional Techniques
Pharmaco - Therapy
1.
Non Opioid Analgesics
1.
Local infiltration
 NSAADs
2.
Wound perfusion
3.
Intra-abdominal inj. of LA/Analg.
4.
Intercostal & Interpleural
5.
Paravertebral
6.
USG-RA: e.g. TAP
7.
Neuraxial:
 Analgesic /Antipyretic
 Analgesic/Anti-inflam/Antipyretic
 NSAIDs
 Non-selective COX inhibitors
 Selective COX-2 inhibitors
2.
Opioids
 Weak Opioids.
 Strong Opioids.
 Mixed agonist-antagonists
3.
Adjuvants









-2 Agonists
LA
SP inhibitors
NMDA inhibitors
Anticonvulsant / Antidepressants
Calcitonin
Relaxants
Cannabinoids
Others
 Epidural:
 Thoracic
 Lumbar
 Spinal
 Single shot
 CSA
 CSE
WHO IV Interventional
WHO Ladder
Updated
Severe pain (7-10)
WHO III
Strong opioids
± Adjuvant
Moderate pain (4-6)
WHO class II Weak opioids
± Adjuvant
Mild pain (0-3)
WHO class I
NSAIDs
± Adjuvant
By the mouth
By the clock
By the ladder
1.
Non Opioid Analgesics
 NSAADs
 Analgesic / Anti-inflam / Antipyretic / Anticoagulant
 ASA
 Analgesic /Antipyretic
 Paracetamol
Severe pain (7-10)
WHO III Strong opioids
± Adjuvant
 NSAIDs
 Non-selective COX inhibitors:
Moderate pain (4-6)
WHO class II Weak opioids
 Diclofenac & Ketoprofen
 Selective COX-2 inhibitors
 Celecoxib & Rofecoxib
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
Scientific Evidence – NON OPIOID ANALGESICS
1. Paracetamol:
1.
is an effective analgesic for acute pain; the incidence of adverse effects comparable to
placebo (Level I [Cochrane Review]).
2.
Paracetamol / NSAIDs given in addition to PCA Opioids   Opioid consumption (Level
I).
2. NSAIDs:
1.
are effective in the treatment of acute postoperative (Level I ).
2.
With careful patient selection and monitoring, the incidence of renal impairment is low
(Level I [Cochrane Review]).
3.
NSAIDs + Paracetamol improve analgesia compared with paracetamol alone (Level I).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010
WHO Ladder II - Weak Opioids:
1. Tramadol:
–
Tramadol : Morphine:
•
•
Parenteral = 1 : 10 & Oral = 1 : 5
Dose: 200 – 400 mg/d
Severe pain (7-10)
2. Codeine:
–
–
WHO III Strong opioids
± Adjuvant
Metabolized to morphine.
Codeine : Morphine = 1 : 10
Moderate pain (4-6)
WHO class II Weak opioids
3. Dextro-propoxyphene:
–
–
Methadone Derivative
Prolongation of Q-T interval.
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
Scientific Evidence – WEAK OPIOIDS
1. Tramadol:
 has a lower risk of respiratory depression & impairs GIT motor function <
other opioids
(Level II).
 is an effective treatment for neuropathic pain
(Level I [Cochrane Review]).
2. Dextropropoxyphene:
 has low analgesic efficacy
(Level I [Cochrane Review]).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010
WHO Ladder III - Strong Opioids
1. Morphine:
1.
Sedation
2.
PONV
3.
Respiratory Depression
2. Fentanyl
1.
Rapid action, Short duration.
2.
Fentanyl : Mophine = (1:10)
Severe pain (7-10)
3. Pethidene:
1.
Active metabolite:  t½ .
2.
Prolongs Q-T interval.
3.
Pethidine : Mophine = (1:10)
WHO III Strong opioids
± Adjuvant
Moderate pain (4-6)
WHO class II Weak opioids
4. Hydromorphone:
1. Powerful, rapidly acting.
2. Release is in distal gut.
3. Hydromorphone : Morphine = 1 : 5
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
WHO Ladder IV – Regional Anesthetic Techniques
1.
2.
3.
4.
5.
6.
7.
8.
Local infiltration
Wound perfusion
Intra-abdominal LA
Intercostal
Interpleural
Paravertebral
USG - RA: e.g. TAP
Neuraxial:



Epidural:
 Thoracic
 Lumbar
Spinal
 Single shot
 CSA
CSE
WHO IV Interventional
Severe pain (7-10)
WHO III Strong opioids
± Adjuvant
Moderate pain (4-6)
WHO class II Weak opioids
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
Neuraxial (Spinal / Epidural)
(LA / Opioids / others)
• Advantages:
– Provide prolonged & effective analgesia
• Side effects
– Respiratory depression.
– N/V.
– Pruritis.
– Urinary retention.
WHO Algorithm for Management of Pain
+ Multidisciplinary:
• Adjuvant therapy.
WHO III
• Psychotherapy.
Strong opioids
• Physioltherapy.
Neuraxial LA
Opioids
Plexus block
• Causal diag. & ttt.
Paravertebral / PNB
WHO class II Weak opioids
Non-pharmacological
LA infiltration
WHO class I NSAIDs
Management Algorithm for Postoperative Pain
Diagnosis
Procedure Specific
Pain manag.
Preventive /
Preemptive
Pain Assessment
ttt of Pain and Co morbidities
1ry Treatment
Supportive Treatment
Pharmacotherapy
Psychological ttt.
Interventional
Physical / Rehab.
PACU Discharge Criteria
• Fully Awake,
• Patent airway,
• Good respiratory function,
• Stable vital signs,
• Patency of tubes, catheters, IV’s
• Pain free,
• Reassurance of surgical site.
Postanesthesia Discharge Scoring System
Vital Signs
(PR & ABP)
Activity
PONV
Pain
Surgical
Bleeding
2: Within 20%
of preoperative
baseline
2: Steady gait,
no dizziness
2: Minimal: treat 2: Acceptable
with PO meds
control per the
patient;
controlled with
PO meds
2: Minimal: no
dressing
changes
required
1: 20-40% of
preoperative
baseline
1: Requires
assistance
1: Moderate:
treat with IM
medications
1: Not
acceptable to
the patient;
not controlled
with PO meds
1: Moderate:
up to 2 dressing
changes
0: >40% of
preoperative
baseline
0: Unable to
ambulate
0: Continues:
repeated
treatment
0: Severe
Uncontrolled
pain
0: Severe:
more than 3
dressing
changes
Reference book and the
relevant page numbers..
Thank You 
Dr.
Date: