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high technology treatment methods
Management of post-operative pain
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Lecture outline
1. Postoperative pain management – what are the
current issues?
2. Which hi-tech methods are available?
3. PCA methods
4. Hi-tech regional anesthesia / analgesia techniques
5. Equipment
6. Summary
1. Postoperative pain - current issues • Major advances in knowledge of physiology & pharmacology over last 40 yrs.
• Introduction of new drugs “incredibly slow” (nothing new in 50 yrs).
• “Old” non-opioids becoming mainstream (gabapentinoids, ketamine).
• Challenge of persistent postoperative pain.
• Special groups: elderly, opioid dependent / opioid tolerant, ambulatory surgery,
children.
• Role of audits, organisation of staff (e.g. Acute Pain Services) more important
than ever.
• Opioids remain mainstay but new delivery systems,
high-tech methods
• Regional techniques best but remain underused;
the trend is to “go peripheral”
topics covered by this talk
topics covered by this talk
2. Which hi-tech methods are available for management of postoperative pain?
• Systemic analgesic techniques:
• I.V. opioid PCA technique
• Transdermal PCA
• Transmucosal PCA (sublingual, intranasal,inhalational)
• Continuous (catheter) regional anaesthesia techniques:
–Central blocks (epidural, Combined Spinal-Epidural)
–Perineural techniques (in hospital, at home)
–Wound catheter techniques
–Local Infiltration Analgesia (LIA) technique for hip and
knee replacement
2. Which hi-tech methods are available for management of postoperative pain?
• Non-pharmacological techniques:
–TENS (Transcutaneous Electrical Nerve
Stimulation)
2. Which hi-tech methods are available for management of postoperative pain?
• Equipment:–Pumps (Electronic, elastomeric, battery-driven)–Ultrasound devices to improve success rates of
regional anaesthesia techniques–Catheters (multiple-hole, stimulating, kink-free)
3. PCA methods for management of postoperative pain
Intravenous Patient Controlled Analgesia (IV-PCA)
Systemic methods for analgesia:
The Pain Cycle – PRN vs PCA dosing
• Patients recovering from surgery are often treated with IM
or IV analgesics given on a PRN basis.
• This is inefficient and labor intensive as it requires
screening, preparing and nurse administration and that
might delay administration of the analgesics by up to 40
minutes.
• Onset of analgesia can be delayed further by variables
related to absorption.
The Pain Cycle – PRN vs PCA dosing
• Patients finally receive relief and some degree of
sedation only to experience pain several hours later.
• This cycle can be repeated every 3-4 hours during the
post operative period.
• PCA administration eliminates the pain cycle by allowing
more frequent patient directed dosing.
The Pain Cycle – PRN vs PCA dosing
screening screening
Sign out medicationSign out medication
Prepare injection Prepare
injection
Give injection Give injection
Absorption from siteAbsorption from site
Relief (analgesia)
Relief (analgesia)
Sedation Sedation
Patient need (pain)
Patient need (pain)
Nurse callNurse call
Nurse responseNurse responsePCA bolusesPCA boluses
35- 40 minutes35- 40
minutes
<<
<<<<
<< <<
Relationship between opioid plasma levels, in PRN dosing vs PCA
Analgesic Window
Analgesic Window
PCA enables patients to remain in the analgesic
window for a greater proportion of the time
compared to conventional PRN administration
PCA enables patients to remain in the analgesic
window for a greater proportion of the time
compared to conventional PRN administration
Ferrante et al, Anesth Analg, 1988;67:457-461Ferrante et al, Anesth Analg, 1988;67:457-461
Aim to stop using IM, SC routes;
encourage administration by IV boluses or oral route.
Caution: IV route depends on availability of staff for observation.
Aim to stop using IM, SC routes;
encourage administration by IV boluses or oral route.
Caution: IV route depends on availability of staff for observation.
Technical schematic of a typical Patient Controlled Analgesia (=PCA) device.
Microprocessors allow caregivers to program drug, dose and lockout interval (=time between doses).
A dose is administered to the patient when he presses on the ‘patient activation button’. The cumulative dose is displayed on a small screen.
The syringe or bag containing drug is placed in a locked, tamper-resistant portion of the device.
Microprocessors allow caregivers to program drug, dose and lockout interval (=time between doses).
A dose is administered to the patient when he presses on the ‘patient activation button’. The cumulative dose is displayed on a small screen.
The syringe or bag containing drug is placed in a locked, tamper-resistant portion of the device.
Physician prescribed settingsPhysician prescribed settings
Patient-Controlled Analgesia
• Demand dosing• Lock-out interval• Constant-rate infusion (optional) plus demand dosing• Variable-rate infusion plus demand dosing• Loading dose (titrated to effect)• Routes of administration
– IV; – ALSO: subcutaneous, oral, epidural, intrathecal,
transdermal, nasal
Principles
Potential advantages of PCA
• Minimizes intervals between analgesic request
& pain relief.• Rapid onset of effect (5-10 min).• Breaks the pain cycle.• Accommodates for inter-individual differences
in analgesic requirements.• High degree of patient acceptance
• and satisfaction? –evidence is mixed.
Potential disadvantages of (IV)-PCA
• Requires expensive devices & tubing.• Requires IV access and dedicated line.• Over-dosage may occur due to programming errors.• Over-dosage may occur when relatives/parents/nurses
administer doses for patient (“PCA by proxy”).
PCA overdose reports
The database of the Institute of Safe Medical Practice received information about 425 incidents involving opioid infusion pumps during 1987 – 2003.
The incidents were associated with 135 injuries, 23 deaths and 127 potential deaths requiring pump deactivation and naloxone administration.
Methods to reduce PCA and analgesic infusion pump injuries and death include:
• Adequate training of nurses and refresher courses.• ‘High alert’ medication labeling.• Two nurses must program the pump.• Safeguards against use of pump by ‘concerned proxy’.• Programming safeguards (smart pumps).
Ref: http://www.ismp-canada.org/index.htm
PCA – contraindications
• Patient rejection or inability to comprehend
technique• Lack of trained nursing staff• Severe chronic obstructive lung disease• Sleep apnea
PCA can be used by all ages ...
…provided that:• Patients receive adequate explanations how to use the technique.
• Sufficient nursing staff to enable follow-up of effectiveness, adverse effects.
…provided that:• Patients receive adequate explanations how to use the technique.
• Sufficient nursing staff to enable follow-up of effectiveness, adverse effects.
PCA for postoperative pain - a systematic review
• Randomized Contolled Trials (RCTs) up to Jan 2000
comparing i.v. PCA vs same opioid s.c., i.m. or i.v.
• 32 trials: 22 morphine (n=1139), 5 pethidine (n=682),
3 piritramide (n=184), 1 nalbuphine (n=47),
1 tramadol (n=20)
• Main findings:
– No major difference in analgesia, amount of opioid
consumed or opioid related adverse effects
– Patients prefer PCA (not necessarily more satisfied)
– Limited evidence of decreased pulmonary complications
– Lack of data on cost-effectivenessWalder B et al Acta Anesth Scand 2001;45:795-804Walder B et al Acta Anesth Scand 2001;45:795-804
PCA for postoperative pain - a systematic review (cont)
These differences are not significant These differences are not significant
Bottom line: If carried out correctly, analgesia can be effective with conventional administration of analgesics, without use of expensive pumps.Bottom line: If carried out correctly, analgesia can be effective with conventional administration of analgesics, without use of expensive pumps.
Walder B et al Acta Anesth Scand 2001;45:795-804Walder B et al Acta Anesth Scand 2001;45:795-804
Patient controlled transdermal system
Pre-programmed, self-contained, non-invasive alternative to i.v. PCA
Operates for 24 h after 1st dose is delivered or delivers a maximum of 80 doses and shuts offDose (controlled by current) is fixed at 40 µg.
Intranasal PCA
Hallett A et al Anaesthesia 2000;55:532-9Hallett A et al Anaesthesia 2000;55:532-9Hallett A et al Anaesthesia 2000;55:532-9Hallett A et al Anaesthesia 2000;55:532-9
Perioperative epidural analgeisa and outcome after major surgery
Advantages of epidural analgesia: • Excellent analgesia - the best technique.• Shorter duration of postoperative ilieus.• Reduced risk of pulmonary complications (Ballantyne 1998).
• Reduced risk of postoperative myocardial infarction
(Beattie 2001).
• Reduced risk of persistent postoperative pain.• Some evidence of reduced risk of cancer recurrence.
Patient controlled epidural analgeisa (PCEA) vs. continuous infusion for labor analgesia
• 9 RCTs, 1980-2001, n = 641 (ropivacaine n = 96)• PCEA (no background infusion) is associated with:
- fewer anesthetic interventions
- significantly less local anesthetic
- less motor block• No difference in pain scores, patient satisfaction or
other outcomes (maternal, fetal, block level,
hypotension, pruritus etc). • Both techniques are safe.
newer meta analysis 2012 cochranenewer meta analysis 2012 cochrane
Van der Vyer et al, Br. J. Anaesth. 2002;89:459-65
• Epidural (CEI or PCEA) is superior to IV-PCA for pain at rest and activity
• Compared with IV-PCA, epidural analgesia is associated with:- lower incidence of PONV, sedation- higher incidence of pruritus, urinary retention, motor block
• PCEA ( vs CEI) is associated with:- inferior analgesia ( at rest and activity)- lower incidence of PONV, motor block- higher incidence of pruritus
cont.cont.299 RCT’s299 RCT’s299 RCT’s299 RCT’s
””In summary, almost without exception, epidural analgesia, regardless of analgesic In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared with intravenous patient-controlled analgesiapostoperative analgesia compared with intravenous patient-controlled analgesia””
””In summary, almost without exception, epidural analgesia, regardless of analgesic In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared with intravenous patient-controlled analgesiapostoperative analgesia compared with intravenous patient-controlled analgesia””
• Prospective. Prospective.
• PCEA (n = 14,223), iv PCA (n = 1591), brachial plexus cath. interscalene or PCEA (n = 14,223), iv PCA (n = 1591), brachial plexus cath. interscalene or axillary (n = 1737), femoral/ sciatic catheter (n = 1374) axillary (n = 1737), femoral/ sciatic catheter (n = 1374)
• pain scores significantly better for regional techniques pain scores significantly better for regional techniques
• Complications : Complications : - - epidural haematoma 1:4741 (0.02 %), risk greater with lumbar (vs epidural haematoma 1:4741 (0.02 %), risk greater with lumbar (vs thoracic) thoracic) - - epidural abscess 1:7142 (0.01 %) epidural abscess 1:7142 (0.01 %) - - severe neurological complications of perineural catheters 2: 3111 (0.06 %) severe neurological complications of perineural catheters 2: 3111 (0.06 %) - - infection (perineural catheter) 3.7 % (no abscess) infection (perineural catheter) 3.7 % (no abscess) - - respiratory depression PCEA 1.1 %, iv PCA 0.7 %respiratory depression PCEA 1.1 %, iv PCA 0.7 %PCEA, IV PCA and perineural catheter techniques "--- are safe and efficient, --- close PCEA, IV PCA and perineural catheter techniques "--- are safe and efficient, --- close
supervision of all these techniques by an acute pain service in the postoperative period is supervision of all these techniques by an acute pain service in the postoperative period is mandatory"mandatory"
Patient Controlled Epidural Analgesia - current status Summary• Both epidural techniques (CEI and PCEA) provide
excellent analgesia• PCEA is superior to CEI for labour analgesia,
conflicting evidence for postoperative analgesia• PCEA allows dose reduction of local anaesthetics
- less motor block (”walking epidural”)
- lower risk of adverse effects (PONV)• Routine use of epidural analgeisa is decreasing
(multiple reasons), but when indicated PCEA
seems to be the best choice.
Anesth Analg 2005;100:1822-33Anesth Analg 2005;100:1822-33
• Strong evidence for improved postoperative analgesia,
sleep quality, patient satisfaction• Decreased need for opioids (& reduced opioid side effects)• Further studies necessary:
selection of appropriate patients and surgical procedures
optimal LA concentration, adjuvants
safest frequency of patient contact?, method of catheter
removal
J Am Coll SurgJ Am Coll Surg2006;203:914-9322006;203:914-932
39 RCT39 RCT’’s (n = 1761) qualitative analysis, 45 RCTs (n = 1761) qualitative analysis, 45 RCT’’s (n = 2031), s (n = 2031), qualitative analysisqualitative analysisSurgical subgroups: abdominal, cardiothoracic, Surgical subgroups: abdominal, cardiothoracic, gynecologic, orthopedic, minorgynecologic, orthopedic, minor
Benefits of wound catheters:Benefits of wound catheters: decreaseddecreased pain scores at rest and activity (32 % reduction) pain scores at rest and activity (32 % reduction) decreaseddecreased need for opioids (25 % reduction) need for opioids (25 % reduction) decreaseddecreased risk of PONV (16 % reduction) risk of PONV (16 % reduction) increasedincreased patient satisfaction (30 % increase) patient satisfaction (30 % increase) decreaseddecreased LOS in hospitalized patients (limited data, 1 day, p = LOS in hospitalized patients (limited data, 1 day, p = 0.01)0.01) no increaseno increase in adverse effects in adverse effects
””Continuous wound catheters appear to be an effective Continuous wound catheters appear to be an effective modality for management of postoperative pain.modality for management of postoperative pain.””
Wound catheter infusions - the evidence
”Continuous local anaesthetic infusions
lead to reductions in pain scores
(at rest and activity), opioid consumption,
postoperative nausea and vomiting, and length
of hospital stay; patient satisfaction is higher and there is
no difference in the incidence of wound infections” (S)
(level 1)
Australian and New Zealand College of Anaesthetists and
Faculty of Pain Medicine.3rd edition 2010.
www.anzca.edu.au <http://www.anzca.edu.au>
LIA technique (knee, hip replacement)• Intraoperative infiltration of surgical area
–ropivacaine 0.2 % 150 mL (300 mg)
–ketolorac 30 mg
–adrenaline 0.5 mg
• Intraarticular catheter (withdrawn morning after surgery)
• Pressure bandage + icepack for 4-6 h (to prolong
analgesia)
LIA technique (knee, hip replacement)• Anaesthesia: spinal with high GA?
• Surgical technique: conventional
• Early mobilization within 3-5 h
~ 50 % discharged day after surgery
(almost all others on day 2)
• Pain management: paracetamol, NSAID’s, weak opioids
• Antithrombotic treatment: only aspirin!
Perioperative injection during total knee arthroplasty.
(A) Injection of the posterior capsule, shown with multiple needles.
(B)Injection of the capsule.
(C)The epidural catheter places behind the medial condyle.
(D)Injection of the subcutaneous layer
Perioperative injection during total knee arthroplasty.
(A) Injection of the posterior capsule, shown with multiple needles.
(B)Injection of the capsule.
(C)The epidural catheter places behind the medial condyle.
(D)Injection of the subcutaneous layer
Perioperative injection during total hip resurfacing.
(A)Injection around acetabulum after insertion of the component.
(B)Injection of the rotators and the gluteal muscles.
(C)The epidural catheter is place in the joint.
Perioperative injection during total hip resurfacing.
(A)Injection around acetabulum after insertion of the component.
(B)Injection of the rotators and the gluteal muscles.
(C)The epidural catheter is place in the joint.
LIA technique for TKA and THA - summary• Emerging technique for total hip and knee replacement
surgery
• Has changed orthopaedic practice in many institutions (75%
TKA in Sweden)
• Promising results- better for TKA
• Need for good, comparative studies with pre-defined
outcome criteria to:
– identify essential components
– reduce inappropriate and unnecessary
interventions
– establish if technique is cost-effective
5. Disposable infusion devices
• Non-electrically powered disposable infusion devices
– in clinical practice for more than 30 years
• Indications
– chemotherapy, antimicrobials, pain management
(acute and chronic)
• Types of pumps:
- Elastomeric
- Spring powered
- Gas pressure pumps
- PCA devices (with and without background
infusion)
Portable, disposable basal- & bolus-capable infusion pumps need to have two slides for this?
If only one, which do you prefer?
• Ambulatory surgery
• Elastomeric disposable pump
• Continuous infusion & boluses
• Patient can be at home
• Ambulatory surgery
• Elastomeric disposable pump
• Continuous infusion & boluses
• Patient can be at home
pt buttonpt button
PCA techniques for postoperative analgesia
• IV-opioid : well-established worldwide, high patient
satisfaction, unimpressive effects on outcome
• Epidural : excellent dynamic pain relief, cost-effective with
good APS. Superior to continuous infusion technique.
• Perineural : excellent alternative to PCEA in appropriate
patients
• Incisional/intraarticular : simpler, safer, less expensive than
other regional techniques
• Transdermal : as good as i.v.. Further studies necessary
• Intranasal, buccal : interesting concepts. Further studies
necessary
PCA - key messages (1)
• IV-opioid-PCA – if property administered - provides better
analgesia than conventional parenteral regimens.• Analgesia effectiveness can be as good with conventional
parenteral opioids if administered appropriately (=e.g.
titrated, combined with non-opioids). points 1 & 2 somewhat
contradict each other; would think #2 more accurate?
• IV-opioid-PCA leads to higher opioid consumption, higher
incidence of pruritus but no difference in length of stay.
compared with traditional intermittent opioid
administration• Patient preference for IV-PCA is higher vs conventional
regimens.
PCA – key messages (2)
• The provision of epidural analgesia by continuous
infusion or patient-controlled administration of
local anesthetic-opioid mixtures is safe on general
hospital wards, as long as supervised by
anesthesia-based service with 24-hour medical
staff cover and monitored by well-trained nursing
staff.
Summary
• Many opioid-based, regional anesthetic and even
non-pharmacological hi-tech methods are
available for treating postoperative pain.• In general most hi-tech methods are patient-
controlled techniques.• A variety of pump devices provide patient-
activated boluses, continuous infusions or both for
opioid-based or regional anesthesia techniques.
Summary
• Operator error remains a relatively common
safety problem with IV-opioid-PCA methods• Minimal-invasive surgical methods can play an
important role in reducing postoperative pain
• There is no evidence of better analgesic
effectiveness with hi-tech PCA if
conventional methods are used optimally.
Talks in the International Pain School include the following:
International Pain School
Physiology and pathophysiology of pain Nilesh Patel, PhD, Kenya
Assessment of pain & taking a pain historyYohannes Woubished, M.D, Addis Ababa, Ethiopia
Clinical pharmacology of analgesicsand non-pharmacological treatments
Ramani Vijayan, M.D. Kuala Lumpur, Malaysia
Management of postoperative pain – low technology treatment methods
Dominique Fletcher, M.D, Garches & Xavier Lassalle, RN, MSF, Paris, France
Management of postoperative pain– high treatment technology methods
Narinder Rawal, M.D. PhD, FRCA(Hon), Orebro, Sweden
Cancer pain– low technology treatment methods Barbara Kleinmann, MD, Freiburg, Germany
Cancer pain– high technology treatment methodsJamie Laubisch MD, Justin Baker MD, Doralina Anghelescu MD, Memphis, USA
Palliative CareJamie Laubisch MD, Justin Baker MD, Memphis, USA
Neuropathic pain - low technology treatment methodsMaija Haanpää, MD, Helsinki & Aki Hietaharju, MD, Tampere, Finland
Neuropathic pain – high technology treatment methodsMaija Haanpää, M.D., Helsinki & Aki Hietaharju, M.D., Tampere, Finland
Psychological aspects of managing pain Etleva Gjoni, Germany
Special Management Challenges: Chronic pain, addiction & dependence, old age and dementia, obstetrics & lactation
Debra Gordon, RN, DNP, FAAN, Seattle, USA