Postoperative Pain Management IMA

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)



PAIN

PAIN

PAIN

PAIN

PAIN

Postoperative

PAIN



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 !!!!!



POST-OPERATIVE PAIN MANAGEMENT

Dr. Ashok Jadon MD, DNB, MNAMS

Fellowship in Interventional Pain management

Sr consultant & H.O.D. Anaesthesia

TATA MOTORS HOSPITAL



Factors for poor pain control

Patients

Doctor Nurse



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



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



Mechanism of Postoperative Pain



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



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



Psychological effects of Pain

Negative emotions: anxiety, depression

Sleep deprivation

Existential suffering:

± may lead to patients seeking active end of life.



Immunological effects of Pain

Decrease natural killer cell counts

Patient become host of infection



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



Objective assessment of subjective pain

V AS

VRS

Picture scales

(facial expressions)

Clinical observation

sighing, groaning,

sweating, ability tomove



Identify High risk patients

Preemptive approach

PROPHYLAXIS

IS

BETTER THAN CURE



Pre-emptive Analgesic Therapy

Before surgery to attempt to decrease theintensity and duration of postoperative pain.

Controlling the "wind-up" phenomenon



Non Pharmacological Strategy

Health-care information

±Information in preparation for

surgery ±Timing of procedures

±Self-care actions

±Pain and discomfort information



Psychosocial support

Identifying and alleviating concerns

Reassurance

Problem-solving

Encouraging questions, and increasing the

frequency of support



Skills teaching

Coughing, breathing and bed exercises,

Relaxation, hypnosis, cognitive reappraisal



Non Pharmaco Adjuvant

Acupuncture

Trans-cutaneous Nerve Stimulation

(TENS)



Trans-cutaneous Nerve Stimulation TENS



Trans-cutaneous Nerve Stimulation

TENS



Pharmacological Treatment

Type of Drugs

Modes & Methods of administration

Recent advances



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



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



Advantage &Disadvantage

Oral Vs Intramuscular Vs Intravenous Rectal and Nasal

Trans cutaneous and Transmucosal

LOC AL ANAESTHETICS

± Less systemic effects

± Combination with Narcotics

MultimodalApproach



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.



The World Federation of Societies of

Anaesthesiologists (WFSA) Analgesic Ladder







Patient Controlled Analgesia

(PCA)



PC A



PC A

Therapeutic level

Time in Hours

Plasma

Level

PCA

IM

IV



Alternate novel drug delivery systems for

intravenous analgesics

Transmucosal Passive patch

Transdermal Passive patch

Iontophoretic patch

Nasal (Inhaled drops, spray)

Rectal



Trans-dermal patch



Trans-dermal patch





Rectal Suppository





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



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



Catheter techniques

first described in 1946,gained popularity only in

the 1970s

Continuous Plexus Block

Intrapleural Catheter

Continuous woundinfiltration



Intrathecal and epidural

Local anaesthetics & opioids



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.



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.



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.



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%



At Tata Motors Hospital !!!!!



Continuous Wound Infiltration



Continuous Epidural Analgesia



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.



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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Postoperative Pain Management IMA