Update in Acute Pain Management - Mahidol University€¦ · combination techniques, and pain protocols have been shown to reduce pain as well as improve ... Common Regional nerve

Update in Acute Pain Management

Lisa Sangkum, Asst Prof.

Department of Anesthesia, Ramathibodi hospital

Bangkok, Thailand

Contents:

Role of Nurse in Acute Pain Management

Standard strategy for Post-operative pain control

Common technique/ drugs in multimodal analgesia regimen

The challenges in Acute & Post-operative pain management

• Poor controlled pain in the postoperative period higher undesirable adverse events e.g. tachycardia, HT, Hypoventilation

• Some patient present with challenging clinical situation e.g. opioid-tolerance

• Patient with medical problems e.g. OSA, cardiovascular/ neurological diseases

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Gan TJ, Journal of Pain Res 2017

Goals of Analgesia

Improve Perioperative

outcome

Early

mobilization

Decrease

Postoperative

Complications

Decrease

Peripheral & Central

sensitization

Decrease risk of developing

Chronic pain

4

Gan TJ, Journal of Pain Res 2017

Enhanced Recovery After Surgery (ERAS)


A puzzle piece to success…….

• Nurse play a critical role in effective pain management because they play a pivotal role in assessment, monitoring, interpretation, intervention and evaluation of pain

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Multimodal Analgesia is a standard strategy for Post-operative pain control

FACT

American Academic of Orthopedic Surgeons

“ Neurostimulation, local anesthetics, regional

anesthetics, epidural anesthetics, relaxation,

combination techniques, and pain protocols have

been shown to reduce pain as well as improve

satisfaction, improve function, reduce complications,

reduce N/V, reduce delirium… “

American College of Surgeons and American

Geriatrics Society

“ An appropriate analgesic plan should be developed

in every older adult patient prior to an operation.

This plan should be multimodal in nature…“

Enhance Recovery After Surgery (ERAS) Society

“ During the postoperative phase, a multimodal analgesic

regimen has been employed aiming to avoid the use of

opioids.…… “

American Pain Society

“ The panel recommends that clinicians offer multimodal

analgesia, or the use of a variety of analgesic medications and

techniques combined with non-pharmacological interventions…..“

What is Multimodal analgesia?

• Use of a variety of analgesic medication

& techniques that target different

mechanisms of action

• Peripheral and/or central nervous system

• Might have additive or synergistic effects

more effective pain relief & less side effects


American Pain Society, 2016

Component of Multimodal analgesia

Opioid

Non-pharmacological therapy

-Cold compression/Music

-PT/ Acupuncture

Non-Opioids

-LA

-NSAIDs

-Acetaminophen

-Anticonvulsant



Opioids • Breakthrough pain

พระเอก

พระรอง


Common techniques/ drugs in Multimodal analgesia

Neuraxial/ Regional anesthesia

• Introduction of local anesthetic drug to temporally interrupt sensation to the specific part of the body

• Provide better analgesia than systemic opioids

• Mechanism of action: Na-channel block


Neuraxial analgesia

• Spinal anesthesia + IT opioids•Morphine •Dose ≈ 1/100• 24-hours•Respiratory depression

• Epidural analgesia


Epidural analgesia


• The catheter is inserted in the epidural space for administrating LA & opioid during post-operative period

• Dosing: ≈ 1/10 the IV opioid dose


Sympathetic blockade

Infection

Drug error

Bleeding


- Bed rest Postural hypotension- Hypotension

- Meningitis- Epidural abscess

- IV opioid OIVI- Wrong route

- Epidural hematomas- Nerve injuries

Time interval before and after Neuraxial puncture/ Catheter removal

Time before puncture/ Removal Time after Puncture/ Removal

UFHs(For treatment)

IV 4-6 hoursSC 8-12 hours

1 hours

LMWH (For prophylaxis)

12 hours 4 hours

LMWH (For treatment)

24 hours 4 hours

Coumadins INR ≤ 1.4 After catheter removal

Plavix 7 days After catheter removal

Cilostazol 42 hours 5 hours after catheter removal

Ticlopidine 10 days After catheter removal

NSAIDs None None


Common Regional nerve block modalities

• Single shot • Continuous catheter infusion


Peripheral nerve block: Orthopedic surgery


Brachial plexus block

Femoral nerve block/ Femoral triangle block/

Adductor canal block

Sciatic/ Popliteal nerve block

General /Gynecologic surgery


General/ Gynecologic surgery


Systematic assessment

1. V/S + Pain (5th vital sign)

2. Underlying + Drugs

3. Sedation level if opioids are administered

4. Motor & Sensory deficit

5. Presence of side-effect e.g. N/V, itching

6. Presence of complications e.g. Nerve injury, Epidural hematoma, Meningitis

7. Insertion site & surrounding tissue redness, tenderness or edema

8. Dressing to ensure it is intact and without leakage

9. Catheter & tubing connections to ensure system is fully connected

10. Insure administration is as prescribed


Clinical case:

• ผูป่้วยชาย 78 ปี Dx Left leg arterial occlusion

• มารบัการผ่าตดั Left femoro-popliteal bypass surgery

• ไดร้บัการระงบัความรูส้กึดว้ย Combined spinal epidural หลงั

off ยา Enoxaprarin 24 ชัว่โมง

• หลงัผ่าตดั 12 ชัว่โมง ผูป่้วยไม่สามารถขยบัและสูญเสยีความรูส้กึบรเิวณขา

ท่านนึกถงึภาวะใดในผูป่้วยรายนี้ ?1) Meningitis

2) Epidural abscess

3) Epidural hematomas


The grading of motor power


Nipple = T4

Umbilicus = T10

Groin = L1

Xiphoid = T6

Dermatome distribution

NSAIDsNSAIDs and Coxib

• Nonsteroidal anti-inflammatory drug

• Lack of tolerance & physical dependence

• Opioids sparing effect 30%

• NSAIDs: Naproxen/ Ibuprofen/ Voltaren

• Coxib: Celebrex/ Acoxia/ Dynastat


Selective COX-2 inhibitor= CoxibInhibit COX-1 and 2

= Non-selective NSIADs


Side-effects

Caution/ Contraindication

• Active peptic ulcer/ GI bleeding: NSAIDs >> Coxib

• Bleeding disorder: NSAIDs >> Coxib

• Cardiovascular/ Cerebrovascular diseases: Coxib >>NSAIDS

• Renal insufficiency: Both

• Asthma: may worsening of asthma: Both


AcetaminophenNSAIDs, Coxibs

Paracetamol

Platelet aggregationVasoconstriction

Vasodilatation

Corticosteroids

• Additive effect with NSAIDs

• Low adverse effect

• Opioid sparing effect 20-30 %

• Mechanism of action• Inhibit prostaglandin production

• Activate descending pathway

Maghsoudi R et al, Journal of Endourology, vol 28, 2014Martinez V, BJA, 2017Wong I et al, Pediatric Anesth, 2013

Acetaminophen: Side effects

• Contraindication in Severe liver damage

• Side effects• Allergic reaction

• Flushing

• Thrombocytopenia/ Leukopenia

• Maximum dose: 4 gram/ days


Opioids

• All substances with morphine-like properties : work at opioid receptors (Mu, Kappa, Delta)

• WHO Classification:

• Weak: Codeine, Tramadol

• Strong: Morphine, Fentanyl, Pethidine

• Ultracet (Acetaminophen 325/ Tramadol 37.5)

• TWC (Acetaminophen 300/ Codeine 15)


Opioids: Mechanism of Action


• Supraspinal action• Periaqueductal gray (PAG)

• Rostroventral medulla (RVM)

• Spinal action• Substantial gelatinosa

• Pre-synaptic: ↓Ca channel activation ↓release small afferent transmitters

• ↓ Neurotransmitter

• Peripheral action• Acting directly on sensory neurons (Aδ, C-fiber) ↓ Pain signal

• Immune cell ↓ Inflammatory pain

Descending inhibitory pathway

Opioids: Adverse effects

• Respiratory Depression

• Diffuse CNS effects• Dizziness, Sedation, Cognitive dysfunction,

Hallucinations

• Nausea/vomiting

• Smooth muscles effects • Urinary retention

• GI : bowel motility decrease

• CVS effects• Bradycardia

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Opioid-induced respiratory impairment

• Severe respiratory depression: RR < 8-10 breaths/min

• Desaturation• Mild hypoxemia: SpO2 < 94%

• Moderate hypoxemia: SpO2 < 90%

• Severe hypoxemia: SpO2 < 85%

• Hypercapnic ventilation


Sedation + Bradypoea

High risk of opioid-induced respiratory depression

•Morbidly obese

•OSA

•Patient with neuromuscular disease

• The very old/ young patient

•The very ill patient


Clinical case

• ผูป่้วยหญงิ อายุ 88 ปี

•U/D: DM, HT, DLP, CAD s/p PCI

•Dx Fx hip

• มารบัการผ่าตดั PFNA

• หลงัผ่าตดัผูป่้วยปวด 9/10 ญาตมิาตามท่านเพือ่ขอ

ยาแกป้วดใหแ้ก่ผูป่้วย


Sedation score

Patient state

0 Awake and calm

1 Minimally sedation: Appropriate response to verbal conversation

2 Light sedation: Briefly awakens with eye contact to voice

3 Moderate sedation: Eye opening to voice (but no eye contact)

4 Deep sedation: No response to voice but movement with physical stimulation

5 Unarousable


Systematic assessment


2. Patient history: U/D + Drugs

3. Sedation level

4. Respiratory assessment: RR

5. Clinical of upper AW obstruction:• Quality of respiration: • Depth: normal/ shallow/ deep

• Ventilatory effort: comfortable/ labored

• Sound: clear/ block/ snore/ gurgling/ stridor




Summary

• Multimodal analgesia is a variety of analgesic medication & techniques that target different mechanisms of action

• Multimodal analgesia is a standard treatment strategy for post-operative pain control• Unless contraindicated, administer non-opioid analgesics

(Acetaminophen + NSAIDs, or Coxib) using around the clock dosing, and consider RA technique if it’s possible

• Administer opioid analgesics as needed.


Systemic assessment


2. Underlying + Drugs:

3. Sedation level if opioids are administered

4. Motor & Sensory deficit


6. Presence of complications e.g. Nerve injury, Epidural hematoma, Meningitis

7. Insertion site & surrounding tissue redness, tenderness or edema

8. Dressing to ensure it is intact and without leakage

9. Catheter & tubing connections to ensure system is fully connected

10. Insure administration is as prescribed


Thank you

Any question???

Documents

Update in Acute Pain Management - Mahidol University€¦ · combination techniques, and pain protocols have been shown to reduce pain as well as improve ... Common Regional nerve