Postoperative Pain Management in Adults

Transcription

1 Postoperative Pain Management in Adults Anil Gupta MD, FRCA, PhD Associate Professor, University Hospital, Örebro and Senior Lecturer, University Hospital, Linköping, Sweden

2 Scandinavia (Norway, Sweden, Denmark) Sweden 9 million people Oslo, Norway Heart of Scandinavia City of Örebro Population: 125,000 Stockholm, Sweden Copenhagen, Denmark

3 University Hospital, Örebro, Sweden

4 Multiple Pain Sites and Pain Mechanisms The intensity of perceived pain is related to: *the type of surgery *the intensity of trauma *previous exposure of pain *sex *age *degree of psycho-social preparation prior to the procedure.

5 Multiple pain sites requires Multimodal analgesia: Paracetamol + Rofecoxib + dexamethasone or palcebo

6 Assessment of Pain Visual analogue pain scale (VAS) No pain imaginable pain Worst Numeric Rating Scale/Verbal Rating Score (NRS/ VRS) Mild pain Moderate pain Severe pain Pain is a subjective experience and cannot always be measured

7 Can pain intensity be predicted?

8 Predictors of Postoperative Pain APAIS: Amsterdam Preoperative Anxiety and Information Scale

9 Incidence of Pain % of patients with Moderate Severe Pain 30% patients had moderatesevere pain Neurosurgery General surgery Orthopedic surgery Hand surgery Plastic surgery McGrath et al. Can J Anesth 2004

10 Postoperative Pain Pain as a factor complicating recovery and discharge after ambulatory surgery Painful Procedures: Inguinal Herniorrhaphy Laparoscopic Surgery Plastic Surgery Pavlin et al, Anesth Analg 2002

11 Anesthesiology 2002 Overall incidence (95% CI) of post-discharge pain was 45% (6 95%)

12 Management Principles Preventive management Prevent pain by reducing nociceptive input Pro-active management Treat the patient even if they have no pain Give drugs regularly irrespective of pain intensity Multi-modal management Use different drugs with different mechanisms of action

13 Preventing Pain

14 Curr Opin Anesth 2006

15 Preventive Analgesia An appropriate postoperative pain treatment: may start before surgery last long enough after surgery avoid pain-induced sensitization processes includes effective analgesic interventions The concept of preventive analgesia includes: Multimodal anti-nociceptive techniques with analgesics Exceed the expected duration of action of these drugs Attenuates peripheral or central hypersensitivity

16 Preventive Analgesia Includes (but is not limited to) the use of: Local anesthetics Paracetamol NSAID s Opioids Others e.g. Gabapentin, pregabalin, ketamine etc. Single or combination of drugs where the duration of effect exceeds the duration of pharmacological analgesia of each drug

17 Treating Pain Pharmacological methods Local anesthetics Paracetamol Non-steroidal anti-inflammatory drugs Opioids and related drugs Other drugs Non-pharmacological methods Cold compresses TENS, music, acupuncture etc.

18 Local Anesthetics Advantages Rapid onset of action Low risk of toxicity Excellent analgesia Cheap Disadvantages Short duration of action when injected locally Can cause hyperalgesia when effect wears off

19 Local Anesthetics Prolonging effect duration Use long-acting LA Use nerve blocks instead of infiltration Combine with adjuvants (clonidine, morphine) Use catheters to inject LA intermittently Microsomal-bound LA (still experimental) LA provide excellent pain relief, but of short duration

20 Procedure-specific Pain Management Because of the varying pain intensity following different types of surgery, a procedure specific pain management approach should be used.

21 Knee Arthroscopy Options: Femoral nerve block Intraarticular analgesia Morphine LA NSAID Oral analgesics

22 Knee Arthroscopy I/A Local anesthetics Conclusion: Weak evidence of mild reduction in postoperative pain of short duration Moiniche et al. 1999

23 Knee Arthroscopy I/A Morphine Mild effect when injected intraarticularly Duration up to 24 h postoperatively Effect is best when pain is moderate-severe Dose of 5 mg is optimal Systemic effect of 5 mg morphine i.a. in the early period cannot be excluded Intraarticular analgesia: Combination of LA with morphine and NSAID are efficacious

24 Local Infiltration Analgesia (LIA)

25 Knee Surgery Local Infiltration Analgesia (LIA) LIA: Ropivacaine + ketorolac + adrenaline infiltration in and around the knee (Group A) Median postoperative hospital stay was less in group A (n = 19) than in group P (n = 19): 1 (1 6) days vs. 3 (1 6) days (p < 0.001). Acta Orth Scand 2009

26 Shoulder surgery Options Paravertebral block Interscalene Block Supraclavicular block Intraarticular analgesia

27 Unilateral shoulder arthroscopy All patients received an interscalene block M-IR: I/A ropivacaine 2 ml/h M-IS: I/A saline 2 ml/h 48 h Prospective, double blind study Lower pain intensity using I/A ropivacaine compared to saline

28 Suprascapular block (SSB): 10 ml bupivacaine 0.25% + adr. Intra-articular analgesia (IA): 20 ml bupivacaine 0.25% + adr. Interscalene block (ISB): 20 ml bupivacaine 0.25% + adr. Interscalene block provides best analgesia. When contraindicated, supra-scapular block is preferable.

29 Herniorrhaphy Options Local anesthetic infusion Spinal anesthesia Ilio-inguinal nerve block Multimodal management

30 Spinal Anesthesia Spinal anesthesia: Bupivacaine 6 mg or 7.5 mg (+ fentanyl 25 µg) Conclusion: VAS < 4 up to 7 days postoperatively? Preventive effect? Gupta et al, Acta Anesth Scand 2003

31 Laparoscopic surgery Options Intraperitoneal LA Multimodal analgesia Intercostal nerve block

32 . Pain on Coughing Conclusion Pain was mild even in the placebo group during 0 7 days VAS = 3 Gupta et al A & A 2002

33 Breast surgery Options Paravertebral block Infiltration analgesia +/- catheters Oral analgesics

34 Breast Augmentation Surgery Pain at rest (0-24 t) VAS 3-6 Pain after infusion of 10 ml LA Rawal et al, EJA 2006

35 Analgesics in Day Surgery

36 NSAID Systemic administration Intravenous Oral Rectal Local Injection Intra-articular IVRA Sub-cutaneous

37 NSAID Advantages Moderately long effect-duration Effective when used in combination with other drugs Disadvantages Not tolerated by all patients (allergy etc) Risk of perioperative bleeding is a cause for concern by some surgeons NSAIDs are efficacious in the presence of moderate pain during day surgery

38 NSAID summary Ketorolac has been found to be efficacious: When used in a dose of 60 mg during IVRA When used for wound infiltration When injected intraarticularly When combined with other drugs Concerns remain about the effects of ketorolac on bone-healing

39 Paracetamol Tablet * satisfactory absorption Suppository * poor absorption Intravenous (Perfalgan) *Rapid effect (< 15 min)

40 Therapeutic concentration IV paracetamol or 2 g oral Conclusion: For rapid onset of effect, use iv paracetamol (Perfalgan ) As premedication, use 2 g paracetamol for best effect. Rectal route should be abandoned! Holmér Pettersson et al. Acta 2006

41 Clonidine Efficacy documented following Intravenous injection Intraarticular injection Spinal injection Following IVRA

42 Conclusions: Clonidine 1 µg/kg (IVRA) results in: 1. Improved analgesia in PACU during first 2 h postoperatively 2. Decreased need for analgesic supplements 3. Well tolerated by patients

43 Drug Combinations R: Ropivacaine M: Morphine K: Ketorolac Decreased morphine consumption in RMK group compared to Group RM or Placebo Anesth & Analg 2006

44 Non-pharmacological Methods Music

45 Day surgery (183 patients): Some beneficial effect of music on postoperative pain. In general, pain scores were low! Acta Anesth Scand 2003

46 Non-pharmacological Methods Acupuncture

47 Acupuncture Intradermal acupuncture: 1. Reduced incisional and visceral pain 2. Reduced analgesic requirements 3. Diminished PONV Easy to use and safe; few side effects Anesthesiology 2001

48 Post-discharge Pain Relief Based upon Tablets (Paracetamol, NSAID etc) LA via catheters Cold compresses Music Wait, watch, hope, pray.. Better methods for pain management at home are urgently needed!

49 The Future Procedure-specific pain management Newer drugs Newer delivery systems Patient-specific pain management Better understanding of the genetic code Pain mapping Surgeon-specific pain management Why some surgeons cause more pain than others!!!!!

50 Conclusions Effective pain management requires a procedure-specific approach Pain is a consequence of surgery and should be anticipated, prevented and treated quickly Poorly treated postoperative pain can lead to chronic pain syndromes Multimodal approach to pain management should be a routine in day surgery

51 Thank you for your attention