Perioperative pain management in Opioid dependent patient

7/30/2019 Perioperative pain management in Opioid dependent patient

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Perioperative painmanagement in Opioid

dependent patient

Perioperative painmanagement in Opioid

dependent patient

Amr Zidan, MD, FIPP

Chairman, Department of Anesthesia and PainManagement, Tawam Hospital

Assistant Professor

Johns Hopkins Medicine

Amr Zidan, MD, FIPP

Chairman, Department of Anesthesia and PainManagement, Tawam Hospital

Assistant Professor

Johns Hopkins Medicine


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ObjectivesObjectives

Pathophysiology

Adverse effects of perioperative pain

Treatment options

Scientific Evidence

Pathophysiology

Adverse effects of perioperative pain

Treatment options

Scientific Evidence


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Pathophysiology of Postoperative

Pain

Pathophysiology of Postoperative

Pain 6 problems:

1. Peripheral sensitization

2. Constant bombardment of the CNS withnoxious input

3. Noxious input processed by the CNS

4. Pathophysiological consequences of acutepain

5. Sensitization of the CNS response, calledwind-up

6. Induced sensitivity in the nervous systemoutlasts the stimulus

6 problems:

1. Peripheral sensitization

2. Constant bombardment of the CNS withnoxious input

3. Noxious input processed by the CNS

4. Pathophysiological consequences of acutepain

5. Sensitization of the CNS response, calledwind-up

6. Induced sensitivity in the nervous systemoutlasts the stimulus


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Pain Pathways:Pain Pathways:

Tissue damage>>>Algesic substansesrelease>>>Noxious stimuli>>>A delta

and C fibers to the neuraxis>>>Manyto anterior andanterolat.Horns>>>Segmental reflexresponses , and others via theSpinothalamic and Spinoreticulartracts>>>Supra-segmental, limbic andcortical responses.

Tissue damage>>>Algesic substansesrelease>>>Noxious stimuli>>>A delta

and C fibers to the neuraxis>>>Manyto anterior andanterolat.Horns>>>Segmental reflexresponses , and others via theSpinothalamic and Spinoreticulartracts>>>Supra-segmental, limbic andcortical responses.


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1. Peripheral sensitization1. Peripheral sensitization


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2. Constant bombardment of the

CNS with noxious input

2. Constant bombardment of the

CNS with noxious input


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3. Noxious input processed bythe CNS

3. Noxious input processed bythe CNS

Adverse spinal reflexes, such as muscle

spasm and sympathetic stimulation, areprovoked.

Supraspinal reflexes incite the mediatorsof the stress response.

Adverse spinal reflexes, such as muscle

spasm and sympathetic stimulation, areprovoked.

Supraspinal reflexes incite the mediatorsof the stress response.


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4. Sensitization of the CNS response4. Sensitization of the CNS response

Central sensitization refers to enhancedexcitability of dorsal horn neurons and ischaracterized by:

1. increased spontaneous activity

2. Enlarged receptive field area

3. An increase in responses evoked by largeand small caliber primary afferent fibers

Central sensitization refers to enhancedexcitability of dorsal horn neurons and ischaracterized by:

1. increased spontaneous activity

2. Enlarged receptive field area

3. An increase in responses evoked by largeand small caliber primary afferent fibers


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4. Sensitization of the CNS response4. Sensitization of the CNS response

Windup refers to the progressive increase in

the magnitude of C-fiber evoked responses ofdorsal horn neurons produced by repetitiveactivation of C-fibers.

Triggered by neurotransmitter glutamate

and neurokinin peptides (substance P)

Windup refers to the progressive increase in

the magnitude of C-fiber evoked responses ofdorsal horn neurons produced by repetitiveactivation of C-fibers.

Triggered by neurotransmitter glutamate

and neurokinin peptides (substance P)


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Cardiovascular

Pulmonary

Gastrointestinal

Renal

Cardiovascular

Pulmonary

Gastrointestinal

Renal

tachycardia, hypertension,increased SVR, increasedcardiac work

hypoxia, hypercarbia,atelectasis; decreased cough,VC, FRC; ventilationperfusion mismatch

nausea, vomiting, ileus, NPO

oliguria, urinary retention

tachycardia, hypertension,increased SVR, increasedcardiac work

hypoxia, hypercarbia,atelectasis; decreased cough,VC, FRC; ventilationperfusion mismatch

nausea, vomiting, ileus, NPO

oliguria, urinary retention


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Extremities

Endocrine

Central nervous system

Immunologic

Extremities

Endocrine

Central nervous system

Immunologic

skeletal muscle pain, limitedmobility, thromboembolism

vagal inhibition; increased

adrenergic activity,metabolism, oxygenconsumption

anxiety, fear, sedation,Delirium, fatigue

impairment

skeletal muscle pain, limitedmobility, thromboembolism

vagal inhibition; increased

adrenergic activity,metabolism, oxygenconsumption

anxiety, fear, sedation,Delirium, fatigue

impairment


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How safe is postoperative

pain therapy?


pain therapy?

Respiratory and haemodynamic effects ofacute postoperative pain management:evidence from published data.

Cashman, J.N. and Dolin, S.J.

British Journal of Anaesthesia, 93 (2004) 212-223.

Respiratory and haemodynamic effects ofacute postoperative pain management:evidence from published data.

Cashman, J.N. and Dolin, S.J.

British Journal of Anaesthesia, 93 (2004) 212-223.


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pain therapy?


pain therapy?

Whereas the incidence of respiratorydepression decreased over the period1980-99, t he inc idence o fhypo t ensi on d id no t

Cashman JN, Dolin SJ.

BJAAug 2004

Whereas the incidence of respiratorydepression decreased over the period1980-99, t he inc idence o fhypo t ensi on d id no t

Cashman JN, Dolin SJ.

BJAAug 2004


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Effectiveness of acute postoperative

pain management

Effectiveness of acute postoperative

pain management

Postoperative pain experience: resultsfrom a National Survey suggestpostoperative pain continues to beundermanaged

Apfelbaum J L et al

Anesth Analg 2003; 97:534-540

Postoperative pain experience: resultsfrom a National Survey suggestpostoperative pain continues to beundermanaged

Apfelbaum J L et al

Anesth Analg 2003; 97:534-540


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Pain - a persistent problemPain - a persistent problem

it remains a common misconceptionamongst clinicians that acute postoperative pain

is a transient condition involving physiologicalnociceptive stimulation, with a variable affectivecomponent, that differs markedly in itspathophysiological basis from chronic pain

syndromes.Cousins MJ, Power I, and Smith G.

Regional Analgesia and Pain Medicine, 25 (2000) 6-21

it remains a common misconceptionamongst clinicians that acute postoperative pain

is a transient condition involving physiologicalnociceptive stimulation, with a variable affectivecomponent, that differs markedly in itspathophysiological basis from chronic pain

syndromes.Cousins MJ, Power I, and Smith G.

Regional Analgesia and Pain Medicine, 25 (2000) 6-21


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Chronic pain after surgery (%)Chronic pain after surgery (%)

Perkins & Kehlet Macrae Macintyre

Mastectomy 11-49 23-49 11-57

Thoracotomy 22-67 5-67 5-65

Cholecystectomy 3-56 3-27 3-50

Inguinal hernia 0-37 15-63 5-63

Vasectomy - 0-37 0-37Amputation - - 30-85

Wilson JA, Colvin LA, Power I

RCoA Bulletin Sept 2002

IASP January 2011

Perkins & Kehlet Macrae Macintyre

Mastectomy 11-49 23-49 11-57

Thoracotomy 22-67 5-67 5-65

Cholecystectomy 3-56 3-27 3-50

Inguinal hernia 0-37 15-63 5-63

Vasectomy - 0-37 0-37Amputation - - 30-85

Wilson JA, Colvin LA, Power I

RCoA Bulletin Sept 2002

IASP January 2011


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Pain - a persistent problemPain - a persistent problem

it is now known that clinical pain differsmarkedly from physiological pain and thatacute, chronic and cancer pains sharecommon mechanisms.

Cousins MJ, Power I, and Smith G.Regional Analgesia and Pain Medicine, 25 (2000) 6-21

it is now known that clinical pain differsmarkedly from physiological pain and thatacute, chronic and cancer pains sharecommon mechanisms.

Cousins MJ, Power I, and Smith G.Regional Analgesia and Pain Medicine, 25 (2000) 6-21


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5. Induced sensitivity in the nervous

system outlasts the stimulus

5. Induced sensitivity in the nervous

system outlasts the stimulus

Clinical pain

Low-threshold

Sensitizationfollowing injury

Allodynia

Hyperethesia

hyperpathia

Clinical pain

Low-threshold

Sensitizationfollowing injury

Allodynia

Hyperethesia

hyperpathia

Physiologic pain

High-threshold

Serve to warn theorganism of harm

Physiologic pain

High-threshold

Serve to warn theorganism of harm

? Can we avoid total analgesia and blo ck only the cl in ical pain

? The sophis t icated goal ofpreemptiv e analgesiato ach ieve a

di f ferent ia l e ffect on p hysio log ic and cl in ica l pain


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Treatment OptionsTreatment Options

1-Systemic opioids.

2-Patient-controlled analgesia(PCA).

3-Regional anesthetic techniques .

a - Intraspinal analgesia.b - Patient-controlled epidural analgesia (PCEA).

c - Peripheral nerve and Plexus blocks.

4-intraarticular analgesia.

5-Nonopioid analgesics (NSAIDs, Muscle relaxant,Acetaminophen, neuropathic pain medications,..)

6-Cryoanalgesia.

7-T.E.N.S.

8-Psychologic and other methods.

1-Systemic opioids.

2-Patient-controlled analgesia(PCA).

3-Regional anesthetic techniques .

a - Intraspinal analgesia.b - Patient-controlled epidural analgesia (PCEA).

c - Peripheral nerve and Plexus blocks.

4-intraarticular analgesia.

5-Nonopioid analgesics (NSAIDs, Muscle relaxant,Acetaminophen, neuropathic pain medications,..)

6-Cryoanalgesia.

7-T.E.N.S.

8-Psychologic and other methods.


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Multimodal AnalgesiaMultimodal Analgesia


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Applying What We Know to

Postoperative Pain Management



1. Prevent sensitization or stimulationof peripheral receptors

Antihistamines

NSAIDs

Local anesthetics

1. Prevent sensitization or stimulationof peripheral receptors

Antihistamines

NSAIDs

Local anesthetics


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2. Diminish or eliminate the

bombardment of the CNS withnociceptive input

Regional anesthesia and Peripheral nerveblocks

Intrathecal or epidural analgesia

Systemic opioids

Small-dose IV ketamine

2. Diminish or eliminate the

bombardment of the CNS withnociceptive input

Regional anesthesia and Peripheral nerveblocks

Intrathecal or epidural analgesia

Systemic opioids

Small-dose IV ketamine


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3. Continue treatment until the inflammatory

reaction that fuels the nociceptive input isminimized

NSAIDS

Sustained release opioids

Consultation with a pain psychologist

3. Continue treatment until the inflammatory

reaction that fuels the nociceptive input isminimized

NSAIDS

Sustained release opioids

Consultation with a pain psychologist


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Opioid Dependent patientsOpioid Dependent patients

Acute

Chronic, cancer-related

Chronic, non cancer-related

Acute

Chronic, cancer-related

Chronic, non cancer-related


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What We Already Know about ThisTopic

What We Already Know about ThisTopic

Acute pain management of patients withchronic pain who are opioid-tolerant is oftendifficult.

Few interventions have reduced

postoperative opioid requirements or painscores in this patient population.

Acute pain management of patients withchronic pain who are opioid-tolerant is oftendifficult.

Few interventions have reduced

postoperative opioid requirements or painscores in this patient population.


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Consensus definitionsConsensus definitions

Tolerance:

a state of adaptation in which exposure to a drug induceschanges that result in a diminution of one or more of the

drug's effects over time.

Physical Dependence:

a state of adaptation that is manifested by a drug classspecific withdrawal syndrome that can be produced by

abrupt cessation, rapid dose reduction, decreasing bloodlevel of the drug, and/or administration of an antagonist.

Tolerance:

a state of adaptation in which exposure to a drug induceschanges that result in a diminution of one or more of the

drug's effects over time.

Physical Dependence:

a state of adaptation that is manifested by a drug classspecific withdrawal syndrome that can be produced by

abrupt cessation, rapid dose reduction, decreasing bloodlevel of the drug, and/or administration of an antagonist.

Savage, et al 2003


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Consensus definitionsConsensus definitions

Addiction:A primary, chronic, neurobiological disease, with genetic,psychosocial, and environmental factors influencing its

development and manifestations. It is characterized bybehaviors that include one or more of the following:

impaired control over drug use, compulsive use,continued use despite harm, and craving.

At variance with WHO & DSM-IV definitions

Addiction:A primary, chronic, neurobiological disease, with genetic,psychosocial, and environmental factors influencing its

development and manifestations. It is characterized bybehaviors that include one or more of the following:

impaired control over drug use, compulsive use,continued use despite harm, and craving.

At variance with WHO & DSM-IV definitions

Savage, et al 2003


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Perioperative Management in

Opioid-Tolerant Patients

Perioperative Management in

Opioid-Tolerant Patients Opioid dependence lowers pain threshold and raises pain

sensitivity

Constant opioid receptor activity may produce hyperalgesia

Chronic opioid users tend to underreport their opioid use.

Psychiatric comorbidities are common.

Cross-addiction to cannabis, cocaine, alcohol, etc.

At risk of under and over treatment

Chronic opioid users have higher postop pain scores, yetmore frequent incidence ofsedation and respiratorydepression

Opioid dependence lowers pain threshold and raises painsensitivity

Constant opioid receptor activity may produce hyperalgesia

Chronic opioid users tend to underreport their opioid use.

Psychiatric comorbidities are common.

Cross-addiction to cannabis, cocaine, alcohol, etc.

At risk of under and over treatment

Chronic opioid users have higher postop pain scores, yetmore frequent incidence ofsedation and respiratorydepression

1. Rapp et al. Pain 1995; 61:195201.2. Compton et al. J Pain Symptom Manage 2000; 20:237 245.

3. Breivik et al. Eur J Pain 2005; 9:127130. 4. Rosenblatt et al. Practice 2005; 5:210.


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Opioid Dose-effect RelationshipOpioid Dose-effect Relationship

Tolerance

OIH


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From: Kuehn BM.Scientists Probe Ways toCurb Opioid Abuse

Without Hindering PainTreatment.JAMA. 2007;297(18):1965-1967.

What Should I do?What Should I do?


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Pre-operativePre-operative

Identify chronic opioid user (whose responsibility?)

Precise opioid use (doses, opioid type, etc.)

Potential for increased postoperative pain

Patients fears and expectations related to pain management

Effective management strategies after previous procedures

Postoperative management options/ appropriate regionaltechniques for complementing opioid analgesia

Post discharge pain management plan

Continuation of preoperative opioid regimen on day of surgery

(prevent withdrawal, falling behind on opioid requirement)

VERY IMPORTANTRapp. Pain 1995; 61:195201.

Identify chronic opioid user (whose responsibility?)

Precise opioid use (doses, opioid type, etc.)

Potential for increased postoperative pain

Patients fears and expectations related to pain management

Effective management strategies after previous procedures

Postoperative management options/ appropriate regionaltechniques for complementing opioid analgesia

Post discharge pain management plan

Continuation of preoperative opioid regimen on day of surgery

(prevent withdrawal, falling behind on opioid requirement)

VERY IMPORTANTRapp. Pain 1995; 61:195201.


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Immediate Preoperative PeriodImmediate Preoperative Period

Conversion of oral to IV route

Consider the bioavailability of oral opioid

(Methadone and Oxycontin higher than morphine) Consider chronic opioid users are at high risk for gastric

aspiration

QT prolongation associated with ventricular arrhythmias in

patients on oral methadone >200 mg (consider preoperativeEKG)

Conversion of oral to IV route

Consider the bioavailability of oral opioid

(Methadone and Oxycontin higher than morphine) Consider chronic opioid users are at high risk for gastric

aspiration

QT prolongation associated with ventricular arrhythmias in

patients on oral methadone >200 mg (consider preoperativeEKG)

1. Brill S. Acute Pain 2003; 5:4550.2. Wallden J. Anesth Analg 2004; 99:429434.3. Kurz A. Drugs 2003; 63:649671.

4. Walker. Pain 2003; 103:321324.


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IntraoperativeIntraoperative

Administration of opioids to meet the followingrequirements:

Chronic need ( daily dose )

Intraoperative surgical pain Anticipated postoperative pain

Avoid muscle relaxant if possible or reverse paralysis early

Titration of opioid to respiratory rate 14 to 16 if possible inspontaneously ventilating patient

Administration of opioids to meet the followingrequirements:

Chronic need ( daily dose )

Intraoperative surgical pain Anticipated postoperative pain

Avoid muscle relaxant if possible or reverse paralysis early

Titration of opioid to respiratory rate 14 to 16 if possible inspontaneously ventilating patient


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Administration of adjuvant medications: Ketamine 0.5 mg/kg IV bolus followed by 4 g/kg/min infusion

Ketorolac 30 mg IV (if NSAID or COX-2 not startedpreoperatively)

Acetaminophen 1,000 mg if not started preoperatively

Institution of appropriate regional technique: Continuous techniques preferable

Local infiltration with local anesthetic if othertechnique not possible

Administration of adjuvant medications: Ketamine 0.5 mg/kg IV bolus followed by 4 g/kg/min infusion

Ketorolac 30 mg IV (if NSAID or COX-2 not startedpreoperatively)

Acetaminophen 1,000 mg if not started preoperatively

Institution of appropriate regional technique: Continuous techniques preferable

Local infiltration with local anesthetic if othertechnique not possible

IntraoperativeIntraoperative


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Fentanyl patch &

Long Acting Opioids

Fentanyl patch &

Long Acting Opioids Continue for minor procedures

To provide background analgesia

Do not apply a warming blanket directly over thepatch

Convert to IV for major procedures

Alterations in body temperature

Alterations in intravascular fluid volume

Set a Basal Rate that is equivalent to their preop.daily requirement

Additional demand doses for post op. pain

Continue for minor procedures

To provide background analgesia

Do not apply a warming blanket directly over thepatch

Convert to IV for major procedures

Alterations in body temperature

Alterations in intravascular fluid volume

Set a Basal Rate that is equivalent to their preop.daily requirement

Additional demand doses for post op. pain1. Rose. Anesth Analg 1997; 84:764772.2. Frolich. Anesth Analg 2001; 93:647648.


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Use of Adjuvant Systemic AnalgesicsUse of Adjuvant Systemic Analgesics

NMDA Antagonists :

Ketamine, Dextrometorphan

NSAIDs Acetaminophen

Gabapentin, Lyrica, Duloxetine, TCAs, SSRI

Alpha 2Agonist

Dexmedetomidine, Clonidine

NMDA Antagonists :

Ketamine, Dextrometorphan

NSAIDs Acetaminophen

Gabapentin, Lyrica, Duloxetine, TCAs, SSRI

Alpha 2Agonist

Dexmedetomidine, Clonidine


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Post-operativePost-operative

Titration of opioids, adjuvant medications, and regionaltechniques to patient comfort: Expect postoperative opiate requirements to be up to 2 to 4 times the dose

required in an opioid nave person.

Individuals requirements can not be predicted with confidence.

Titrate opioids aggressively to achieve adequate pain control in thepostoperative care unit.

Start opioid PCA: If oral route is available, start with 1.5 times the preoperative oral opioid

dose and PCA for breakthrough pain. If oral route is unavailable, consider basal rate for PCA.

In patients undergoing a regional technique : Administer at least half of the preoperative opiate requirement systemically.

Consider use of high-potency opioids such as fentanyl/sufentanil in place of

morphine for epidural management.

Titration of opioids, adjuvant medications, and regionaltechniques to patient comfort: Expect postoperative opiate requirements to be up to 2 to 4 times the dose

required in an opioid nave person.

Individuals requirements can not be predicted with confidence.

Titrate opioids aggressively to achieve adequate pain control in thepostoperative care unit.

Start opioid PCA: If oral route is available, start with 1.5 times the preoperative oral opioid

dose and PCA for breakthrough pain. If oral route is unavailable, consider basal rate for PCA.

In patients undergoing a regional technique : Administer at least half of the preoperative opiate requirement systemically.

Consider use of high-potency opioids such as fentanyl/sufentanil in place of

morphine for epidural management.


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Post-operativePost-operative

Continue acetaminophen 1,000 mg every 6 hours, and/orNSAID, or COX-2 inhibitor for several days with attention torenal function and risk of bleeding.

Continue ketamine if started in OR, or institute ketamineinfusion if pain proves refractory to other measures.

Monitoring for over sedation and opioid withdrawal: Chronically opioid-consuming patients are at higher risk for respiratory

depression than are opioid nave

patients and must be monitored appropriately with regular evaluationof sedation and oxygen saturation.

Continue acetaminophen 1,000 mg every 6 hours, and/orNSAID, or COX-2 inhibitor for several days with attention torenal function and risk of bleeding.

Continue ketamine if started in OR, or institute ketamineinfusion if pain proves refractory to other measures.

Monitoring for over sedation and opioid withdrawal: Chronically opioid-consuming patients are at higher risk for respiratory

depression than are opioid nave

patients and must be monitored appropriately with regular evaluationof sedation and oxygen saturation.


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KetamineKetamine

Single low dose bolus 0.15-0.5 mg/kg

Low-dose infusion 2-4 mcg/kg/min

Avoid fixed dose ratio with opioids Psychotropic SEs are common

Unclear: Combined administration of benzo

Who benefits more?

Single low dose bolus 0.15-0.5 mg/kg

Low-dose infusion 2-4 mcg/kg/min

Avoid fixed dose ratio with opioids Psychotropic SEs are common

Unclear: Combined administration of benzo

Who benefits more?

1. Dix Paediatr Anaesth 2003;13:422-426.2. Duncan. J Pain Symptom Manage 2002;24:8-11.

3. Eilers.Anesth Analg 2001;93:213-214.

4. Unlugenc. Eur J Anaesthesiol 2003;20:416-421.

5. Unlugenc.Acta Anaesthesiol Scand 2002;46:1025-1030.

6. Jahangir. Bangladesh Med Res Counc Bull 1993;19:21-27.

7. Sveticic.Anesthesiology 2003;98:1195- 1205.

8. Edwards.Anaesthesia 1993; 48:124-


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Small-Dose Ketamine Enhances Morphine-

Induced Analgesia After Outpatient Surgery

Small-Dose Ketamine Enhances Morphine-

Induced Analgesia After Outpatient Surgery

IV coadministration of ketamine 50-100 g/kg with morphine 50

g/kg 15 min before the end of the operation

1. Although opiates produce antinociception through receptor agonist activity, they activate NMDA receptors,

resulting in hyperalgesia and the development of

tolerance to opiates.

2. The marked reduction in both pain score and morphine

requirement may be explained by the interaction of

ketamine with NMDA receptors that had been activatedby perioperative nociceptive inputs, as well as by the

administration of morphine.

Manzo Suzuk i , Kentaro Tsueda, e t a l.

Anesth Analg 1999;89:98-103


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Intraoperative Ketamine Reduces Perioperative OpiateConsumption in Opiate-dependent Patients with Chronic

Back Pain Undergoing Back Surgery

Intraoperative Ketamine Reduces Perioperative OpiateConsumption in Opiate-dependent Patients with Chronic

Back Pain Undergoing Back Surgery

Randomized, prospective, double blinded, and placebo-controlled trial involving opiate-dependent patients

52 patients in the treatment group were administered

0.5 mg/kg IV ketamine on induction of anesthesia, andinfusion 10mcg/kg/min and terminated at wound closure

50 patients in the placebo group received saline ofequivalent volume. Patients were observed for 48 hpostoperatively and followed up at 6 weeks. The primaryoutcome was 48-h morphine consumption

Randomized, prospective, double blinded, and placebo-controlled trial involving opiate-dependent patients

52 patients in the treatment group were administered

0.5 mg/kg IV ketamine on induction of anesthesia, andinfusion 10mcg/kg/min and terminated at wound closure

50 patients in the placebo group received saline ofequivalent volume. Patients were observed for 48 hpostoperatively and followed up at 6 weeks. The primaryoutcome was 48-h morphine consumption

Randy Loftus et al.Anesthesiology 2010


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Results:

Total morphine consumption (or equivalents) wassignificantly reduced in the treatment group 48 h

after the procedure.

It was also reduced at 24 h and at 6 weeks.

The average reported pain intensity was significantlyreduced in the post anesthesia care unit and at 6weeks.

Results:

Total morphine consumption (or equivalents) wassignificantly reduced in the treatment group 48 h

after the procedure.

It was also reduced at 24 h and at 6 weeks.

The average reported pain intensity was significantlyreduced in the post anesthesia care unit and at 6weeks.

Randy Loftus et al.Anesthesiology 2010


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NSAIDsNSAIDs

Often omitted

Efficacy supported by several reviews and meta-analyses

As a component of multimodal treatment

Concerns: Renal, gastric, coagulation, cardiac

Often omitted

Efficacy supported by several reviews and meta-analyses

As a component of multimodal treatment

Concerns: Renal, gastric, coagulation, cardiac

1. Barden J. Cochrane Database Syst Rev2003;CD004233.2. Kokki. Paediatr Drugs 2003;5:103-123.3. McCrory.Anesth Analg 2002; 95:169-176.4. Katz. Cleve Clin J Med 2002;69(suppl 1):SI65-SI75.5. Hyllested. Br J Anaesth 2002;88:199-214.6. White.Anesth Analg 2002;94:577-585.

7. Gilron.Anesthesiology 2003; 99:1198-1208.


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Scientific EvidenceScientific Evidence


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Levels of evidenceLevels of evidence

I Evidence obtained from a systematic reviewof all relevant randomized controlled trials.

II Evidence obtained from at least oneproperly designed randomized controlled trial

III-1 Evidence obtained from well-designed

pseudo-randomized controlled trials(alternate allocation or some other method)

I Evidence obtained from a systematic reviewof all relevant randomized controlled trials.

II Evidence obtained from at least oneproperly designed randomized controlled trial

III-1 Evidence obtained from well-designed

pseudo-randomized controlled trials(alternate allocation or some other method)


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Levels of evidenceLevels of evidence

III-2 Evidence obtained from comparative studies with

concurrent controls and allocation not randomized (cohortstudies), case-controlled studies or interrupted time serieswith a control group

III-3 Evidence obtained from comparative studies withhistorical control, 2 or more single-arm studies, or

interrupted time series without a parallel control groupIV Evidence obtained from case series, either post-test or

pre-test and post-test

III-2 Evidence obtained from comparative studies with

concurrent controls and allocation not randomized (cohortstudies), case-controlled studies or interrupted time serieswith a control group

III-3 Evidence obtained from comparative studies withhistorical control, 2 or more single-arm studies, or

interrupted time series without a parallel control groupIV Evidence obtained from case series, either post-test or

pre-test and post-test


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Pre-emptive and preventiveanalgesia

Pre-emptive and preventiveanalgesia

The timing of a single analgesic intervention (preincisional versus post incisional), defined as pre-emptive analgesia, does not have a clinicallysignificant effect on postoperative pain relief(Level I).

There is evidence that some analgesic interventionshave an effect on postoperative pain and/oranalgesic consumption that exceeds the expectedduration of action of the drug, defined as preventive

analgesia (Level I). NMDA (n-methyl-D-aspartate) receptor antagonist

drugs in particular may show preventive andanalgesic effects(Level I).

The timing of a single analgesic intervention (preincisional versus post incisional), defined as pre-emptive analgesia, does not have a clinicallysignificant effect on postoperative pain relief(Level I).

There is evidence that some analgesic interventionshave an effect on postoperative pain and/oranalgesic consumption that exceeds the expectedduration of action of the drug, defined as preventive

analgesia (Level I). NMDA (n-methyl-D-aspartate) receptor antagonist

drugs in particular may show preventive andanalgesic effects(Level I).


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Organizational requirementsOrganizational requirements

Preoperative education improves patient or carerknowledge of pain and encourages a more positiveattitude towards pain relief (Level II).

Implementation of an acute pain service mayimprove pain relief and reduce the incidence of side-effects (Level III-3).

Staff education and the use of guidelines improvepatient assessment, pain relief and prescribingpractices (Level III-3).

Even simple methods of pain relief can be moreeffective if attention is given to education,documentation, patient assessment and provision ofappropriate guidelines and policies (Level III-3).

Preoperative education improves patient or carerknowledge of pain and encourages a more positiveattitude towards pain relief (Level II).

Implementation of an acute pain service mayimprove pain relief and reduce the incidence of side-effects (Level III-3).

Staff education and the use of guidelines improvepatient assessment, pain relief and prescribingpractices (Level III-3).

Even simple methods of pain relief can be moreeffective if attention is given to education,documentation, patient assessment and provision ofappropriate guidelines and policies (Level III-3).


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Patient-controlled analgesiaPatient-controlled analgesia

1. Intravenous opioid PCA provides better analgesia thanconventional parenteral opioid regimens (Level I).

2. Patient preference for iv PCA is higher when compared withconventional regimens (Level I).

3. Opioid administration by iv PCA does lead to lower opioidconsumption, hospital stay or lower adverse effects

4. (Level I).

5. The addition of ketamine to PCA morphine does improve

analgesia or reduce the incidence of opioid-related adverseeffects (Level I).

6. PCEA for pain results in the use of lower doses of LA, lessmotor block and fewer anesthetic interventions (Level I).

1. Intravenous opioid PCA provides better analgesia thanconventional parenteral opioid regimens (Level I).

2. Patient preference for iv PCA is higher when compared withconventional regimens (Level I).

3. Opioid administration by iv PCA does lead to lower opioidconsumption, hospital stay or lower adverse effects

4. (Level I).

5. The addition of ketamine to PCA morphine does improve

analgesia or reduce the incidence of opioid-related adverseeffects (Level I).

6. PCEA for pain results in the use of lower doses of LA, lessmotor block and fewer anesthetic interventions (Level I).


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Take HomeTake Home

Mind likeparachute,does not workif not open

Charlie Chan


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God heals and the Doctor canclaim the fees

Benjamin Franklin 1740

God heals and the Doctor canclaim the fees

Benjamin Franklin 1740


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Perioperative pain management in Opioid dependent patient

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