Prof. Husni - Improving Postoperative Pain Management
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Transcript of Prof. Husni - Improving Postoperative Pain Management
Improving postoperative pain management, what is unsolved?
Hasanuddin University Faculty of MedicineDepartment of Anesthesiology, IC and Pain
ManagementMakassar
A.Husni Tanra
ISAPM National Meeting, Manado 14-15 October 2015
Among nociceptive pain, postoperative pain is well understood.
• We know what causes it• We know the mechanism• We know how to treat it• We know the best drugs for it• We know mostly self limited
(Lema MJ, Department of Anesthesiology, Buffalo State University )
So, no more reason to feel pain after surgey
Nature of post operative pain• Four out or five patients undergoing surgery
experiences postoperative pain– 86% of these patient rating
Moderate Severe Extreme pain
• > 50% of patients report inadequate pain relief• 10% to 50% acute post operative pain may become
chronic, depending on the surgical procedure
Pain, ASHP advantage E-NEWSLETTER, March 2014
• Why Management of postoperative pain: still a long way to go?
Editorial Pain (2008) 233-234
Powel et al. Analyzed the obstacle in APS in UK.• Dr. Powel AE et al. from UK explained:
“Misconception of the surgeon”“ Acute pain vanishes in a few days, and as long as the
operation was successful the postoperative pain will soon be forgotten”. So why bother with costly APS, with epidural or peripheral nerve analgesia, which are also not compleatly free of complication. They do not expect, acute pain may develop into chronic pain Every time this comes as a big surprise to them. They have never heard of this phenomenon, nor do they have any idea how to treat it.
Editorial, Pain 137 (2008) 233:234
BSSP and SARPS - Dhaka 2006
What is Traditional Postoperative Pain Management
Unimodal analgesia, using Morphine
or Pethidine.
10 mg morphine, or Pethidin im as
needed.
done by SURGEON
Applied by the nurses.Courtesy S.A. Schug
PainCall for Nurse
Nurse Responds
Screening
Sign out Medication
Prepare Medication
Administer Med (im)
Absorption from site
Pain Relief
Sedation
PCA
Traditional pain relief vs PCA
After the Surgical injury
PeripheralSensitization
of Nociceptors
Primaryhyperalgesia
Surgical Injury
CentralSensitization
of Dorsal Horn
SecondaryHyperalgesia
LTP(Chronic
pain)
Can be treated by Opioid, Ketamine, alpha2agonist, gabapentinoid or continuous epidural with LA.
Problem of after surgery condition
Primary HYPERALGESIA Can be easily treated by NSAID (Cox1 or Cox2)
Secondary HYPERALGESIA
PRIMARY HYPERALGESIA
• Rational treatment of primary hyperalgesia is anti inflammatory agents;
NSAID non selective Coxib (selective NSAID ) Dexamethazone Infiltration of LA
In
Prostaglandins produced in response to tissue injury; increase sensitivity of nociceptor (pain)
Nociceptor then releases substance P, which dilates blood vessels and increases release of inflammatory mediators, such as Bradykinin (redness & heat)
Substance P also promotes degranulation of mast cells, which release histamine (swelling)
1
2
3
Pain-sensitive tissue
Painful stimulus
Prostaglandin
Substance P
Histamine
Mast cellBlood vessel
Bradykinin
Nociceptor
Substance P
23
1
Peripheral sensitization
Infiltration of LA means blocking the release of Subtance P
SECONDARY HYPERALGESIA
• Rational treatment of secondary hyperalgesia is the drug/technique that can prevent the occurrence of Central sensitization;
Opioid (Mo, Fentanyl or Pethidine). Ketamine (NMDA antagonist). Gabapentinoid (Gabapentin or Pregabalin).
Alpha2 agonist , Dexmetomidine. Continuous Epidural Block
Secondary HyperalgesiaCommonly ignored or discounted in the evaluation and treatment of postoperative pain
Neuroplastic changes in the CNS that may amplify pain perception
Not relieved or may be worsened by conventionalmedicationsPersistence of CNS sensitisation may lead to chronicpost-surgical pain
Wilder-Smith OHG, Arendt-Nielsen L. Anesthesiology 2006;104:601-607
So what is unsolved issues?• To improving postoperative pain management, we
need to;1. Always applies multi-modal analgesia.
(get the advantages of multimodal analgesia)
2. Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
3. Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
1. What is multimodal analgesia?
Multimodal Analgesia is
• Administration of two or more drugs that act by different mechanism it can be:
The same or different routesProvide additive or synergic effectMinimal side effectShould be given by around the clock (ATC)
Main goals of Multimodal Analgsia is to reduce the amount of Opioid
1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
Potentiation
• Reduced doses of each analgesic
• May reduce side effects of each drug
• Improved pain relief due to synergistic or additive effects
Opioids
NSAIDs,acetaminophen,
nerve blocks
Benefits of Multimodal Analgesia
Philosophy of Multimodal AnalgesiaNot only just giving 2 or more drugs which different mechanism, but;
• One drug should be effective at peripheral
sensitization and other at central sensitization.
• Combine drugs must be synergetic or addictive.
• Must be proven by laboratory or clinical data.
• Some drugs may act at several point at nociceptive
pathway.
Local anesthetics
CorticosteroidsNSAIDsCOXIBs
Local Anesthetic
CNS
DRG
OpioidsGabapentinoids
Clonidine
Modify by AHT
KetaminParacetamol
COXIBs
Transduction
TransductionModulation
Perception
TransmissionModulation
Target Point of Analgesic Drugs
2. Evidence based of the use of nonopioid + opioid on an as needed basis.
Efficacy of Postoperative Patient-Controlled and Continuous Infusion Epidural Analgesia vs Intravenous PCA with Opioids
• Meta-analysis of 299 RCTs• Epidural analgesia in any combination (except
epidural morphine alone) > to IV PCA up to 3 days • Continuous epidural analgesia > PCEA for pain at
rest and with activity but more PONV and motor block, less pruritus
• Epidural LA + Opioid > Epidural Opioid alone
Wu et al Anesthesiology 2005
Regional Analgesia
Prevention
Andreae MH and Andreae DH. Br J Anaesth 2013.
• Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about 1 out of every 5 women treated.
Conclusions:• Epidural anesthesia may reduce the risk of
developing chronic pain after thoracotomy in about 1 out of every 4 patients treated.
Regional Analgesia
Continuous Peripheral Nerve Blocks provide superior pain control to opioids?
• Meta-analysis 12 studies [360 pts] lower limb• Reduced Pain scores 24/48 hours ~ 50%• Reduced side effects
Nausea/vomiting Sedation Pruritus
• ‘Perineural catheters provided superior analgesia to opioids for all catheter locations and times’
Continuous PNB
Richman et al Anesth Analg 2006
Peripheral Nerve Block
Efficacy of Continuous Wound Catheters Delivering LA for Postoperative Analgesia: A Quantitative and
Qualitative Systematic Review of RCTs
• 39 RCTs (n=1761) quali analysis, 45 RCTs (n= 2031) quantitative analysis
• Surgical subgroups: abdominal, gynaecologic, cardiothoracic, urologic, orthopaedic
• Benefits of wound catheters:– Decreased pain scores (32% reduction)– Decreased opioid consumption (25% reduction)– Decreased risk of PONV (16% reduction)– Increased patient satisfaction (30%)
• No increase in adverse effectsLiu et al. J Am Coll Surg 2006
Wound Catheter Delivery
• IV Acetaminophen prolonged time to first opioid administration
• Reduced nausea when given before surgery or before arrival in PACU
• When given prophylactically, reduction of nausea and vomiting correlated with the reduction of pain
• Significant reduction in pain scores at 24 hrs
• Less PONV and pruritus
• Opioid sparing at 24 hours
• No significant differences in acute pain outcomes with pregabalin 100-300mg between single preop dose and additional doses postop
PreventionGabapentinoids
Prevention
A systematic review of intravenous Ketamine for postoperative analgesia
Laskowski et al. Can J Anaesth 2011
• IV Ketamine is an effective adjunct for postop analgesia.
• Particular benefit observed in upper abdominal, thoracic and major orthopaedic surgeries.
• Analgesic effect of ketamine was independent of the type of IV opioid, timing of ketamine administration, and ketamine dose.
Ketamine
KETAMINMore Frequently Use in Postorthopedic Surgical Pain Management
Arthroscopic Anterior Cruciate Ligament Surgery
Outpatient Knee Arthroplasty
Total Knee Arthroplasty
A Single intraoperative injection of ketamin (0,15 mg/kg) improved analgesia and passive knee mobilization 24 hour after surgery
Improved Postoperative Outcome
When combine with epidural or femoral nerve block, increase postoperative pain relief for total knee arthroplasty.
• Menigaux C, Guignard B, Fletcher D, Dupont X, Guirimand F, Chauvin M. Anesth Analg. 2000;90:129–135.• Menigaux C, Guignard B, Fletcher D, Sessler DI, Dupont X, Chauvin M. Anesth Analg. 2001;93:606–612.
• Himmelseher S, Ziegler-Pithamitsis D, Agiriadou H, Martin Jjelen-Esselborn S, Koch E. Anesth Analg. 2001;92: 1290–1295.• Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Anesth Analg. 2005;100:475–480.
Conclusions:
• A single IV perioperative dose of dexamethasone had small but statistically significant analgesic benefits.
• There was no dose-response with regard to the opioid-sparing effect
• There was no increase in infection or delayed wound healing with dexamethasone, but blood glucose levels were higher at 24 hrs.
Waldron et al. Br J Anaes 2013
Glucocorticoids
Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensitySystematic review and meta-analysis of RCTs
• Periop systemic α2 agonists decrease postop opioid consumption, pain intensity, and nausea.
• Recovery times are not prolonged.
• Common AEs are bradycardia and arterial hypotension.
Blaudszun et al. Anesthesiology 2012
α2 Agonists
3. Specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site)
Prevention
White P and Kehlet H. Anesthesiology 2010.
Take home message• To improving postoperative pain management, we
need to;1. Always applies multi-modal analgesia.
(get the advantages of multimodal analgesia)
2. Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.
3. Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).
Thank youvery much