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Acute post operative pain management
Transcript of Acute post operative pain management
Anaesthetic Team's Role
Providing safe, effective anaesthesia, including peri-operative analgesia
-Knowledge about anaesthesia
-Knowledge about surgery
Definitions regarding pain
Recognition of pain
Mechanism of nociception
Role of the spinal cord
Analgesia administered systemically
Acts mostly at the chemical interface
Targets the ascending & descending
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
The neural response evoked by any noxious stimulus
Absence of the perception of pain
Pain that resolves within 1 month of the disease process or injury.
Within normal expected parameters of pain experience.
Nociceptive, disease, injury as causes.
Nociceptors: Nerve receptors that are activated by nociceptive inputs -> "Pain receptors"
Blocks the Na+ channels
Types of Local Anaesthetic blocks:
Neuraxial - Epidural / Spinal
Regional - specific nerve targets
Infiltration of the skin
Truncal / lower limb
Single shot / infusion
Requires significant skill
Syringes (2x 20ml, needles)
Local anaesthetic (skin, block)
Specific nerve / roots are targeted
Using landmarks / PNS / US
Single shot / catheter + infusion
Require significant skill
Monitoring required as well
Also a sterile procedure
A specific needle is required
PNS vs US or both
ECG electrode for PNS, U/S probe cover
Second Target: Systemic analgesia
Two methods of targeting pain:
Nerve blocks, spinals, epidurals
Not devoid of disadvantages - toxicity
OA: PO - 30min
IV - 5min
Part of MMA!
May form part of premed
Role - adjunct
Added if safe
Dosing interval NB
Correct dose! (NB children)
Non Steroidal Anti-Inflammatories
Group of drugs with various minor differences
MOA - preventing formation of Prostaglandins
Neonates now included.
Reduce amount of opioid use (eg Morphine)
Some have potent analgesic properties
Reduce peripheral sensitisation - role in chronic pain
Benefit - no respiratory depression / sedation
Reduces inflammation & "inflammatory soup"
Prostaglandins & NSAID side effects
Enhances sensitivity to pain
Causes swelling & edema
Regulates blood pressure
HPT / elderly / Kidney
PUD / gastritis
When to use NSAIDS
Always if no contra-indication
Communicate with surgeon
Hypertension and/or Diabetes
Peptic ulcer or gastritis history
Risk of poor bone union
High risk of bleeding
MOA - opioid receptors
Major role in MMA
Creates indifference to pain
Various unwanted side effects
Various formulations: PO/TD/SC/IMI/IV/IT
CNS - sedation, dysphoria
CVS - bradycardia, hypotension
Resp - depression, apnea, hypoventilation, hypoxia
GIT - N&V, constipation
Other - allergic reactions, bronchoconstriction
Acute post operative pain
Any other drugs with synergistic effects on board?
Patient's hemodynamic status
Risk of nausea / vomiting
Last dose of morphine & time given (ROA?)
BP within normal limits?
Tachycardic - is it pain or is there something else?
Beware someone on antihypertensive treatment!
Elderly are VERY sensitive to opioids!
High risk after anaesthesia
Is there prophylaxis on board?
Female, Laparoscopic, NonSmoker, history of PONV
Safe combined dose: 0.1mg/kg
Use addition morphine with caution!
Use alternative drugs - MMA!
Some scary statistics
80% of US adults experience acute pain post-op
70% of them - moderate to severe pain (PROSPECT)
Painful procedures treated vs "painless" procedures not
Well known connection with development of chronic pain:
Non-Cosmetic Breast surgery
Empower with knowledge
Able to recognise post-op pain
Know where to start in Mx
Know why it is important
When is it safe to administer drugs
Preperation for procedures saves time & enhances our confidence to perform them -> patient's benefit
Lack of confidence -> cautious -> under treatment?
Knowledge takes the worry away -> safe & effective