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Acute post operative pain management

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by

Ettienne Coetzee

on 1 November 2014

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Transcript of Acute post operative pain management

Acute post operative pain management
Anaesthetic Team's Role
Providing safe, effective anaesthesia, including peri-operative analgesia

-Knowledge about anaesthesia
-Knowledge about surgery
Surgeon's Role
Course Content
Definitions regarding pain
Targeting pain
Recognition of pain

Pain Physiology
Mechanism of nociception
Role of the spinal cord
Systemic Analgesia
Analgesia administered systemically
Acts mostly at the chemical interface

Targets the ascending & descending
Targets brain
Ettienne Coetzee
Anaesthetic Team:
Pain:
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
Nociception:
The neural response evoked by any noxious stimulus

Analgesia:
Absence of the perception of pain
Acute 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.
Electrical
Chemical
Na+
Na+
Nociceptors: Nerve receptors that are activated by nociceptive inputs -> "Pain receptors"
Nerve terminal
Local Anaesthetics
First target:
Blocks the Na+ channels
Types of Local Anaesthetic blocks:
Neuraxial - Epidural / Spinal
Regional - specific nerve targets
Infiltration of the skin
Epidural
Truncal / lower limb
Single shot / infusion
Surgical anaesthesia
Analgesia
Requires significant skill
Requires monitoring

Syringes (2x 20ml, needles)
Local anaesthetic (skin, block)
Dressing (transparent)
Standard monitors
Regional blocks
Specific nerve / roots are targeted
Using landmarks / PNS / US
Single shot / catheter + infusion
Limbs, truncal
Require significant skill
Monitoring required as well
Hints
Also a sterile procedure
A specific needle is required
PNS vs US or both
ECG electrode for PNS, U/S probe cover
Electrical??
Second Target: Systemic analgesia
Two methods of targeting pain:
Regional Analgesia
Nerve blocks, spinals, epidurals
Systemic analgesia
Drugs
Paracetamol
NSAIDs
Morphine

Paracetamol
Acetaminophen
MOA
Advantages
Not devoid of disadvantages - toxicity

OA: PO - 30min
IV - 5min
Acute pain?
Part of MMA!
May form part of premed
PO/PR/IV
Role - adjunct
Added if safe
Dosing interval NB
Correct dose! (NB children)
Appropriate ROA
Non Steroidal Anti-Inflammatories
Group of drugs with various minor differences
MOA - preventing formation of Prostaglandins
PR/PO/IM/IV
Most common:
Ibuprofen (Brufen)
Diclofenac (Voltaren)
Indomethacin (Arthrexin)
Ketorolac
Parecoxib (Rayzon)

Neonates now included.
Administration method.
Role
MMA
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
Fever
But:
Regulates blood pressure
Bronchial tone
Stomach lining
Clotting
HPT / elderly / Kidney
Asthmatics
PUD / gastritis
Bleeding
When to use NSAIDS
Always if no contra-indication
Communicate with surgeon
Beware:
Asthmatics
Above 65yrs
Hypertension and/or Diabetes
Renal disease
Peptic ulcer or gastritis history
Risk of poor bone union
Sepsis
High risk of bleeding
MOA - opioid receptors
Potent analgesic
Major role in MMA
Creates indifference to pain
Various unwanted side effects
Morphine
MOA
Morphine
Various formulations: PO/TD/SC/IMI/IV/IT
Side effects:
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?)
Synergistic
Benzodiazepines
Inhalational anaesthetics
Other opioids
Muscle relaxants
Other analgesics?
Hemodynamics
BP within normal limits?
Tachycardic - is it pain or is there something else?
Beware someone on antihypertensive treatment!
Elderly are VERY sensitive to opioids!
PONV
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!
Thank you
Questions...

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
Thoracic surgery
Cholecystectomy
Limb amputations
Purpose:
Empower with knowledge
Able to recognise post-op pain
Know where to start in Mx
Know why it is important
So what?
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
Full transcript