dr vivek orho post op pain.pptxhhhhhhhhhhh

fhhjhjgh

1. Presented By Dr Vivek Sharma junior resident Moderator :- Dr Vibha Soni Associate professor Dept of Anaesthesiology &Critical Care

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6612372/pdf/aapm-09-02-84674.pdf Management of Post-Amputation Pain - PubMed (nih.gov) https://doi.org/10.1186/s12891-022-05388-5 Clin Orthop Relat Res (2018) 476:101-109 DOI 10.1007/s11999.0000000000000018 https://doi.org/10.1016/j.apme.2012.08.012 Orthopedics-19.indd (unm.edu) Postoperative Pain Management in Total Knee Arthroplasty (wiley.com) RESOURCES

3. An unpleasant sensory & emotional experience associated with actual or potential tissue damage . Pain Definition Pain is a personal & subjective experience only be felt by sufferer. Katz & Melzack What is Pain?

4. Post operative pain management

5. Patients' overall ranking (median scores) of the importance of addressing questions : Macario et al 2008 n= Will the surgery affect my abilities to care for myself? 29 Hip 5 19 Knee 5 Am I going to need physical therapy? 5 5 How mobile will I be after my surgery? 5 5 When will I be able to walk normally again? 5 5 What are my options if I decide not to receive surgery? 5 4 Will the surgery cause pain afterwards? 5 4 How long will I be in the hospital? 5 4 Is there anything I can do to eliminate pain after surgery? 4 5 Will I receive medication to manage the pain? 4 4 What do major orthopedic surgery patients inquire ?

6. What do surgeons require ? Complete pain free post –operative period but along with: Early mobilization Enteral nutrition Attenuate stress response Enhanced recovery Maintained muscle power Minimal complications

7. What do Anaesthetists want? Good quality analgesia for patients Incorporate newer Regional Anaesthesia techniques: e.g. Neuraxial blocks with newer additivies and USG guided Nerve blocks to improve outcomes Maintain clinical skills Optimise patient outcome

8. ACUTE EFFECTS OF POSTOPERATIVE PAIN Neuroendocrine stress response hypothalamic-pituitary-adrenocortical and sympathoadrenal interactions. Increased sympathetic tone, catecholamine ,catabolic hormone secretion hypermetabolic, catabolic state Sodium/water retention Increased RBS, free fatty acids, ketone bodies, lactate. hypercoagulability. Inhibition of fibrinolysis, platelet reactivity,plasma viscosity Deep venous thrombosis Vascular graft failure Myocardial ischemia Immunosuppression poor wound healing.

9. Chronic persistent postsurgical pain (CPSP) is a largely unrecognized Poorly controlled acute postoperative pain is an important factor Transition from acute to chronic pain occurs quickly Long-term behavioral and neurobiologic changes occur sooner Control of acute postop pain improve longterm recovery or quality of life. pain controlled in early postop ( esp with epidural or peripheral catheter) pt may be able to actively participate in postop rehabilitation, may improve short- long-term recovery. CHRONIC EFFECTS OF POSTOPERATIVE PAIN

10. Consequences of poorly managed acute post-operative pain The Patient may suffer from: CVS: Tachycardias, Ischaemia Hypercoagulable state: DVT Diminished range of joint motion and Arthrofibrosis are closely related to the degree of postoperative pain

11. Psychological: Anxiety, Depression, Sleep Deprivation Prolonged hospital stays, increased hospital readmissions and increased opioid use ForThe Healthcare professional: Low Morale Complaints to/towards/against Institute Litigation Consequences of poorly managed acute post-operative pain

12. Surgical pain Mild Intensity Pain Herniotomy Varicose vein Gynecolo g ical laparotomy Moderate Intensity Pain Hip replacement Hysterectomy Maxillofacial Severe Intensity Pain Thoracotomy Major abdominal surgery Knee surgery Surgical procedure

13. How to Evaluate Pain (Scale)

14. Pathophysiology The generation of pain involves interaction between all parts of the nervous system. Pain ultimately transmitted to: Thalamus Medulla oblongata Cerebral cortex.

15. How Pain Occurs Tissue damage bradykinin and which activate or sensitize p ro sta g l a n di n s , nociceptors. Activation of nociceptors leads to the release of substance P and calcitonin gene related peptide (CGRP). Substance P acts on mast cells in the vicinity of sensory endings and release of histamine, which directly excites nociceptors. Substance P and CGRP produces dilation of peripheral blood vessels. The resultant edema causes additional liberation of bradykinin. Thus Nociceptors activate and cause pain .

16. Analgesic benefits maximized Multiple strategies Patient education, local anesthetic-based techniques (local infiltration, peripheral nerve blocks, and neuraxial analgesia) Multiple drug classes Combination of analgesics act via different mechanisms on different receptors /synergistic effect, superior analgesia,physiologic benefits A multimodal approach is an integral part of enhanced recovery after surgery (ERAS) pathways Minimization of opioid use MULTIMODAL STRATEGY

17. OPIOIDS μ-receptors in the CNS, at peripheral opioid receptors. tolerance or nausea, vomiting, sedation, or respiratory depression. subcutaneous, transcutaneous, transmucosal, or intramuscular route, but the most common are oral and intravenous (iv). specific anatomic sites such as the intrathecal or epidural Space for the treatment of moderate to severe postoperative pain, in part because these routes provide a more rapid and reliable onset of analgesic action Codiene , Morphine, pethidine, fentanyl, methadone, sufentanyl , oxycodone SYSTEMIC ANALGESIC TECHNIQUES

18. Effect is through inhibition of cyclooxygenase (cox) and synthesis of prostaglandins, which are important mediators of peripheral sensitization and hyperalgesia. Cox-1 participates in platelet aggregation, hemostasis, and gastric mucosal protection, whereas cox-2 participates in pain, inflammation, and fever NSAIDS given alone generally provide effective analgesia for mild to moderate pain. NSAIDS are also traditionally considered a useful adjunct to opioids for the treatment of moderate to severe pain. Administered orally or parenterally Perioperative use of nsaids has several side effects, including decreased hemostasis, renal dysfunction, and gastrointestinal hemorrhage. Inhibition of COX and the formation of prostaglandins cause many of the side effects, NON-OPIOIDS Nonsteroidal Antiinflammatory Agents Nonsteroidal antiinflammatory drugs (NSAIDs)

19. ACETAMINOPHEN Have a central role of action in analgesia. It has antipyretic and antiinflammatory properties Activate serotonergic pathways in CNS/inhibition of prostaglandin synthesis. Maximum recommended dose is 4 gm/day in adult patients. Taking > 4gm daily pcm  severe liver and kidney dysfunction Route  oral , iv Dose in adult  500 to 1000 mg per dose 4 hourly ( not > 4gm in a day ) As multimodal analgesia  significant decrease in pain score and opioid consumption Nausea and vomiting were decreased

20. Diclofenac Uses : Analgesic, anti-inflammatory, and antipyretic Presentation as 25/50/100 mg tablets, and in ampoules 25 mg/ml or 75 mg/2ml of diclofenac sodium for injection Mode of  action -- a non-specific inhibitor of COX (COX-2:COX-1 ratio  =  1:1) Route of administration/doses  adult oral dose is 75–150 mg/day in divided doses; the rectal dose is 100 mg, usually at night with further suppositories or tablets up to a maximum dose of 150 mg per 24 hours; The IM is 75 mg once or twice daily. I.V. dose is 25–75 mg, up to a maximum daily 150 mg. Some preparations require dilution in 100–500 ml of 0.9% NS less gastrointestinal damage than aspirin or indometacin . Dyspepsia, nausea, bleeding from gastric and duodenal vessels, mucosal ulceration, perforation, and diarrhoea are expected COX-1 effects. Rashes and hepatic, renal, and haematological impairment have been reported

21. GABAPENTINOIDS GABAPENTIN AND PREGABALIN, ANTIEPILEPTIC DRUGS Also used in the treatment of neuropathic pain, inhibit calcium influx and subsequent release of excitatory neurotransmitters. Side effects such as dizziness/light-headedness or visual disturbances. Increased rates of respiratory depression Gabapentinoids may not provide any additional analgesia for surgical procedures including total hip arthroplasty. The use of gabapentinoids should be considered on an individual basis after surgery

22. Pregabalin 1. Peripheral and central neuropathic pain 2. Partial seizures 3. Generalized anxiety disorder. Presentation  as 25/50/75/100/150/200/225/300 mg capsules. Routes of administration/doses  the dose range is 150–600 mg/day in two or three divided doses. initial dose is 150 mg/day, increased to 300 mg/day after 1 week, with subsequent increases achieved on a weekly Basis, based on individual response and tolerability. Discontinuation should be performed over at least a week . The dose needs to be Reduced in patients with renal impairment. Side effects  dizziness , somnolence. Blurred vision, reduced visual acuity, diplopia. Excretion approximately 98% in the urine. avoided in patients with galactose intolerance, lactase deficiency

23. Tramadol Management of moderate to severe pain. A synthetic opioid & Main action centrally mediated analgesia. Presentation  inj. 50 mg/ml and tablets 50/100/150/200/300/400 mg Routes of  administration/doses  orally, im , slow iv, or infusion. The adult dose is 50–100 mg 4- to 6-hourly for all routes of administration. Principal side effects  nausea, dizziness, sedation, and diaphoresis. Potential for tolerance and dependence appears to be low. Excretion 90% excreted in the urine, Not recommended in end-stage renal failure Dosage interval should be increased to 12 hours in pts with renal or hepatic impairment. Effective in treatment of post-operative shivering. used with caution in pts with seizures or increased intracranial pressure and is contraindicated in those taking monoamine oxidase inhibitors.

24. KETAMINE Traditionally intraop anesthetic; However, small subanesthetic dose (analgesic) ketamine can facilitate postop analgesia Orally, intravenously ( pca or as a continuous infusion), subcutaneously, or intramuscularly. may also be administered orally, rectally, nasally, intrathecally, or extradurally Perioperative analgesic doses of ketamine reduce rescue analgesic requirements and pain intensity. Side effects infrequently occur when the medication is given in analgesic doses. For analgesia, an intramuscular dose of 2–4 mg/kg or an intravenous dose of 0.2–0.75 mg/kg may be used, followed by an infusion of 5–20 micrograms/kg/min. Tolerance develops with repeated drug exposure.

25. Site of Action of Analgesics

26. The preparation for Post-Operative Analgesia should start in the Pre-Operative

27. The administration of analgesic agents prior to an injury in order to prevent development of central nervous system hyperexcitability Preemptive analgesia

28. Using rofecoxib 24 hours and 1 hour before surgery with continued postoperative drug administration for 14 days had better outcomes in total knee arthroplasty. These patients showed reduced opioid requirements, faster time to physical rehabilitation , reduced nausea and vomiting, better sleep patterns and greater patient satisfaction after surgery. Preemptive analgesia

29. Non-Opioid drugs : Antineuropathic : Pregablin 150 mg or Gabapentin 1200 mg PO COX 2 inhibitors: Celecoxib 400mg or Valdecoxib 40 mg PO NSAIDS: Ketorolac 15-30mg PO/IV; Ibuprofen 400- 800 mg -Reduce excess intra-operative opioid usage -Reduce the possible effect of opioid-induced hyperalgesia (paradoxical lowering of pain threshold resulting in greater opioid requirements) post-operatively Preemptive analgesia

30. Epidural Anaesthesia/Analgesia Epidural Catheter placed in lumbar segments. LA+ Opioids given via bolus dosing, Infusion pump or Patient Controlled Analgesia pump Superior analgesia compared to Intravenous drugs Reduced systemic opiate requirements Can extend analgesia for postoperative period

31. Provides better analgesia than IV drugs at rest and during mobilization. Can be connected to PCA pump for continuous analgesia. Side effects: Motor blockade may increase probability of patient fall during mobilization. In patients on anti-coagulants insertion and removal of catheter required extra precautions Arterial hypotension Retention of urine Epidural Analgesia

32. Spinal anesthesia is administered using bupivacaine with Addition of Fentanyl or Addition of Clonidine or Addition of Morphine Intrathecal Analgesics

33. Single-dose neuraxial opioids administration Single dose of opioid may be efficacious as a sole or adjuvant analgesic drug when administered intrathecally or epidurally. Hydrophilic opioids ( i.E. , Morphine) tend to remain within the CSF and produce a delayed but longer duration of analgesia, along more frequent side effects Lipophilic opioids, such as fentanyl provides a rapid onset of analgesia, and their rapid clearance , less side effects

34. CONTINUOUS EPIDURAL ANALGESIA Delivered through an indwelling epidural catheter is a safe and effective method for management of acute postoperative pain. Can provide analgesia superior to that of systemic opioids Intraoperative use of the epidural catheter as part of a combined epidural general anesthetic technique results in less pain and faster patient recovery immediately after surgery than general anesthesia followed by systemic opioids does. Each of these options may affect the quality of postoperative analgesia, patient-reported outcomes, and even rates of morbidity and mortality

35. Risks with epidural analgesia The benefits must be weighed against the risks Epidural hematoma and abscess Anticoagulants Neurologic complications rate is less than 4 in 10,000 (0.04%); The rate of neuropathy is less than 3 in 100 (3%). Permanent neurologic injury is rare in contemporary anesthetic practice. Infection associated may result from exogenous or endogenous sources. Serious infections ( e.G. , Meningitis, spinal abscess) are rare (<1 in 10,000) Use of epidural analgesia in the general surgical population with a typical duration of postoperative catheterization (approximately 2-4 days) is not generally associated with epidural abscess formation.

36. Patient Controlled Analgesia Pump

37. Regime for using Epidural Opioids with LA in PCA pump

38. Advantages of PCA: Allows patient participation and gives them autonomy in their treatment Rapid titration Precise Analgesic calculations for scientific studies Reduced analgesic requirements Reduced incidence of breakthrough pain Less staffing and monitoring concerns

39. Peripheral nerve blocks

40. PERIPHERAL REGIONAL ANALGESIA as a single injection or continuous infusion can provide site-specific analgesia superior to that with systemic opioids may even result in improvement in various outcomes. A variety of wound infiltration and peripheral regional techniques (e.g., brachial plexus, lumbar plexus, femoral, sciatic-popliteal, and scalp nerve blocks) Peripheral regional techniques may have several advantages over systemic opioids (i.e., superior analgesia and decreased opioid-related side effects) and neuraxial techniques (i.e., decreased risk for spinal hematoma and less hemodynamic instability). A one-time injection of local anesthetic for peripheral regional techniques may be used primarily for intraoperative anesthesia or as an adjunct to postoperative analgesia. The duration of postoperative analgesia resulting from the local anesthetic in the peripheral nerve block varies but may last up to 24 hours after injection. Additives to local anesthetics can also increase the duration of action of local anesthetic and improve the quality of nerve blocks. Some of these adjuvants include dexamethasone, clonidine, and dexmedetomidine.

41. Truncal Blocks Several nonepidural/truncal regional analgesic techniques can be used paravertebral and intercostal blocks, transversus abdominis plane (TAP) blocks, quadratus lumborum blocks, erector spinae plane blocks, interpleural (intrapleural) analgesia, and cryoanalgesia . Thoracic paravertebral block has been used for thoracic, breast, and upper abdominal surgery and for the treatment of rib fracture pain.

42. Local Infiltration Therapy Review Done by Denis Mc Carthy (2013) on 10 RCT ’ s o n L o c a l I n f i l t r a t i on An a l g e s ia f o l low i ng TH R showed reduced post operative opioid requirements and more patient satisfaction. Review by S. Brener (2012) on 13 RCT’s concluded that the impact on pain and length of stay in hospital in patients undergoing either total hip or knee arthroplasty were inconsistent. Limitation: Different cocktails in varying concentration and volumes

43. Ranawat Orthopaedic Center (ROC) cocktail for local infiltration in joint with/without catheter Medication Strength/dose Amount First injection Bupivacaine 0.5% (200–400 mg) 24 cc Morphine sulphate 8 mg 0.8 cc Epinephrine (1:1000) 300ug 0.3 cc Methylprednisolone 40 mg 1 cc Cefuroxime 750 mg 10 cc (in NS) Sodium chloride 0.9% 22 cc Second injection Bupivacaine Sodium chloride 20 cc 0.5% 0.9% 20 cc 20 cc

44. Other nonpharmacologic techniques, Transcutaneous electrical nerve stimulation (TENS), Passively applied physical approaches, such as acupuncture, massage, transcutaneous electrical nerve stimulation (TENS), heat or cold packs. Physical activities like walking, deep breathing or light to moderate sportive activities. Psychological/spiritual approaches, such as praying, imagery, visualization, relaxation or meditation. Distractions, like watching TV, listening to music or talking to people. Use of NPMs for chronic pain is well-documented in the literature. Mechanism  modulation of nociceptive impulses, release enkephalins, analgesic efficacy is controversial, Tens and acupuncture may provide postoperative analgesia, decrease postoperative opioid requirements

45. Multimodal (Balanced) Analgesia Using more than one drug for pain control Different drugs with different mechanisms/ sites of action along pain pathway Each with a lower dose than if used alone Additive/ synergistic effects on Analgesia Lesser side effects (mainly opiate related S/E)

46. Multimodal analgesia regimes after Arthroplasty at PPMC, Pennsylvania, Philadelphia Preoperative: Gabapentin 300mg PO + Celecoxib 200mg PO + Acetaminophen 1g PO (2hrs before procedure) Intraoperative: Spinal anesthesia using 10-15mg bupivacaine Postoperative: Continuous Femoral nerve or adductor canal block infusion – 0.2% Ropivacaine @ 8-10mls/hr in case of Knee arthroplasty. Single shot Lumbar plexus or Fascia Iliaca block in case of Hip Joint arthroplasty. Gabapentin 300mg PO Q8 for 7 Days . Celecoxib 200mg PO for 72 hrs. Acetaminophen 1g PO for 72 hrs. Oxyodone PO

47. .......In a Nutshell Prefer Multi-modal approach for an excellent Post Operative analgesia thus leading to: Improved patient satisfaction and Doctor-Patient relationship. Early Mobilisation Early Discharge Reduced Complications ↓ likelihood of chronic pain