Management of Post Operative Pain: to make doctors conscious about the benefits of multimodal analgesia.

Multimodal analgesia.

1. Management of postoperative pain Dr Nilima Afrin Anirban Anaesthesiologist , Department of Anaesthesia & ICU, Shaheed Ziaur Rahman Medical College Hospital

2. Introduction Optimal management of postoperative pain is important for early mobilisation, reduce morbidity, minimise long term impact on function and quality of life

3. What is pain? According to IASP, “An unpleasant sensory and emotional experience associated with or resembling that associated with, actual or potential tissue damage.” This definition highlights that, pain perception is subjective. Individual’s emotion has a huge impact on pain perception.

4. Factors influencing experience of pain

5. Pain Pathway

6. Classification of Postoperative Pain according to duration

7. Risk factors for persistent postsurgical pain

8. Pain measurement tools

9. VISUAL ANALOGUE SCALE

10. Wong-Baker FACES Pain Rating Scale

11. Adverse effects of postoperative pain

12. Treatment of Postoperative Pain WHO designed Modified Analgesic ladder is widely used concept in management of postoperative pain

13. Multimodal Analgesia Combines different classes of medications having different (multimodal) pharmacological mechanisms of action,resulting in additive of synergistic effects to reduce postoperative pain

14. Effects of Analgesics on Pain Pathway

15. Pre-emptive analgesia An intervention given before surgical incision with the intention to provide greater analgesia. E.g.tab paracetamol, tab gabapentin taken orally within two-three hours preoperatively.

16. Preventive Analgesia Interventions during the perioperative period with the aim of reducing postoperative pain and/or analgesic consumption.

17. Regional Anaesthesia

18. Types of Regional Anaesthesia

19. Some neuraxial block techniques

20. Peripheral nerve block techniques

21. Some peripheral block techniques..

22. Benefits of Regional Analgesia

23. Disadvantages

24. The Opioid The backbone of most postoperative analgesic regimens. Analgesic requirements vary according to type of surgery,fitness of patients etc.

25. Common routes of opioid administration Intramuscular : Commonly used. Painful to administer and results in variable plasma drug levels. Intravenous : More reliable method. It includes -Incremental small boluses titrated against effect. So, accidental overdose is reduced but analgesia may be inadequate. -Continuous infusion -Patient-controlled analgesia Subcutaneous Transdermal (fentanyl, buprenorphine)

26. Continued… Subcutaneous : useful if iv access is limiteed Transdermal : slow- release patches are stuck to the skin . eg , fentanyl, buprenorphine patches Oral : use may be restricted by inability to drink, nausea, vomiting, delayed gastric emptying, first-pass metabolism. Sublingual : avoids injection but suffers the disadvantages of intermittent administration. Rectal : less common Regional : Spinal, epidural, intra-articular

27. Patient Controlled Analgesia

28. Side effects of opoids

29. Non-opioid Analgesics(NSAID) NSAID : analgesic, anti-inflammatory. Associated with GI upset and acute kidney injury, impairment of platelet function . Contraindications of NSAID : h/o PUD, GI bleeding, renal impairment, previous hypersensitivity reactions, asthma, bleeding diathesis Should be avoided in dehydrated and hypovolaemic patient Should be used carefully in elderly. The Salicylates are absolutely contraindicated under 12 years of age to prevent Reye’s syndrome.

30. Acetaminophen(Paracetamol) A common component of multimodal analgesia Analgesic effect is 20-30% less than NSAID Produce synergistic effect together with NSAID Routine use of paracetamol along with regional technique may allow NSAID to be reserved for breakthrough pain

31. Continued… Gabapentinoids : Use of Oral gabapentin and pregabalin, preoperatively as a single dose may reduce postoperative pain and opioid consumption in first 24 hr following surgery. Common side effects : sedation, dizziness, risk of patient fall NMDA Antagonist (Ketamine): Beneficial in patient on chronic opioid use. But side effects involving CNS & CVS are present

32. Continued…

33. Postoperative pain management in pediatric patient Should follow the same basic principles as for adults: Multimodal technique with regional anaesthesia Care should be taken regarding dose calculation. eg in case of circumcision, herniotomy: caudal block under deep sedation which provide back up in postoperative period. Then regular paracetamol/ NSAID

34. Acute pain service A multidisciplinary approach to control postoperative pain effectively. It involves Anaesthetists, specialist nurses, clinical pharmacist They provide regular patient assessment, provide training of medical and nursing stuff to improve understanding of analgesic method and pain asessment

35. Some practical examples

36. Continued… In laparoscopic procedures: Pre-emptive analgesia> Administration of local anaesthetics in intraperitoneally and port side –reduces postoperative analgesia requirements. In major orthopaedic surgeries: neuraxial blocks using epidural catheter, other peripheral blocks are beneficial for postoperative pain management.

37. Continued… In neck surgeries , Cervical plexus block is very helpful to manage postoperative pain and it reduces opioid requirement. In neurosurgeries , Scalp block is very much effective for this purpose. In obstetric surgeries neuraxial blockade with or without Cather in situ along with initially opioid then NSAID with paracetamol are used.

38. Sono guided Femoral nerve block In Orthopedics OT by Anaesthesia Dept in SZMCH

39. Glimpse of activities of our Anaesthesia Dept Postoperative pain management by epidural technique by honourable head sir of Anaesthesia dept

40. Sono guided rectus sheath block for postoperative pain management in cholecystectomy patient

41. Management of per operative and postoperative pain in radiology dept for brachytherapy probe insertion

42. Part of Anaesthesia Dept of SZMCH