post op pain mgt and care of patient pptx

hello this is post op

1. kEY cONCEPTS iN pOST -OPERATIVE pAIN mANAGEMENT

2. An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage . IASP Pain Definition (1994, 2008 ) According to Katz and Melzack , pain is a personal and subjective experience that can only be felt by the sufferer. It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience. Julius Caesar What is Pain?

3. ACUTE PAIN CUTANEOUS PAIN DEEP SOMATIC PAIN VISCERAL PAIN CHRONIC PAIN REFERRED PAIN NEUROPATHIC PAIN PHANTOM PAIN TYPES OF PAIN

4. Pain Assessment Visual Analogue Scale

5. Why Treat Pain? Basic human right! Moral responsiblity ↓ suffering and post operative complications ↓ likelihood of chronic pain development ↑ patient satisfaction

6. Consequences of poorly managed acute post-operative pain The Patient may suffer from: CVS: Tachycardias , dysrhythmias , Ischaemia Resp : atelectasis , pneumonia GI: ileus , anastamosis failure Hypercoagulable state: DVT Impaired immunological state: Delayed wound healing

7. Psychological: Anxiety, Depression, Fatigue, Sleep Deprivation Chronic Post-surgery Pain ForThe Healthcare professional: Low Morale Complaints to/towards/against Institute Litigation Consequences of poorly managed acute post-operative pain

8. CAUSES OF VARIATION IN ANALGESIC REQUIREMENTS Site and type of surgery Age, gender Psychological factors Pharmacokinetic variability Pharmacodynamic variability

9. Surgical pain Mild Intensity Pain Herniotomy Varicose vein Gynecological laparotomy Moderate Intensity Pain Hip replacement Hysterectomy Maxillofacial Severe Intensity Pain Thoracotomy Major abdominal surgery Knee surgery Paracetamol /NSIADs / weak opiods Wound infiltration Regional block analgesia Add weak opioid or rescue analgesia Paracetamol /NSIADs +Wound infiltration Peripheral nerve block Systemic opioids PCA Paracetamol / NSIADs + Wound infiltration Epidural anesthesia Systemic opioids PCA Treatment modality Surgical procedure

10. WHO Analgesic Ladder

11. WHO analgesic guidelines Oral medications whenever possible Dose “by the clock” – but always have “as needed”medications for breakthrough pain Titrate the dose Use appropriate dosing intervals Be aware of relative potencies Treat side effects

12. 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 Can provide additive or synergistic effects Provides better analgesia with less side effects (mainly opiate related S/E) Always consider multimodal analgesia when treating pain

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

14. Methods to Treat Postoperative Pain Pharmacologic (Medications (PO/IV/PR) Acetaminophen ( Paracetamol ) NSAIDs Opioids Alpha-2 agonists Procedures Regional Anesthesia LA infiltration at incision site Nonpharmacologic Approaches Music and Audioanalgesia Transcutaneous electrical nerve stimulation (TENS)

15. Site of Action of Analgesics

16. Acetaminophen ( Paracetamol ) First-line treatment if no contraindication Mechanism: thought to inhibit prostaglandin synthesis in CNS → analgesia, antipyretic Typical dose: 650 to 1000 mg PO every 6H Max dose: 4 g / 24 hrs from all sources Warning: ↓ dose / avoid in those with liver damage

17. NSAIDs First-line treatment Mechanism Block cyclooxygenase (COX) enzyme → ↓ prostaglandin synthesis COX-2 → Prostaglandins → pain, inflammation, fever COX-1 → Prostaglandins → gastric protection, hemostasis  No physical dependence  No tolerance  Ceiling effect

18. NSAID Drug Dosage Maximum daily dose Diclofenac Piroxicam Ibuprofen Ketorolac Ketoprofen 50 mg PO bd / tds 20 mg OD 200-800 mg q 6 hr. 3 x 30-40 mg/day (only IV form) 4 x 50 mg/day 200 mg 40 mg 3200 mg Cox-2 inhibitor Celecoxib Parecoxib 100-200 mg PO bid 40 mg followed by 1-2 x 40 mg/day (IV form) 400 mg

19. NSAIDs Warnings: ↓dose / avoid if GI ulceration Bleeding disorders / Coagulopathy Renal dysfunction High cardiac risk – COXII inhibitors Asthma Allergy

20. Tramadol Multiple mechanism Weak µ-receptor agonist Inhibit serotonin & NE reuptake Application : Mild to Moderate Post-op pain Dose : 50-100 mg PO q 4-6 hr. Max. 400 mg/d Side effect: Nausea and Vomitting

21. Opioids Essential element of pain management Mechanism Action on opioid receptor Located mainly in spinal cord & brain stem, some in peripheral tissue

22. Opioids receptors Receptors Mu ( μ or OP3) μ 1 μ 2 Kappa ( κ or OP2) Delta ( δ orOP1) Sigma( σ ) Clinical effect Analgesia, sedation, euphoria Resp. depression, physical dependence Spinal analgesia, resp. depression Analgesia, resp. depression Dysphoria , hallucination, tachycardia hypertension

23. Opioids 1.Agonists : stimulate receptor : no ceiling effect ( no limit mg/kg) : moderate to severe pain : Codiene , morphine, pethidine , fentanyl , methadone

24. Opioids 2. Partial agonists : ceiling effects eg . Buprenorphine

25. Opioids 3. Agonists-antagonists : agonist- κ or σ receptor but antagonist to μ receptor : can used in mild to moderate pain : ceiling effects : precipitate withdrawal in opioids dependent E.g : P entazocine , Nalbuphine , Nalorphine

26. Side Effects include: Nausea / Vomiting, Pruritus , Constipation, Urinary Retention, Ileus , Sedation, Respiratory Depression, Tolerance Opioid Overdose Manifests as Somnilence , respiratory depression, bradycardia , miosis . Management: Stimulate patient Attach Monitors/ IV Lines and record Vitals Airway, Breathing, Circulation Shift to ICU Opioids

27. Opioid Overdose Opioid Reversal Naloxone - Pure antagonist at all the Opioid receptors Reverses effects of opioid overdose (for 30-45min) 0.4mg ampuole Dilute: 1mL Naloxone + 9mL Saline = 0.04 mg/ mL conc. Give 0.04 to 0.08 mg (1 to 2 mL ) IV every 3-5 minutes till condition improves

28. Local Anaesthetics LA bind sodium channels preventing propagation of action potentials along nerves Wide variety of LA with different characteristics: Lidocaine (Lox) – fast onset, short duration of action Bupivacaine ( Sensorcaine ) – slow onset, longer duration Ropivacaine : longer duration, less cardiotoxic

29. Agents Lidocaine -infiltration -epidural -plexus or nerve Bupivacaine -infiltrate -epidural -plexus or nerve % solution 0.5-1 1-2 0.75-1.5 0.125-0.25 0.25-0.75 0.25-0.5 Duration(h) 1-2 1-2 1-3 1.5-6 1.5-6 8-24+ Max dose 7mg/kg 3 mg/kg Local Anaesthetics

30. Potential side effects of Local anesthetics - Residual motor weakness - Peripheral nerve irritation - Cardiac arrhythmias - Allergic reactions Sympathomimetic effects (due to vasoconstrictors)

31. Regional Anesthesia techniques in PostOperative Pain Management

32. Peripheral nerve blocks Ilioinguinal / hypogastric : herniorrhaphy Brachial plexus : arm, hand Thoracic: Intrapleural Regional Anaesthesia (IPRA), Paravertebral , intercostal blocks Penile : circumcision Intercostal / paravertebral : breast Lower Limb: Femoral, sciatic, popliteal , ankle Paracervical : F&C, D&C, cone biopsy Abdomen:TAP blocks

33. Epidural Analgesia Epidural Catheter placed in lumbar or thoracic segments. LA+ Opioids given via bolus dosing, Infusion pump or Patient Controlled Analgesia pump Superior analgesia compared to Intravenous drugs in thoracic/ abdominal procedures Reduced systemic opiate requirements Improves GI blood supply

34. Patient Controlled Analgesia Pump

35. Regime for using IV Morphine in PCA pump

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

37. 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

38. A model for organizing postoperative pain management unit

39. A model for organizing postoperative pain management

40. ....... In a Nutshell Excellent Post Operative analgesia means : Improved patient satisfaction and Doctor-Patient relationship. Better rehabilitation Earlier discharge from hospital & return to function ↓ likelihood of chronic pain Reduced health care costs