Post operative pain management

pain physiology. pain management. post operative procedure to manage pain. different analgesic formulas.

1. POS T - OPER A TIVE P AIN MAN A GEME N T DR. SUMAN PAUL Medical Officer Dept. of Orthopedic Surgery & traumatology Rajshahi Medical College Hospital

2. Der i v ed f r om G r eek “ P oi n ”; meani ng “ P enalt y ” De r i v ed f r om L a t i n “ P o e n a ”; mean i ng “ Pu n is h me n t f r o m God” HI S T O R Y 2

3. Homer - Ar r o w s Sho t b y th e G o ds Ari st otle – di s tinguish fi v e senses , c on s ide r ed pai n t o b e P assi o n o f the Soul Pl at o – pai n and pleasu r e a r o s e f r o m within and c on s ide r ed pain t o b e an e moti o na l e xp e rienc e than a lo c ali z ed bod y sens a tion Hi p poc r at e s – imbalanc e o f bod y fluids Bi b le - Anguish o f t h e Soul F r eu d - Solutio n t o Emotiona l Co n flicts 3

4. P ain is … p r o t ecti v e mechanism lo c ali z e d sens a tion as a r esu l t o f n o xiou s s t i mu l a t i on n o w r e c ogni z ed as bein g mo r e o f an e xper i enc e than a sen s a t i on 10 CHANGIN G C ONCEP T O F P AIN

5. An un p leasa n t emotional e x p e r ience associ a t ed with ac t ua l o r po t e n tial tissue dama g e o r descr ibed in t erms o f suc h dama g e. I n t e rnati o na l Ass o ciation f o r the Stud y o f P ai n (IASP ) (W H O ) 5 DEFINITION

6. T r ans i e n t P ain Shor t du r a tion S e v e r e Sel f limiting Acu t e Associ a t ed with po s t ope r a ti v e, po s t i n jury R equ i r es pharm a c ologi c al assi s t ance ( anal g es i cs) P e r si s t e n t Lon g t e r m du r a tion E g. : Cance r & neu r o g enic pain Pharma c ol o gi c al assi s t anc e ( anal g esic s ) and c o g niti v e app r oach Ch r onic or Disabling Co n tinue be y on d e xp e c t a tion f o r di s ea se p r ocess P ain and pai n the r a py domin a t e the li f e Dep r ession, a n xiety Dependi ng O n Du r a tion 15

7. PHY S ICAL CO N DITIONS P S YCHOLOGIC CO N DITIONS SO M A TI C P AIN NEU R O P A THI C P AIN M O O D D I SOR D E R S ANX IET Y D I SOR D E R S SO M A T O F OR M D I SOR D E R S O THE R C ON D ITI O NS 7

8. 2 P H YSIOL O GY OF PAIN

9. Pain invo l ves four physio l ogical processes: Transdu c tion Transmissi o n Perception Modulation

10. A x on R ef l ex Np : N e u r o - p ept i d e s , B V : Bl oo d V e ss el s

11. Bio l o g i c al Ge net i c v ari a t i ons leads di f f e r enc e s in am o u n t & type o f neu r ot r ansmi t t e r s. P r e vi o us pain e xp e rienc e Gen d er C o g n iti v e Y oun g er – r eport g r e at er le v el o f pain Olde r child r en unde rs t and the me a nin g o f pain U p t o 3 m o n th s - n o un d e r s t anding o f pai n bu t m e m o ry is p r e s e n t B y 6 m o n th r espond t o pain b y anger B y 20 mo n ths anger beco m es m o r e domina n t F ac t o r s Th a t I n fluen c e P ain

12. P s y cholog ial F e e ling o f lack o f c o n t r o l - i n t ensify pai n pe r c e p ti o n Sociocultu r al Di f f e r en c e in pe r c e p tion e xi s t among di f f e r e n t cultu r al g r oup P a r e n ts p e r ce p ti o n & r espo n se t o their child ’ s p ain s t r o n gly i n fluence child ’ s pe r c e p tion & hi s r ea ction t o pain

13. 3 POST OPERA T IVE PAIN

14. CA U SES OF POST OPERA T IVE PAIN Inc i sional Skin Subc u tan e o u s tiss u e Deep c u t t ing c o agulation I / V site Needle trauma E x travasation Irritation Tube D r a in N a s o g a s t r ic Endotr a c h ial tube Opera t i v e site Cast Tight dre s sing Others U r ina r y reten t i o n A mbulation

15. Acute Post - opera t ive Pain S u r ge r y T issue trau m a or ne r ve in j u r y I n fla m m a t ion d u e to rel e ase of infla m m a t o r y m edi a tors Hype r a l gesia and Allodynia

16. S e nsory r e c e pt o rs 1st or d er n e u ron D o rs a l r oo t Sp i nal cord 2 nd or d er n e ur o n Sp i n o thala m ic pat h w ay Inter n e u ron 3 r d or d er n e u ron T h al a mus & c ortex Muscle 40

17. Chronic Post -surgica l Pa i n Pain l a st i ng f o rm m o r e than 1 m o n th after su r ge r y R i sk factors f o r CPSP R e peat su r ge r y C a t a stro p hiz i ng A n xie t y Ge n e t ic p r edisposi t i on R a diat i on thera p y to that area Moderate to seve r e p o st-ope r a t i ve pain Su r gic a l appr o ach wi t h risk of ner v e da m age Ne u r o tox i c che m othera p y De p ression

18. P AIN MAN A G E ME NT

19. Wh a t d o surgeons want? Complete pain fre e post –operative period bu t al o ng wit h : Ear l y mobilizati o n E n hanced recovery Mai n taine d mu s c l e po w er Mi n ima l c o mpli c ations

20. Consequences of p oorly managed acute post-operative pain The Patient m ay s u f fer f r om : CV S : T a c h y ca r d i a s , Isc h a em ia Hy p e r co a g u l a ble s t at e: DVT Dimin i sh ed r a n g e of j o i nt mot i on a n d Arth r of i b r o s is a r e c l osely r e l ated to the d e g r ee of p o s t o p e r at i ve p ain

21. Psy c h o l o g i ca l: Anx i et y , D e p r es si on, Slee p Dep r iv at i on Pro l o n g e d h osp it a l s ta y s, i nc r e ase d h o s p i tal r e a dmis s i ons a n d i n cr e a s ed o p i oid use ForThe Hea l th c a r e p r of e s si o n a l: Low Mor ale Comp l a i nts to / towa r ds / a g a i n st In s t it ute L i ti gat i on Cons e quenc e s of poorly m a naged acu t e pos t -operative pain

22. How to E v aluate Pain (Scale)

23. WHO an a lgesic guidelin e s Ora l medications w h ene ve r possible Dose “by the c l o c k” – but a l w ays have “as ne e de d ”medi c ations fo r breakthroug h pain T itra t e t h e d o se Use appro p riat e dosin g i n tervals B e a w are of re l ative potencies T r eat side effe c ts

24. A n algesic l a dd e r

25. WHO An a lgesic La d der

26. PR E -OPER A TIVE MA N AGEME N T P R E -P R O C E D U R E E V A L U A TION P A TIENT E D U C A TION P R E -EM P TIVE A N D P R E V E N T A TIVE A N A L G E SIA PL A N

27. The preparation for Pos t- Ope r ative Analgesi a should start in th e Pr e - Operative

28. INTRA-OPER A TIVE MAN A GEME N T I . V MED I C A TIONS NEU R AXIAL TECHNIQUES TR A NS V ERSE A B D O M I NIS PLA N E BL O C K S PERIPHERAL NE R VE BLO C KS W OUND INF I L TR A TION ANEST H ESIA TUMESCENT ANAEST H ESIA T OPICAL LO C AL A N AES H TESIA

29. Me t hods t o Tr e at Posto p erative Pain Ph a rmacologic Ac e tami n op h en ( P a racetamo l ) N S AIDs Opio i ds A l ph a -2 ag o n i sts Procedures R e g i on a l A n esthes i a LA infiltration at i ncis i on site N o nph a rmacologic A p proa c hes Music and A u d i oa n a l gesia T ransc u tane o us e l ectrical n e rve stimul a tion (TE N S)

30. O p i o i d An a l ge s ics We a k opi o i ds C o d e i n e ph o s p hate 3 0- 6 m g 4 h D i hydr o c o deine 30 m g 4 -6 h po or 5 m g 4 - 6h im B u p r en or p hine 2 - 4 m c g s l 4 - 6 h T r a m a d ol w e a k ago n i s t 50- 1 m g 4h Stron g op i oids Na l buphine Morphine Di a m orph i ne Pet hid i ne: m ax 1.2g d a i l y

31. N on - o p i o i d A n al ges i cs Pa r a ceta m ol : A c e t a m i n o phen cen t r a ll y ac ti ng 5 m g - 1g 6h or 1 5 - 2 m g / kg f o r ch il d r en D i c l o f ena c s o di u m : 5 m g T D S o r a l l y As p i r i n : 3 00 -9 00 m g 4 h N SAID s : A n a l gesic, a n t i p y r e ti c ,ant ii n f l a m m a t o r y O p i oi d s p a r i ng S E : Pr o s t a g l a n di n and p r ost a c y c l i n e f f e c t I b up r o f e n , di c l o f e n a c, n a pr oxen, pi r oxi c a m

32. Sit e of Actio n of Analgesics

33. Multimo dal (Balanced ) Analgesia Us i n g more t h an one d r u g fo r pain c o ntrol Different drug s wit h diffe r ent mec h ani s ms/ sites of a c tio n al o n g pain pat h way Each wit h a lo w er dos e th a n i f use d al o ne Can provide ad d iti v e or sy n ergist i c effe c ts Provides bette r analgesia wit h less side effe c t s (mai n ly opiate rela t ed S/E) Alwa y s c o n s ider m ulti m odal analge s ia when treating pain

34. The a dmini s t r a t ion of analge s ic agen t s prior t o an injury in o rder to pr e vent develo p m e nt of central nervous s y s t em hypere x ci t ability . Pre e mptive an a lgesia

35. Acetamin o phen ( Parace t amo l ) Firs t- line t r eatment if no co n t r aindi c ation Me c h a ni s m : tho u g h t to inhi b it pro s tagla n din s y nth e sis in CNS → a n alg e si a , a n tipyretic T y p ic a l d o s e : 6 5 0 to 10 0 mg PO e v ery 6H Max d o s e : 4 g / 2 4 hrs from all so u rces W arnin g : ↓ do s e / avoid in t h o se with liver d a ma g e

36. NSAIDs Firs t - line tre a tment Mechanism Bloc k cyc l oox y genase (C O X) e n zym e → ↓ pro s t a glandin s y nt h esis CO X - 2 → Pr o s t a g land i n s → p a in , inf la m m a ti o n, f e ver CO X - 1 → Pro s t a glandins → g a st r ic protection, h e m o st a sis  No physic a l dependence  No to l erance

37. NSA ID Drug Dosage Maxi m um daily dose  Diclofe nac  Piroxic am  Ibuprofen  Ketorolac  Ket o profen 5 mg PO b d / t d s 2 mg O D 200 - 80 mg q 6 hr. x 30 - 4 mg / d a y (onl y I V for m ) x 5 m g / day 20 mg 4 mg 320 mg Cox- 2 in h ibitor  C ele coxib  P a recoxib 100 - 20 mg PO bid 4 mg fol l owed b y 1 - 2 x 4 m g / day (I V form) 40 mg

38. NSAIDs Warni ngs : ↓ dos e / avo i d if GI u lce ration Bl e eding disorder s / Coa g ulop a thy R e n al d y sfunction H i gh cardiac r i sk – CO X II in h ibitors Asthma All e rgy

39. Tramadol Multiple mechanism Weak µ -rec e ptor a g onist Inhi b i t serot o ni n & NE reuptake Applic a tio n : Mild t o Moderate Post - op pain Dose : 5 -10 mg PO q 4 - 6 hr. Max. 4 mg/d Side ef f e c t: Nausea and Vomitting

40. Opioids Es s ential element of pain man a gement Me c hanism Actio n on opioid rec e ptor Loc a te d m a in l y i n s pinal cord & b rai n ste m , s o me in peripheral tis sue

41. Opioid s receptors R e c e ptors Mu (μ or OP3) μ1 μ2 K a ppa ( κ or OP2) Delta ( δ orOP1) Sig m a ( σ ) C lini c al e f f e ct Analgesi a, sed a tion , eup h oria R e sp. depressi o n , physical dep e nde n ce Spina l anal g esi a , re s p. depres si o n Analgesi a, resp . depressi on D y sphori a , hallucina t ion , t a c h ycar d ia hyperte nsion

42. Opioids 1.Agonists : stimulate re c ep t or : n o ceiling ef f ect ( n o limit mg/kg) : moderate t o severe pain : Codiene, mor p hine, pe t hidine, fentany l , methadone

43. Opioids 2 . Partial agonists : cei l i ng effe c ts e g . Bupre n orp hi ne

44. Opio i ds 3 . Agonists - ant a gonists : ag o nis t -κ or σ re c ep t or bu t antagonist t o μ re c ep t or : can used i n mild t o moderate pain : c eiling effects : p re c ipitate withdrawa l in o p ioids dep e ndent E. g: P entazocine, Na l bup h ine , Nalorphine

45. Si de Effects inclu d e: Nausea / Vom i ting , Pruri t u s , C o nstipatio n , Urina ry Ret e ntion , Ileus , Sedati on, Respirator y Depre s si o n, T o lerance Opi o id Overdose M a nifest s as Somnil e nc e, respirator y d e pressi o n, b r adycard i a, miosis . Manage m ent: S t im u late p a t i e nt Attac h Monitors/ I V Lines and recor d Vitals Airway , Breathing , C i rculation Shif t t o ICU Opioids

46. Loc a l Anaesth etics LA bi n d sodium c h annels preven tin g propa g ati o n of a c tio n potentials al o n g ner v es Wide variet y of LA wit h diffe r ent c h ara c teristics: Li d ocaine – fas t onset, short dur a tio n of ac t ion Bupiva caine – slow onset, longe r dur a tion Ropivac a in e : l onger d ura t ion , le ss car d iot o xic

47. LOC A L A N AES T HE T ICS All l o ca l anaesthetic drugs can cause to x ic effects i f g i v en i n large d o ses o r i f acc i d e nt a l i n t r avascu l ar i n jection occurs. Central nervous system an d cardiov a scular tox i city can result in restl e ssness, hypotens i o n, convu l s ions, cardiac arrhythmias an d ev e n card i ores p iratory arrest. Dr u g S a fe Do s e B u p i vaca i ne 2 mg/kg L i gn o cai n e 3 mg/kg L i gn o cai n e (with adrena l i n e) 7 mg/kg

48. Poten tia l side effe c t s of Local anesth e tics R e si dual m o to r w e akness Peripheral nerv e irrit a ti o n Cardi a c arrhythmias Alle r gic reactions -Sympathomi m etic ef f e c t s ( d ue t o v a s o constrictor s )

49. N o n - Opi o id drugs : A n tin e ur o p a thic : Pre g a b lin 1 5 0 mg or Ga b a p e n tin 1 2 00 mg PO COX 2 i n hi b itor s : Cele c oxib 40 mg or V alde c oxib 40 mg PO N S AI D S: Ketor o lac 15 - 3 mg P O / I V; Ib u pr o fen 4 - 8 m g - R e d u ce e x c e ss int r a - o p erative o p ioid u s a g e - R e d u ce the p o s s ible e f fect of o p ioi d - in d u c ed h y p e ral g e s ia (para d o x ic a l low e ring of p a in thre s h o ld re s ulti n g in gr e at e r opioid requirements) p o s t- o p erativ e ly Preemptive an a lgesia

50. U s ing ro f ecoxib 24 h o u rs a n d 1 h o ur b e f o re surgery with cont i nued postop e rative drug adm i nistrati o n for 14 days h ad be t ter outcomes in t otal knee art h ro p last y . Th e se patient s s howe d redu c e d o p i o id requ i reme n ts, faster ti m e t o physi c al reha b il i tat i on, red u ced na u sea and vomitin g , b ett e r sleep pat t erns and gre a ter p a ti e nt satisfacti o n a f ter surger y . Preemptive an a lgesia

51. Spinal an e sthe s ia is administered usi n g 1 - 15mg b u pi v a c ain e . Ad d it i on of F e nta n yl 2 - 25 ug in c rea s es the p o st op e rat i ve an a lge s ia for 2 - 3 hours. Ad d it i on of Clo n idine 2 5 - 50 ug in c rea s es the p o st o p erative a n alg e sia for 6 - 8 h o urs. Addition of Mo r phine 0. 2 - 0.3 mg exte n ds the post o p erative a n alg e sia for 1 2 - 15 ho u rs. Intrathec al Analgesi cs

52. Epidur al Analgesia Ep id u ra l Ca t he t er plac e d i n lumbar or thoraci c s e g m ent s . LA+ Opioid s given via b olus dosing , I n fusio n pump or Pati e n t C o ntrolled An alg e sia pump • Superio r a nalgesia compared to Intr a venou s drug s in thoracic / a b domin al proc e d u res • Reduce d systemic opiate requirements • Im p ro v es GI b lood supp l y

53. Peripheral nerv e blo c ks

54. U P PER E X TR E MITY N E R VE BL O C K S TYPE NE R VES BLOCKED PROCED U RE S I TE CONT R A I N D I C A TION I N T ER S CA L E N E B RACH I AL P L E X US C5 - 7 SH O U L D E R A N D UP P ER ARM SE V ERE PU L MO N A R Y D I SE A SE PREE X I ST I NG CO N TRA L A TERAL PHRE N I C N E R V E P A L SY SUPRAC L A V I CU L AR B RACH I AL P L E X US A T OR B E L OW T H E E L B OW SE V ERE PU L MO N A R Y D I SE A SE PREE X I ST I NG CO N TRA L A TERAL PHREN I C N E R VE P A L SY I N F RAC L A V I C U L A R B RAC H I A L P L E X US D I S T A L T O E L B O W V A SC U L A R C A T H E T ERS I N T H I S RE G I O N . I PS I L A TER A L P ACEMA K ERS A X I LL A R Y B RACH I AL P L E X US D I S T AL T O E L B OW

55. LOWER E XTRE M ITY NE R VE BLOCKS TYPE NE R VES BLOCKED PROCE D U R E C/I SI T E L UM B AR P L E X US L 1 - 4 AN T T H I GH A N D MED I AL L EG SACRAL P L EX U S L 4- 5 AN D s 1- 4 POST T H I G H AN D MOST OF L EG A N D F O O T F EM O RAL H I P ,T H I GH , KN EE AND SAPHE N O U S N E R VE OF T H E A N K L E PRE V I OU S V A SC U L A R GRA F T I NG L A T E RAL F EM O RAL CU T A N E O US L 2- 3 L A T E RAL T H I G H O B T U R A T OR COMP L ETE ANA EST H ES I A O F T H E K N EE MED I AL L EG A N D ANK L E H I P ,T H I G H ,K N EE , L OWER L EG AN D F OO T SAPHE N O U S MOST MED I AL B RA N CH O F T H E F EM O RAL N E R V E SC I A T I C L 4 - 5 A N D S1 - 3 A N K L E SAPHE N O U S N E R V E ,D E EP PERON E A L ,SUP PERO N E A L ,POST T I B I A L ,SUR A L F O O T

56. Patient Con trolle d A n algesia Pump

57. A d vant a ges of PCA : Allow s patient participati o n and gives th e m autonomy in t heir tr e atment R a pid titration Precise Analgesi c calculations fo r scient if i c studies Reduce d an a lgesic requirements Reduce d inciden c e of br eakthr o ugh pain Less sta f fin g and monit o rin g co n cer ns

58. Coanalge s i c A gents A nx iol y ti c d r ug s A n ti c o nvu ls an ts A n tid e p r e s san ts K e ta m i n e

59. Ke t a mi n e P o te n t ana l ges i c e f f ec t Smal l d o se s i n co m b i n ati on o f o pi o ids s ubs ta n ti a l l y i m p r o ve p ai n c o n tro l B o l u s dos e o f 1 m cg /kg fol l owe d b y a c on ti n u ou s d rip o f 1 -3 m cg /k g / min i s i dea l f o r c hr on i c op i o i d us er s p os to p e r a tiv e ly

60. U s ag e o f A n t i - E p il e p t i c D r ug s i n A c u t e P a i n • E v e r y s u r g i c a l i n c i s io na l pa i n h a s N e u r op a t h i c c o m po n e n t S tud ie s s h o w e d g i v i n g 1 2 m g o f G a b a pe n t i n 1 h p r i o r t o s u r g e r y d e cr e a s e s th e op ioi d s r e q ui r e m e n t p o s t - o p a n d r e s u l t s i n b e t te r p a i n c o n t r o l w ith o u t i n c r e a s e d s e dat i o n Co m b i n in g Ga b ap e n t i n wi t h o p i oi d s i s i de a l f o r r e - d o b a c k s u r g e r y c a s e s wi t h c h r o n i c op i o id s u s a g e T he s e c l a s s o f d r u g s a r e a l s o m o d e s tab ili z e r s • • •

61. No n Chemi c a l T e c hniq u es P syc h o logi c a l t r e at m en t s : R e la x at ion , h y pn o s i s C o gnit i v e the r a p y et c . . T E N S U nit s Ph ys io t he r a p y

62. M u l t i d isci p l i na r y Ap p roac h A n ae s t heti st Ps y c h o l ogi s t S u rg e on P h ar m a c i s t N u r s e A c ute P a in T e am P h y si o t h e r a pis t

63. A m o de l fo r organiz in g postope r ati v e pain management unit

64. A model fo r organizing posto p erative pain man a gem e nt

65. Multimodal an a lgesia regime s a f ter Arthr o plasty Preoperat i ve: Gabape n tin 30 mg PO + C e l e co x ib 200mg PO + Acetaminophen 1g PO (2hrs b e fore proce d ure) In t raope r at i v e : S p i n al an e sthesia usi n g 1 -15mg bupivacaine Postoperat i ve: C o nti n u o us F e moral n e rve or a d d u ctor canal block infusion – 0.2% R o p i vaca i ne @ 8 -10mls/hr in case of Kn e e arth r op l ast y . Sing l e shot Lumbar ple x us or Fascia Ili a ca b l ock in case of Hip Joint arthrop l ast y . Gabapen t in 300mg PO Q8 for 7 D ays . Celeco x ib 20 mg PO for 72 hrs. Ac e tami n op h en 1g PO for 72 hrs. Oxyodone PO

66. .......In a Nutshell Prefer Multi - modal approach fo r an exc ellent Post Op e rative analgesia thu s l eading t o: Impr o ve d pati e n t sat i sfact i on and D o ct o r -Pat i ent relationship. Early Mobil i sation Early Di scharge Re d uced C o mplicat i ons ↓ like lihoo d of chronic pain