ug class pain ppt 7-12-22.pptx .for the pgs

useful for pgs too

1. REGIONAL ANESTHESIA & PAIN MEDICINE DR.G.UMA DEPT OF ANESTHESIOLOGY KIMS&RC

2. Anesthesia for the area to be operated Spinal, Epidural, Caudal Plexus Blocks(e.g.) - Brachial plexus block Peripheral Nerve blocks What is Regional Anesthesia?

3. Instructions Equipment Choice of anesthetic Positioning the patient Preparation of area to be blocked Choosing the nerves to block Preparation

4. Suitability for the type of surgery being performed Surgeon’s preference Experience in performing the block Physiological/mental state of the patient General Considerations

5. Improved patient satisfaction Less immunosuppression Less nausea and vomiting Non-general anesthetic option for patient with malignant hyperthermia Patient who is hemodynamically unstable or too ill to tolerate a general anesthetic Advantages of Peripheral Nerve Blocks

6. Neuraxial Techniques Spinal (subarachnoid) anesthesia Epidural anesthesia (lumbar and thoracic) Regional Anesthesia

7. In addition to some of the peripheral nerve block indications… Patient mentally prepared to accept neuraxial blockade No contraindications No need for routine labs unless meds or conditions dictate this Indications for Neuraxial Blockade

8. Patient refusal Infection at the site of injection Coagulopathy Severe hypovolemia Increased Intracranial pressure Severe Aortic Stenosis Severe Mitral Stenosis Ischemic Hypertrophic Sub-aortic Stenosis Absolute Contraindications for Neuraxial Blockade

9. Sepsis Uncooperative patients Pre-existing neuro deficits/neurological deficits Demylenating lesions Stenotic valvular heart lesions (mild to moderate Aortic Stenosis/Ischemic Hypertrophic Sub-aortic Stenosis) Severe spinal deformities Relative Contraindications

10. Superior analgesia to IV PCA in open abdominal procedures & specifically in colorectal surgery Reduce incidence of paralytic ileus Blunt surgical stress response Improves dynamic pain relief Reduces systemic opiate requirements Facilitates early oral intake, mobilization and return of bowel fx when part of fast track protocols Benefits of Epidural Analgesia

11. Involves blockade of nerve impulses using local anesthetics (LA) LA bind sodium channels preventing propagation of action potentials along nerves Wide variety of LA with different characteristics: ie. Lidocaine – fast onset, short duration of action ie. Bupivacaine (Marcaine) – slow onset, longer duration Regional Anesthesia

12. Peripheral Nerve Blocks Upper Limb: Brachial plexus Lower Limb: Femoral, sciatic, popliteal, ankle Abdomen: TAP blocks Thoracic: Paravertebral, intercostal blocks Use of Ultrasound Imaging has revolutionized peripheral nerve blockade Safety? Accuracy / Improved Success Efficiency Regional Anesthesia

13. Distortion from local infiltration Large area Most efficacious Extensive manipulation

14. Pain is the fifth vital sign

15. Pain is perfect miserie , The worst of all Evils, And if excessive, Overturns all patience! Milton

16. “It is important what you have, What is more important is what you do With what you have”

17. Multi modal analgesia Individualized therapy New modalities---- Transdermal patches of opioids,NSAIDS etc analgesia in low dose & less side-effects Sustained-release epidural morphine ‘ Depodur ’- microcapsules epidurally --single-dose extended-release epidural morphine Tapentadol -an interesting new molecule that activates opioid receptors and inhibits norepinephrine uptake Basic research is in the inhibition of breakdown of endogenous opioids with opiorphin , targeting of the endocannabinoid system, and the use of ampakines to obtund opioid-induced side-effects Availability of infusion pumps and syringe pumps- for continuous infusions Acute pain

18. “Pain is all in the mind” “Surgery will be associated with pain” Does it have to???

19. ROLE OF PAIN 1. Focus attention and empathy 2. Protect body from further damage 3. Gives rest to the part - helps healing 4. Immediate benefit to patient/caregiver 5. Disposition to care for people in pain

20. “Unpleasant sensory or emotional experience associated with actual or potential damage or described in terms of such damage!” IASP definition of PAIN

21. Most common annoying complaint Most inadequately assessed & treated symptom Most difficult sensation to define - protopathic Subjective, but not personal & is of vital importance Most important person is the observer - hears beyond the words - sees behind the picture PAIN

22. Post - operative Trauma Burns Medical procedures Signals organic disease,easy to diagnose Disappears with Rx Opioids are specifically effective WHAT IS ACUTE PAIN?

23. Lack of awareness - surgery is assoc. with pain “Pain not visible”- not assessed Understaffed anaesthesia dept.( freelancing) Myths & fears assoc. with opiates/ underprescription , Unavailability of opiates and preservative free drugs Patient expenditure when using sophisticated equip WHY IS ACUTE PAIN BADLY MANAGED?

24. Surgery--> tissue damage/ release of mediators CNS stimulation and pain perception CVS - Increase BP, HR, Workload RS - Increase work of breathing Renal /GIT - decreased function Inadequate --- cause of 30% chronic pain WHY TREAT ACUTE PAIN?

25. Stress hormone release, catabolism, lipolysis Hyperglycaemia & glucose intolerance Retention of Na+ & H2O, excretion of K+ Impaired wound healing–reflex vasoconstriction Reflex skeletal muscle spasm-hypoventilation Recovery & Rehabilitation delayed NEURO – ENDOCRINE RESPONSES

26. Pain atleast 2 months duration after surgery Other causes excluded - malignancy, c/c inf Mastectomy, cholecystectomy, thoracotomy Inguinal hernia, laminectomy, amputations Phantom sensations with / without pain Neuroplasticity / continuation of pre-op pain CHRONIC PAIN AFTER SURGERY

27. “Patient is the best sensor of his pain, Believe his pain”

28. Pain receptors – free nerve endings Nerve fibres - A delta (a/c) & C fibres (c/c) Neurotransmitters – excitatory / inhibitory Algogenic substances - leucotrienes -serotonin -substance P -histamine -Prostaglandins PAIN MECHANISMS

29. Pain receptors Spinal cord - dorsal horn cells Spinal cord tracts Reticular formation - HR, BP, resp changes Thalamus, Cortex- conscious awareness WIND–UP of pain, PRE-EMPTING pain PAIN PATHWAY

30. Nociceptors – activated by tissue damage Pain – perception of noxious stimulus Suffering - negative affective response Pain behaviours - linked to suffering Subjective - emotional, psychological CLINICAL PHENOMENA

31. Every patient different, Multimodal therapy All pain protocols not suitable for all patients If one protocol fails, choose another Rescue analgesics mandatory No IM opiates when already on other opiates Discuss with the surgeons / assure safety EMPHASISE AND STRESS

32. Medical Reasons: Improved respiratory function Earlier ambulation --> DVT Shorter post - op hospitalisation Cost to patient and hospital less Comfortable and pain- free patient NEED FOR ADEQUATE PAIN RELIEF

33. Traditional I/M route disliked by all Big prn doses ---> sedation, analgesia, pain Underprescription due to myths & fears Relies on another person for pain relief Multiple needle sticks --> infection Variability in absorption ---- peak time & conc : NEED FOR NEWER METHODS

34. ANY PAIN THERAPY not “One size fits all or Set and forget therapy. Is essentially a maintenance therapy”

35. GOALS OF ACUTE PAIN SERVICES “ NO MAGIC BULLETS” Ensure all patients pain-free at rest, on movt . Discourage IM analgesics and prn orders Switch to S/C routes wherever possible Standard protocols to avoid confusion Prevent pain – round the clock drugs

36. Posters Make “PAIN” visible APS Sheets Free services initially and contactable any time Equipment technician-maintenance/record of equip. Anaesthesia technician –adequate supply of epi.cocktail IMMEDIATE back up and advice whenever required. Encouragement / acknowledgement in plenty

37. “Any drug is valueless if it remains in the ampoule, bottle on infusion pump.” It has to be give in adequate doses at adequate time intervals to be effective, whatever technique you use.

38. MODALITIES AVAILABLE 1.Intravenous 8. Oral 2. Subcutaneous 9. Rectal 3. Intrathecal 10. Transmucosal 4. Epidural 11. Transdermal 5. Via peripheral nerves 12. Sublingual 6. Direct wound infiltration 13. Intranasal 7. Interpleural 14. Intra- articular

39. Multimodal pain therapy NSAIDs, Opiods Spinal & Systemic Opiods Regional

40. Subcutaneous opiates Continuous opiate infusions - I/V, S/c Epidural / intrathecal LA + opiates / infusion PCA via I/V, S/C, epidural routes Nerve blocks / Interpleural / intra-articular/ PV Oral / rectal / parenteral NSAIDs

41. . Improves controllability through any route Prevents fluctuating analgesic concs : Does not have to rely on others Rate adjustments may be required Post-op pain intensity not the same thru CONTINUOUS INFUSIONS

42. Continuous I/V, S/C, epidurally Morphine-1mg/ml: pethidine10mg/ml: Initially 1 ml/ hr with naloxone I/V or S/C Ensure pumps functioning well Most common causes of patient mishaps - pump dysfunction - errors in programming OPIATE INFUSIONS

43. Infusions set at 5-10 ml / hr for 72 hrs 0.1%bupivacaine + 2-5ug/ml fentanyl Monitor pulse, BP, respiration closely PCEA - bolus 5-8ml: LOI-15-20 mins Catheter migration - I/V or dural space Premixed syringes - LA + opioids EPIDURAL INFUSIONS

44. Fig.2. ELECTRONIC PCA PUMP MEAC

45. Analgesia on demand Patients can regulate analgesic to MEAC Sense of control over his pain High acceptance and popular Decreased drug usage via any route Trained staff, back up, education PATIENT - CONTROLLED ANALGESIA (PCA)

46. Must understand the concept of PCA Must be willing to use it Must be able to perceive pain intensity Must be able to respond Must be relieved of all doubts Must not be an `Opiate-abuser ’ THE PATIENT IN PCA

47. Pumps with patient demand button Ensure pump is locked, key kept safe Set 1 ml boluses, no background infusion Lockout interval - 5-10 mins 1/V, S/C Disposable PCA pumps available Note total dose consumed by the patients PCA PUMPS

48. Demand made only by the patient Lock- out interval for full effect of drug Negative feed- back and dose limits Demand/infusion modes/computer integrated PCEA Fail-proof designing of pumps ( max.dose limits) Lockable, monitor incorporated pumps (O2,BP) SAFETY ASPECTS OF PCA

49. Fig.1.DISPOSABLE PCA PUMPS

50. Intrathecal Analgesia Spinalcord stimulation Radiofrequency ablation Ultrasound guided/Nerve stimulator guided specific nerve blocks Chronic pain

51. Resp depression/ sedation/ pruritis Hypotension/ bradycardia/ urine retention Have mephentine & naloxone in the ward Call the Pain physician Meanwhile treat with O2,vasopressors & fluids Instructions on the APS sheets COMPLICATIONS WITH OPIATES

52. “ACUTE PAIN SERVICES Looks good from far, Actually Far from good!” RAWAL

53. All patients pain-free entire post-op period Standard protocols to avoid confusion Discourage IM analgesics/ use other techniques Switch to other routes whenever one fails Routine patient observation charts/ audits Create Awareness among Surgeons/ Nurses Better relationship between Nursing staff & pts APS IS TO ENSURE

54. Origin of Pain Acute Pain ie. Incisional pain, acute appendicitis Chronic Pain ie. Chronic back pain Acute on Chronic Pain Acute and chronic causes may or may not be related to each other Pain Assessment

55. Pain Assessment Visual Analogue Scale

56. Current Pain Medications Accuracy and detail are very important! Name, dose, frequency, route ie. Oxycontin 10mg PO TID Don ’ t forget to re-order or factor in patient ’ s pre-existing pain Rx usage when writing orders Conflicts with HPI / PMH Renal disease → avoid morphine, NSAID ’ s Vomiting → avoid oral forms of medication Short gut/high output stomas → avoid CR formulations Pain Assessment

57. Allergies / Intolerances Drug allergies Document drug, adverse reaction and severity Intolerances Nausea / vomiting, hallucinations, disorientation, etc. Very important to differentiate between an allergy and an intolerance! Pain Assessment

58. Pharmacologic Medications (po, iv, im, sc, pr, transdermal) Acetaminophen NSAIDs Opioids Gabapentin NMDA antagonists Alpha-2 agonists Procedures Regional Anesthesia LA infiltration at incision site Surgical Intervention Non-Pharmacologic / Non-Surgical Methods to Treat Pain

59. WHO Analgesic Ladder

60. 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 Multimodal Analgesia

61. First-line treatment if no contraindication Mechanism: thought to inhibit prostaglandin synthesis in CNS → analgesia, antipyretic Only available in po form in Canada Typical dose: 650 to 1000 mg PO Q6H Max dose: 4 g / 24 hrs from all sources Warning: ↓ dose / avoid in those with liver damage Acetaminophen

62. Also, first-line treatment Mechanism Block cyclooxygenase (COX) enzyme → ↓ prostaglandin synthesis COX-2 → Prostaglandins → pain, inflammation, fever COX-1 → Prostaglandins → gastric protection, hemostasis NSAIDs

63. Warnings: ↓dose / avoid if GI ulceration Bleeding disorders / Coagulopathy Renal dysfunction High cardiac risk – COXII inhibitors Asthma Allergy ?Avoid celecoxib if allergic to Sulpha Concern for anastomotic leaks? NSAIDs

64. Dilaudid 1-4mg PO/IM/IV/SC Q3H PRN Any concerns? Opioids

65. Key Points: Centrally acting on opioid receptors No ceiling effect High dose/response variability in non-opiate users Previous dependence creates a challenge in acute on chronic pain management cases Balancing safety and efficacy can be difficult (OSA patients) Side effects may limit reaching effective dose Opioids

66. Side Effects Nausea / Vomiting Sedation Respiratory Depression Pruritus Constipation Urinary Retention Ileus Tolerance Opioids

67. Morphine Most commonly prescribed opioid in hospital Metabolism: Conjugation with glucuronic acid in liver and kidney Morphine-3-glucuronide (inactive) Morphine-6-glucuronide (active) Impaired morphine glucuronide elimination in renal failure Prolonged respiratory depression with small doses Due to metabolite build-up (morphine-6-glucuro nide) Opioids

68. Hydromorphone (Dilaudid) Better tolerated by elderly, better S/E profile Preferred over morphine for renal disease patients Low cost, IV and PO forms available Oxycodone Good S/E profile, but $$ PO form only Percocet (oxycodone + acetaminophen) Opioids

69. Codeine 1/10 th Potency of morphine Metabolized into morphine by body Ineffective in 10% of Caucasian patents Challenge with combination formulations Meperidine (Demerol) Not very potent Decreases seizure threshold, dystonic reactions Neurotoxic metabolite (normeperidine) Avoid in renal disease Opioids

70. Short acting forms Need to be dosed frequently to maintain consistent analgesia Controlled Release forms Provides more consistent steady state level Helpful for severe pain or chronic pain situations Never crush / split / chew controlled release pills Opioids - Formulations

71. Drug Equianalgesic Dose Initial Adult Dose (>50kg) IV/SC/IM Oral IV/SC/IM Oral Morphine 10 mg 20-30 mg 2-10 mg q4h 5-20 mg q4h Hydromorphone 1.5 mg 4-7.5 mg 0.5-2 mg q4h 1-4 mg q4h Oxycodone N/A 10-20 mg N/A 5-10 mg q4h Opioid Equianalgesic Table

72. Opioids – PCA

73. Allows patient to reach their own minimum effective analgesic concentration (MEAC) Rapid titration (Morphine 1mg IV every 5 min) Better analgesia and less side effects than IM prn Opioids – PCA

74. Anti-epileptic drug, also useful in: Neuropathic pain, Postherpetic neuralgia, CRPS Blocks voltage-gated Ca channels in CNS Additive effect with NSAIDs Reduces opioid consumption by 16-67% Reduces opioid related side effects Drowsiness if dose increased too fast Gabapentin

75. Nausea / Vomiting Ondansetron (Zofran) Dimenhydrinate (Gravol) Metoclopramide (Maxeran) Changing medication(s) / ↓ dose Pruritus Diphenhydramine (Benadryl) Changing medication(s) / ↓ dose Management of Side Effects

76. Radiofrequency ablation

77. Accurate pain assessment Make sure to continue or account for patient ’ s pre-hospital pain regimen Use Multimodal pain management Discharge pain management plan Acute Pain Service available 24 hrs/day Summary

78. Superior analgesia, ↓ side effects means: Improved patient satisfaction Better rehabilitation Earlier functional return Earlier discharge from hospital ↓ likelihood of chronic pain Reduced health care costs Summary

79. Nerve Blocks of the Digits Anatomy Technique Dorsal approach

80. Nerve Blocks of the Digits Anatomy Technique Dorsal approach Ring block Palm approach

81. Nerve Blocks of the Lower Extremity

82. Ankle Metatarsals Toes Nerve Blocks of the Lower Extremity

83. Nerve Blocks of the Ankle

84. IVRA-BIER’S BLOCK