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Title: Anesthesia


1

Lecture Title Acute Pain Management
Lecturer name Osama Ibraheim
MD,SOB. Lecture date
2
Lecture Objectives..
3
Fundamental Considerations
  • Millions of patients worldwide undergo surgery.
  • Although developing more effective techniques
    for postoperative analgesia, many patients
    experience pain.

4
PAIN
An unpleasant sensory and emotional experience
associated with actual or potential tissue
damage.
IASP, Subcommittee on Taxonomy, 1979
5
ETIOLGY OF PAIN
  • HEAT
  • COLD
  • CHEMICAL
  • MECHANICAL
  • TORSION STRETCH CUT PINCH PRICK
    COMPRESS CRUSH

6
TYPOLOGY OF PAIN
  1. Acute
  2. Chronic benign
  3. Chronic cancer

7
Chronic Pain vs Acute Pain
  • Acute A Symptom of Injury or Disease
  • Chronic Benign Pain itself is the disease
  • Chronic Cancer Actual Tissue destruction

8
Adverse Effects of Pain
  1. Cardiovascular
  2. Pulmonary
  3. Gastrointestinal
  4. Renal
  • Extremities
  • Endocrine
  • CNS
  • Immunologic

9
Adverse Effects of Pain
  • Cardiovascular Tachycardia, hypertension,
    increased SVR, increased cardiac work, increased
    myocardial O2 demand.
  • Pulmonary Hypoxia, hypercarbia, atelectasis,
    decreased cough, decreased vital capacity and
    function residual capacity, V/Q mismatch.
  • Gastrointestinal Nausea, vomiting, ileus,
    intolerance for oral intake.
  • Renal Oliguria, urinary retention.

10
Adverse Effects of Pain
  • Extremities Skeletal muscle spasm, limited
    mobility, thromboembolism.
  • Endocrine Excessive adrenergic activity, vagal
    inhibition, catabolic metabolism, increased O2
    consumption.
  • CNS Sedation, fatigue, anxiety, and fear cause
    central sympathetic stimulation.
  • Immunologic Inhibited cellular immunity,
    increased risk of infection, ?? impaired wound
    healing ??

11
FREE NERVE ENDINGS ARE PRESENT IN ESSENTIALLY ALL
BODY TISSUES IN VARYING AMOUNTS
12
IN RESPONSE TO A PAINFUL STIMULUS, SUBSTANCES ARE
EXCRETED.
13
ALGOGENIC(substances released by pain)
  • SEROTONIN POTASSIUM
  • HISTAMINE ACETLYCHOLINE
  • BRADYKININS LEUKOTRIENES
  • PROSTAGLANDINS SUBSTANCE P29
  • NOREPINEPHRINE

14
THE RECEPTORS IN THE FREE NERVE ENDINGS RESPOND
TO THE SUBSTANCES BY BECOMING CHARGED
ELECTROCHEMICALY
15
RECEPTORS THEN PROPAGATE AN ELECTROCHEMICAL
STIMULUS TO DIFFERING NERVE FIBERS
16
NOCICEPTION
  • This electrochemical event that occurs
    between the site of tissue damage or injury sets
    off a series of neural transmissions that
    eventually results in the perception of
    painCollectively this known as nociception

17
NERVE FIBERPAIN CLASSIFICATION
  • A FIBER..SHARP-STABBING-LOCAL
  • FIRST PAIN
  • B FIBER....PHYSIOLOGIAL REACTION
  • C FIBER....DULL-ACHE-BURN-THROB
  • NONLOCALIZED-RADIATE
  • SECOND PAIN

18
NERVE FIBER CLASSIFCATION
  • TYPE
    FUNCTION
  • A a myelinated motor
  • A alpha myelinated touch-pressure
  • A beta myelinated touch-pressure
  • A delta myelinated
    pain-temperature
  • A gamma myelinated proprioception

19
A Delta
  • 1 - 4 micrometers diameter
  • Myelinated, Rapid conduction
  • Sharp, localized
  • Heat, cold
  • First pain

20
  • B myelinated
  • preganglionic autonomic
  • C non-myelinated
  • pain-temperature

21
C Fibers
  1. Small
  2. Slow Conduction
  3. Unmyelinated
  4. Postganglionic autonomic

22
C Fibers
  • Dull pain, burning, Aching throbbing
  • Nonlocalized - radiating - diffused
  • Temperature,Touch,Mechanical
  • Second pain

23
Gate Theory
  • Balance between A delta and C fibers to dorsal
    horn determines the intensity of the stimulus
    that is passed to higher brain center

24
Area of High Nociceptor Concentration
  1. Mucosal membranes
  2. Periosteum
  3. Deep fascia
  4. Ligaments
  5. Joint capsules
  6. Cornea
  7. Subcutaneous tissue

25
Areas of Moderate Nociceptor Concentration
  1. Skeletal muscle
  2. Cardiac muscle
  3. Smooth muscle

26
Areas of Minimal Nociceptor Concentration
  1. Bone
  2. Cartilage
  3. Marrow

27
Physiologic Processes of Nociception
  1. Detection
  2. Transduction
  3. Transmission
  4. Modulation
  5. Perception

28
Detection
  1. First pain
  2. Second pain

29
TRANSDUCTION
  • NOXIOUS STIMULI TRANSLATED INTO ELECTRICAL FIRING
    AT THE SENSORY NERVE ENDINGS

30
TRANSMISSION
  1. PROPAGATION OF IMPULSE TRAVELS VIA NEURAL
    PATHWAYS.
  2. SENSORY AFFERENT NEURONS PROJECT INTO THE
    SPINAL CORD
  3. ASCENDING NEURONS RELAY TO BRAINSTEM AND THALAMUS
  4. THALAMUS RELAYS TO CEREBRAL CORTEX

31
MODULATION
  • INTRINIC PAIN MODIFICATION
  • 1.DIFFERENT IN INDIVIDUALS
  • 2.DEPENDS ON.....
  • PAST EXPERIENCES
  • CULTURE
  • PSYCHIC

32
MODULATION-CONT
  1. STIMULUS PRODUCED ANALGESIA
  2. NEUROENDOCRINE ANALGESIA
  3. CNS/PNS ANALGESIA
  4. OPIOID ANALGESIA
  5. SITUATION
  6. PATHOLOGY
  7. PHYSIOLOGY

33
Modulation Excitatory Substances
  • Peripheral
  • Prostaglandins, bradykinins, histamine, K,
    substance P, serotonin (5HT2)
  • Spinal
  • Glutamate, aspartate, amino acids, substance P,
    norepinephrine (alpha 1)

34
Modulation - Inhibitory
  • Supraspinal
  • Endorphins, enkephalins, dynorphins,
    norepinephrine (alpha 2), GABA, somatostatin
    (5HT1), neurotensin

35
First Neuron Pain
  • Peripheral afferent fibers to dorsal horn
  • Second Neuron Pain
  • Dorsal horn to thalamic
  • Third Neuron Pain
  • Thalamus to cortex

36
Pain Pathways
  • Tissue damagegtgtgtAlgesic substanses
    releasegtgtgtNoxious stimuligtgtgtA delta and C
    fibersgtgtgtto the NeuraxisgtgtgtMany to Ant. and
    Anterolat.HornsgtgtgtSegmenal reflex responses , and
    others via the Spinothalamic and Spinoreticular
    tractsgtgtgtSuprasegmental and cortical responses.

37
Classification Function of Peripheral Nerve
Fibers
  • A. Myelinated A- Fibers
  • a Motor , Proprioception (afferent)
  • b Motor, Touch (afferent)
  • g Muscle spindles (efferent)
  • d Pain, Temperature (afferent)
  • B. Myelinated B-Fibers
  • Pre-ganglionic Sympathetic Fibers
  • C. Non-Myelinated C- Fibers Pain, Temperature.

38
Nociceptive pathways peripheral sensory nerves
39
Ascending Pain Pathways
  • Topographic representation maintained
  • Sites for pain modulation are spinal cord and
    thalamus

Pons
40
  • Suprasegmental
  • reflex responses
  • Increased Sympathetic tone , Hypothalamic
    stimulation.
  • Segmental reflex responses
  • Increased skeletal muscle tone , Increased
    oxygen consumption , Lactic acid production

41
Chemical Mediators
  • Membrane ion channels of Nociceptive neurons
  • Directly coupling to membrane receptors
  • Hydrogen
  • ATP
  • Serotonin
  • 5HT3
  • Indirectly (more commonly) mediating
    intracellular secondary messages
  • Bradykinins B1, B2
  • Cytokines
  • Prostanoids
  • Histamine H1
  • Serotonin
  • 5HT1

42
Factors that modify perioperative pain
  • 1- Site ,nature and duration of surgery.
  • 2- Type and extent of incision.
  • 3- Physiologic and psychologic makeup of the
    patient.
  • 4- Pre operative preparation of the patient.
  • 5- Presence of complications of surgery.
  • 6- Anesthetic management.
  • 7- Quality of perioperative care.
  • 8- Preoperative treatment of painful stimuli .

43
Preemptive Analgesia
  • Antinociceptive treatment of that prevents the
    establishment of altered central prossesing,
    which amplifies postop. Pain.
  • Windupfunctional changes in the dorsal horn
    because of pain .
  • This type of therapy ,in addition to reducing
    acute pain ,attenuates chronic postop. Pain.

44
Principles of Pain Management
  • Anticipate pain
  • Recognize patient
  • Ask the patient
  • Look for signs (HR, BP, facial grimacing, tears,
    sweating, etc)
  • Find the source
  • Quantify pain (mild, moderate, severe)
  • Treat
  • Quantify the patients perception of pain
  • Correct the cause where possible
  • Give appropriate analgesics regularly as
    required
  • Remember most sedative agents do not provide
    analgesia
  • Reassess

45
Modalities of Pain Relief
  • Non-opioid analgesicsopioid analgesics
  • Regular injections of opioids
  • Continuous IV or SC infusion of opioids
  • Patient controlled analgesia (PCA)
  • Extradural opioids or local anesthetics
  • Combined exrtadural spinal analgesia
  • Long acting oral opioids
  • Long acting regional blocks
  • Ketamine (S)

46
Modalities of Pain Relief
  • Pharmacological
  • Non-pharmacological

47
DRUGS
  • NSAIDs
  • COX-1 Minor Moderate pain
  • COX-2 rofecoxib, parecoxib-inj Severe pain
  • Actions
  • Inhibit synthesis of PG-E
  • Direct analgesic effect on higher centers
  • Modify nociceptive responses-bradykinins
  • Antiplatelet
  • Hypothrombinaemia
  • Lowers body temp
  • Hypoglycemia
  • Metabolic acidosis
  • Adverse gastrointestinal effects

Lower doses only
48
Systemic Opioids
  • Analgesic effects of opioids via receptors in
    the CNS.
  • Roots of administeration I.M. ,I.V. ,Transdermal
    ,Oral ,Topical ,I.V. regional ,Perineural ,etc.
  • I.M. root is the most treatment choice after
    surgery.
  • The As Needed part of the order is often
    interpreted to mean As little as possible .
  • No relation exists between Gender and opioid
    requirement.

49
Analgesic Opiates
  • Morphine
  • Pethidine
  • Fentanyl
  • Sufentanil
  • Alfentanil
  • Remifentani
  • ANTIDOTE Naloxone

50
Routes of administration of analgesics
  • Oral Intravenous
  • Sublingual/buccal Epidural (opioid)
  • Oral transmucosal Intrathecal (opiod)
  • Intranasal Intra articular (opioid)
  • Transdermal Topical - EMLA cream
  • Rectal Intradermal
  • Inhalational Peripheral N block
  • Subcutaneous Nerve plexus block
  • Intramuscular Intravenous regional

51
Modalities of Pain Relief
  • Non-pharmacological
  • Transcut. Electrostimulation
  • Cryoanalgesia(obselete)
  • Acupuncture
  • Hypnosis

52
New Modalities Of Systemic Drug Administration
  • The goals of new methods are
  • 1. Precise,controlled delivery of the prescribed
    dose
  • 2. A rapid onset of action
  • 3. Avoidance of first-pass hepatic metabolism
  • 4. Maintenance of a steady-state concentration of
    drug
  • 5. An improved side-effect profile and
  • 6. Improved patient compliance

53
Transdermal Route Advantages
  1. Decreased first-pass hepatic metabolism
  2. Decreased gastrointestinal degradation
  3. Stable plasma concentrations,and
  4. Improved patient compliance

54
Treatment methods
  • 1-Systemic opiods.
  • 2-Patient-controlled analgesia.
  • 3-Regional anesthetic techniques .
  • . a Intraspinal analgesia.
  • b Patient-controlled epidural analgesia.
  • c Combined spinal-epidural technique.
  • 4-intraarticular analgesia.
  • 5-Nonopioid analgesics.
  • 6-Cryoanalgesia.
  • 7-T.E.N.S.
  • 8-Psychologic and other methods.

55
Patient-Controlled Analgesia
  • PCA was originally developed to minimize the
    effects of pharmacokinetic and
  • Pharmacodynamic variability among patients.
  • A negative feedback loop exists experiencing
    paingtgtgtMedication demandedgtgtgtReducing pain gtgtgtNo
    further demand .
  • If Nurses, Relatives,or Parents assume
    responsibility for drug administration,or if
    using this device by the patient is for reasons
    other than pain relief ,this loop fails.

56
  • Cases of respiratory depression during PCA use
    have been reported.
  • Causes advanced age, hypovolemia, large doses,
    use of background continuous-infusion mode.
  • No difference in respiratory mechanics between
    PCA and IM opioids (FEV1,FRC,PFR)is seen.

57
Side effects of PCA
  • Nausea ,Vomiting ,Itching.
  • Treated by changing opioid or using drugs that
    provide symptomatic relief.
  • A pre printed set of standard orders can
    facilitate a uniform standard of care.

58
Regional Anesthetic Techniques
  • Advantages
  • Positive respiratory, cardiovascular and
    neuroendocrine effects reduced thromboembolic
    complications and blood loss and reduced
    convalescence

59
IDEAL COMPONENTS
  • Block SENSORY feeling
  • Immobilize MOTOR responses
  • Obtund REFLEXES
  • wipe out MEMORY
  • Control VC and CTZ
  • Not permanent
  • Cause sense of well-being

60
REGIONAL ANESTHESIA
  • SEGMENTAL LOSS OF SENSATION
  • BY BLOCKING NERVE CONDUCTION

61
REGIONAL
  • 1. SPINAL
  • 2. EPIDURAL
  • 4. INTRAVENOUS ( BIER )
  • 5. AXILLARY (INFILTRATION)
  • 6. RETROBULBAR

62
LOCAL ANESTHETICS
  • AMIDES MAX / DOSE
  • BUPIVACAINE 2 MG/KG
  • LIDOCAINE 7 MG/KG
  • ROPIVACAINE 4 MG/KG
  • MEPIVACAINE 7 MG/KG
  • PRILOCAINE 6MG/KG

63
LOCAL ANESTHETICS
  • ESTERS MAX /DOSE
  • CHLOROPROCAINE 20 MG/KG
  • COCAINE 3 MG/KG
  • NOVOCAINE 12 MG/KG
  • TETRACAINE 3 MG/KG

64
LOCAL ANESTHETICS
  • Local anesthetics are the drugs, which reversibly
    block the generation, propagation and
    oscillations of electrical impulses in the
    excitable tissues.

65
MECHENISM OF ACTION
  • Block nerve fiber conduction by acting directly
    on nerve membranes to inhibit sodium ion from
    crossing the membrane
  • Nerves cannot depolarize
  • Conduction of impulses is blocked

66
Mechanism of Action
  • Decrease or prevent transient increase in the
    permeability of excitable membranes to Na ions
  • Direct interaction with voltage gated Na
  • channels
  • Increase in threshold
  • Decrease in the rate of rise of A.P.
  • Slows down the conduction

67
Mechanism of Action
  • Site of action - Inside the membrane
  • Binding sites within the Na channel
  • Heterotrimeric complexes of glycosylated
    proteins ( 300 k Da)
  • 3 sub units- a, b1 b 2
  • a has I- IV homologous domains
  • Each domain has 6 transmembrane domains
  • Bind with S6 transmembrane domain.

68
CONTRAINDICATIONS
  • RELATIVE
  • Patient Appropriateness
  • Local Infection near injection site
  • Hypovolemia
  • CNS Disease
  • Chronic Back Pain or Prior Lami
  • Prior SAB with difficulty

69
Nerve Fiber and Local Anesthetic Setup
  • Sequence of clinical anesthesia
  • Sympathetic block (vasodilate skin T0)
  • Loss of pain and temperature sensation
  • Loss of proprioception
  • Loss of touch and pressure sensation
  • Loss of motor function

70
  • Interscalene brachial plexus blocks analgesia
    for 12-24 hrs.
  • Sciatic and Femoral n. blocks similar results.
  • Intercostal n. blocks 6-12 hrs. analgesia.
  • Administration of long acting L.A.s from a
    catheter into pleural cavity unilat. Analgesia
    with little or no sensory block.
  • L.A. infusion into Axillary sheath, Femoral
    sheath, and the vicinity of the Sciatic
    n.analgesia and particularly useful to
    facilitate perfusion after extensive
    revascularization.

Interscalene
71
L.A. boluses or infusions
  • Advantages over parenteral opioids
  • Early ambulation, improve bowel function, higher
    arterial O2 tension, fewer pulmonary
    complications.
  • For optimal results, the catheter tip should be
    near the segments innervating the insicision.

72
PLUXES BLOCK
73
BRACHEAL PLUXEX BLOCK
74
Segmental Level of Block Required
  • T-4 to T-6
  • IntraAbdominal
  • T-6 to T-8
  • GU, Low Abdominal
  • T-8 to T-10
  • GU, A/R, Legs

T-4
T-6
T-10
75
IVRA (BIERS BLOCK)
76
SPINAL ANESTHESIA
77
Intraspinal analgesia
  • With
  • Opioids
  • Opioid-L.A. mixture
  • Ketamine
  • Clonidine
  • Neostigmine

78
Opioids
  • Initial reports in 1979.
  • Single injection of intrathecal Morphin provides
    about 24 hrs. analgesia.
  • Epidural root uses more, because
  • Popularity of technique during surgery, ability
    to leave catheter in place, familiarity with
    technique, no risk of PDPH.

79
  • Elderly patients require remarkably small doses
    of epidural morphine.
  • Fentanyl is useful when rapid onset of epidural
    analgesia is important.
  • Epidural meperidine is widely used in some parts
    of the world and as with other opioids,
    respiratory depression can occure.

80
Respiratory depression
  • early
  • In the first two hrs.
  • Is the result of vascular uptake and
    redistribution.
  • Delayed
  • Between 6 and 12 hrs.
  • Consequent of rostral spread of opioid in CSF to
    respiratory center in the floor of 4th. Ventricle.

81
  • Pruritus is a common side effect and is seen more
    in obstetrics patients.
  • Face is a common site of itching.
  • Although it is not due to histamine release,
    antihistamines provide symptom relief.
  • Nalbuphine is also of value.
  • Naloxone is consistently effective (repeated
    doses or infusion).

82
  • Urinary retention is higher in volunteers than in
    patients and in men than in women.
  • Naloxone prevents or reverses it but may require
    doses that antagonizes analgesia.
  • Most patients are able to void spontaneously when
    the catheters are removed.

83
  • Nausea and vomiting due to rostral spread of
    opioid in CSF to the vomiting center and the CTZ
    .
  • Treatment
  • first line antiemetics (may produce unwanted
    sedation and resp. depression ) , Scopolamine
    patches.
  • Second line I.V. droperidol, Ondansetrone.

84
  • Sedation produced by intraspinal opioids may be
    the result of spread of the drug in CSF to
    receptors in the thalamus, limbic system or
    cortex and hypercarbia can augment it.
  • Epidural buprenorphine 0.15 mg. produces
    prolonged depression of the CO2 response that
    lasts 8-12 hrs.

85
Ketamine
  • Produces analgesia via interaction with
    cholinergic, adrenergic, and serotonergic
    systems.
  • Side effects sedation, blurred vision,
    tachycardia, hypertension, and hallucinations.
  • In some studies on baboons neurotoxic changes.
  • The routine use of intrathecal ketamine in humans
    is not recommended.

86
Clonidine
  • If administered by the oral route can augment
    spinally mediated opioid analgesia.
  • Epidural or intrathecal clonidine can provide
    effective analgesia alone.
  • Intrathecal clonidine does not provide surgical
    anesthesia.

87
Intra-Articular analgesia
  • Following arthroscopic surgery, a combination of
    systemic Ketorolac and intra-articular
    bupivacaine decreased analgesic requirement and
    pain.

88
Nitrous oxide
  • Useful, especially for painful experiences of
    short duration (dressing changes, debridements).
  • Rapid onset of analgesia and rapid recovery.
  • In concentrations of 30-50 is as potent as 10
    mg. I.M. morphine.
  • Anesthesia may occurgtgtgtrisk of aspiration.

89
  • Long term administration causes bone marrow
    suppression and leukopenia (reversible when
    detected early).
  • Entonox50mixture of N2O with oxygen.

90
Cryoanalgesia
  • Temp.s between -5 and -20causes disintegration
    of axons and breakdown of myelin sheaths while
    the perinurium and epinurium remain intact.
  • Is used most common for thoracotomy pain and
    hernia repair pain.
  • Residual neuropathic pain has been seen following
    cryoanalgesia.

91
Transcutaneous electrical nerve
stimulation(T.E.N.S.)
  • Uses both for chronic pain and acute
    perioperative pain.
  • Advantages absence of opioids side effects
    (resp. depression, sedation, nausea and vomiting,
    urinary retention)
  • It is simple, noninvasive and free of toxicity.

92
  • The mechanism of analgesia by TENS is not known
    and it may be by
  • Modulation of nociceptive impulses in the spinal
    cord (gate control theory).
  • Activation of inhibitory area in the brain stem.
  • Stimulation of the release of endorphins, or a
    combination of these mechanisms.
  • A placebo effect may play a role.

93
Psychologic and other methods
  • After surgery patients may suffer discomfort
    due to headache, NG tubes, drains, IV catheters,
    or anxiety, fear, and insomnia.
  • Therapy of these problems may result in reporting
    of less pain.
  • Preoperative discussion, reassurance and
    provision information results in less anxiety,
    less opioid use and shorter hospital stay.

94
  • Relaxation tapes prior to surgery results in less
    analgesic use and a smoother recovery.

95
Perioperative analgesia in special populations.
96
Pediatric patients
  • Misconceptions about pain in children are common
    (e.g. children dont feel pain, or if it is felt
    it is not remembered.
  • Pain causes suffering and psychologic
    abnormalities in children of all age.
  • Special scales are available for young children
    (self reporting of pain).
  • In preverbal children, the interpretation of
    behavior must be used to estimate intensity of
    pain.

97
  • Because of fear of IM injections alternatives
    are sublingual, rectal and transdermal routs.
  • I.V. PCA is effective in children.
  • Caudal opioid analgesia can be used in children.
  • Regional techniques dorsal nerve block of the
    penis, or lidocaine jelly, or EMLA creams for
    circumcision, ilioinguinal and iliohypogastric
    nerve blocks for pains after orchiopexy and
    herniorrhaphy, etc.

98
  • NSAID,s are considered as adjuncts rather than as
    primary agents.

99
Elderly patients
  • The average age of surgical patients will
    increase in the future.
  • Older patients have more complex cases than
    younger.
  • PCA PCEA is ineffective in some elderly
    patients because of their reluctance.

100
  • Treatment of perioperative pain in elderly
    remains inadequate because
  • Fear of complications associated with treatment
    of pain.
  • Pain is reported less in elderly.

101
  • NSAID,s may have benefits in elderly because
  • Different site of action that may be more
    effective.
  • Opioid sparing.
  • An additional anti-inflammatory effect.
  • But they have increased risk of side effects
    because of decreased renal clearancegtgtgtthey doses
    must be decreased.

102
Advantages of regional anesthesia
  • Minimizing physiologic trespass.
  • Pharmacologic simplicity.
  • Reduced blood loss.
  • Fewer thromboembolic complications.
  • Reduced stress response.
  • Less confusion.
  • Less postoperative pain.

103
Patients with chronic pain and /or chronic opioid
use
104
  • General principles
  • 1-expect high self-reported pain scores.
  • 2-base treatment decision on objective pain
    assessment (deep breathing, coughing, etc.).
  • 3-recognize and treat nonnociceptive sources of
    suffering.
  • Continue opioids for as long as is appropriate
    for acute pain.

105
Addiction
  • A chronic disorder characterized by compulsive
    use of a substance resulting in physical,
    psychologic, or social harm to the user and
    continued use despite that harm.

106
Clinical triad suggestive of addiction
  • 1-high self-reported pain scores.
  • 2-high opioid use compared with other patients
    having similar procedures.
  • 3-a relative absence of opioid-induced side
    effects.

107
  • PCA is not good for providing basal opioid
    replacement.
  • PCA is good for extra opioids needed for
    postoperative pain.

108
ROLE OF THE ANESTHESIOLOGIST IN PERIOPERATIVE
PAIN MANAGEMENT
109
  • Anesthesiologists are a logical choice to provide
    periop. Pain relief, because they are
  • 1-familiar with the pharmacology of analgesics
    and L.A.s.
  • 2-aware of short- and long-term effects of drugs
    given intraoperatively.
  • 3-knowledgeable about pain pathways and their
    interruption.
  • 4-are skilled in techniques available to provide
    superior pain control.

110
EPIDURAL ANESTHESIA
111
EPIDURAL DRUG ADMINISTRATION
112
FIXATION OF CATHETER
113
FINAL SKIN FIXATION AND DRESSING
114
LEST YOU FORGET
  • Discomfort from
  • Full bladder/bowel/gasses
  • Noise
  • Alarms
  • Visitors
  • Painful IV site
  • Multiple lines
  • Repeated disturbance from medical personnel
  • Complications of analgesic drugs
  • Other pathological complications

115
Reference book and the relevant page numbers..
116
Thank You ?
  • Dr.
  • Date
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