Postoperative pain treatment strategies - PowerPoint PPT Presentation

Loading...

PPT – Postoperative pain treatment strategies PowerPoint presentation | free to download - id: 3b77a8-OTAyO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Postoperative pain treatment strategies

Description:

Postoperative pain treatment strategies Dr Marc Reynvoet AZ Groeninge Dept Anesthesia Kortrijk Postoperative pain treatment strategies Methods of acute postoperative ... – PowerPoint PPT presentation

Number of Views:803
Avg rating:3.0/5.0
Slides: 76
Provided by: kuleuvenB9
Learn more at: http://www.kuleuven.be
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Postoperative pain treatment strategies


1
Postoperative pain treatment strategies
  • Dr Marc Reynvoet
  • AZ Groeninge
  • Dept Anesthesia
  • Kortrijk

2
(No Transcript)
3
Postoperative pain treatment strategies
  • Methods of acute postoperative pain relief
  • On demand pain controll
  • Patient controlled analgesia
  • New developments
  • Iontophoretic transdermal fentanyl pca
    (Ionsys) - needle free pca
  • Intranasal opioids

4
Postoperative pain treatment strategies
  • Patient controlled analgesia
  • Benefits
  • analgesic efficacy
  • patient satisfaction
  • reduced workload of nursing staff
  • reduced chances of medication errors

5
Postoperative pain treatment strategies
  • Patient controlled analgesia
  • Disadvantages
  • patient may be physically or mentally unable to
    use pca
  • failing dosing regime
  • device malfunction
  • high cost of the pca devices
  • fear of addiction

6
Postoperative pain treatment strategies
  • Patient controlled analgesia
  • Total knee replacement surgery
  • ? patient controlled epidural analgesia
    (pcea)
  • Surgery of the shoulder
  • ? patient controlled continuous interscalene
    brachial plexus block (pcia)
  • Surgery of the back lumbar spinal fusion
  • ? patient controlled intravenous analgesia
    (pca)

7
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Effective pain controll
  • Early commencement of physiotherapy

8
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Patient controlled epidural analgesia (PCEA)
  • - improved quality of analgesia
  • - improved postoperative rehabilitation
  • - antithrombotic effect

9
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Anaesthetic technique
  • premedication
  • oral lorazepam 2mg
  • normal morning medication
  • intraoperative monitoring
  • pulse oximetry, ECG, non-invasive or
    invasive arterial pressure

10
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Anesthetic technique
  • spinal anesthesia (CSE)
  • fluid preload hydroxyethyl starch 500ml
  • L2-L3 or L3-L4
  • bupivacaine 0.5 2,5ml (12,5mg)
  • sufentanil 5µg or clonidine 10µg
  • intraoperative sedation
  • propofol (TCI) and/or midazolam

11
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Postoperative pain treatment
  • recovery room
  • epidural catheter connected to PCEA pump
  • epidural infusion started
  • - regression of sensory block
  • - recovery of motor function of lower
    extremities

12
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Postoperative pain treatment
  • recording side effects of spinal/epidural opioids
    and clonidine
  • - nausea/vomiting
  • - pruritis
  • - urine retention
  • - sedation
  • - bradycardia
  • - hypotension

13
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Postoperative pain treatment (48 hours)
  • PCEA content 250ml NaCl 0.9 20ml
    ropivacaine 1 (200mg)

  • 750µg clonidine

  • 250µg sufentanil
  • ropivacaine 0,07
  • clonidine 2,67µ/ml
  • sufentanil 0,9µg/ml

14
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Postoperative pain treatment (48 hours)
  • PCEA settings
  • loading dose
    none
  • continuous background infusion
    3ml/hr
  • bolus dose
    5ml
  • lockout time
    20 minutes
  • 4hr limit
    40ml
  • Rescue medication
  • IV paracetamol, IV diclofenac, IM/IV
    piritramide

15
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Postoperative pain treatment (PCEA)
  • Cumulative dose infused (ml)
  • 8hr 58
  • 12hr 84
  • 18hr 136
  • 24hr 152
  • 48hr 210

16
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Average infusion rate (ml/hr) 4,3ml
  • Average dosage
  • ropivacaine (mg/hr)
    3,0mg/hr
  • clonidine (µg/hr)
    11,5µg/hr
  • sufentanil (µg/hr)
    3,9µg/hr

17
Postoperative pain treatment strategies
  • Total knee replacement surgery

18
Postoperative pain treatment strategies
  • Total knee replacement surgery

19
Postoperative pain treatment strategies
  • Total knee replacement surgery (PCEA)

20
Postoperative pain treatment strategies
  • Total knee replacement surgery (PCEA)

21
Postoperative pain treatment strategies
  • Total knee replacement surgery (PCEA)

22
Postoperative pain treatment strategies
  • Total knee replacement surgery (PCEA)

23
Postoperative pain treatment strategies
  • Total knee replacement surgery (PCEA)

24
Postoperative pain treatment strategies
  • Total knee replacement surgery (PCEA)

25
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Postoperative pain treatment (PCEA)
  • Conclusions
  • - adequate postoperative analgesia with triple
    mixture
  • - reduced rescue opioid consumption
  • - hemodynamic stability
  • - acceptable side effects
  • - high incidence of sedation score 3

26
Postoperative pain treatment strategies
  • Total knee replacement surgery
  • Conclusions (spinal clonidine)
  • - prolonged sensory and moter block
  • - prolonged time to first request of an
    analgesic
  • - hemodynamic stability
  • - no increased risk of bradycardia
  • - no pruritis
  • - less urinary retention

27
Postoperative pain treatment strategies
  • Patient controlled continuous interscalene
    brachial plexus block
  • Shoulder surgery
  • Arthroscopic rotator cuff repair
  • Arthroscopic acromioplasty
  • Arthroscopic capsular release
  • AC joint reconstruction
  • Shoulder arthroplasty

28
Postoperative pain treatment strategies
  • Patient controlled continuous interscalene
    brachial plexus block
  • Shoulder surgery
  • ? severe postoperative pain
  • - adequate postoperative analgesia
  • - high degree of patient satisfaction
  • - early mobilisation
  • - successful functional rehabilitation

29
Postoperative pain treatment strategies
  • Shoulder surgery
  • Anaesthetic technique
  • premedication
  • oral lorazepam 2mg
  • normal morning medication
  • intraoperative monitoring
  • pulse oximetry, ECG, non-invasive or
    invasive arterial pressure, capnography

30
Postoperative pain treatment strategies
  • Shoulder surgery
  • Anaesthetic technique
  • General anesthesia with intubation
  • Total intraveneus (propofol, remifentanil,
    O2/air)
  • Interscalene brachial plexus catheter
  • StimuCathTM Arrow (19G needle 60 cm catheter)
  • Nerve stimulator - Stimuplex HNS 12 (B/Braun)
  • Ropivacaine 0,5 - 30ml

31
Postoperative pain treatment strategies
  • Shoulder surgery
  • Postoperative pain treatment (48hr)
  • recovery room
  • PCIA started 4hr after placement of plexus
    catheter
  • PCIA content
  • 400ml ropivacaine (Polybag Naropin) 0.2

32
Postoperative pain treatment strategies
  • Shoulder surgery
  • Postoperative pain treatment (48hr)
  • PCIA settings
  • loading dose
    none
  • continuous background infusion
    6ml/hr
  • bolus dose
    4ml
  • lockout time
    20 minutes
  • 4hr limit
    40ml
  • Rescue medication
  • IV paracetamol, IV diclofenac, IM/IV
    piritramide

33
Postoperative pain treatment strategies
34
Postoperative pain treatment strategies
  • Shoulder surgery
  • Postoperative pain treatment (PCIA)
  • Cumulative dose infused (ml)
  • 8hr 59.8
  • 12hr 87,3
  • 18hr 139,5
  • 24hr 172
  • 48hr 279,2

35
Postoperative pain treatment strategies
  • Shoulder surgery
  • Postoperative pain treatment (PCIA)
  • Average infusion rate (ml/hr) 5,82
  • Average dosage
  • ropivacaine (mg/hr)
    11,64

36
Postoperative pain treatment strategies
  • Shoulder surgery

37
Postoperative pain treatment strategies
  • Shoulder surgery

38
Postoperative pain treatment strategies
  • Shoulder surgery

39
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)

40
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)

41
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)

42
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Side effects of interscalene brachial plexus
    block
  • Hoarseness/dysphagia(ipsilateral recurrent
    laryngeal nerve block)
  • Horners syndrome (ipsilateral cervical
    sympathetic block)
  • Respiratory depression (ipsilateral phrenic
    nerve block)

43
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Anesthesia-related nerve injuries
  • Residual paresthesia
  • Residual hypoesthesia
  • Permanent paresis
  • 0.02 - 0.4

44
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)

45
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Local anesthetic related cardiac toxicity
  • Cardiac arrest after interscalene brachial plexus
    block with ropivacaine and lidocaine
  • Reinikainen M. et al
  • Acta Anaesthesiologica Scandinavica 2003
    47 904
  • Successful resuscitation of a patient with
    ropivacaine-induced asystole after axillary
    plexus block using lipid infusion
  • Litz, R. J. et all
  • Anaesthesia 200661(8), 800-801

46
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Local anesthetic related cardiac toxicity
  • Lipid infusion resuscitation for local anesthetic
    toxicity
  • Proof of clinical efficacy
  • Guy Weinberg, MD University of illinois at
    Chicago
  • Anesthesiology 2006105 7-8

47
Cardiac toxicity of local anesthetics
  • 20 lipid emulsion infusion (Intralipid? 20)
  • 1. bolus 1 1,5 ml/kg (70kg 70-100ml)
  • continue CPR
  • 2. Start an infusion at a rate of 0.25ml/kg/min
  • (70kg 1.000ml/h)
  • 3. Repeat bolus every 3 to 5 min (max 3-8 ml/kg)
    until circulation is restored
  • 4. Continue infusion until hemodynamic stability
    is restored
  • 5. Increase infusion rate to 0,50 ml/kg/min if BP
    declines
  • www.lipidrescue.org

48
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Local anesthetic related cardiac toxicity
  • A lipid emulsion is a crucial antidote that
    should be routinly kept in areas in which
    peripheral nerve blocks are being performed

49
Postoperative pain treatment strategies
  • Shoulder surgery
  • Postoperative pain treatment (PCIA)
  • Conclusions
  • - provides very good pain relief following
    shoulder surgery
  • - high degree of patient satisfaction
  • - use low-volume local anesthetic
  • - use low-concentration local anesthetic
  • - use a properly fitted arm sling
  • - lipid emulsion is a crucial antidote and
    must be available

50
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Controversies
  • Nerve localisation/catheter placement
  • ? Peripheral nerve stimulation or
    ultrasound guided?
  • Regional anesthesia in anesthetized or heavily
    sedated patients?

51
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Controversies
  • Nerve localisation/catheter placement
  • ? peripheral nerve stimulation or
    ultrasound guided?
  • Ultrsound-guided peripheral nerve blocks What
    are the benefits?
  • Revieuw article
  • Z.J. Koscielniak-Nielsen
  • Acta Anasthesiol Scand 2008 52 727-737

52
Postoperative pain treatment strategies
  • Ultrsound-guided peripheral nerve blocks What
    are the benefits?
  • - Shortens block performance time
  • - Reduces the number of needle insertions
  • - Shortens block onset time
  • - Allows reduction of the LA dose

53
Postoperative pain treatment strategies
  • Ultrsound-guided peripheral nerve blocks What
    are the benefits?
  • - Satisfactory images difficult to obtain in
    all patients
  • (advisable to use a nerve stimulator as a
    back-up)
  • - Block effectiveness is not significantly
    better
  • - Incidense of neuropraxia is similar
  • - Further studies are needed to confirm the
    superiority of ultrasound over other methods of
    nerve localisation

54
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Controversies
  • Nerve localisation/catheter placement
  • ? peripheral nerve stimulation or
    ultrasound guided?
  • Ultrsound guidance improves succes rate of
    axillary brachial plexus block
  • Chann VW et al
  • Can J Anesth 2007 54176-182

55
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Controversies
  • Ultrsound guidance improves succes rate of
    axillary brachial plexus block
  • Chann VW et al
  • Can J Anesth 2007 54176-182
  • 30 min post-block succes rate
  • Ultrasound
    62,9
  • Untrasound nerve stimulator
    80,7
  • Nerve stimulator
    82,8

56
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Controversies
  • Ultrsound guidance improves succes rate of
    axillary brachial plexus block
  • Chann VW et al
  • Can J Anesth 2007 54176-182
  • After comment
  • Experts who can achieve block succes of 90 or
    higher with nerve stimulation technique may not
    need ultrasound guidance to enhance block succes
    rate
  • Before we can conclusively adress clinical
    outcomes and develop evidence-based practise of
    ultrasound-guided regional techniques, large
    scale randomised controlled trials are needed

57
Postoperative pain treatment strategies
58
Postoperative pain treatment strategies
  • Shoulder surgery (PCIA)
  • Controversies
  • Regional anesthesia in anesthetized or heavily
    sedated patients?
  • Regional Anesthesia in Anesthetized or Heavily
    Sedated Patients
  • Christopher M. Bernards et al
  • Reg Anesth Pain Med 2008 33 449-460

59
Postoperative pain treatment strategies
  • Regional Anesthesia in Anesthetized or Heavily
    Sedated Patients?
  • Interscalene blocks should not be performed in
    anesthetized or heavily sedated adult or
    pediatric patients (class I recommendation)
  • conclusions
  • The decision to perform regional anesthesia or
    pain medicine procedures in anesthetized or
    heavily sedated patients is controversial,
    complicated, and must be made in the absence of
    traditional forms of evidence-based medicine

60
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Patient controlled intravenous analgesia (PCA)
  • Well accepted
  • Excellent way to provide analgesia
  • Pain relief available around the clock
  • High patient satisfaction
  • IV PCA related adverse drug effects
  • Fear of addiction

61
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Anaesthetic technique
  • premedication
  • oral lorazepam 2mg
  • normal morning medication
  • intraoperative monitoring
  • pulse oximetry, ECG, non-invasive or
    invasive arterial pressure, capnography

62
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Anaesthetic technique
  • General anesthesia with intubation
  • Induction propofol, sufentanil, atracurium
  • Maintenance O2/N2O and sevoflurane
  • PCA started after induction
  • PCA content NaCl 0,9 500ml 500µg sufentanil
  • Sufentanil 1µg/ml

63
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Anaesthetic technique
  • PCA settings
  • loading dose
    none
  • continuous background infusion
    0,1µg/kg/hr
  • bolus dose
    0,025-0,05µg/kg
  • lockout time
    20 minutes
  • max doses/h
    2
  • Rescue medication
  • IV paracetamol, IV diclofenac, IV tramadol

64
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Group 1
    Group 2
  • Methylprednisolone
    diclofenac
  • D1 4x 40mg
    2x 75mg (IV)
  • D2 3x 40mg
    2x 75mg (oral)
  • D3 2x 40mg
  • D4 1x 40mg
  • Rescue medication
  • IV paracetamol, IV diclofenac, IV tramadol
    IV paracetamol, IV tramadol

65
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Postoperative pain treatment (PCA)
  • Cumulative dose infused (ml)
  • 4hr 41,9
  • 8hr 75,8
  • 12hr 99,9
  • 18hr 139,9
  • 24hr 183,4
  • 48hr

66
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Postoperative pain treatment (PCA)
  • Average infusion rate (ml/hr) 7,65
  • Average dosage
  • sufentanil (µg/hr) 7,65

67
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis

68
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis

69
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis

70
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis

71
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis

72
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis

73
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • Patient controlled intravenous analgesia (PCA)
  • Conclusions
  • - adequate pain relief
  • - acceptable side effects

74
Postoperative pain treatment strategies
  • Spinal fusion surgery - Arthrodesis
  • High dose methylprednisolone ?
  • H2O and salt retention
  • Hypertension
  • Steroid associated diabetes
  • Gastric ulcer
  • Delayed wound healing

75
Postoperative pain treatment strategies
  • Future planning
  • Daily ward rounds
  • education nursing staff
  • inpatient acute pain management team
  • Collecting correct data
  • Spinal/epidural sufentanil ?
  • Ideal dose of spinal/epidural clonidine ?
  • Ultrasound-guided peripheral nerve blocks ?
  • Regional Anesthesia in anesthetized or heavily
    sedated patients?
About PowerShow.com