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Department of Anesthesiology

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No reason to give Percocet when you can give oxycodone alone. ... 3 Percocets(15 mg oxycodone) = 15 mg IV morphine. Total: 95 mg of IV morphine ... – PowerPoint PPT presentation

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Title: Department of Anesthesiology


1
Practical Approaches to Peri-Operative Pain
Management
Department of Anesthesiology
David P. Tarantino, MD, MBA
2
Case Presentation
  • You are caring for a 75 year old female who is
    s/p laparoscopic right hemicolectomy. She is
    receiving morphine via a PCA set at 0/2/6.
  • She is continuing to complain of terrible pain.

3
Questions to Answer
  • Why is this patient still complaining of pain?
  • How do I evaluate the pain?
  • How do I get the patient comfortable?
  • What pain medicine(s) should I give?
  • How should I order the pain medicine?

4
Why is this Patient Still Complaining of Pain?
5
Pain Well Thinking
  • The Bigger the Surgery You Experience.
  • The More It Should Hurt..
  • And the Greater Amount of Pain Medicine You
    Should Receive

6
Pain Well Thinking
  • Therefore, a Small Surgery Requires a Small
    Amount of Pain Medicine.
  • A Bigger Surgery Requires More.
  • And a Really Big Surgery Deserves the Most Pain
    Medicine

7
Whats A Really Big Surgery?
8
A Really Big Surgery is any one that happens to
ME!
  • Just because something works for most patients
    doesnt mean it is going to work for all patients
  • You must individualize therapy
  • Protocols are a GUIDELINE only!

9
Basic Principle I Talk to the Patient
  • Is the patient a Pharmacologic Virgin?
  • Get a pain medication history
  • What medications does he/she take?

10
Basic Principle I Talk to the Patient
  • Get a Pain History
  • Did he/she have pain prior to this episode?
  • What is the pain like now?
  • Where does it hurt?
  • When did it start to hurt?
  • How much does it hurt?
  • What makes it better or worse?
  • How does it hurt?

11
Pain Definitions
  • Allodynia Pain from a stimulus which normally
    does not produce pain
  • Hyperalgesia Increased response from a stimulus
    that is normally painful
  • Both are indicative of neuropathic pain

12
Specifics of the Pain Examination
  • Are there musculoskeletal or neurologic deficits
    associated with the pain?
  • Is allodynia or hyperalgesia present?

13
Basic Principle II
  • Must obtain pain history and perform a directed
    physical examination

14
Front Loading
  • It takes five half lives to achieve steady state
    levels in the plasma
  • For most opioids that we use the half-life is
    three hours (15 hours to steady state)

15
Front Loading
  • Lack of appropriate front loading is the most
    common cause for analgesic failure

16
How Do I Front Load?
  • Step 1 Obtain a pain score
  • Step 2 Give IV Analgesic
  • Step 3 Wait 5-10 minutes
  • Step 4 Obtain a Pain Score
  • Step 5 If Ever I Believe My Work is Done, then
    Ill Start Back at One.

17
Intravenous Opioid Therapy
  • Principle 1 There is little to no reason to
    use IM or SQ therapy to treat acute pain.
  • Principle 2 The most common opioids have a
    half-life of three hours
  • Principle 3 You must front load the patient
  • Principle 4 If you can multiply or divide by
    10, you can easily use these agents

18
Intravenous Opioid Therapy
  • The Rule of Ten
  • 100 mg of Demerol 10 mg of Morphine 1 mg of
    Dilaudid 100 ug of Fentanyl

19
Intravenous Opioid Therapy
  • A Caution about the use of Demerol
  • The active metabolite of Demerol is normeperidine
    which can produce CNS Toxicity
  • Half-life of normeperidine is 8-24 hrs
  • Use should be very limited, if at all!
  • Keep the dose less than 1000mg/day
  • Avoid in Elderly and Renal Failure

20
Intravenous Opioid Therapy
  • A Caution about the use of Morphine
  • Morphine is metabolized to M6G and M3G
  • M6G can accumulate in patients with renal
    insufficiency
  • M6G is 100 times more potent than morphine in the
    CNS

21
Patient-Controlled Analgesia
  • Three Components
  • Bolus Dose How much can the patient receive?
  • Basal Rate Background continuous infusion
  • Lockout Period Period between doses (6-10
    minutes)

22
PCA Problems
  • PCA Overdose
  • Use of Other agents with PCA
  • Bolus dosing must be patient-controlled
  • Some patients are not Rocket Scientists

23
Stopping a PCA
  • Give the patient at least two doses of oral
    opioid prior to D/C of PCA
  • Allows the patient to maintain analgesia while
    waiting to achieve steady state plasma levels
    with the oral medication

24
How Should I Order the Pain Medicine?
25
Problem with Early PRN Dosing
  • Prevents achieving and maintaining steady-state
    plasma levels

26
Basic Principle III
  • Avoid PRN Dosing for the First 24-48 hours
  • Give Medications on a Round-the-Clock basis
    according to half-life

27
Oral Analgesic Therapy
28
Oral Analgesics which can be Problematic
  • Codeine
  • Must be metabolized to be effective
  • 10 of Caucasians lack the enzyme
  • High incidence of nausea and vomiting, especially
    in elderly
  • Darvon (propoxyphene)
  • Active metabolite norpropoxyphene
  • CNS Toxicity seizures
  • Half life 23-36 hours

29
Single Agent Therapy
  • Given the availability of single agent opioids,
    there is no reason to give combination therapy
    agents
  • Acetaminophen adds little analgesic potency,
    while severely limiting dosage limits and
    intervals
  • No reason to give Percocet when you can give
    oxycodone alone.

30
Non-steroidal Anti-inflammatory Drugs
31
The Role of Cyclo-oxygenase (COX)
Arachidonic acid
Cyclo-oxygenase activity of COX
PGG2
Peroxidase activity of COX
PGH2
PGD2
PGI2
PGF2?
PGE2
TXA2
32
Prostanoids and Their Physiologic Activities
  • Activities/Properties
  • Produced in many organs, (eg, kidney, intestinal
    tract)
  • GI mucosal protection/repair
  • Vasodilates
  • Diuresis and natriuresis
  • Inhibits inflammatory/ allergic cells
  • ? platelet activation
  • ? intravascular platelet aggregation
  • ? smooth muscle contraction in arteries and
    bronchi
  • ? platelet aggregation
  • Vasodilates
  • ? renin release in kidney

Prostanoid PGE2
Thromboxane A2
Prostacyclin (PGI2)
33
Two Forms of Cyclooxygenase (COX)
COX-1
COX-2
  • Constitutive
  • Mediate homeostaticfunctions
  • Especially important in
  • Gastric mucosa
  • Kidney
  • Platelets
  • Vascular endothelium
  • Inducible (in most tissues)
  • Mediate inflammation, pain, and fever
  • Induced mainly at sites of inflammation by
    cytokines

34
Special Issues
35
Pre-Emptive Analgesia
  • Agents Shown to be of Pre-Emptive Benefit
  • Ketamine 0.25-1 mg/kg
  • Cox-2 Inhibitors
  • Neurontin 300 mg
  • Local Anesthetics

36
How can Four Different Classes of Drugs All
Provide the Benefits of Pre-Emptive Analgesia
and why dont they work as well after Surgery?
37
Brain
Inflammatory Mediators
Neuropathic Pain
Nociceptive Pain
Tissue Injury
Local Anesthetics
Nerve Injury
TCAs Anti-convulsants
A delta C fibers
Peripheral Nociceptors
Depolarization
PGE2
Cox-2 Inhibitors
PKC
Mg
I, II Inhbitory interneurons
V (WDR neurons)
NMDA Receptor
Glutamate
Phosphorylation
Ca
Mg
Gabapentin Pregabalin
Ketamine Dextromethorphan Methadone
38
Pre-Emptive Analgesia
  • Works by preventing acute changes in the
    responsiveness of dorsal horn neurons to noxious
    stimuli
  • Must be done before the noxious stimulation of
    surgical incisionoccurs

39
Substance Abuse
40
Defining the Problem
  • General Population 10 have a substance abuse
    history
  • U.S. Trauma Centers 40 incidence
  • Baltimore Nations Highest Heroin Use
  • Highest STDs
  • Third most violent
  • Third highest HIV

41
Defining the Problem
  • Little to No Formal Training in addiction during
    medical or nursing school
  • Little to No Understanding of Addiction Medicine
  • Result Patients who are mislabeled and
    under-treated

42
Understanding the Terminology
  • AddictionCompulsive use of a substance
    resulting in physical, psychological or social
    harm with continued use despite harm from that
    drug (JAMA 1988259555-557)
  • Addiction is inappropriate drug-seeking behavior

43
Understanding the Terminology
  • Pseudoaddictionappropriate drug-seeking
    behavior (Pain 198936363-366)
  • Pseudoaddiction refers to patients who present
    like addicts not because they are addicted, but
    because they seek pain relief
  • Incidence of pseudoaddiction is unknown

44
Understanding the Terminology
  • Dependence physiologic and pharmacologic effect
    that manifests itself as withdrawal
  • Tolerance diminished effect with continued use
    of the same amount of substance
  • Neither dependence nor tolerance are indicative
    of addiction

45
Understanding the Terminology
  • Drug-seeking Behavior may be appropriate if its
    purpose is to relieve pain
  • Therefore, achieving adequate pain control is
    essential in determining appropriate behavior

46
Opioid Agents to Avoid and to Use
47
Agents to Avoid
  • Agonist-antagonist agents
  • May precipitate withdrawal symptoms

48
Agents to Avoid
  • Avoid short-acting agents
  • Example 5 mg of oxycodone 5 mg of IV Morphine
  • 10 mg of oxycodone q4hr 60 mg of IV morphine
  • Average Substance User at STC uses
  • 150 200 mg IV morphine/day

49
Agents to Use
  • IV Morphine or Hydromorphone (Dilaudid)
  • Oral Long-acting Opioids
  • Sustained -release Morphine or Oxycodone
  • Methadone
  • NSAIDS
  • Regional Analgesia

50
Equi-Analgesic Dosing
  • Example 1
  • The patient takes 60 mg of MS Contin 3 times per
    day
  • 1 mg MS Contin 1 mg IV morphine
  • 60 mg MS Contin 60 mg IV morphine
  • 180 mg of IV morphine per day

51
Equi-Analgesic Dosing
  • Example 2
  • The patient takes 40 mg of Oxycontin twice per
    day
  • 2 mg Oxycontin 1 mg IV morphine
  • 40 mg MS Contin 20 mg IV morphine
  • 40 mg of IV morphine per day

52
Equi-Analgesic Dosing
  • Example 3
  • The patient takes 80 mg of methadone per day
  • 0.5 mg methadone 1 mg IV morphine
  • 80 mg methadone 40 mg IV morphine
  • 40 mg of IV morphine per day

53
Equi-Analgesic Dosing
  • Example 4
  • The patient uses 4 dime bags of heroin per day
  • 1 dime bag of heroin 1 mg IV morphine
  • 4 dime bags 40 mg IV morphine

54
Equi-Analgesic Dosing
  • Example 5 Were you paying attention?
  • A pedestrian struck by a car is in a methadone
    program and gets 60 mg per day. After he visits
    the clinic, he buys and snorts 5 dime bags of
    heroin. Because hes in pain, a bystander gives
    him 3 of her Percocets. What is this patients
    current morphine equivalent?
  • 60 mg methadone 30 mg IV morphine
  • 5 dime bags of heroin 50 mg IV morphine
  • 3 Percocets(15 mg oxycodone) 15 mg IV morphine
  • Total 95 mg of IV morphine

55
Sending the Patient Home
  • Is the patient going to Methadone maintenance or
    detoxification program?

56
Problems Sending the Patient Home
  • May need to wean methadone dose prior to
    discharge
  • May need to use combination long-acting agents
  • Methadone for addiction
  • MS Contin for pain

57
Weaning Long-Acting Agents
  • Do not attempt to wean until the acute process
    has subsided!
  • Pain increases when you go home
  • Wean by 10-20 of the total dose every 3 days
  • Faster if you add clonidine
  • If t.i.d. dosing, wean the afternoon dose first,
    then the morning dose, then the night dose
  • Done properly, weaning is a slow process
  • It will take weeks to months to properly wean a
    patient from high doses of opioids

58
The Alcohol Dependent Patient
  • Withdrawal symptoms begin within 6-48 hours and
    peaks at 24-36 hours
  • Reverse inhibition from ETOH
  • Increased stress hormones, CNS excitation
  • May mimic signs of injury (changes in HR or BP)
  • Treatment benzodiazepines (symptom triggered vs.
    fixed dose)
  • 10 develop seizures
  • 5 experience delirium tremens

59
The Alcohol Dependent Trauma Patient
  • 100 of alcohol dependent injured trauma patients
    have pain!
  • Must treat the pain!
  • If the patient becomes sedated, it is most likely
    the result of the benzodiazepines
  • Therefore reduce the benzodiazepines and not
    the opioids

60
Managing the Patient in Recovery
61
Managing the Patient in Recovery
  • Must treat the pain
  • Use regional techniques whenever possible
  • PCA works very well allows patient to maintain a
    sense of control
  • Input from drug/alcohol counselor (if available)
  • Continued commitment to twelve step program

62
Regional Analgesia
63
Epidural Analgesia
64
Epidural Anatomy
Epidural Space
Ligamentum Flavum
Epidural Space
Epidural Needle
Dura
Epidural Veins
65
Epidural Opioids Mechanism of Action
  • Opioid Receptors in the Dorsal Horn of the Spinal
    Cord
  • Systemic Absorption (Lipophilic Agents)

66
Combined Opioid/Local Anesthetic Epidural
Analgesia
  • Two Sites of Action
  • Use Less of Each Agent Fewer Adverse Effects
  • May Prevent Adverse Effects

67
Patient-Controlled Epidural Analgesia PCEA
  • Usual Combination 0.125 bupivacaine or
    ropivacaine and an opioid
  • Most of analgesia from basal infusion
  • Bolus dose is for breakthrough pain

68
Benefits of Combined Epidural Analgesia
  • Better pain control
  • Earlier ambulation
  • Improved Pulmonary Mechanics
  • Decreased incidence of DVT
  • Faster return of bowel function

69
Epidurals and Lovenox
  • Current Guidelines
  • If on Lovenox, hold for 12 hrs
  • After epidural catheter removal, you may start
    Lovenox 2 hrs later
  • You should not use Lovenox if the patient has an
    indwelling epidural catheter
  • bid dosing
  • ? single dosing

70
Ultrasound Guided Regional Analgesic Techniques
71
Continuous Nerve Block Delivery Systems
72
Conclusions
  • Treat aggressively/Individualize therapy
  • Front Load!
  • Give medications on a timed schedule and not
    PRN
  • Dose based on the half -life
  • Utilize pre-emptive analgesia
  • Utilize regional analgesic techniques

73
Thank You
Questions?
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