Perioperative Pain Management - PowerPoint PPT Presentation

1 / 48
About This Presentation
Title:

Perioperative Pain Management

Description:

Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael s Hospital Management of Side Effects Nausea / Vomiting Ondansetron (Zofran ... – PowerPoint PPT presentation

Number of Views:1134
Avg rating:3.0/5.0
Slides: 49
Provided by: Nick2159
Category:

less

Transcript and Presenter's Notes

Title: Perioperative Pain Management


1
Acute Perioperative Pain Management
AHMED HAMDY Staff Anesthesiologist St. Michaels
Hospital
2
Outline
  • Introduction
  • Why Treat pain?
  • Pain Assessment
  • Methods to Treat Pain
  • Management of Opiate Overdose
  • Acute Pain Service

3
Introduction
  • What is Pain?
  • An unpleasant sensory and emotional experience
    associated with actual or potential tissue damage
    or described in terms of such damage.
  • IASP Pain Definition (1994, 2008)

4
Introduction
  • Classification of Pain
  • Acute or Chronic
  • Nociceptive or Neuropathic

5
Introduction
  • Pain Signal Processing
  • Pain perception is a complex phenomenon involving
    sophisticated transmission pathways in the
    nervous system
  • With many pain signal transmission points, there
    exists opportunity!

6
Why Treat Pain?
7
Why Treat Pain?
  • Basic human right!
  • ? pain and suffering
  • ? complications next slide
  • ? likelihood of chronic pain development
  • ? patient satisfaction
  • ? speed of recovery ? ? length of stay ? ? cost
  • ? productivity and quality of life

8
Adverse Effects of Poor Pain Control
  • CVS MI, dysrhythmias
  • Resp atelectasis, pneumonia
  • GI ileus, anastomotic failure
  • Endocrine stress hormones
  • Hypercoagulable state DVT, PE
  • Impaired immunological state
  • Infection, cancer, wound healing
  • Psychological
  • Anxiety, Depression, Fatigue
  • Chronic Post-surgery/trauma Pain

9
Adverse Effects of Poor Pain Control
  • it remains a common misconception amongst
    clinicians that acute postoperative pain is a
    transient condition involving physiological
    nociceptive stimulation, with a variable
    affective component, that differs markedly in its
    pathophysiological basis from chronic pain
    syndromes.
  • Cousins MJ, Power I, and Smith G.
  • Regional Analgesia and Pain Medicine, 25 (2000)
    6-21

10
Pain Assessment
11
Pain Assessment
  • Pain History
  • O Onset
  • P Provoking / Palliating factors
  • Q Quality / Quantity
  • R Radiation
  • S Severity
  • T Timing

12
Pain Assessment
  • 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

13
Pain Assessment Visual Analogue Scale
14
Pain Assessment
  • Current Pain Medications
  • Accuracy and detail are very important!
  • Name, dose, frequency, route
  • ie. Oxycontin 10mg PO TID
  • Dont forget to re-order or factor in patients
    pre-existing pain Rx usage when writing orders
  • Conflicts with HPI / PMH
  • Renal disease ? avoid morphine, NSAIDs
  • Vomiting ? avoid oral forms of medication
  • Short gut/high output stomas ? avoid CR
    formulations

15
Pain Assessment
  • 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!

16
Methods to Treat Pain
17
Methods to Treat Pain
  • 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

18
WHO Analgesic Ladder
19
Multimodal Analgesia
  • 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

20
Acetaminophen
  • 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

21
NSAIDs
  • Also, first-line treatment
  • Mechanism
  • Block cyclooxygenase (COX) enzyme ? ?
    prostaglandin synthesis
  • COX-2 ? Prostaglandins ? pain, inflammation,
    fever
  • COX-1 ? Prostaglandins ? gastric protection,
    hemostasis

22
NSAIDs
  • 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?

23
Opioids
  • Dilaudid 1-4mg PO/IM/IV/SC Q3H PRN
  • Any concerns?

24
Opioids
  • 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

25
Opioids
  • Side Effects
  • Nausea / Vomiting
  • Sedation
  • Respiratory Depression
  • Pruritus
  • Constipation
  • Urinary Retention
  • Ileus
  • Tolerance

26
Opioids
  • 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-glucuronide
    )

27
Opioids
  • 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)

28
Opioids
  • Codeine
  • 1/10th 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

29
Opioids - Formulations
  • 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

30
Opioid Equianalgesic Table
Drug Equianalgesic Dose Equianalgesic Dose Initial Adult Dose (gt50kg) Initial Adult Dose (gt50kg)
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
31
Opioids PCA
32
Opioids PCA
  • 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

33
Gabapentin
  • 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

34
Management of Side Effects
  • Nausea / Vomiting
  • Ondansetron (Zofran)
  • Dimenhydrinate (Gravol)
  • Metoclopramide (Maxeran)
  • Changing medication(s) / ? dose
  • Pruritus
  • Diphenhydramine (Benadryl)
  • Changing medication(s) / ? dose

35
Regional Anesthesia
36
Regional Anesthesia
  • 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

37
Regional Anesthesia
  • 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

38
Regional Anesthesia
  • Neuraxial Techniques
  • Spinal (subarachnoid) anesthesia
  • Epidural anesthesia (lumbar and thoracic)

39
Benefits of Epidural Analgesia
  • 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

40
Epidural Analgesia
  • Recommended as part of ERAS/fast track protocols
    for colon/colorectal surgery
  • Increased incidence of hypotension and urinary
    retention
  • Management of postoperative hypotension?

41
Contraindications to Neuraxial Blockade
  • Absolute
  • Pt refusal or allergy to LA
  • Uncorrected hypovolemia
  • Infection at insertion site
  • Raised ICP
  • ? Coagulopathy
  • Relative
  • Uncooperative patient
  • Fixed cardiac output states
  • Systemic infection/sepsis
  • Unstable neurological disease
  • Significant spine abnormalities or surgery

42
Management of Opioid Overdose
43
Management of Opioid Overdose
  • For ?LOC, somnolent patient
  • Stimulate patient
  • Vitals/Monitors/Lines
  • Airway
  • Breathing
  • Circulation
  • CODE BLUE? CCRT? ICU? APS

44
Opioid Overdose Management
  • Opioid Reversal
  • Naloxone - opioid antagonist
  • Reverses effects of opioid overdose (for
    30-45min)
  • MUST BE diluted before use
  • 0.4mg ampule
  • Dilute 1mL Naloxone 9mL Saline 0.04 mg/mL
  • Give 0.04 to 0.08 mg (1 to 2 mL) IV q3-5 minutes
  • If no change after 0.2mg, consider other causes

45
Opioid Overdose Management
  • Ddx
  • Seizure, stroke
  • Hypoxia, Hypercarbia
  • Hypotension
  • Other medication effect
  • Severe electrolyte or acid base abnormalities
  • MI
  • Sepsis
  • ..etc.

46
Acute Pain Service
  • Consult service for complex / specialized pain
    management
  • Anesthesia Staff Advanced Practice Nurses
  • Many post-op patients will be followed by APS
  • If APS involved, APS must write all pain Rx
  • Call for
  • Advice
  • Difficult to manage cases

47
Summary
  • Accurate pain assessment
  • Make sure to continue or account for patients
    pre-hospital pain regimen
  • Use Multimodal pain management
  • Discharge pain management plan
  • Acute Pain Service available 24 hrs/day

48
Summary
  • 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
Write a Comment
User Comments (0)
About PowerShow.com