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KEY CONCEPTS IN ACUTE PAIN MANAGEMENT - 2 SURGERY RESIDENTS Nov. 15, 2011

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Title: KEY CONCEPTS IN ACUTE PAIN MANAGEMENT Author: Susan Madden Last modified by: jpenning Created Date: 12/7/1998 5:51:22 PM Document presentation format – PowerPoint PPT presentation

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Title: KEY CONCEPTS IN ACUTE PAIN MANAGEMENT - 2 SURGERY RESIDENTS Nov. 15, 2011


1
KEY CONCEPTS IN ACUTE PAIN MANAGEMENT -
2SURGERY RESIDENTS Nov. 15, 2011
  • John Penning MD FRCPC
  • Director Acute Pain Service
  • The Ottawa Hospital

2
Objectives
  • Review the new acute pain ladder
  • When step 3 on the ladder isnt working?
  • Pronociception, glial activation??
  • Role of anti-hyperalgesic drugs
  • Fundamentals of IV PCA
  • What is an epidural anyway?
  • Epidural pitfalls for the surgeon
  • Review principles discussed by case presentation
  • Opioid tolerance, conversion from IV to PO
  • When, how to use naloxone
  • Assessing the hypotensive epidural patient

3
Tramadol
Foundational
4
Multi-modal Analgesia Orders
  • Celecoxib 100 200 mg PO Q12H
  • or
  • Naproxen 250 375 mg PO Q8H
  • Available OTC as Aleve 220 mg
  • Acetaminophen 650 mg PO Q4H
  • Tramadol 25 50 75 mg PO Q4H prn
  • Hydromorphone 1 2 mg PO Q4H prn
  • To supplement Tramadol if required

5
Case Problem32 yr. Male with multiple ribs
  • Patient previously healthy, MVA with no other
    injuries.
  • In Trauma Unit, c/o 9/10 pain. Difficultly
    breathing due to severe splinting.
  • Analgesic orders are
  • Hydromorphone 2 4 mg PO Q4H prn or
  • 1 2 mg SC Q4H prn
  • Nurse just gave 1 mg S/C one hour ago and now
    wont give anything for 3 hours!
  • What do you do?

6
Case Problem32 yr. Male with multiple ribs
  • Review of PHx reveals no drug use.
  • Patient has received total of 3 mg hydromorphone
    sc in the 6 hours since admission.

7
Case Problem32 yr. Male with multiple ribs
  • Acetaminophen 650 mg PO Q4H W/A
  • Ketorolac 30 mg IV stat followed by 10 mg IV Q4H.
  • Tramadol 50 75 mg PO Q4H
  • Hydromorphone 1 2 mg s.c. Q2H prn
  • Hydromorphone 0.5 - 1 mg IV Q1H prn

8
Case Problem32 yr. Male with multiple ribs
  • You are at the top of the analgesic ladder and
    the patient still has inadequate control of acute
    pain.
  • With more pain is more opioid always the answer?
  • NO! Why??
  • The problem likely is HYPERALGESIA

9
A New Dawn in Analgesia
10
Scientific American Nov 2009. Pg. 54. Douglas
Fields
11
E MC2
12
Hyperalgesia
Pro-nociceptive modulation
Nociceptive Stimulus
Pain
Anti-nociceptive modulation
Analgesia
13
Analgesic Drugs that act by Nociceptive
Modulation
  • Pro-antinociceptive
  • Augments inhibitory modulation of nociception i.e
    opioids
  • Anti-pronociceptive
  • Inhibits the facilitatory modulation of
    nociception i.e. ketamine, gabapentin and
    pregabalin

New
New
14
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15
Grande et al. Anesth and Analg Oct 08
16
NMDA Receptor Antagonists -To prevent or reverse
pathological acute pain
  • Ketamine, Dextromethorphan
  • Ketamine is widely known as a dissociative
    general anesthetic - 3 mg/Kg IV bolus
  • Ketamine 2.5 - 5.0 mg IV bolus for analgesia in
    post-op patient -
  • Ketamine as co-analgesic - combined 0.51 with
    hydromorphone IV PCA. Better analgesia, less S/E
  • Dextromethorphan 30 mg PO Q8H available OTC as
    Benylin DM, 3 mg/ml.

17
Case Problem32 yr. Male with multiple ribs
  • IV PCA with hydromorphone / ketamine
  • Ketorolac changed to naproxen when eating. 250
    mg PO Q8H
  • Or
  • Celecoxib 200 mg PO Q12H for 5 days then 100 mg
    Q12H until no longer needed.

18
Case Problem32 yr. Male with multiple ribs
  • On day three patient is doing well and planning
    for D/C tomorrow.
  • Convert to PO hydromorphone.
  • Daily IV PCA use is 20 mg per day.
  • Equals about 40 mg per day orally.
  • Order about 50 as long acting.
  • 9 mg HM Contin Q12H and 2 4 mg PO Q4H prn.

19
Case Problem32 yr. Male with multiple ribs
  • Weaning instructions
  • As daily breakthough hydromorphone
    requirements decrease, reduce the HM
    Contin dose by 25 increments.
  • The NSAID or coxib is D/C after the opioids D/C
  • Acetaminophen is last to be D/C

20
Analgesic Drugs that act by Nociceptive
Modulation
  • Anti-pronociceptive
  • Inhibits the facilitatory modulation of
    nociception i.e. ketamine, gabapentin and
    pregabalin, lidocaine

New
New
21
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22
Pregabalin for acute pain?
  • Acute pain is off-label use
  • Be cautious of Over-sedation
  • Sleep deprivation
  • Elderly
  • Patient already has significant opioids

23
Pregabalin The Good, The Bad and the Ugly
  • The Good
  • Chronic pain in region of surgery, when
    pronociceptive mechanisms play a role such as
    joint arthroplasty, bowel surgery in IBD
    patients, chronic limb ischemic pain, opioid
    tolerant patients
  • The Bad
  • Mild pain when simple analgesics like
    acetaminophen, NSAIDs or low dose opioid or
    tramadol suffice.
  • The Ugly
  • Too large a dose in sleep deprived patient
    already in state of morphine-failure

24
Pregabalin dosage
  • This is NOT a one size fits all.
  • Drugs binding to receptors have considerable
    patient to patient variability in doseresponse
  • Alpha-2 delta sub-unit of Voltage-Gated Calcium
    Channel
  • 75 mg PO 2 hours pre-op (50 150)
  • 50 mg PO Q8H for 3 to 5 days (25 75)

25
The New Challenges in Managing Acute Pain after
Surgery and Trauma
  • The Opioid Tolerant Patient
  • The greatest change in practice/attitudes in the
    last 10 years is the now wide spread acceptance
    of the use of opioids for CHRONIC NON-MALIGNANT
    PAIN
  • Renders the usual standard box orders totally
    inadequate in these patients
  • Get a pre-op Anesthesia/APS consult
  • The Brief Pain Inventory BPI

26
Eipe and Penning 2009
27
Opioid Conversions total daily ORAL dose
equivalents
  • Tramadol 500 mg
  • Tapentadol 250 mg
  • Morphine 100 mg
  • Oxycodone 50 mg
  • Hydromorphone 20 mg
  • Fentanyl patch 25 mcg/hr

28
The surgeon and IV PCA?
  • Hydromorphone opioid of choice
  • (0.5 mg/ml)
  • Less active metabolites than morphine
  • Better tolerated in renal insufficiency/elderly
  • Safety? In setting of having both available it
    is better to be more familiar with HM
    (substitution errors) i.e. want to avoid giving
    HM at the morphine dose!

29
The surgeon and IV PCA?
  • Loading dose required
  • HM 0.03 mg/kg, 2 mg in 70 kg
  • Bolus dose
  • HM 0.2 mg (0.1 0.4)
  • Lock-out interval 6 minutes
  • Continuous infusion
  • Not always required (0 0.2 mg/hr)
  • One hour limit - ( 1.6 mg)

30
Naloxone, a two-edged sword!
  • Is there a down side to the administration of
    naloxone, 0.4 mg IV in the post-op patient where
    opioid induced respiratory depression is
    suspected?
  • Severe acute pain, sympathetic response,
    pulmonary edema, MI, dysrhythmias

31
Case Presentation Somnolence and hypoxemia
while on IV PCA hydromorphone
  • 65 yr. Female with large ventral hernia repair on
    IV PCA hydromorphone
  • PMHx Angioplasty 9 yr. ago, MI, CHF in past
  • Moderate COPD, NIDDM
  • Doing well day 1, but day 2 found to be somewhat
    confused, somnolent and SaO2 remains in high 80s
    despite Oxygen by N/P
  • Is Narcan Indicated? Urgently?

32
Case Presentation Somnolence and hypoxemia
while on IV PCA Hydromorphone
  • Further patient evaluation
  • Patient arousable, RR 8-16, pupils slightly
    constricted, BP 130/70, pulse 90 and reg.
  • Chest A/E fair bil. And some mild basilar creps
  • ABG pH 7.46 pCO2 50 pO2 55 BiCarb 36 FiO2 gt
    .50
  • Chest X-ray Extensive bilateral, diffuse,
    interstitial infiltrate consistent with ARDS
  • Naloxone would probably have had a serious
    adverse effect on this patient. Hypoxemia
    despite supplemental O2 in a breathing patient.
    Look beyond the Opioids!

33
Case Presentation Somnolence and hypoxemia
while on IV PCA Hydromorphone
  • Management of suspected opioid induced
    respiratory depression
  • Support A/W
  • Simulate breathing
  • Supply supplemental oxygen
  • Assess SaO2, BP, Pulse
  • Naloxone titration, IF INDICATED
  • 0.04 mg Q5 min. X 3 as needed
  • Hypoxemia is a medical emergency
  • Hypercarbia is NOT

34
Opioids
  • Issue
  • With parenteral opioids the patient may
    experience intolerable side effects before
    adequate analgesia is attained

35
Opioids
  • CONCEPT
  • Targeted regional
  • administration of opioid
  • results in enhancement of
  • the therapeutic index (ratio
  • of analgesia/side effects)

36
Neuraxial Opioids the good
  • Intrathecal morphine
  • simple technique
  • potent analgesia for 12 -16 hrs.
  • highly effective for pain in lower abdomen and
    lower limbs

37
Neuraxial Opioids adverse effects
  • Risk of delayed onset of respiratory depression,
    peaks at 6 hours
  • Urinary retention gt50 for 16 hours
  • Pruritus, is not an allergy

38
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39
What is an EPIDURAL?
  • Anatomical
  • Location of the catheter, C7 L5
  • Cervical, thoracic and lumbar epidurals
  • Segmental Blockade
  • Drugs
  • Opioids (hydrophillic vs. lipophillic)
  • morphine, hydromorphone, demerol, fentanyl
  • Hydrophillic drugs migrate rostrally and also
    yield greater spinal selectivity

40
What is an EPIDURAL?
  • Drugs
  • Local Anesthetics
  • Lidocaine, bupivacaine, ropivacaine
  • Varying concentrations/drug mass produces
  • Differential Blockade
  • sympathetics gt somatosensory gt motor
  • Adjuncts epinephrine
  • Mode of Drug Delivery
  • Intermittent bolus vs. continuous infusions

41
True or False?
  • Epidural analgesia impairs the resolution of
    post-operative ileus i.e. it slows down the gut
    delaying return of normal bowel function.

42
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43
Epidural analgesia and recovery of bowel
motililty??
  • Thoracic placement of epidural with the
    administration of local anesthesic and minimal
    opioid will promote bowel recovery via
    sympathetic blockade
  • If the primary mode of epidural analgesia is via
    potent opioid, recovery of motility may be
    delayed.

44
True or False?
  • Epidural analgesia necessitates a foley catheter
    until the epidural is removed.

45
What about epidurals and the foley catheter??
  • Less Urinary Tract Infection by Earlier Removal
    of Bladder Catheter in Surgical Patients
    Receiving Thoracic Epidural Analgesia.
  • Zaouter C, Kaneva P, Carli F (McGill)
  • Regional Anesthesia and Pain Medicine
    Nov-Dec 2009 pp. 542-552.

46
Epidural Pit-falls for the Surgeon
  • Epidural hematoma
  • gt 50 reported cases in USA in patients treated
    with LMWH
  • Epidural insertion and removal of the catheter
  • Risk factors Elderly, low body weight, twice
    daily dosing, anti-coagulation vs. prophylactic
    dose range
  • The decision to fully anti-coagulate a patient
    with an epidural in-situ should be made in
    consultation with anesthesia and thrombosis
    medicine

47
Epidural Pit-falls for the Surgeon
  • More epidural hematoma risks!!
  • Heparin 5000 units s.c. Q8H for
    thromboprophyllaxis??
  • This is full clinical anti-coagulation for some
    patients!
  • Once daily LMWH at thromboprophyllactic dose is
    safer.

48
What about anti-platelet agents?
  • Plavix
  • ASRA guidelines state no neuraxial anesthesia or
    epidural catheters implemented until D/C for 7
    days
  • Plavix may be started 12 24 hour after
    neuraxial block or catheter removal
  • concensus only, speculative
  • Obviously risk is much lower than with
    heparin/coumadin since reports are extremely rare
  • New agents on horizon??

49
Epidural Pit-falls for the Surgeon
  • Masked-Mischief
  • The potential high efficacy of the modality could
    block pain related to complications
  • Peritonitis anastomosis dehiscence
  • Wound infection, wound hematoma
  • Limb ischemia, compartment syndrome
  • Delay in appropriate therapy, diagnosis
  • Neurological problems inappropriately attributed
    to the epidural i.e. anterior spinal artery
    syndrome
  • Hypovolemia

50
The Hypotensive Patient with an Epidural
  • 64 yr. female, 48 kg, with no Hx of CVS problems,
    had an esophagectomy for cancer with combined
    GA/epidural anesthesia.
  • Later that evening you are called because the
    patients BP is 85/50.
  • Epidural at T5/6 and running hydromorphone 10
    µg/ml in 0.1 bupivacaine with epinephrine 2
    mcg/ml at 8 ml/hr

51
The Hypotensive Patient with an Epidural
  • Possibilities?
  • Normal for this patient
  • all is well and confirmed by Hx and absence of
    postural changes in BP or HR
  • vascular patients may have marked discrepancy
    between arms establish baseline pre-op
  • Surgical complications
  • Medical complications
  • Side-effect of Epidural induced sympathetic block
  • decreased venous return and decreased SVR
  • Combination of any 4 above

52
Is the Epidural causing the hypotension?
  • What drugs have been administered epidurally?
  • Pure opioids morphine, hydromorphone, fentanyl
  • sympathetics not blocked directly so look for
    another cause
  • Demerol
  • mild direct sympatholytic effect and some
    systemic effects in large doses. Rarely cause of
    significant Hypotension. Be careful to R/O other
    causes.
  • Local Anesthetics /- opioids
  • In a euvolemic patient with normal CVS function
    hypotension is unlikely if lt 8 sensory dermatomes
    blocked

53
Is the Epidural Local Anesthetic causing the
hypotension?
  • Intrathecal catheter migration
  • Inadvertent overdose
  • Un-masking of problem with the patient.
  • Sensitive patient

54
Is the Epidural Local Anesthetic causing the
hypotension?
  • Management
  • ABCs
  • supplemental O2, fluid bolus, elevate legs
  • ephedrine 5 mg or phenylephrine 50 µg IV bolus
  • Hold the epidural infusion
  • Quantify the extent of block
  • motor block? Thoracic epidural?, thats a
    problem!
  • Sensory block (cold, sharp)
  • In a euvolemic patient with normal CVS function
    hypotension is unlikely if lt 8 sensory dermatomes
    blocked

55
Management of Hypotension Contd
  • High thoracic epidural blockade may block the
    compensatory tachycardia response to hypovolemia.
  • Cardio-accelerator sympathetic nerve fibres arise
    from T1 - T4
  • sympathetic block may extend several dermatomes
    above the sensory blockade
  • Correct the underlying cause
  • Remove bupicacaine and change to epidural
    hydromorphone if patient remains hemodynamically
    unstable

56
36 yr. Open Cholecystectomy patient experiencing
difficulty weaning from IV PCA
  • Endometriosis, fibromyalgia and chronic low back
    pain- has been on Tylenol 3 for several years-
    functions well and stable usage of 8-10/day
  • Day 3 post-op Tylenol 3, 2 tabs Q4h started and
    IV PCA D/C
  • Patient c/o severe pain, not able to go home

57
36 yr. Open Cholecystectomy patient experiencing
difficulty weaning from IV PCA
  • Review of APS meds
  • Acetaminophen 650 mg Q4H
  • Naproxen 250 mg Q8H
  • Pregabalin 50 mg Q8H
  • Tramadol 50 mg Q4H
  • Plus using 20 mg IV HM in last 24 hr.
  • Continue above A/N/P/T plus will likely require
    about 40 mg daily HM PO (4 6 mg PO Q4H prn)
  • Plan for transition back to Fam MD

58
Conclusion Key Concepts
  • The foundation of all acute pain Rx protocols is
    NSAIDS and acetaminophen.
  • Codeine is a pro-drug. Problems may occur with
    under or over conversion to morphine
  • Tramadol to be considered as second step in the
    acute pain ladder
  • Naloxone can be a dangerous drug, careful
    titration is almost always possible

59
Conclusions
  • Inadequate analgesia despite cyclo-oxygenase
    inhibitors and opioids?
  • Think Hyperalgesia
  • Consider an anti-hyperalgesic like ketamine,
    pregabalin
  • All epidurals are not equivalent
  • Epidural pitfalls

60
Useful texts
  • Free!! From Canadian Pain Society
  • Managing Pain The Canadian Healthcare
    Professionals Reference. Edited by Roman Jovey.
    2008.

61
ACUTE PAIN MANAGEMENT SCIENTIFIC EVIDENCE 3nd
Edition Feb 10 Australian and New Zealand
College of Anaesthetists And Faculty of Pain
Medicine.
http//www.anzca.edu.au/publications/acutepain.pdf
The above web site has the entire document and is
freely Available to download.
62
Useful websites on Pain
  • ProspectProcedure Specific Post-op Pain
    Management
  • http//www.postoppain.org/frameset.htm
  • Pain Explained
  • http//www.painexplained.ca/content.asp?node4
  • The Canadian Pain Society
  • http//www.canadianpainsociety.ca/indexenglish.htm
    l

63
Useful websites on Pain
  • Pain Institute
  • http//www.medscape.com/infosite/paininstitute/art
    icle-5?src0_0_ad_ldr
  • Internation Association for the Study of Pain
  • http//www.iasp-pain.org//AM/Template.cfm?Section
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