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Principles of Surgery PERI-OPERATIVE ANALGESIA

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Principles of Surgery PERI-OPERATIVE ANALGESIA Joseph Kay, MD FRCPC Sunnybrook & Women s College HSC Assistant Professor, University of Toronto – PowerPoint PPT presentation

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Title: Principles of Surgery PERI-OPERATIVE ANALGESIA


1
Principles of Surgery PERI-OPERATIVE ANALGESIA
  • Joseph Kay, MD FRCPC
  • Sunnybrook Womens College HSC
  • Assistant Professor, University of Toronto

2
Why should we treat peri-operative pain?
  • ? pain and suffering
  • ? complications
  • ? likelihood of chronic pain
  • ? patient satisfaction
  • ? speed of recovery ? LOS ?cost
  • ? productivity and quality of life

3
Adverse effects of poor pain management
  • Cardiovascular
  • Respiratory
  • Gastrointestinal\Genitourinary
  • Neuroendocrine\Metabolic
  • Musculoskeletal
  • Immunological
  • Psychological

4
Current pain management
  • Pain can virtually be eliminated with minimal
    side effects
  • BUT
  • 70 inpatients still have moderate or severe pain
  • 40 outpatients have significant pain in 1st 24 h
  • WARFIELD Anesthesiol 1995 831090
    BEAUREGARD Can J Anesth 1998 45304

5
Barriers to effective pain management I
  • ANESTHESIOLOGIST
  • Inadequate pain education
  • Underestimation analgesic requirements
  • Failure to recognize patient variability
  • Inadequate use local\regional techniques
  • Complications from side effects

6
Barriers to effective pain management II
  • PATIENT
  • Expectation of severe pain
  • Inadequate pain education
  • Analgesic side effects
  • Fear of addiction

7
Barriers to effective pain management III
  • NURSE
  • Expectation of severe pain
  • Inadequate pain education
  • Fear of causing analgesic side effects e.g
    respiratory depression, addiction
  • Insufficient time for assessment/ treatment

8
Barriers to effective pain management IV
  • SURGEON
  • Belief that pain is normal and not harmful
  • Concern that pain may mask injury
  • Inadequate pain education
  • Dont ask dont tell
  • Complications from side effects\addiction

9
Barriers to effective pain management V
  • HOSPITAL
  • Inadequate funding resources with pain as low
    priority
  • Inadequate commitment
  • Lack of accountability

10
Traditional opioid analgesia
  • Parenteral
  • prn

11
Traditional opioid analgesia
  • Sedation
  • Respiratory depression
  • Nausea Vomiting
  • Urinary retention
  • Ileus
  • Constipation
  • Pruritus

12
Multimodal Analgesia
  • Using more than one drug, acting at a
    different place or with a different mechanism,
    each with a lower dose than if used alone, thus
    providing better analgesia with less side effects.

13
Multimodal Analgesia
  • Opioid
  • NSAID (COXIB)
  • Acetaminophen
  • Local anesthetic block
  • Other adjuncts

14
Multimodal Analgesia
15
Multimodal Analgesia
  • Better analgesia
  • Less side effects
  • Can decrease hospital stay
  • May improve surgical outcome
  • May decrease chronic pain
  • KEHLET Br J Surg 1999 86227
    CAPDEVILLA Anesthesiol 1999 918
  • REUBEN Anesthesiol 2001 95390

16
Multimodal Analgesia Opioids
  • Systemic - oral/parenteral/transdermal
  • Neuraxial - spinal/epidural
  • Peripheral - intra-articular, periosteal

17
Multimodal Analgesia Opioids

  • Sites of action
  • Central dorsal horn spinal cord
  • Peripheral synovium
  • periosteum

18
Multimodal Analgesia Opioids

  • Systemic
  • Oral - contin b/t
  • Parenteral - iv PCA
  • sc infusion b/t

19
Multimodal Analgesia Opioids

  • Neuraxial
  • Spinal - single shot
  • Epidural - continuous infusion
  • (local anesthetic)

20
Multimodal Analgesia Opioids

  • Peripheral
  • Intra-articular
  • Iliac crest bone graft

21
Opioid Intraoperative vs Postoperative
  • THA 40 pts
  • Intra-operative group
  • achieved VASlt3 42 vs 76 min
  • ? morphine PACU 7 vs 15 mg
  • ? respiratory depression
  • PICO Can J Anesth 2000 47309

22
Opioid Oral Controlled Release
  • Oxycontin
  • TKA 59 pts
  • 29 oxycontin vs 30 placebo
  • Oxycodone q4h prn
  • Oxycontin group ? pain ? LOS 2.3 days
  • ?ROM
  • CHEVILLE J Bone Jt Surg Am 2001 83A6915

23
Opioid Iliac Crest Infiltration
  • Spine fusion 60 pts
  • Group I saline into donor site
  • Group II 5 mg i.m morphine
  • Group III 5 mg morphine into donor site

24
Opioid Iliac Crest Infiltration
  • Gp III 50 less morphine 24h
  • lower pain scores gt 2h
  • ? pain at 1 yr 5 vs 33
  • REUBEN Anesthesiol 2001 95390

25
Multimodal Analgesia NSAID / COXIBS
  • potent analgesics for mild-moderate pain
  • adjunct to opioid for moderate-severe pain
  • ? VAS 2/10
  • ? opioid consumption 30-50
  • ? opioid related side effects

26
NSAID
  • Spinal fusion 70 pts
  • Morphine PCA ketorolac 0-30 mg iv q6h
  • Ketorolac 7.5-30 mg
  • ? morphine use
  • ? pain VAS
  • ? sedation ? nausea

  • REUBEN Anesth Analg 1998 8798

27
NSAID side effects
  • GI ulceration
  • mild platelet dysfunction
  • inhibition bone fusion
  • mild Na retention / hypertension
  • ? renal function in low flow states

28
NSAID side effects
  • CAN WE MAKE A BETTER NSAID?
  • Keep analgesic potency
  • Reduce side effects

29
NSAID mechanism of action
  • inhibits cyclo-oxygenases (COX-12) which
    convert arachidonic acid to prostaglandins (PG)
  • ? PGE2 to sensitize nociceptors
  • ? PGE2, PGI2, TXA2 for homeostasis


30
COX 2 isoforms
  • COX-1 constitutive everywhere
  • housekeeping
  • PGE2, PGI2, TXA2
  • COX-2 constitutive in kidney, CNS
  • induced by trauma / pain
  • main source PGE2 for sens.

31
PGE2 production







EP receptor
BK receptor
Tissue Injury
Peripheral induction of COX-2
IL-1?
Central induction of COX-2
32
PGE2 sensitization







PGE2
EP receptor
BK receptor
Bradykinin
Tissue Injury
PGE2
33
YES
  • Can we make a selective COX-2 inhibitor with
    excellent analgesia and less side effects than a
    conventional NSAID?

34
COX-2
  • COX-1



Active site
Active site
NSAID
NSAID
Arachidonic acid
Arachidonic acid
35
COX-2
  • COX-1



Active site
Active site
PGE2 PGI2 TXA2
COX-2 Inhibitor
Arachidonic acid
Arachidonic acid
COX-2 Inhibitor
36
COX-2 inhibitors
  • Celecoxib
  • Rofecoxib
  • Valdecoxib

37
COXIB analgesic potency
  • similar to or more potent than NSAIDs
  • valdecoxib 40 mg ketorolac 30 mg
  • 2 percocets!
  • 24h duration
  • DANIELS J Am Dent Assoc 2002 133611 MEHLISCH
    J Oral Maxillofac Surg 2003


  • 611030

38
COXIB pre-emptive effect
  • rofecoxib 50 mg given 1 h pre-incision vs post ?
    pain ? opioid consumption
  • prevents PGE2 sensitization from up-regulated
    COX-2
  • REUBEN Anesth Analg 2002 9455

39
COXIB side effects GI
  • ? incidence ulcers or bleeding compared to
    conventional NSAIDs
  • BOMBARDIER NEJM 2000 3431520

40
COXIB side effects renal function
  • COX-2 constitutive in kidney
  • same effect as conventional NSAID
  • mild Na retention, blood pressure ?
  • ? renal blood flow in hypovolemia or ? CO
  • Avoid in hypovolemia, CHF, renal dysfunction,
    uncontrolled ? BP ,DM
  • BRATER J Pain Symptom Management 2002 23S15

41
COXIB side effects bone fusion
  • conventional NSAIDs inhibit bone growth fusion
  • coxibs do not appear to clinically affect bone
    fusion
  • rofecoxib/celecoxib vs control vs ketorolac in
    spinal fusion patients
  • 9/132 vs 6/90 vs 23/120
  • GLASSMAN Spine 1998 23834 REUBEN ASRA
    Annual mtg 2002 Abstract PD-16 LEWIS Proc NA
    Spine mtg 2000 64

42
COXIB side effectsallergy
  • Can use in asthmatics
  • May use rofecoxib with caution in ASA allergy
  • Avoid celecoxib/valdecoxib with sulfa allergy
  • GLASSER Pharmacotherapy 2003 23551 STEVENSON
    J Allergy Clin Immun


  • 2001 108 47

43
COXIB side effects platelet function
  • NO effect on platelets
  • NO effect on bleeding
  • Patients on warfarin may have ? INR
  • (need to adjust dose for cel/rof)
  • LEESE Am J Emerg Med 2002 20275 HOMONCIK
    Clin Exp Rheumatol

  • 2003
    21 229

44
Summary COXIBS compared to NSAIDs
  • more potent analgesic avoid opioid
  • longer duration once a day
  • pre-emptive effect use pre-op
  • no effect on platelets use pre-op
  • less or no GI S/E use in risk
  • no effect on bone fusion use in ortho

45
Multimodal Analgesia Acetaminophen
  • Central COX 3 inhibitor
  • ? opioid use by 30
  • ? opioid related side effects
  • SHUG Anesth Analg 1998

46
Multimodal Analgesia Acetaminophen
  • Avoid with
  • hepatic insufficiency
  • alcoholism
  • malnutrition
  • P450 inducers

47
Multimodal Analgesia Acetaminophen NSAID
  • usual adjunct for PCA opioid
  • combination better than either alone
  • VAS ? rest dynamic
  • FLETCHER Can J Anesth 1997 44479

48
Multimodal Analgesia Local anesthetic
  • Infiltration
  • Intraperitoneal
  • Nerve block
  • Neuraxial


49
Local anesthetic
  • Movement assoc pain reduces function
  • Local anesthetic blocks A? c fibres

50
Incisional local infiltration
  • Lap chole 157 pts
  • periportal intraperitoneal bupivacaine
  • pre-incision or at end
  • ? pain first three hours with pre-incisional
  • periportal bupivacaine (/- intraperitoneal)
  • LEE Can J Anesth 2001 48545

51
Peritoneal local infiltration
  • Appendectomy Peritoneal infiltration 0.5
    bupivacaine
  • ? pain scores
  • ? analgesic consumption
  • COLBERT Can J Anesth 1998 45734

52
Local infiltration
  • Bupivacaine
  • is
  • BACTERICIDAL
  • AYDIN Eur J Anesth 2001 18687

53
Nerve Block Single shot
  • ankle block
  • interscalene
  • 0.5 bupivacaine
  • 6-24h postop analgesia

54
Nerve Block Continuous
  • Continuous Femoral Nerve Blk
  • post total knee arthroplasty
  • compared to
  • PCA or epidural

55
Nerve Block Continuous femoral
  • Better analgesia
  • Less morphine use
  • Less opioid related side effects
  • Better ambulation hemodynamic stability
  • CAPDEVILLA Anesthesiol 1999 918 SINGELYN
    Anesth Analg 1998 8788
  • CHELLY J Arthroplasty 2001 16436

56
Nerve Block Continuous femoral
  • Better surgical outcome
  • Less perioperative bleeding
  • Increased flexion with CPM
  • Earlier hospital discharge
  • Less time in rehabilitation
  • CAPDEVILLA Anesthesiol 1999 918 SINGELYN
    Anesth Analg 1998 8788
  • CHELLY J Arthroplasty 2001 16436

57
Nerve Block Single shot femoral
  • 40 ml 0.25 bupivacaine vs saline post TKA
  • ? pain VAS ? 1-2
  • 50 ? morphine use
  • 50 ? morphine related side effects
  • Better ambulation
  • LOS 3 vs 4 days
  • WANG Reg Anesth Pain Med 2002 27139

58
Nerve Block Continuous interscalene /popliteal
  • Disposable pumps
  • Major shoulder /leg surgery can be done as an
    outpatient
  • ?

59
Nerve Block Continuous popliteal nerve block at
home
  • 30 pts randomized to local anesthetic or saline
  • Rescue oral opioids
  • VRS 0 vs 4/10
  • Sleep disturbances 10x less
  • O opioid pills vs 8
  • ILFIELD Anesthesiology 2002 97208

60
Epidural Analgesia
61
Epidural Analgesia
  • LOCAL /OPIOID
  • superior analgesia
  • better cardiopulmonary function
  • earlier return bowel function

62
Epidural Analgesia
  • LOCAL /OPIOID
  • better ambulation
  • decreased hospital stay
  • safe to use on wards

63
Epidural Analgesia
  • Sigmoidectomy
  • Early ambulation feeding
  • 2 day median hospital stay
  • KEHLET Br J Surg 1999 86227

64
Summary
  • Pre-op Coxib
  • Local infiltration / block
  • Acetaminophen / Coxib post-op
  • Controlled release opioid
  • Thoracic epidural for major abdominal thoracic
    surgery
  • Continuous nerve blocks for extremity surgery

65
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