Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.
-
Upload
chastity-atkinson -
Category
Documents
-
view
245 -
download
0
Transcript of Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.
![Page 1: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/1.jpg)
Acute Perioperative Pain Management
AHMED HAMDYStaff AnesthesiologistSt. Michael’s Hospital
![Page 2: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/2.jpg)
OutlineIntroduction
Why Treat pain?
Pain Assessment
Methods to Treat Pain
Management of Opiate Overdose
Acute Pain Service
![Page 3: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/3.jpg)
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)
![Page 4: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/4.jpg)
Introduction
Classification of PainAcute or ChronicNociceptive or Neuropathic
![Page 5: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/5.jpg)
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!
![Page 6: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/6.jpg)
Why Treat Pain?
![Page 7: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/7.jpg)
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
![Page 8: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/8.jpg)
Adverse Effects of Poor Pain Control
CVS: MI, dysrhythmiasResp: atelectasis, pneumoniaGI: ileus, anastomotic failureEndocrine: “stress hormones”Hypercoagulable state: DVT, PEImpaired immunological state
Infection, cancer, wound healing
Psychological:Anxiety, Depression, Fatigue
Chronic Post-surgery/trauma Pain
![Page 9: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/9.jpg)
“… 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
Adverse Effects of Poor Pain Control
![Page 10: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/10.jpg)
Pain Assessment
![Page 11: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/11.jpg)
Pain Assessment
Pain HistoryO – Onset P – Provoking / Palliating factorsQ – Quality / QuantityR – RadiationS – Severity T – Timing
![Page 12: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/12.jpg)
Pain Assessment
Origin of PainAcute Pain
ie. Incisional pain, acute appendicitis
Chronic Painie. Chronic back pain
Acute on Chronic PainAcute and chronic causes may or may not be related to each
other
![Page 13: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/13.jpg)
Pain Assessment Visual Analogue Scale
![Page 14: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/14.jpg)
Pain Assessment
Current Pain MedicationsAccuracy and detail are very important!
Name, dose, frequency, routeie. Oxycontin 10mg PO TID
Don’t forget to re-order or factor in patient’s pre-existing pain Rx usage when writing orders
Conflicts with HPI / PMHRenal disease → avoid morphine, NSAID’sVomiting → avoid oral forms of medicationShort gut/high output stomas → avoid CR formulations
![Page 15: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/15.jpg)
Pain Assessment
Allergies / IntolerancesDrug allergies
Document drug, adverse reaction and severity
IntolerancesNausea / vomiting, hallucinations, disorientation, etc.
Very important to differentiate between an allergy and an intolerance!
![Page 16: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/16.jpg)
Methods to Treat Pain
![Page 17: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/17.jpg)
Methods to Treat PainPharmacologic
Medications (po, iv, im, sc, pr, transdermal)AcetaminophenNSAIDsOpioidsGabapentinNMDA antagonistsAlpha-2 agonists
ProceduresRegional AnesthesiaLA infiltration at incision site
Surgical Intervention
Non-Pharmacologic / Non-Surgical
![Page 18: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/18.jpg)
WHO Analgesic Ladder
![Page 19: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/19.jpg)
Multimodal Analgesia
Using more than one drug for pain controlDifferent drugs with different mechanisms/sites of action
along pain pathwayEach with a lower dose than if used aloneCan provide additive or synergistic effectsProvides better analgesia with less side effects (mainly
opiate related S/E)
Always consider multimodal analgesia when treating pain
![Page 20: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/20.jpg)
AcetaminophenFirst-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
![Page 21: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/21.jpg)
NSAIDs
Also, first-line treatment
MechanismBlock cyclooxygenase (COX) enzyme → ↓ prostaglandin
synthesisCOX-2 → Prostaglandins → pain, inflammation, feverCOX-1 → Prostaglandins → gastric protection,
hemostasis
![Page 22: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/22.jpg)
NSAIDs
Warnings: ↓dose / avoid ifGI ulceration Bleeding disorders / CoagulopathyRenal dysfunctionHigh cardiac risk – COXII inhibitorsAsthmaAllergy
?Avoid celecoxib if allergic to Sulpha
Concern for anastomotic leaks?
![Page 23: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/23.jpg)
Opioids
Dilaudid 1-4mg PO/IM/IV/SC Q3H PRN
Any concerns?
![Page 24: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/24.jpg)
Opioids
Key Points:Centrally acting on opioid receptorsNo ceiling effectHigh dose/response variability in non-opiate usersPrevious dependence creates a challenge in acute on chronic pain management casesBalancing safety and efficacy can be difficult (OSA patients)Side effects may limit reaching effective dose
![Page 25: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/25.jpg)
Opioids
Side EffectsNausea / VomitingSedationRespiratory DepressionPruritusConstipationUrinary Retention IleusTolerance
![Page 26: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/26.jpg)
Opioids
MorphineMost commonly prescribed opioid in hospitalMetabolism:
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)
![Page 27: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/27.jpg)
Opioids
Hydromorphone (Dilaudid)Better tolerated by elderly, better S/E profilePreferred over morphine for renal disease patientsLow cost, IV and PO forms available
OxycodoneGood S/E profile, but $$PO form onlyPercocet (oxycodone + acetaminophen)
![Page 28: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/28.jpg)
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
![Page 29: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/29.jpg)
Opioids - Formulations
Short acting formsNeed to be dosed frequently to maintain consistent
analgesia
Controlled Release formsProvides more consistent steady state levelHelpful for severe pain or chronic pain situationsNever crush / split / chew controlled release pills
![Page 30: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/30.jpg)
Opioid Equianalgesic Table
Drug Equianalgesic Dose Initial Adult Dose (>50kg)
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
![Page 31: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/31.jpg)
Opioids – PCA
![Page 32: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/32.jpg)
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
![Page 33: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/33.jpg)
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
![Page 34: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/34.jpg)
Management of Side Effects
Nausea / VomitingOndansetron (Zofran)Dimenhydrinate (Gravol)Metoclopramide (Maxeran)Changing medication(s) / ↓ dose
PruritusDiphenhydramine (Benadryl)Changing medication(s) / ↓ dose
![Page 35: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/35.jpg)
Regional Anesthesia
![Page 36: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/36.jpg)
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
![Page 37: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/37.jpg)
Regional Anesthesia
Peripheral Nerve BlocksUpper Limb: Brachial plexusLower Limb: Femoral, sciatic, popliteal, ankleAbdomen: TAP blocksThoracic: Paravertebral, intercostal blocks
Use of Ultrasound Imaging has revolutionized peripheral nerve blockadeSafety?Accuracy / Improved SuccessEfficiency
![Page 38: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/38.jpg)
Regional Anesthesia
Neuraxial TechniquesSpinal (subarachnoid) anesthesiaEpidural anesthesia (lumbar and thoracic)
![Page 39: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/39.jpg)
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
![Page 40: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/40.jpg)
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?
![Page 41: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/41.jpg)
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
![Page 42: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/42.jpg)
Management of Opioid Overdose
![Page 43: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/43.jpg)
Management of Opioid Overdose
For ↓LOC, somnolent patient:Stimulate patient Vitals/Monitors/LinesAirway BreathingCirculation CODE BLUE? CCRT? ICU? APS
![Page 44: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/44.jpg)
Opioid Overdose Management
Opioid Reversal Naloxone - opioid antagonistReverses effects of opioid overdose (for 30-45min)MUST BE diluted before use:
0.4mg ampuleDilute: 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
![Page 45: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/45.jpg)
Opioid Overdose Management
Ddx:Seizure, strokeHypoxia, HypercarbiaHypotensionOther medication effectSevere electrolyte or acid base abnormalitiesMISepsis…..etc.
![Page 46: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/46.jpg)
Acute Pain ServiceConsult 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:AdviceDifficult to manage cases
![Page 47: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/47.jpg)
Summary
Accurate pain assessment
Make sure to continue or account for patient’s pre-hospital pain regimen
Use Multimodal pain management
Discharge pain management plan
Acute Pain Service available 24 hrs/day
![Page 48: Acute Perioperative Pain Management AHMED HAMDY Staff Anesthesiologist St. Michael’s Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081417/56649d895503460f94a6f697/html5/thumbnails/48.jpg)
Summary
Superior analgesia, ↓ side effects means: Improved patient satisfactionBetter rehabilitationEarlier functional returnEarlier discharge from hospital↓ likelihood of chronic painReduced health care costs