Pain relief after major oncologic surgery

Ksenija Mahkovic HergouthOnkološki inštitut

Surgical procedures for

GIT carcinomas

Retroperitoneal sark.

Liver metastases

Sarkomas of thoracic/ abdominal wall with reconstruction

Peritonectomies, cyto- reductive surgery

Urologic,gynec.carcin.

Postoperative pain is Postoperative pain is due todue to

Surgical woundSurgical wound (laparatomy – (laparatomy – somatic pain; organ resections – somatic pain; organ resections – visceral, sympatic pain)visceral, sympatic pain)

Analgesia during operationAnalgesia during operation (opioid, (opioid, LA consumptionLA consumption

Genetic determination of Genetic determination of analgesic requirements analgesic requirements (gene (gene polymorphism for opioid receptors)polymorphism for opioid receptors)

Havashida M, Pharmacogenomics 2008Havashida M, Pharmacogenomics 2008

Good pain relief after surgery is important part of quick and

successfull recovery

It diminishes perioperative stress response to surgery

Pain relief after major Pain relief after major oncologic surgeryoncologic surgery

1.1. Continuous/PCEA epidural analgesia – Continuous/PCEA epidural analgesia – based on long acting local anestheticsbased on long acting local anesthetics

2.2. Continuous/PCA intravenous analgesia Continuous/PCA intravenous analgesia – based on opioids– based on opioids

3.3. Continuous drip of local anesthetics by Continuous drip of local anesthetics by the catheter in the surgical wound ?the catheter in the surgical wound ?

All ways effective when proper used and with PCA All ways effective when proper used and with PCA technicktechnick

Mann C et all, Anesthesiology 2000Mann C et all, Anesthesiology 2000

Epidural analgesia – golden standard, insertion of epidural catether (EK) in

the thoracic region (most of the abdominal wall and organs are

inervated from Th6–Th12)

Physiologic effects of epidural analgesia

Blocade of aferent pain impulses Blocade of aferent pain impulses

Blokade of aferent sypmatic impulses from Blokade of aferent sypmatic impulses from intestine intestine

of pain and of pain and sympatic nerves activity in GIT sympatic nerves activity in GIT

↓ ↓ stress and inflammatory response to surgerystress and inflammatory response to surgery

of postoperative ileus, shortens time to passing of postoperative ileus, shortens time to passing stoolsstools

Improves mobilisation after surgeryImproves mobilisation after surgery

Clemante A,Carli F. Minerva Anesthesiol 2008Clemante A,Carli F. Minerva Anesthesiol 2008

1. group.:general anesthesia + piritramid i.v. postoperatively

2. group.: general + toracic epidural anesth. + piritramid i.v. postoperatively

3. group.: general + toracic epidural anesth. + epidur. analgesia postoperatively

Hormonal and inflammat.response and recovery after radical cystectomy

Results

↑Cortisol and epinephrin: no difference among groups

group 3 ↓less inflammatory response (↓CRP, ↑albumini)

group 3 ↓less fatigue

group 3 ↓less postoperative pain

group 3 ↑better enteral feeding and passing stools sooner Brodner G et al. Multimodal perioperative management- combining thoracic epidural analgesia, forced mobilisation and oralnutrition-reduces hormonal and metabolic stress after major urologic surgery.AnesthAnalg 2001;92:1594-1600.

Stress response I

Stress response IIStress response II

study of 45 patients on hormonal and study of 45 patients on hormonal and inflammatory stress responce to major inflammatory stress responce to major abdominal surgery abdominal surgery

1st group: epidural analgesia during surgery

2nd group: i.v. opioid analgesia during surgeryResult

s Epidural group: lower plasma epinephrine and cortisol higher lymphocyte number and T-helper cells no difference in IL 12 and clinical course

Ahlers O et al. Intraoperative thoracic epidural anesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-7.

Advantages of epidural analgesia to systemic analgesia

• Better analgesia (still and moving) than with systemic Better analgesia (still and moving) than with systemic opioids (1,2,3)opioids (1,2,3)

• Less adverse events than with opioids –Less adverse events than with opioids –↓↓ nausea,vomiting, sedation (2,3,4)nausea,vomiting, sedation (2,3,4)

• Less paralytic ileus, less respiratory complications (5)Less paralytic ileus, less respiratory complications (5)• But no difference in mortality compared to systemic But no difference in mortality compared to systemic

opioid analgesia (3)opioid analgesia (3)• Low incidence of motor block with thoracic epidurals Low incidence of motor block with thoracic epidurals

compared to lumbal epidurals(2)compared to lumbal epidurals(2)• Importance of the LA dose compared to volume or Importance of the LA dose compared to volume or

concentration (6)concentration (6)

1.Nishimori M et al. Cochrane Data Base Rev 20062.Flisberg P et al..Acta Anaesthesiol Scand 2003;47:457-653.Rudin A et al. J Cardiothorac Vasc Anesth 2005;19:350-74.Saeki H et al. Surgery Today 2009.5..Popping DM et al .Arch Surg 20086..Dernedde M et al. Anaesth Intensive Care 2008

ASAASA EK working EK working VASVAS mgmg of of piritramid in piritramid in 48 h 48 h ((rescue.analrescue.analg.g.))

34 34 patientspatients

2 2 0,7 0,7 In In 31 31 patientspatients

2 2 1,6 1,6 3 3 4 4

Random group of our patients after abdominal surgery in year 2006 with

epidural analgesia

Dg.: 6 colon carcinoma,7 carcinoma of sygmoid colon, 9 rectum carcinoma, 5 stomac carcinoma, 7 retroperitoneal sarcoma

Postoperative pain relief by epidural analgesia (we practice)

48h after surgery:48h after surgery: continuous epidural infusion of local anesthetic continuous epidural infusion of local anesthetic (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, LO 30 – 60 min. Sometimes combined with low dose opioid LO 30 – 60 min. Sometimes combined with low dose opioid epiduraly or in i.v. infusion (< 30%)epiduraly or in i.v. infusion (< 30%)

Metamizol 2,5g/12 h i.v.Metamizol 2,5g/12 h i.v. Piritramid 3 – 5mg i.v. when VAS>4Piritramid 3 – 5mg i.v. when VAS>4

3.-5. day:3.-5. day: 10 ml boluses of 0,25% levobupivacain /6–8h into EK 10 ml boluses of 0,25% levobupivacain /6–8h into EK ±±opioids p.os (oksicodon) opioids p.os (oksicodon)

after 5th day removal of epidural catheter.after 5th day removal of epidural catheter.

from 5th day on:from 5th day on: analgesic drugs p.o. (oksicodon, tramadol, NSAID, analgesic drugs p.o. (oksicodon, tramadol, NSAID, paracetamol)paracetamol)

Complications with epidural catheters

Punction of dura (incidence 0,3 – 1,2%) Transitory neropathy (0,01 – 0,02%) Punction of epidural vein (3 – 12%), epidural

hemmatoma very rare (1:150 000) Infection: local on insertion site 4%,

epidural absscess: 0,05 – 0,1% (perioperative epidural catheters)

Migration of the catheter into spinal space (0,18%)

Postoperative pain relief by systemic opioid analgesia

(we practice)

Systemic opioid analgesia – when epidural analgesia is containdicated, Systemic opioid analgesia – when epidural analgesia is containdicated, technically not possible or refused by the patient. technically not possible or refused by the patient. PPump needed.ump needed.

Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses

Sufentanil 50–100 Sufentanil 50–100 μμg/24h in continuous i.v. infusion + PCA bolusesg/24h in continuous i.v. infusion + PCA boluses

Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses s.c./i.v.s.c./i.v.

I.v.analgesia up to 3 days+metamizol/neodolpasseI.v.analgesia up to 3 days+metamizol/neodolpasseAfter 2-3-days analgetic drugs in tablets by mouth (oxicodon,After 2-3-days analgetic drugs in tablets by mouth (oxicodon,tramadol, paracetamol, NSAID)tramadol, paracetamol, NSAID)

Monitoring pain (VAS) and side effects

Monitoring of the patient

Day of surg.: pulse oximetry, blood pressure, VAS. Day of surg.: pulse oximetry, blood pressure, VAS. Broader monitoring according to patient’s state.Broader monitoring according to patient’s state.

Next days: blood pressure /1-2 h, pulse oximetry, Next days: blood pressure /1-2 h, pulse oximetry,

VAS. 50 – 100 VAS. 50 – 100 μμg/24 h. Broader monitoring g/24 h. Broader monitoring according to patient’s state.according to patient’s state.

Patient can be moved to the ward when Patient can be moved to the ward when cont.epidural infusion is stopped and regular cont.epidural infusion is stopped and regular epidural boluses given. Time of epidural catheter epidural boluses given. Time of epidural catheter removal should be planned. removal should be planned.

Bolnica 3.dan po op ca recti Bolnica 3.dan po op ca recti (LAR,TME)(LAR,TME)

54 let, ASA 154 let, ASA 1

94 bolnik Dg: Ca cekuma,eksulceriran. Op: desna hemikolektomija

3. dan po operaciji

Hvala za Hvala za pozornost!pozornost!

Vloga sester in tehnikov

poznati morajo delovanje EK kot tudi poznati morajo delovanje EK kot tudi kontinuirano i.v. analgezijo kontinuirano i.v. analgezijo

Redno morajo spremljati pooperativno Redno morajo spremljati pooperativno bolečino z merjenjem bolečine po VAS bolečino z merjenjem bolečine po VAS

Redno meriti bolnikove vitalne znake. Redno meriti bolnikove vitalne znake. Pomembna je tudi tudi odzivnost na Pomembna je tudi tudi odzivnost na

bolnikovo bolečino ali neželjene učinke in bolnikovo bolečino ali neželjene učinke in ukrepanje v okviru možnosti in navodil.ukrepanje v okviru možnosti in navodil.

Multimodalno perioperativno okrevanje

Predoperativno informiranje in priprava bolnika Predoperativno informiranje in priprava bolnika na opna op

↓ ↓ kirurškega stresa (krg. tehnika, anestezija)kirurškega stresa (krg. tehnika, anestezija) Optimalna pooperativna epidural. Optimalna pooperativna epidural.

analgezija z LA analgezija z LA ((torakalni EKtorakalni EK)) Hitra mobilizacija Hitra mobilizacija Zgodnje enteralno hranjenjeZgodnje enteralno hranjenje

Pooperativni problemi po operacijah v trebuhu

Bolečina Bolečina Pooperativni ileusPooperativni ileus Okužbe kirurške rane & druge Okužbe kirurške rane & druge

okužbeokužbe intraabdomin.pritiskintraabdomin.pritisk Motnje v delovanju organovMotnje v delovanju organov