Improving postoperative pain management, what is unsolved?

Hasanuddin University Faculty of MedicineDepartment of Anesthesiology, IC and Pain

ManagementMakassar

A.Husni Tanra

ISAPM National Meeting, Manado 14-15 October 2015

Among nociceptive pain, postoperative pain is well understood.

• We know what causes it• We know the mechanism• We know how to treat it• We know the best drugs for it• We know mostly self limited

(Lema MJ, Department of Anesthesiology, Buffalo State University )

So, no more reason to feel pain after surgey

Nature of post operative pain• Four out or five patients undergoing surgery

experiences postoperative pain– 86% of these patient rating

Moderate Severe Extreme pain

• > 50% of patients report inadequate pain relief• 10% to 50% acute post operative pain may become

chronic, depending on the surgical procedure

Pain, ASHP advantage E-NEWSLETTER, March 2014

• Why Management of postoperative pain: still a long way to go?

Editorial Pain (2008) 233-234

Powel et al. Analyzed the obstacle in APS in UK.• Dr. Powel AE et al. from UK explained:

“Misconception of the surgeon”“ Acute pain vanishes in a few days, and as long as the

operation was successful the postoperative pain will soon be forgotten”. So why bother with costly APS, with epidural or peripheral nerve analgesia, which are also not compleatly free of complication. They do not expect, acute pain may develop into chronic pain Every time this comes as a big surprise to them. They have never heard of this phenomenon, nor do they have any idea how to treat it.

Editorial, Pain 137 (2008) 233:234

BSSP and SARPS - Dhaka 2006

What is Traditional Postoperative Pain Management

Unimodal analgesia, using Morphine

or Pethidine.

10 mg morphine, or Pethidin im as

needed.

done by SURGEON

Applied by the nurses.Courtesy S.A. Schug

PainCall for Nurse

Nurse Responds

Screening

Sign out Medication

Prepare Medication

Administer Med (im)

Absorption from site

Pain Relief

Sedation

PCA

Traditional pain relief vs PCA

After the Surgical injury

PeripheralSensitization

of Nociceptors

Primaryhyperalgesia

Surgical Injury

CentralSensitization

of Dorsal Horn

SecondaryHyperalgesia

LTP(Chronic

pain)

 Can be treated by Opioid, Ketamine, alpha2agonist, gabapentinoid or continuous epidural with LA.

Problem of after surgery condition

Primary HYPERALGESIA Can be easily treated by NSAID (Cox1 or Cox2)

Secondary HYPERALGESIA

PRIMARY HYPERALGESIA

• Rational treatment of primary hyperalgesia is anti inflammatory agents;

NSAID non selective Coxib (selective NSAID ) Dexamethazone Infiltration of LA

In

Prostaglandins produced in response to tissue injury; increase sensitivity of nociceptor (pain)

Nociceptor then releases substance P, which dilates blood vessels and increases release of inflammatory mediators, such as Bradykinin (redness & heat)

Substance P also promotes degranulation of mast cells, which release histamine (swelling)

1

2

3

Pain-sensitive tissue

Painful stimulus

Prostaglandin

Substance P

Histamine

Mast cellBlood vessel

Bradykinin

Nociceptor

Substance P

23

1

Peripheral sensitization

Infiltration of LA means blocking the release of Subtance P

SECONDARY HYPERALGESIA

• Rational treatment of secondary hyperalgesia is the drug/technique that can prevent the occurrence of Central sensitization;

Opioid (Mo, Fentanyl or Pethidine). Ketamine (NMDA antagonist). Gabapentinoid (Gabapentin or Pregabalin).

Alpha2 agonist , Dexmetomidine. Continuous Epidural Block

 

 

 

 

Secondary HyperalgesiaCommonly ignored or discounted in the evaluation and treatment of postoperative pain

Neuroplastic changes in the CNS that may amplify pain perception

Not relieved or may be worsened by conventionalmedicationsPersistence of CNS sensitisation may lead to chronicpost-surgical pain

Wilder-Smith OHG, Arendt-Nielsen L. Anesthesiology 2006;104:601-607

So what is unsolved issues?• To improving postoperative pain management, we

need to;1. Always applies multi-modal analgesia.

(get the advantages of multimodal analgesia)

2. Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.

3. Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).

1. What is multimodal analgesia?

Multimodal Analgesia is

• Administration of two or more drugs that act by different mechanism it can be:

The same or different routesProvide additive or synergic effectMinimal side effectShould be given by around the clock (ATC)

Main goals of Multimodal Analgsia is to reduce the amount of Opioid

1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

Potentiation

• Reduced doses of each analgesic

• May reduce side effects of each drug

• Improved pain relief due to synergistic or additive effects

Opioids

NSAIDs,acetaminophen,

nerve blocks

Benefits of Multimodal Analgesia

Philosophy of Multimodal AnalgesiaNot only just giving 2 or more drugs which different mechanism, but;

• One drug should be effective at peripheral

sensitization and other at central sensitization.

• Combine drugs must be synergetic or addictive.

• Must be proven by laboratory or clinical data.

• Some drugs may act at several point at nociceptive

pathway.

Local anesthetics

CorticosteroidsNSAIDsCOXIBs

Local Anesthetic

CNS

DRG

OpioidsGabapentinoids

Clonidine

Modify by AHT

KetaminParacetamol

COXIBs

Transduction

TransductionModulation

Perception

TransmissionModulation

Target Point of Analgesic Drugs

2. Evidence based of the use of nonopioid + opioid on an as needed basis.

Efficacy of Postoperative Patient-Controlled and Continuous Infusion Epidural Analgesia vs Intravenous PCA with Opioids

• Meta-analysis of 299 RCTs• Epidural analgesia in any combination (except

epidural morphine alone) > to IV PCA up to 3 days • Continuous epidural analgesia > PCEA for pain at

rest and with activity but more PONV and motor block, less pruritus

• Epidural LA + Opioid > Epidural Opioid alone

Wu et al Anesthesiology 2005

Regional Analgesia

Prevention

Andreae MH and Andreae DH. Br J Anaesth 2013.

• Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about 1 out of every 5 women treated.

Conclusions:• Epidural anesthesia may reduce the risk of

developing chronic pain after thoracotomy in about 1 out of every 4 patients treated.

Regional Analgesia

Continuous Peripheral Nerve Blocks provide superior pain control to opioids?

• Meta-analysis 12 studies [360 pts] lower limb• Reduced Pain scores 24/48 hours ~ 50%• Reduced side effects

Nausea/vomiting Sedation Pruritus

• ‘Perineural catheters provided superior analgesia to opioids for all catheter locations and times’

Continuous PNB

Richman et al Anesth Analg 2006

Peripheral Nerve Block

Efficacy of Continuous Wound Catheters Delivering LA for Postoperative Analgesia: A Quantitative and

Qualitative Systematic Review of RCTs

• 39 RCTs (n=1761) quali analysis, 45 RCTs (n= 2031) quantitative analysis

• Surgical subgroups: abdominal, gynaecologic, cardiothoracic, urologic, orthopaedic

• Benefits of wound catheters:– Decreased pain scores (32% reduction)– Decreased opioid consumption (25% reduction)– Decreased risk of PONV (16% reduction)– Increased patient satisfaction (30%)

• No increase in adverse effectsLiu et al. J Am Coll Surg 2006

Wound Catheter Delivery

• IV Acetaminophen prolonged time to first opioid administration

• Reduced nausea when given before surgery or before arrival in PACU

• When given prophylactically, reduction of nausea and vomiting correlated with the reduction of pain

• Significant reduction in pain scores at 24 hrs

• Less PONV and pruritus

• Opioid sparing at 24 hours

• No significant differences in acute pain outcomes with pregabalin 100-300mg between single preop dose and additional doses postop

PreventionGabapentinoids

Prevention

A systematic review of intravenous Ketamine for postoperative analgesia

Laskowski et al. Can J Anaesth 2011

• IV Ketamine is an effective adjunct for postop analgesia.

• Particular benefit observed in upper abdominal, thoracic and major orthopaedic surgeries.

• Analgesic effect of ketamine was independent of the type of IV opioid, timing of ketamine administration, and ketamine dose.

Ketamine

KETAMINMore Frequently Use in Postorthopedic Surgical Pain Management

Arthroscopic Anterior Cruciate Ligament Surgery

Outpatient Knee Arthroplasty

Total Knee Arthroplasty

A Single intraoperative injection of ketamin (0,15 mg/kg) improved analgesia and passive knee mobilization 24 hour after surgery

Improved Postoperative Outcome

When combine with epidural or femoral nerve block, increase postoperative pain relief for total knee arthroplasty.

• Menigaux C, Guignard B, Fletcher D, Dupont X, Guirimand F, Chauvin M. Anesth Analg. 2000;90:129–135.• Menigaux C, Guignard B, Fletcher D, Sessler DI, Dupont X, Chauvin M. Anesth Analg. 2001;93:606–612.

• Himmelseher S, Ziegler-Pithamitsis D, Agiriadou H, Martin Jjelen-Esselborn S, Koch E. Anesth Analg. 2001;92: 1290–1295.• Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Anesth Analg. 2005;100:475–480.

Conclusions:

• A single IV perioperative dose of dexamethasone had small but statistically significant analgesic benefits.

• There was no dose-response with regard to the opioid-sparing effect

• There was no increase in infection or delayed wound healing with dexamethasone, but blood glucose levels were higher at 24 hrs.

Waldron et al. Br J Anaes 2013

Glucocorticoids

Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensitySystematic review and meta-analysis of RCTs

• Periop systemic α2 agonists decrease postop opioid consumption, pain intensity, and nausea.

• Recovery times are not prolonged.

• Common AEs are bradycardia and arterial hypotension.

Blaudszun et al. Anesthesiology 2012

α2 Agonists

3. Specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site)

Prevention

White P and Kehlet H. Anesthesiology 2010.

Take home message• To improving postoperative pain management, we

need to;1. Always applies multi-modal analgesia.

(get the advantages of multimodal analgesia)

2. Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis.

3. Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).

Thank youvery much