Post Operative Pain Relief

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Post Operative Pain Relief

• Dr. Vasudeva Upadhyaya K S
• Professor And Head
• Dept. Of Anesthesiology
• St. Johns Medical College Hospital
• Bangalore - 34

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• To Cure Occasionally,
• To Relieve Often,
• To Comfort Always.
• - Hippocrates
• (5th century BC)

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• How many of you have experienced pain??
• How many of you dont want pain??!!

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Pain Punishment ??!!

• No Pain!!
• No Gain??
• We need pain to survive!!

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Pain - Definition

• An unpleasant sensory and emotional
  experience associated with actual or
  potential tissue damage, or described in
  terms of such damage (IASP)
• Pain is what patient says Hurts !!
• Pain is also physiological important part of
  bodys defense system

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Pain

• Is always subjective.
• Pain is the most common amongst the most
  compelling reasons for seeking medical attention.
• Acute pain acts as a warning signal
• Chronic pain has no such useful role

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Post-operative Pain (POP)

• Pain that is present in a surgical patient
  because of pre-existing disease, surgical
  procedure (drains, chest tubes etc.) or a
  combination of both sources.
• Factors that modify post-op. pain
  (intensity, quality duration) are
  multifactorial.
• In USA 50 70 post-op. Pts. experience
  severe pain!!
• Routine IM opioids will not achieve pain
  relief in gt50 of these patients!!

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Why treat pain??
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Adverse Effects Of POP

• Psychological Helplessness ,depression,irritabil
  ity distress, fear, anxiety, anger,
  resentment, insomnia, adverse relationship.
• CNS Sensitisation, chronic pain
• CVS Tachycardia, HT, ? cardiac work
  oxygen consumption ischaemia, infarction,
  venous stasis, ? platelet aggregation -
  ?venous thrombosis / embolism.

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...Adverse Effects Of POP

• RS ? VC, TV, FRC, FEV1 -
• pain, muscle rigidity, distended
  bowel.
• ? cough deep breathing
• hypoxia, hypercarbia,
  pneumonia.
• Musculoskeletal Immobility, muscle atrophy,
  spasm, vasoconstriction.
• GIT, UT ? motility - ileus, PONV,
  distension urinary retention.
• Metabolic / endocrine ? ACTH, cortisol,
  catecholamines, interleukin-1, ? insulin.
  Water Na retention.

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...Adverse Effects Of POP

• Social Family finance, loss of - job, income,
  prestige, social position, role in the family,
  feeling of abandonment isolation, Delayed
  hospital discharge !!
• Physical Reduced activity, physical
  deterioration, other symptoms, insomnia
  (sleeplessness), chronic fatigue, adverse effects
  of treatment
• Spiritual Why me ??, what is the point ??,
  purpose of life ??,blame God ?!,repent ?!

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Pain

• Perception
• Threshold
• Tolerance

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Factors affecting pain threshold

• Age, gender
• Culture, society, religion
• Personality, family
• Previous experience
• Understanding, relevance
• Beliefs, attitude

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Factors lowering pain threshold

• Discomfort
• Sleeplessness
• Fatigue
• Anxiety, Fear, anger
• Sadness, depression, boredom
• Mental isolation, social abandonment

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Factors increasing pain threshold

• Relief from other symptoms
• Sleep
• Understanding, companionship
• Creativity, relaxation
• Reduction in anxiety
• Elevation of mood, antidepressants
• Analgesics

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Factors Affecting Intensity of POP

• Type / extent of surgery
• Site of surgery
• Pre op. / intra op. techniques used
• Modalities of analgesic
• Other symptoms

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Management of Pain - Goals

• Achieve maximum reduction in pain
• (By ? frequency / or intensity)
• Maintain medications that clearly provide
  positive relief
• Improve patients functional capacity level
  of activity
• Assist in coping with residual pain
  psychological issues
• Reduce use of healthcare resources
• Improve Quality of life

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Management of Pain - Principles

• Thorough assessment
• Good communication
• Reassure about pain relief
• Discourage acceptance of pain
• Encourage patient participation

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Algorithm for comprehensive evaluation
longitudinal assessment
History - pain, medications, medical Physical
examination Psychological examination Diagnostic
evaluation
Impression Probable Requirements
Treatment plan Contingencies Plan for reassessment
Persistent pain New pain Worsening pain
Adequate pain relief
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Pain - Assessment

• History, examination, investigations
• Site
• Duration
• Cause / mechanism
• P - provocative / palliative factors
• Q - quality
• R - radiation
• S - severity (pain scales)
• T - temporal factors

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Pain Assessment Tools
One Dimensional Scales
Multi Dimensional Instruments
McGill pain questionnaire
Brief pain inventory
Faces pain rating scale
Numerical rating scale
Visual analog scale
Verbal descriptor scale
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Pain assessment (and management) special
population

• Infants Neonatal / Infant pain scale (NIPS),
  neonatal pain, agitation and sedation scale
  (N-PASS)
• Toddlers FLACC ( face, legs, activity, cry ,
  consolability) , CHEOPS
• School Age VAS , McGill pain questionnaire
• Cognitively Impaired pain assessment in
  advanced dementia (PAINAD) scale, abbey pain
  scale

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Post-op. Pain - Management

• I. Non pharmacological
• Pre-op. Visit
• Relaxation
• Hypnosis
• Psychotherapy
• Other modalities
• TENS, Acupuncture, Cold
  heat

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Post-op. Pain - Management

• II. Pharmacological methods.
• Preemptive analgesia
• antinociceptive treatment that
  prevents establishment of altered central
  processing of afferent input which amplifies
  post-op. Pain.

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Pre-emptive / Preventive Analgesia

• 1) The analgesic treatment starts before the
  nociceptive primary event is caused
• 2) The preventive drug treatment is maintained
  throughout the perioperative period
• 3) The onset of the central sensitization state,
  caused by the nociceptive primary event is
  prevented
• 4) The central sensitization caused by peripheral
  inflammatory response is prevented.

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Post-op. Pain - Management

• II. Pharmacological methods.
• Regional analgesia SAB, Epidural- LA,
  opioids, ketamine, etc.
• Regional blocks TAPB, Paravertebral etc,
  intra-articular inj., local infiltrations.
• PCAs

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Post-op. Pain - Management

• II. Pharmacological methods.
• Non-opioids paracetamol, NSAIDs
• Opioids weak strong
• Co-analgesics / Adjuvants

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Post-op. Pain - Management

• Paracetamol
• Neglected analgesic !!
• Minimal side effects
• Inhibits COX (??COX 3) in brain
• Additive action with other NSAIDs

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Post-op. Pain - Management

• Paracetamol
• Dose (oral)
• Up to 20 mg. / kg. q4-6 h (adults)
• Up to 15 mg. / kg. Q4-6 h
  (children)
• Disadvantages
• Hepatotoxicity
• Frequency of
  administration
• Ceiling effect !
  

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Post-op. Pain - Management

• NSAIDs - Mechanism of action
• Stimuli
  
  
• Physiological Pathological
• ?
  ?
• COX I COX
  II
• (constitutive)
  (inducible)
• ?
  ?
• PG
  Proinflammatory PGs
• -Gastric protection
  other inflammatory mediators
• -Platelet function
  ?
• -Renal function
  Inflammation

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Post-op. Pain - Management

• NSAIDs
• Classification
• Nonselective Selective COX II inhibitors
• Uses / advantages
• -sole analgesic in mild to moderate pain
• -additive synergistic with opioids
• -address root of the problem inflammation
• -good oral bioavailability with reasonable
  duration of action

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Post-op. Pain - Management

• NSAIDs other advantages
• Rapid onset of action
• Mostly inexpensive
• Easily available
• Relatively less adverse effects
• - no sedation, resp. depression, dependence
• - no effect on bowel motility
• - no tolerance

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Post-op. Pain - Management

• NSAIDSs Disadvantages
• - gastritis / GI bleeding
• - renal impairment
• - reduced platelet function
• - bronchospasm
• - ceiling effect !!
• - delayed bone healing

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Post-op. Pain - Management

• Opioid analgesics
• Gold standard in systemic analgesia for acute
  pain
• Act on opioid receptors
• Dose adjusted to optimize effect
• Some have ceiling effect
• Incomplete cross tolerance
• ?? Fear of addiction Resp. Depression
• Adverse effects on CNS, CVS, RS, GIT, UT
• Can cause hyperalgesia

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Post-op. Pain - Management

• Opioid analgesics
• Weak opioids - Codeine
  
• - Pentazocine
• - Tramadol
• Strong opioids - Buprenorphine
• - Pethidine
• - Morphine
• - Fentanyl
  

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Post-op. Pain - Management

• Tramadol
• Triple action µ agonist, ? 5 HT NA
  uptake inhibition
• Good bioavailability orally - 50 - 70 (up to
  90)
• Adverse effects on CNS, CVS, RS, GIT,
  renal - comparatively less
• Caution in head injury / epilepsy
• Not a scheduled narcotic easy availability,
  insignificant abuse potential
• Synergistic action with NSAIDs, paracetamol

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Post-op. Pain - Management

• Issues about Morphine
• Addiction
• - Respiratory depression
• - Tolerance
• Availability
• Other adverse effects
• No ceiling effect

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Regular Fentanyl Patch??

• Takes 12 to 24 hrs. to reach therapeutic
  level
• Takes about 24 hrs. for plasma level to
  come down after removing the patch
• Acts for about 72 hours
• Not suitable for POPM

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Fentanyl iontophoretic transdermal system (F-ITS)
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Pain - treatment plan

• Adjuvants
• Antidotes - antiemetics, laxatives
• Psychotropic drugs night sedatives,
  anxiolitcs, antidepressants
• Adjuvant analgesics tricyclic
  antidepressants, anticonvulsants,
  corticosteroids , alfa- blockers etc.

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WHO Ladder Chronic pain
WHO Ladder acute pain
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Post-op. Pain - Management

• Combination of analgesics /
  techniques
• - Additive synergistic effect
• - ? dose requirement ?adverse
  effects
• Multimodal approach is the best approach
• Least dose Least adverse effects
  Long duration

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Recent Advances in POPM

• Emerging
• Molecular mechanisms, central / peripheral
  sensitisation
• Routes modes of delivery EREM(DepoDur),
  Fentanyl ITS, PCA, PCRA,PCINA, PCTPA(AeroLEF)
• Liposome / polymer encapsulated LA
• Re emerging
• Ketamine. Alfa-2 agonists, anticonvulsants
• LA RA / Infiltration with indwelling cath.
• Hypnosis, acupuncture
• Future
• Very long acting LA, neooxitoxin(neoSTX)- Site
  1Na toxin
• Nanoanaesthesia

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Cerebral cortex
Opioids
Hypnosis

Paracetamol
Relaxation
Acupuncture
Thalamus
Hypothalamus


Opioids Adj. Analgesics
Brain stem

Opioids
NSAID Steroids
Dorsal horn Sp.cord

Acupuncture TENS
C fibers (slow tract)
Aß Ad fibers (fast tract)


L.A.
NSAID Steroids

Nerve endings
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POPM Monitoring

• Pain
• Adverse effects PONV, CVS/RS,pruritis,
  sedation, sensory/ motor system
• Concurrent drugs
• Device failures
• Break through pain
• Rx adverse effects

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Unrelieved Pain

• Related to pt.
• Failure to report
• Failure to receive / take medications
• Related to treatment team
• Disbelief in pt. /poor assessment
• Poor choice of treatment modality
• Failure to use multiple modalities
• Poor use of analgesics dose, interval,
  adjuvant, breakthrough pain relief
• Continuity / follow up
• Difficult pain problems !!!

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Scientific Approach For POPMOrganisational
Aspects

• Hospitals without pain
• QUIPS Quality improvement in post op. pain
  services
• PROSPECT
• APS
• PRAN

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summary

• Pain is grossly under treated !
• Systematic approach can relieve pain in
  majority of patients in a simple,
  affordable and effective way.
• Multi-modal approach (Balanced analgesia) is
  the best available option!

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Take home message

• Pain is no longer accepted as punishment
• Pain is almost always unpleasant
• Pain has no adaptation
• Majority of postop. pts. suffer from pain
• 80 to 90 can be relieved!
• Pain relief is a human right
• Pain relief is our responsibility as caregivers

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Thank you