Anesthesia

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Lecture Title Acute Pain Management
Lecturer name Osama Ibraheim
MD,SOB. Lecture date
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Lecture Objectives..
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Fundamental Considerations

• Millions of patients worldwide undergo surgery.
• Although developing more effective techniques
  for postoperative analgesia, many patients
  experience pain.

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PAIN
An unpleasant sensory and emotional experience
associated with actual or potential tissue
damage.
IASP, Subcommittee on Taxonomy, 1979
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ETIOLGY OF PAIN

• HEAT
• COLD
• CHEMICAL
• MECHANICAL
• TORSION STRETCH CUT PINCH PRICK
  COMPRESS CRUSH

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TYPOLOGY OF PAIN

1. Acute
2. Chronic benign
3. Chronic cancer

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Chronic Pain vs Acute Pain

• Acute A Symptom of Injury or Disease
• Chronic Benign Pain itself is the disease
• Chronic Cancer Actual Tissue destruction

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Adverse Effects of Pain

1. Cardiovascular
2. Pulmonary
3. Gastrointestinal
4. Renal

• Extremities
• Endocrine
• CNS
• Immunologic

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Adverse Effects of Pain

• Cardiovascular Tachycardia, hypertension,
  increased SVR, increased cardiac work, increased
  myocardial O2 demand.
• Pulmonary Hypoxia, hypercarbia, atelectasis,
  decreased cough, decreased vital capacity and
  function residual capacity, V/Q mismatch.
• Gastrointestinal Nausea, vomiting, ileus,
  intolerance for oral intake.
• Renal Oliguria, urinary retention.
  

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Adverse Effects of Pain

• Extremities Skeletal muscle spasm, limited
  mobility, thromboembolism.
• Endocrine Excessive adrenergic activity, vagal
  inhibition, catabolic metabolism, increased O2
  consumption.
• CNS Sedation, fatigue, anxiety, and fear cause
  central sympathetic stimulation.
• Immunologic Inhibited cellular immunity,
  increased risk of infection, ?? impaired wound
  healing ??

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FREE NERVE ENDINGS ARE PRESENT IN ESSENTIALLY ALL
BODY TISSUES IN VARYING AMOUNTS
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IN RESPONSE TO A PAINFUL STIMULUS, SUBSTANCES ARE
EXCRETED.
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ALGOGENIC(substances released by pain)

• SEROTONIN POTASSIUM
• HISTAMINE ACETLYCHOLINE
• BRADYKININS LEUKOTRIENES
• PROSTAGLANDINS SUBSTANCE P29
• NOREPINEPHRINE

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THE RECEPTORS IN THE FREE NERVE ENDINGS RESPOND
TO THE SUBSTANCES BY BECOMING CHARGED
ELECTROCHEMICALY
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RECEPTORS THEN PROPAGATE AN ELECTROCHEMICAL
STIMULUS TO DIFFERING NERVE FIBERS
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NOCICEPTION

• This electrochemical event that occurs
  between the site of tissue damage or injury sets
  off a series of neural transmissions that
  eventually results in the perception of
  painCollectively this known as nociception

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NERVE FIBERPAIN CLASSIFICATION

• A FIBER..SHARP-STABBING-LOCAL
• FIRST PAIN
• B FIBER....PHYSIOLOGIAL REACTION
• C FIBER....DULL-ACHE-BURN-THROB
• NONLOCALIZED-RADIATE
• SECOND PAIN

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NERVE FIBER CLASSIFCATION

• TYPE
  FUNCTION
• A a myelinated motor
• A alpha myelinated touch-pressure
• A beta myelinated touch-pressure
• A delta myelinated
  pain-temperature
• A gamma myelinated proprioception

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A Delta

• 1 - 4 micrometers diameter
• Myelinated, Rapid conduction
• Sharp, localized
• Heat, cold
• First pain

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• B myelinated
• preganglionic autonomic
• C non-myelinated
• pain-temperature

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C Fibers

1. Small
2. Slow Conduction
3. Unmyelinated
4. Postganglionic autonomic

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C Fibers

• Dull pain, burning, Aching throbbing
• Nonlocalized - radiating - diffused
• Temperature,Touch,Mechanical
• Second pain

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Gate Theory

• Balance between A delta and C fibers to dorsal
  horn determines the intensity of the stimulus
  that is passed to higher brain center

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Area of High Nociceptor Concentration

1. Mucosal membranes
2. Periosteum
3. Deep fascia
4. Ligaments
5. Joint capsules
6. Cornea
7. Subcutaneous tissue

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Areas of Moderate Nociceptor Concentration

1. Skeletal muscle
2. Cardiac muscle
3. Smooth muscle

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Areas of Minimal Nociceptor Concentration

1. Bone
2. Cartilage
3. Marrow

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Physiologic Processes of Nociception

1. Detection
2. Transduction
3. Transmission
4. Modulation
5. Perception

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Detection

1. First pain
2. Second pain

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TRANSDUCTION

• NOXIOUS STIMULI TRANSLATED INTO ELECTRICAL FIRING
  AT THE SENSORY NERVE ENDINGS

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TRANSMISSION

1. PROPAGATION OF IMPULSE TRAVELS VIA NEURAL
   PATHWAYS.
2. SENSORY AFFERENT NEURONS PROJECT INTO THE
   SPINAL CORD
3. ASCENDING NEURONS RELAY TO BRAINSTEM AND THALAMUS
4. THALAMUS RELAYS TO CEREBRAL CORTEX

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MODULATION

• INTRINIC PAIN MODIFICATION
• 1.DIFFERENT IN INDIVIDUALS
• 2.DEPENDS ON.....
• PAST EXPERIENCES
• CULTURE
• PSYCHIC

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MODULATION-CONT

1. STIMULUS PRODUCED ANALGESIA
2. NEUROENDOCRINE ANALGESIA
3. CNS/PNS ANALGESIA
4. OPIOID ANALGESIA
5. SITUATION
6. PATHOLOGY
7. PHYSIOLOGY

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Modulation Excitatory Substances

• Peripheral
• Prostaglandins, bradykinins, histamine, K,
  substance P, serotonin (5HT2)
• Spinal
• Glutamate, aspartate, amino acids, substance P,
  norepinephrine (alpha 1)

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Modulation - Inhibitory

• Supraspinal
• Endorphins, enkephalins, dynorphins,
  norepinephrine (alpha 2), GABA, somatostatin
  (5HT1), neurotensin

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First Neuron Pain

• Peripheral afferent fibers to dorsal horn
• Second Neuron Pain
• Dorsal horn to thalamic
• Third Neuron Pain
• Thalamus to cortex

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Pain Pathways

• Tissue damagegtgtgtAlgesic substanses
  releasegtgtgtNoxious stimuligtgtgtA delta and C
  fibersgtgtgtto the NeuraxisgtgtgtMany to Ant. and
  Anterolat.HornsgtgtgtSegmenal reflex responses , and
  others via the Spinothalamic and Spinoreticular
  tractsgtgtgtSuprasegmental and cortical responses.

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Classification Function of Peripheral Nerve
Fibers

• A. Myelinated A- Fibers
• a Motor , Proprioception (afferent)
• b Motor, Touch (afferent)
• g Muscle spindles (efferent)
• d Pain, Temperature (afferent)
• B. Myelinated B-Fibers
• Pre-ganglionic Sympathetic Fibers
• C. Non-Myelinated C- Fibers Pain, Temperature.

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Nociceptive pathways peripheral sensory nerves
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Ascending Pain Pathways

• Topographic representation maintained
• Sites for pain modulation are spinal cord and
  thalamus

Pons
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• Suprasegmental
• reflex responses
• Increased Sympathetic tone , Hypothalamic
  stimulation.

• Segmental reflex responses
• Increased skeletal muscle tone , Increased
  oxygen consumption , Lactic acid production

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Chemical Mediators

• Membrane ion channels of Nociceptive neurons
• Directly coupling to membrane receptors
• Hydrogen
• ATP
• Serotonin
• 5HT3
• Indirectly (more commonly) mediating
  intracellular secondary messages
• Bradykinins B1, B2
• Cytokines
• Prostanoids
• Histamine H1
• Serotonin
• 5HT1

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Factors that modify perioperative pain

• 1- Site ,nature and duration of surgery.
• 2- Type and extent of incision.
• 3- Physiologic and psychologic makeup of the
  patient.
• 4- Pre operative preparation of the patient.
• 5- Presence of complications of surgery.
• 6- Anesthetic management.
• 7- Quality of perioperative care.
• 8- Preoperative treatment of painful stimuli .

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Preemptive Analgesia

• Antinociceptive treatment of that prevents the
  establishment of altered central prossesing,
  which amplifies postop. Pain.
• Windupfunctional changes in the dorsal horn
  because of pain .
• This type of therapy ,in addition to reducing
  acute pain ,attenuates chronic postop. Pain.

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Principles of Pain Management

• Anticipate pain
• Recognize patient
• Ask the patient
• Look for signs (HR, BP, facial grimacing, tears,
  sweating, etc)
• Find the source
• Quantify pain (mild, moderate, severe)
• Treat
• Quantify the patients perception of pain
• Correct the cause where possible
• Give appropriate analgesics regularly as
  required
• Remember most sedative agents do not provide
  analgesia
• Reassess

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Modalities of Pain Relief

• Non-opioid analgesicsopioid analgesics
• Regular injections of opioids
• Continuous IV or SC infusion of opioids
• Patient controlled analgesia (PCA)
• Extradural opioids or local anesthetics
• Combined exrtadural spinal analgesia
• Long acting oral opioids
• Long acting regional blocks
• Ketamine (S)

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Modalities of Pain Relief

• Pharmacological
• Non-pharmacological

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DRUGS

• NSAIDs
• COX-1 Minor Moderate pain
• COX-2 rofecoxib, parecoxib-inj Severe pain
• Actions
• Inhibit synthesis of PG-E
• Direct analgesic effect on higher centers
• Modify nociceptive responses-bradykinins
• Antiplatelet
• Hypothrombinaemia
• Lowers body temp
• Hypoglycemia
• Metabolic acidosis
• Adverse gastrointestinal effects

Lower doses only
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Systemic Opioids

• Analgesic effects of opioids via receptors in
  the CNS.
• Roots of administeration I.M. ,I.V. ,Transdermal
  ,Oral ,Topical ,I.V. regional ,Perineural ,etc.
• I.M. root is the most treatment choice after
  surgery.
• The As Needed part of the order is often
  interpreted to mean As little as possible .
• No relation exists between Gender and opioid
  requirement.

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Analgesic Opiates

• Morphine
• Pethidine
• Fentanyl
• Sufentanil
• Alfentanil
• Remifentani
• ANTIDOTE Naloxone

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Routes of administration of analgesics

• Oral Intravenous
• Sublingual/buccal Epidural (opioid)
• Oral transmucosal Intrathecal (opiod)
• Intranasal Intra articular (opioid)
• Transdermal Topical - EMLA cream
• Rectal Intradermal
• Inhalational Peripheral N block
• Subcutaneous Nerve plexus block
• Intramuscular Intravenous regional

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Modalities of Pain Relief

• Non-pharmacological
• Transcut. Electrostimulation
• Cryoanalgesia(obselete)
• Acupuncture
• Hypnosis

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New Modalities Of Systemic Drug Administration

• The goals of new methods are
• 1. Precise,controlled delivery of the prescribed
  dose
• 2. A rapid onset of action
• 3. Avoidance of first-pass hepatic metabolism
• 4. Maintenance of a steady-state concentration of
  drug
• 5. An improved side-effect profile and
• 6. Improved patient compliance

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Transdermal Route Advantages

1. Decreased first-pass hepatic metabolism
2. Decreased gastrointestinal degradation
3. Stable plasma concentrations,and
4. Improved patient compliance

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Treatment methods

• 1-Systemic opiods.
• 2-Patient-controlled analgesia.
• 3-Regional anesthetic techniques .
• . a Intraspinal analgesia.
• b Patient-controlled epidural analgesia.
• c Combined spinal-epidural technique.
• 4-intraarticular analgesia.
• 5-Nonopioid analgesics.
• 6-Cryoanalgesia.
• 7-T.E.N.S.
• 8-Psychologic and other methods.

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Patient-Controlled Analgesia

• PCA was originally developed to minimize the
  effects of pharmacokinetic and
• Pharmacodynamic variability among patients.
• A negative feedback loop exists experiencing
  paingtgtgtMedication demandedgtgtgtReducing pain gtgtgtNo
  further demand .
• If Nurses, Relatives,or Parents assume
  responsibility for drug administration,or if
  using this device by the patient is for reasons
  other than pain relief ,this loop fails.

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• Cases of respiratory depression during PCA use
  have been reported.
• Causes advanced age, hypovolemia, large doses,
  use of background continuous-infusion mode.
• No difference in respiratory mechanics between
  PCA and IM opioids (FEV1,FRC,PFR)is seen.

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Side effects of PCA

• Nausea ,Vomiting ,Itching.
• Treated by changing opioid or using drugs that
  provide symptomatic relief.
• A pre printed set of standard orders can
  facilitate a uniform standard of care.

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Regional Anesthetic Techniques

• Advantages
• Positive respiratory, cardiovascular and
  neuroendocrine effects reduced thromboembolic
  complications and blood loss and reduced
  convalescence

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IDEAL COMPONENTS

• Block SENSORY feeling
• Immobilize MOTOR responses
• Obtund REFLEXES
• wipe out MEMORY
• Control VC and CTZ
• Not permanent
• Cause sense of well-being

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REGIONAL ANESTHESIA

• SEGMENTAL LOSS OF SENSATION
• BY BLOCKING NERVE CONDUCTION

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REGIONAL

• 1. SPINAL
• 2. EPIDURAL
• 4. INTRAVENOUS ( BIER )
• 5. AXILLARY (INFILTRATION)
• 6. RETROBULBAR

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LOCAL ANESTHETICS

• AMIDES MAX / DOSE
• BUPIVACAINE 2 MG/KG
• LIDOCAINE 7 MG/KG
• ROPIVACAINE 4 MG/KG
• MEPIVACAINE 7 MG/KG
• PRILOCAINE 6MG/KG

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LOCAL ANESTHETICS

• ESTERS MAX /DOSE
• CHLOROPROCAINE 20 MG/KG
• COCAINE 3 MG/KG
• NOVOCAINE 12 MG/KG
• TETRACAINE 3 MG/KG

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LOCAL ANESTHETICS

• Local anesthetics are the drugs, which reversibly
  block the generation, propagation and
  oscillations of electrical impulses in the
  excitable tissues.

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MECHENISM OF ACTION

• Block nerve fiber conduction by acting directly
  on nerve membranes to inhibit sodium ion from
  crossing the membrane
• Nerves cannot depolarize
• Conduction of impulses is blocked

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Mechanism of Action

• Decrease or prevent transient increase in the
  permeability of excitable membranes to Na ions
• Direct interaction with voltage gated Na
• channels
• Increase in threshold
• Decrease in the rate of rise of A.P.
• Slows down the conduction

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Mechanism of Action

• Site of action - Inside the membrane
• Binding sites within the Na channel
• Heterotrimeric complexes of glycosylated
  proteins ( 300 k Da)
• 3 sub units- a, b1 b 2
• a has I- IV homologous domains
• Each domain has 6 transmembrane domains
• Bind with S6 transmembrane domain.

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CONTRAINDICATIONS

• RELATIVE
• Patient Appropriateness
• Local Infection near injection site
• Hypovolemia
• CNS Disease
• Chronic Back Pain or Prior Lami
• Prior SAB with difficulty

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Nerve Fiber and Local Anesthetic Setup

• Sequence of clinical anesthesia
• Sympathetic block (vasodilate skin T0)
• Loss of pain and temperature sensation
• Loss of proprioception
• Loss of touch and pressure sensation
• Loss of motor function

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• Interscalene brachial plexus blocks analgesia
  for 12-24 hrs.
• Sciatic and Femoral n. blocks similar results.
• Intercostal n. blocks 6-12 hrs. analgesia.
• Administration of long acting L.A.s from a
  catheter into pleural cavity unilat. Analgesia
  with little or no sensory block.
• L.A. infusion into Axillary sheath, Femoral
  sheath, and the vicinity of the Sciatic
  n.analgesia and particularly useful to
  facilitate perfusion after extensive
  revascularization.

Interscalene
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L.A. boluses or infusions

• Advantages over parenteral opioids
• Early ambulation, improve bowel function, higher
  arterial O2 tension, fewer pulmonary
  complications.
• For optimal results, the catheter tip should be
  near the segments innervating the insicision.

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PLUXES BLOCK
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BRACHEAL PLUXEX BLOCK
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Segmental Level of Block Required

• T-4 to T-6
• IntraAbdominal
• T-6 to T-8
• GU, Low Abdominal
• T-8 to T-10
• GU, A/R, Legs

T-4
T-6
T-10
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IVRA (BIERS BLOCK)
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SPINAL ANESTHESIA
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Intraspinal analgesia

• With
• Opioids
• Opioid-L.A. mixture
• Ketamine
• Clonidine
• Neostigmine

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Opioids

• Initial reports in 1979.
• Single injection of intrathecal Morphin provides
  about 24 hrs. analgesia.
• Epidural root uses more, because
• Popularity of technique during surgery, ability
  to leave catheter in place, familiarity with
  technique, no risk of PDPH.

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• Elderly patients require remarkably small doses
  of epidural morphine.
• Fentanyl is useful when rapid onset of epidural
  analgesia is important.
• Epidural meperidine is widely used in some parts
  of the world and as with other opioids,
  respiratory depression can occure.

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Respiratory depression

• early
• In the first two hrs.
• Is the result of vascular uptake and
  redistribution.

• Delayed
• Between 6 and 12 hrs.
• Consequent of rostral spread of opioid in CSF to
  respiratory center in the floor of 4th. Ventricle.

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• Pruritus is a common side effect and is seen more
  in obstetrics patients.
• Face is a common site of itching.
• Although it is not due to histamine release,
  antihistamines provide symptom relief.
• Nalbuphine is also of value.
• Naloxone is consistently effective (repeated
  doses or infusion).

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• Urinary retention is higher in volunteers than in
  patients and in men than in women.
• Naloxone prevents or reverses it but may require
  doses that antagonizes analgesia.
• Most patients are able to void spontaneously when
  the catheters are removed.

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• Nausea and vomiting due to rostral spread of
  opioid in CSF to the vomiting center and the CTZ
  .
• Treatment
• first line antiemetics (may produce unwanted
  sedation and resp. depression ) , Scopolamine
  patches.
• Second line I.V. droperidol, Ondansetrone.

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• Sedation produced by intraspinal opioids may be
  the result of spread of the drug in CSF to
  receptors in the thalamus, limbic system or
  cortex and hypercarbia can augment it.
• Epidural buprenorphine 0.15 mg. produces
  prolonged depression of the CO2 response that
  lasts 8-12 hrs.

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Ketamine

• Produces analgesia via interaction with
  cholinergic, adrenergic, and serotonergic
  systems.
• Side effects sedation, blurred vision,
  tachycardia, hypertension, and hallucinations.
• In some studies on baboons neurotoxic changes.
• The routine use of intrathecal ketamine in humans
  is not recommended.

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Clonidine

• If administered by the oral route can augment
  spinally mediated opioid analgesia.
• Epidural or intrathecal clonidine can provide
  effective analgesia alone.
• Intrathecal clonidine does not provide surgical
  anesthesia.

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Intra-Articular analgesia

• Following arthroscopic surgery, a combination of
  systemic Ketorolac and intra-articular
  bupivacaine decreased analgesic requirement and
  pain.

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Nitrous oxide

• Useful, especially for painful experiences of
  short duration (dressing changes, debridements).
• Rapid onset of analgesia and rapid recovery.
• In concentrations of 30-50 is as potent as 10
  mg. I.M. morphine.
• Anesthesia may occurgtgtgtrisk of aspiration.

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• Long term administration causes bone marrow
  suppression and leukopenia (reversible when
  detected early).
• Entonox50mixture of N2O with oxygen.

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Cryoanalgesia

• Temp.s between -5 and -20causes disintegration
  of axons and breakdown of myelin sheaths while
  the perinurium and epinurium remain intact.
• Is used most common for thoracotomy pain and
  hernia repair pain.
• Residual neuropathic pain has been seen following
  cryoanalgesia.

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Transcutaneous electrical nerve
stimulation(T.E.N.S.)

• Uses both for chronic pain and acute
  perioperative pain.
• Advantages absence of opioids side effects
  (resp. depression, sedation, nausea and vomiting,
  urinary retention)
• It is simple, noninvasive and free of toxicity.

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• The mechanism of analgesia by TENS is not known
  and it may be by
• Modulation of nociceptive impulses in the spinal
  cord (gate control theory).
• Activation of inhibitory area in the brain stem.
• Stimulation of the release of endorphins, or a
  combination of these mechanisms.
• A placebo effect may play a role.

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Psychologic and other methods

• After surgery patients may suffer discomfort
  due to headache, NG tubes, drains, IV catheters,
  or anxiety, fear, and insomnia.
• Therapy of these problems may result in reporting
  of less pain.
• Preoperative discussion, reassurance and
  provision information results in less anxiety,
  less opioid use and shorter hospital stay.

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• Relaxation tapes prior to surgery results in less
  analgesic use and a smoother recovery.

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Perioperative analgesia in special populations.
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Pediatric patients

• Misconceptions about pain in children are common
  (e.g. children dont feel pain, or if it is felt
  it is not remembered.
• Pain causes suffering and psychologic
  abnormalities in children of all age.
• Special scales are available for young children
  (self reporting of pain).
• In preverbal children, the interpretation of
  behavior must be used to estimate intensity of
  pain.

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• Because of fear of IM injections alternatives
  are sublingual, rectal and transdermal routs.
• I.V. PCA is effective in children.
• Caudal opioid analgesia can be used in children.
• Regional techniques dorsal nerve block of the
  penis, or lidocaine jelly, or EMLA creams for
  circumcision, ilioinguinal and iliohypogastric
  nerve blocks for pains after orchiopexy and
  herniorrhaphy, etc.

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• NSAID,s are considered as adjuncts rather than as
  primary agents.

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Elderly patients

• The average age of surgical patients will
  increase in the future.
• Older patients have more complex cases than
  younger.
• PCA PCEA is ineffective in some elderly
  patients because of their reluctance.

100

• Treatment of perioperative pain in elderly
  remains inadequate because
• Fear of complications associated with treatment
  of pain.
• Pain is reported less in elderly.

101

• NSAID,s may have benefits in elderly because
• Different site of action that may be more
  effective.
• Opioid sparing.
• An additional anti-inflammatory effect.
• But they have increased risk of side effects
  because of decreased renal clearancegtgtgtthey doses
  must be decreased.

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Advantages of regional anesthesia

• Minimizing physiologic trespass.
• Pharmacologic simplicity.
• Reduced blood loss.
• Fewer thromboembolic complications.
• Reduced stress response.
• Less confusion.
• Less postoperative pain.

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Patients with chronic pain and /or chronic opioid
use
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• General principles
• 1-expect high self-reported pain scores.
• 2-base treatment decision on objective pain
  assessment (deep breathing, coughing, etc.).
• 3-recognize and treat nonnociceptive sources of
  suffering.
• Continue opioids for as long as is appropriate
  for acute pain.

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Addiction

• A chronic disorder characterized by compulsive
  use of a substance resulting in physical,
  psychologic, or social harm to the user and
  continued use despite that harm.

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Clinical triad suggestive of addiction

• 1-high self-reported pain scores.
• 2-high opioid use compared with other patients
  having similar procedures.
• 3-a relative absence of opioid-induced side
  effects.

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• PCA is not good for providing basal opioid
  replacement.
• PCA is good for extra opioids needed for
  postoperative pain.

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ROLE OF THE ANESTHESIOLOGIST IN PERIOPERATIVE
PAIN MANAGEMENT
109

• Anesthesiologists are a logical choice to provide
  periop. Pain relief, because they are
• 1-familiar with the pharmacology of analgesics
  and L.A.s.
• 2-aware of short- and long-term effects of drugs
  given intraoperatively.
• 3-knowledgeable about pain pathways and their
  interruption.
• 4-are skilled in techniques available to provide
  superior pain control.

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EPIDURAL ANESTHESIA
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EPIDURAL DRUG ADMINISTRATION
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FIXATION OF CATHETER
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FINAL SKIN FIXATION AND DRESSING
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LEST YOU FORGET

• Discomfort from
• Full bladder/bowel/gasses
• Noise
• Alarms
• Visitors
• Painful IV site
• Multiple lines
• Repeated disturbance from medical personnel
• Complications of analgesic drugs
• Other pathological complications

115
Reference book and the relevant page numbers..
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Thank You ?

• Dr.
• Date