1. Post-Operative Pain Management Raafat Abdel-Azim Professor of Anesthesia, Intensive Care and Pain Management Anesthesia Department

2. Raafat Abdel-Azim I L O Intended Learning Outcomes By the end of this lecture, the student will be able to: 1.Understand the importance of POP relief 2.Assess the severity of POP 3.Plan for POP management 4.Identify the appropriate way of POP management for different cases 2

3. Raafat Abdel-Azim OR (Operating Room) PACU (Post-Anesthesia Care Unit) =RR (Recovery Room) ICU (Intensive Care Unit) Surgical Ward 3

4. Importance of Postoperative Pain (POP) Management Raafat Abdel-Azim 4

5. Goals of Postoperative Care Raafat Abdel-Azim Significant pain relief  Patient satisfaction Improved mobility  Postoperative complications  Fatigue Earlier return to bowel function Earlier hospital discharge 5

6. Consequences of Unrelieved POP Undesirable effects on vital functions  Morbidity & mortality  Risk of acute postoperative stress syndrome  Risk of mental & psychological stress Delayed return to normal activity Prolonged hospital stay Readmission to hospital Potential development of chronic pain & long-term effects on quality of life  Patient satisfaction  Costs associated with staffing & resources Raafat Abdel-Azim 6

7. Benefits of Effective POP Management  Hormonal & metabolic stress –  SNS response: hypertension, tachycardia & dysrhythmias  Morbidity & postoperative complications Earlier discharge from hospital Cost-effectiveness Quality of life scores & patient satisfaction Raafat Abdel-Azim 7

8. Key Elements for POP Management 8

9. Recommendations for POP Management Adequate medical & nursing staff training Adequate patient information Use of balanced analgesia, patient- controlled analgesia (PCA) & epidural drug administration Use of written protocols Regular assessment of pain intensity Raafat Abdel-Azim 9

10. Assessment of POP Inexperienced nurses overestimate a patient's pain, whereas more experienced nurses tend to underestimate. Either error leads to inappropriate treatment POP should be assessed several times a day in every patient, at rest and in dynamic conditions (cough, movement). Assessment should be recorded in a clear and concise manner to serve as a guide to intervention Raafat Abdel-Azim 10

11. Raafat Abdel-Azim 11  The CNS signs of o Hypoxemia o Acidemia o Cerebral hypoperfusion often mimic those of pain, especially during emergence.  Evaluating o Orientation o The level of arousal o Cardiovascular or pulmonary status usually identifies such patients.  Fear, anxiety, and confusion often  POP, especially after general anesthesia.

12. Raafat Abdel-Azim 12  To avoid masking signs of an unrelated condition or a surgical complication, ascertain that the nature and intensity of pain are appropriate for the surgical procedure before analgesics or sedatives are administered  Administration of parenteral analgesics or sedatives can acutely worsen hypoventilation, airway obstruction, or hypotension, causing sudden deterioration and arrest

13. Commonly Used Pain Scales Visual analogue scale (VAS) Numerical rating scale (NRS) Verbal rating scale (VRS) Other methods The choice of the pain scale depends on the patient’s age, ability to communicate, or other factors Raafat Abdel-Azim 13

14. Visual Analogue Scale (VAS) From 0 to 100 mm 0 = no pain at all 100 = the worst possible pain Raafat Abdel-Azim 14 0 10080 90 70601020304050 No painThe worst possible pain

15. Numerical Rating Scale (NRS) From 0 to 10 0 = no pain 10 = the worst possible pain Raafat Abdel-Azim 15 Verbal rating scale (NRS) 4-point scale 0 = no pain 1 = mild pain 2 = moderate pain 3 = severe pain

16. Raafat Abdel-Azim 16 OR PACU Home ICU Ward Surgeon Anesthesiologist Nurse The Multidisciplinary Team (The Multidisciplinary Approach) Improved pain relief, patient satisfaction & outcome

17. Treatment of POP Raafat Abdel-Azim 17

18. Pharmacological Treatments of POP Classification Non-opioids –Non-steroidal antiinflammatory drugs (NSAIDs) –Paracetamol Opioids –Strong opioids: morphine, pethidine, fentanyl, nalbuphine –Weak opioids: tramadol Local anesthetics: lidocaine, bupivacaine, … Raafat Abdel-Azim 18

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20. Dose Schedule Raafat Abdel-Azim 20 Administration on a regular basis Administration only when the patient complains of pain Prevents inadequate pain control Analgesic gaps as patients wait for drug administration

21. Precautions for Use Raafat Abdel-Azim 21 ParacetamolNSAIDsOpioids Liver disease Severe renal insufficiency Chronic alcoholism Chronic malnutrition, dehydration H/O Peptic ulcer Renal insufficiency Liver insufficiency Cardiac insufficiency Asthma Elderly Drug interactions Renal insufficiency Liver insufficiency Respiratory insufficiency Elderly Infants < 3 months

22. Raafat Abdel-Azim 22 Contraindications ParacetamolNSAIDsOpioids Allergy to paracetamol Severe liver disease Allergy to NSAIDs Active peptic ulcer Renal insufficiency Liver insufficiency Asthma (aspirin or NSAID-related) Drug interactions 3 rd trimester pregnancy Allergy to opioids Severe liver insufficiency Respiratory insufficiency  ICP or head injury

23. Raafat Abdel-Azim 23 Side Effects ParacetamolNSAIDsOpioids Malaise Hypotension  Transaminases Hypersensitivity reactions Hematologic disorders (rare or very rare) GI disorders (nausea, vomiting, constipation, bleeding) Nephrotoxicity Hepatotoxicity Hypersensitivity reactions Hematologic disorders Prolonged bleeding GI disorders (nausea, vomiting, constipation) CNS effects: sedation, hallucinations, confusion) Itching Urinary retention Respiratory depression

24. Raafat Abdel-Azim 24 Route of Administration ParacetamolNSAIDsOpioids Oral (PO) Intravenous (IV) Rectal PO IV infusion IM Rectal PO IV IM SC Epidural

25. Raafat Abdel-Azim 25 The IV route:  During iv titration of opioids, analgesia is achieved while incremental respiratory or cardiovascular depression is assessed.  Sufficient analgesia is the end point, even if large doses of opioids are necessary in tolerant patients

26. Raafat Abdel-Azim 26  Disadvantages of the IM route include o larger dose requirements o delayed onset o unpredictable uptake in hypothermic patients  Oral and transdermal analgesics have a limited role in the PACU but are helpful for ambulatory patients.  Rectal analgesics are useful in children.

27. Delivery Techniques of POP Treatment Patient Controlled Analgesia (PCA) Self-administration of analgesics using a computerized pump by either the IV or epidural route AdvantagesDisadvantages Gold standard of POP therapies Enables the patients to titrate their own analgesia No analgesic gaps High level of patient satisfaction Significant time and resources needed Staff programming of the PCA pump  the potential for medication errors Potential for device malfunction Raafat Abdel-Azim 27

28. Raafat Abdel-Azim 28 Epidural Analgesia Injection of analgesics into the epidural space close to the spinal cord and spinal nerves where they exert a powerful analgesic effect AdvantagesDisadvantages Very effective pain relief Low doses of opioids   side effects  Stress response to surgery Invasive Staff time and training High catheter failure rate (25%) Post-dural puncture headache Risk of spinal hematoma

29. Raafat Abdel-Azim 29 Peripheral Nerve Blockade Injection of local analgesics close to peripheral nerves to produce analgesia by blocking pain impulses from the nerve AdvantagesDisadvantages Excellent analgesia Tergeted analgesia  Systemic exposure to opioids  Adverse effects Staff time and training Potential for infection, hematoma & local anesthetic toxicity Not useful for abdominal and cardiothoracic procedures

30. Balanced or Multimodal Analgesia Combination of various analgesic agents and/or delivery techniques with different mechanism of action Potential to enhance analgesia (additive or synergistic effects) and to  side effects Raafat Abdel-Azim 30

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32. Benefits of Balanced Analgesia Improved pain control & patient satisfaction  morbidity  length of stay  adverse events Earlier mobilization Earlier return to bowel function  cost of care Raafat Abdel-Azim 32

33. Treatment of “At Risk” Patients Elderly –  opioid sensitivity –  ability to metabolize & eliminate analgesics –polymedication Patient with cardiovascular disease –  ability to tolerate sympathetic/hemodynamic responses to severe pain or certain analgesics Raafat Abdel-Azim 33

34. Patient with hepatic/renal disease –  ability to metabolize analgesics,  risk of analgesic toxicity Patient with severe pulmonary disease –  risk of atelectasis & pneumonia by incident pain Neonates –Immaturity of enzyme systems involved in drug metabolism –  GFR –  ventilatory response to hypoxia Raafat Abdel-Azim 34

35. At risk patients are more sensitive to adverse effects of opioid and non-opioid analgesics Opioids –  risk of respiratory depression –  sedation & confusion –Metabolite toxicity NSAIDs –  risk of bleeding –  risk of renal impairment –  risk of hypertension & CHF Raafat Abdel-Azim 35

36. Patient Information about POP Increasing patient education and awareness of the postoperative experience is one way to improve POP management Raafat Abdel-Azim 36

37. 1.Pain can follow surgery but there are effective treatments to relieve it. 2.Your pain will be assessed regularly after surgery. (Patient must be trained on pain assessment before surgery). 3.Always alert your healthcare team when you feel pain. 4.You will receive treatment for your pain. 5.You may experience side effects as a consequence of surgery, anesthesia or from your pain treatment (e.g. nausea, drowsiness, constipation, itching, …) Raafat Abdel-Azim 37

38. 6.Specific information related to the different techniques (PCA, epidural analgesia, nerve blocks, …) Raafat Abdel-Azim 38

39. Raafat Abdel-Azim Summary of important points Benefits of effective POP management Recommendations for POP management Evaluation of POP The multidisciplinary team & approach Pharmacological treatments of POP Balanced or multimodal analgesia Treatment of at risk patients Patient information about POP 39

40. Raafat Abdel-Azim 40 Anesthesia lectures are available at: http://telemed.shams.edu.eg/moodle6 http://telemed.shams.edu.eg/moodle

41. Thank You Raafat Abdel-Azim 41