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Surviving Surgery’s Aftermath Judith Handley MD Assistant Professor OUHSC October 5, 2012.

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Presentation on theme: "Surviving Surgery’s Aftermath Judith Handley MD Assistant Professor OUHSC October 5, 2012."— Presentation transcript:

1 Surviving Surgery’s Aftermath Judith Handley MD Assistant Professor OUHSC October 5, 2012

2 Disclosures I have no disclosures

3 Objectives Discuss basic pathophysiology of acute pain Identify options in treatment of acute post operative pain Discuss a multi-modal approach to pain management in the post operative patient

4 Pain: Definition The IASP defines pain as “Unpleasant sensory and emotional experience associated with real or perceived tissue injury” “Whatever the person says it is, wherever the person says it is”

5 Impact on Healthcare Pain is the most common reason a patient seeks healthcare The cost in healthcare dollars in significant annually

6 Acute Pain Sudden onset Usually lasts < 6months Has a known cause/circumstance – Surgery – Burns/cuts – Broken bones, pulled muscles – Labor and childbirth

7 Post-Operative Pain You wake up from surgery hurting, why? -Skin/Incision Pain -Muscle Pain -Bone Pain -Tendon/Ligament Pain -Movement Pain -Throat Pain

8 Pathophysiology


10 Why is it so important to control and treat Post-Op pain?  Good Post-Op Pain Control = › Faster recovery and discharge › Ability to utilize deep breathing exercises  Decrease post-op pneumonia/collapsed lung  Decrease O2 requirements › Ability to sit up, get out of bed, walk sooner  Decreases decubitis ulcers and blood clot formation › Active participation in Physical Therapy › Comfortable and satisfied patient

11 Unrelieved Post-Op Pain Poor Post Op Pain Control = – Increases risk of post operative morbidity and mortality Pneumonia Decubitis Ulcers Blood Clots – Increases hospitalization and costs of care – Can develop into chronic pain – Unnecessary patient suffering, unsatisfied patient

12 Other Thoughts To control pain post-operatively, you need to know information pre-operatively. – Allergies – Does the patient take any pain medication at home regularly or intermittently? – Where is current pain? – Introduce and educate about pain scales

13 Post-Op Pain Control Options  Regional Anesthesia/Analgesia › Peripheral Nerve Blocks › Single Injection Intrathecal/Caudal Analgesia › Epidural Analgesia  Non-Opioids  Opioids › IV vs. PO › PRN vs. PCA  Adjuvants

14 Regional/Neuraxial Anesthesia  Administration of local anesthetics (often with other drugs) into the epidural space, around a peripheral nerve plexus, or into the intrathecal space to block pain transmission.  Types: 1. Peripheral Nerve Blocks 2. Epidural Analgesia 3. Single Injection Intrathecal/Caudal Analgesia

15 Regional Anesthesia: Nerve Blocks  Commonly used for surgery involving the upper or lower extremities › Types: Interscalene, Axillary, Femoral, Sciatic, Caudal  Typically used for outpatient procedures (although can be used inpatient and as a continuous infusion)  Nerve stimulators and ultrasound guided  Typically lasts 4-24 hours

16 Regional Anesthesia: Nerve Blocks Advantages: – Reduced amount of additional systemic opioids – Reduction of side effects Nausea/vomiting Puritis Drowsiness

17 A thin catheter that is threaded into the epidural space which provides anesthesia by continuous infusion via an epidural pump Indications: Thoracic/heart surgeries, abdominal surgeries, limb amputation, thoracotomies, urology surgeries

18 Epidural Analgesia Drugs infused through an epidural catheter – Local Anesthetics (Bupivacaine, Ropivacaine…) – Opioids (fentanyl, hydromorphone…) – All are preservative free

19 Advantages of Epidural Analgesia  Local Anesthetics via Epidural= can prevent the pain response with minimal physiologic alterations  Opioids via Epidural= can provide prolonged analgesia at low doses  Systemic Opioids= modify perception of nociceptive input so patients are better able to tolerate pain  GOAL: Reduction of systemic opioids, better pulmonary profile, better OOB and PT profile

20 Single Injection Analgesia Caudal Intrathecal Duramorph – Extended Release morphine – Peaks in 6 hrs and lasts 18-24

21 Single Injection Analgesia Intrathecal Duramorph – 3:1 ratio or PICU admit Caudal Duramorph Dosing: – Less than 15mcg/kg – discharge home – 15-45mcg/kg – admitted, 3:1 ratio or PICU – Greater than 45mcg/kg – automatic PICU

22 Opioids Drug options – Morphine – Fentanyl – Hydromorphone PRN Bolus or PCA

23 Patient Controlled Analgesia (PCA) Common agents used – Morphine – Hydromorphone – Fentanyl PCA demand dose Basal Rate

24 Non-Opioids and Adjuvants Drug Options – Ketoralac – Acetaminophen – Ibuprofen Route of administration options Other adjuvants

25 Post-Op Pain Management Care Plans Individualized Tailored to the specific surgical procedure Perioperative pain control optimized Utilize a multi-modal approach

26 Multi-Modal Approach Outpatient – Cyst removal right elbow Regional, opioid with adjuvant medications Inpatient – Posterior Spinal Fusion

27 Thank You Questions

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