JOYDEEP GHOSE

Peri operative pain

What is Pain ?
According to the International Association for the Study of Pain (IASP),pain is defined as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." (IASP 1979)

Undertreated Pain
The Silent Epidemic

Barriers for proper pain management

Limited training in medical schools
Lack of up to date knowledge Pain management not seen as a priority in the

disease-centered model of care Lack of consultation and treatment resources Time consuming Biases and fears about use of opioid analgesics Too many patients, not enough time

Patient and family barriers

Communication problems in a stressed health

care system Fear of taking opioids biased media reports Confusion regarding: dependence, tolerance vs. addiction to therapeutic opioids Poor pain management is accepted as normal

Pain Well Thinking

The Bigger the Surgery You Experience.
The More It Should Hurt.. And the Greater Amount of Pain Medicine You Should Receive

Whats A Really Big Surgery?

A Really Big Surgery is any one that happens to ME!

How does pain arise?

Pain involves four physiological processes

Transduction Transmission Modulation Perception

Why should treat post-operative pain?

1) Respiratory effects
2) Cardiovascular effects 3) Neuroendocrine

4) Effects on mobilization

Pain associated with different surgerical procedures- decreasing order of severity:

1 thoracic 2 upper abdominal 3 lower abdominal 4 inguinal 5 head/ neck/ limb

Monitoring of pain :
Verbal rating scale- e.g. none, mild, moderate, severe
Numerical rating scale (NRS) Visual analogue scale(VAS)

Faces scale

Methods available to treat post-operative pain:

A) pre operative counselling

1) Non-pharmacological

B) transcutanous electrical nerve stimulation(TENS)

C) acupuncture

2) Pharmacological
Simple pain ladder (WHO)- for administration of analgesia: Minor pain PCM, NSAIDs Moderate pain codene, propoxyphene, buprenorphin, tramadol Severe pain Opioids( morphine, diamorphene, oxycodone, etc.)

NSAIDs :-

Inhibit COX enzymes Do not relieve severe pain when used alone but they are valuable in multimodal analgesia because they decrease opioid requirement and improve the quality of opioid analgesia.

The Role of Cyclo-oxygenase (COX)

Arachidonic acid
Cyclo-oxygenase activity of COX
PGG2

Peroxidase activity of COX

PGH2
PGD2 PGF2 PGE2 PGI2 TXA2

Two Forms of Cyclooxygenase (COX)

COX-1
Constitutive Mediate homeostatic functions Especially important in: Gastric mucosa Kidney Platelets Vascular endothelium

COX-2
Inducible (in most tissues) Mediate inflammation, pain, and fever Induced mainly at sites of inflammation by cytokines

Adverse effects of NSAIDS : 1. Gastric ulcerations

2. nephrotoxicity 3. impaired haemostasis

4. aspirin induced asthma

Opioids
Act at spinal and supraspinal levels
OP1, OP2, OP3 Minor opioids- codene, propoxyphene, tramadol.

Intermediate opioids- buprenorphin

Major opioids- morphine, diamorphine, fentanyl,

sulfentanyl, remifentanyl.

Routes of administration : 1. oral

2. IM 3. IV

4. transdermal
5. sublingual 6. rectal 7. subcutenous 8. nebulizer 9.regional

Morphine :
IM- traditional method of administration.
Duration of action- 3-6 hrs Dosage- 0.05 0.1 mg/kg

Side effects- sedation, itching, nausea, vomiting,

respiratory depression Requires monitoringSpO2 Sedation score Antagonist - naloxone

Local anaesthetics :
1. Ester class- cocaine, procain, chlorprocaine,

tetracaine .

2. Amide class lidocaine, prilocaine,

bupivacaine,ropivacaine,levobupivacaine

Mode of action : Membrane stabilization

Na+ channel blockade inhibits transmission of

impulses.

Differential blockade :autonomic(sympathetic) > sensory(pain, touch, temp)> motor

Systemic absorption :Intercostal> epidural>brachial>sciatic

 Prolongation of action with epinephrine.

Contraindicationsend arteries unstable angina uncontrolled HTN cardiac

Side effects : CNS toxicity- lightheadedness, numbness of tongue,

sedation, muscular twitching, seizures. Cardiotoxicity hypotension, arrhythemias, acute cardiovascular collapse

Patient controlled analgesia(PCA) :

Superior- allows the patient to self administer small doses

of opioid when pain occurs. Microprocessor control pump Loading dose

Relative contraindications :drug abusers major metabolic disorders end-stage renal or hepatic disease COPD sleep apnoea

Epidural analgesia :
Injection of LA into epidural space- block nerve root

transmission . Low dose LA e.g. bupivacaine 0.1% and opioid e.g. fentanyl 0.0002%.

Advantages :
effective analgesia reduced opioid requirement reduction in stress response after surgery early return of GI function after abdominal surgery reduction in mortality and serious morbidity

Absolute contraindications Patient refusal

allergy to LA drugs Local infections

Relative contraindicationshypovolaemia, neurological disease, coagulopathy

Complications :
Cardiovascular- sympathetic blockade- T1 to T4
Respiratory- motor blockade. Late onset of respiratory

blockade of morphine Dural puncture- total spinal block, post duralpuncture headache Infection Spinal haematoma

Relative efficacy of analgesics- numbers needed to treat (NNT)

It is the number of patients who need to receive the

active drug for one to achieve at least 50% relief of pain compared with placebo over a period of 6hrs. Effective analgesics, NNT <2-3

Pre-emptive analgesia:
Surgery- pain signals-priming of CNS-enhanced

postoperative pain. So, by providing per surgery/ pre emptive analgesia these sensitizing neuroplastic changes can be prevented diminished post operative pain sensation

Although few people die of pain, many die in pain and even more live in pain

THANK YOU