Nyeri

PERIOPERATIVE PAIN RELIEF

THE TOTAL ANALGESIA PACKAGE

PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE

‘PRE-EMPTIVE’ CHRONIC PAIN

IV PCA
COX-2s: Parecoxib
Recovery Pain Protocol
Paracetamol
IV: Fentanyl, PO/IV COXIBs
Opioids: Morphine
Alfentanil, Morphine PO/PR Paracetamol
NSAIDs: Diclofenac,
PO COXIBs/NSAIDS: Ketorolac, Ibuprofen PO/PR NSAIDs
Ibuprofen, Celecoxib
NMDA: Ketamine Pain Buster Soakers
NorAdr/5HT: Tramadol Pregabalin
Local Anaesthetics PCEA
Risk Factors for Chronic Post-Surgical Pain
Preop Risk Factors Pain (moderate – severe) lasting >1month
Repeat surgery
Psychological vunerability
Workers’ compensation
Intraop Risk Factors Surgical approach with risk of nerve injury
Postop Risk Factors Acute pain (moderate – severe)
Radiation therapy to area
Neurotoxic chemotherapy
Depression
Psychological vulnerability
Neuroticism Stephen Gatt

Anxiety

after Perkins & Kehlet

Morphine side effects preclude increasing the dose
Reuben S, Raghunathan K, Cheung R: Dose-response
relationship between opioid use and adverse events after spinal
fusion surgery. Anesthesiology 105:A1646, 2006.

• Nausea & vomiting

• Drowsiness
• Dry mouth significantly
reduced (p<0.05)
• Constipation
• Feeling dizzy
• Difficulty passing urine
• Feeling confused all reduced by (p<0.013)

• Weakness celecoxib 400 88.0+/-2.4

• Itchiness pregabalin 150 77.4+/-1.7

• Headache both 400/150 43.0+/-1.3

(placebo 134+/-3.3)
No moderate/severe symptoms in celecoxib and
pregabalin groups (vs 14% in placebo) (p<0.001)
mg morphine
Why not use a bigger dose of
opioids?

… because opioids can cause:

–drowsiness & somnolence
–respiratory depression
–nausea & vomiting
–constipation
–addictiveness & dependence
 Morphine
• 1mg/mL
• Prepare 1x120mg amp in 20
• Add to100mL bag of N/S
• 120mg in 120mls

• Bolus: 0.5-2.0mg
 Fentanyl
100mcg/mL
• Prepare 2x500mcg amp in 10 mls
• Remove 20mls from 100mL bag of N/S

• Bolus: 10-20mcg
 Pethidine
• 10mg/mL
• Prepare 2x500mg amp in 10mls
• Remove 20mls from 100mL bag of N/S

• Bolus: 10-20mg
• Norpethidine toxicity: <800mg
 Ketamine Infusion
• 200mg in 50ml via syringe driver
– IV in acute pain
– Subcut in chronic pain
2mL/hr

OR

• 100mg added to PCA bag of 100mL

 Ketamine Infusion RHW
• 2mg/hr if <60kg
• 4 >60kg

• Increase by 0.1mg/kg/hr increments

(Bag & Gemstar pump)
 Parecoxib & Caesarean Section
• NSAIDs and COX-2s are not approved in breast-feeding women.

• Diclofenac and ibuprofen are used almost universally off-label in most countries for
post-CS pain.

• Once the infant is delivered, there is little risk of (and much benefit from) closure of
the ductus arteriosus.

• Loading the patient with IV parecoxib intraoperatively after delivery of the

neonate(s) and following on with oral valdecoxib or rectal or oral ibuprofen/diclofenac
+ oral/rectal paracetamol makes good management sense.

• It does not interfere with the epidural/intrathecal analgesia and allows for a ‘soft’
transition from major neuraxial blockade to simple oral analgesia.

Stephen Gatt, MD - SESIAHS

 Sub-optimal pain management can
have serious consequences…

Acute postoperative pain

Inadequate pain
management

Clinical and Decreased

psychological changes mobilisation
Induction of
chronic pain
Increased risk of
deep vein thrombosis, pulmonary embolism,
myocardial infarction and coronary ischaemia

Mortality/morbidity, longer hospital stay, re-admission, decreased quality of life,

decreased patient satisfaction and increased health costs

Ballantyne et al. Anesth Analg 1998;86:598;

Wu et al. Anesth Analg 2003;97:1078;
Pavlin et al. Anesth Analg 2002;95:627;
Anesthesiology 2004;100:1573;
Perkins et al. Anesthesiology 2000;93:1123