Surviving Surgery’s Aftermath

Judith Handley MDAssistant Professor OUHSC

October 5, 2012

Disclosures

• I have no disclosures

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

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”

Impact on Healthcare

• Pain is the most common reason a patient seeks healthcare

• The cost in healthcare dollars in significant annually

Acute Pain

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

Post-Operative Pain

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

Pathophysiology

Pathophysiology

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

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

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

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

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 Analgesia3. Single Injection Intrathecal/Caudal Analgesia

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

Regional Anesthesia: Nerve Blocks

• Advantages:– Reduced amount of additional systemic opioids– Reduction of side effects• Nausea/vomiting• Puritis• Drowsiness

• 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

Epidural Anesthesia

Epidural Analgesia

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

Advantages ofEpidural 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

Single Injection Analgesia

• Caudal

• Intrathecal

• Duramorph – Extended Release morphine

– Peaks in 6 hrs and lasts 18-24

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

Opioids

• Drug options

– Morphine– Fentanyl– Hydromorphone

• PRN Bolus or PCA

Patient Controlled Analgesia (PCA)

• Common agents used

– Morphine– Hydromorphone– Fentanyl

• PCA demand dose• Basal Rate

Non-Opioids and Adjuvants

• Drug Options– Ketoralac– Acetaminophen– Ibuprofen

• Route of administration options

• Other adjuvants

Post-Op Pain Management Care Plans

• Individualized

• Tailored to the specific surgical procedure

• Perioperative pain control optimized

• Utilize a multi-modal approach

Multi-Modal Approach

• Outpatient – Cyst removal right elbow

• Regional, opioid with adjuvant medications

• Inpatient– Posterior Spinal Fusion

Thank You

• Questions