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8/2/2019 Acute Post Operative Pain+PATHOS
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Acute Post Operative Pain Acute Post Operative Pain
Dr.Magdi Ramzi Iskander
MD, FFARCSI, FIPP
Professor of Anaesthesia & Algesiology
National Cancer Institute
Cairo University
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Rationale for Active Treatment of
Post-Operative Pain Relief
Pulmonary function has
improved. Incidence of DVT is lower when epidural
anaesthesia used
Lessening immune suppression Decrease incidence and severity of
phantom limb pain.
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Psychological Preparation
Some degree of post-operative pain is
inevitable.
Different choices of post-operative painmanagement.
Established pain is more difficult to
control than new pain.
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Methods of Pain Relief Perioperatively
1.NSAID¶s(adult& paediatric)
2.Narcotics
Parentral IM by the clock
IV by continuous infusion
by PCA
3. Regional Block (Single or continuous)
Axillary in forearm surgery
Intercostal for subcostal incision in Cholecystectomy
Ileoinguinal & ileohypogastrlc in inguinal hernia
Thoracic epidural in upper GIT surgery
Lumbar epidural in Lower Limb surgery
Sacral epidural in pelvic operations esp. in children
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Patient ± Controlled Analgesia
Avolds delay in administration of pain medication
Proper selection of patients not too old, too
confused, and not for short procedures
Microprocessor controlled pump programming:Requirements
- Dose
- Dose intervals
- Maximum dose per set time
- Back ground infusion rate
Example
Morphine 1 mg/ ml
5 min.10-12 mg/hour
0.5 mg/hour
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Lumbar & Thoracic Epidurals
Patients having thoracic or upper abdominal surgery.
Patients having thoracic or upper & lower abdominalsurgery & who have significant pulmonary disease.
Patients having lower limb surgery or vascular by-pass inwhich sympathetic bloc is desirable.
Patients having orthopaedic surgery; e.g. total hip, & totalknee replacement.
Dose:
BUPIVACAINE 0.1%5-15 ml +2 g/ml FENTANYL/hourSide Effects:
Dizziness, nausea, & retention of urine
Indications
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Infusion Rate
(ML/ HR)
Bupivacaine Load
(0.25-0.5% ML)
Morphine
Load (MG)
Patient
Age (yrs)
Bupivacaine
0.1%
Morphine 0.05
mg/ mL
Infusion
6-88-12315-44
4-66-8245-65
3-45-7166-75
2-33-60 ± 0.576+
Infusion Rate
(ML/ HR)
Bupivacaine Load
(0.25-0.5% ML)
Morphine
Load (MG)
Patient
Age (yrs)
Bupivacaine
0.1%
Fentanyl
2-5 mcg/ mL
Infusion
6-88-12100-20015-44
4-66-8100-15045-65
3-45-750-10066-75
2-43-625-5076+
Recommended Solutions for Thoracic Epidural Analgesia(Thoracic Epidural Catheters, T6 h T8)
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Infusion Rate
(ML/ HR)
Bupivacaine Load
(0.25-0.5% ML)
Morphine
Load (MG)
Patient
Age (yrs)
Bupivacaine
0.1%
Morphine 0.05
mg/ mL
Infusion
6-810-15315-44
4-68-12245-65
3-46-10166-75
2-35-70 ± 0.576+
Infusion Rate
(ML/ HR)
Bupivacaine Load
(0.25-0.5% ML)
Morphine
Load (MG)
Patient
Age (yrs)
Bupivacaine
0.1%
Fentanyl
2-5 mcg/ mL
Infusion
6-1010-15100-20015-44
4-88-12100-15045-65
4-66-1050-10066-75
3-45-75076+
Recommended Solutions for Thoracic Epidural Analgesia(Thoracic Epidural Catheters, T8 h T12)
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Preemptive Analgesia
Preventing the establishment of altered central
processing by analgesics (regional or systemic) that
covers incisional (intraoperative) and inflammatory
(postoperative) is clinically fruitful.
Maximal clinical benefit is observed when there is
complete blockade of noxious stimuli, with extensionof this block into the postoperative period.
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Paediatric Patients
Children do feel, but cannot easily quantify their pain.
Rectal administration of acetaminophen at a higher
dose 40 mg/ kg followed by 3 doses of 20 mg/ kg at 6
hours interval result into proper serum analgesic
level.
Epidural through caudal approach with catheterdeposition in the proper dermatome (advanced easily
cephalad) is very effective.
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This picture was coloured in by
AN YOU COLOUR IN THIS PICTURE OF HERBIE AND HIS FRIEND DR OWL?
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Paediatric Sacral Epidural
Indication:
All pelvic and lower abdominal surgery
Analgesic Dose: 0.056 ml / segment / kg of 0.25%
BUPIVACAINE .
0.3 ml/ kg of 0.25% BUPIVACAINE
Side Effects:
Nausea, retention of urine,intravascular inject..
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Elderly Patients
There is a clinically significant reduction in theintensity of pain perception or symptoms with
increasing age ± due to decrease in A and C-fiber
nociceptive function ± resulting into delay in central
sensitization, increase in pain thresholds and decreasein sensitivity to low intensity noxious stimuli.
Postoperative delirium is among the devastating
complications in the elderly:
- Uncontrolled postoperative pain may be a
contributing factor.
- Higher pain scores predict a decline in mental status
& an increased risk of delirium.
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INPOS T ANAES TH. RECOVERY SCORE
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
43
21
Respirations:Able to breathe deeply & coughAble to breathe adequately
Limited respirationApnoea
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
Activity:No impaired muscle activityAble to move as directedLimited MobilityUnable to move
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
Color:
Normal for patientPale/ flushedDusky ² blotchyCyanotic
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
Circulation:B.P.=Pre-anaes. B.P +/- 20mm HgB.P.=Pre-anaes. B.P +/- 30mm HgB.P.=Pre-anaes. B.P +/- 40mm HgB.P.=Pre-anaes. B.P +/- 50mm Hg
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
4321
Consciousness:Awake & alertSleepyResponds to stimuliNo responding
Recovery score totals