IL DOLORE POST-OPERATORIO - siaarti.it didattico/Dolore Post-Operatorio/Samolsky.pdf · Il dolore...

Il dolore postoperatorio nella chirurgia maggiore e vascolare

Dipartimento di Scienze Mediche e Chirurgiche - Università di Bologna APS e Ambulatorio Terapia Antalgica, UO Anestesiologia e Terapia del Dolore, Prof. RM Melotti,

Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola Malpighi.

Boaz Samolsky-Dekel

IL DOLORE POST-OPERATORIO

CORSOSIAARTI

RazionaleIl dolore post-operatorio è una tipologia di dolore che insorge come conseguenza diretta di un intervento chirurgico, caratterizzato da un’intensità variabile che dipende dalla soglia individuale di percezione del dolore. Questo corso SIAARTI nasce dall’esigenza di migliorare la qualità della cura e della degenza del paziente attraverso una migliore conoscenza ed approfondimento delle diverse tipologie di dolore associate all’atto chirurgico. Il principio fondamentale di questo approccio mira a prevenire, monitorare e curare questo tipo di dolore attraverso le conoscenze della valutazione e rilevazione corretta dell’intensità del dolore, l’aggiornamento continuo e costante dei protocolli d’avanguardia come l’analgesia epidurale e plessica continua, l’infusione dei farmaci con l’analgesia controllata dal paziente con il fine di diminuire la sofferenza ed assicurare un trattamento del dolore che consenta di ridurre i tempi di ricovero.

PRIMO GIORNOOre 14.00-14.15 Registrazione dei partecipantiOre 14.15-14.30 Introduzione, obiettivi e finalità del corso Antonio Corcione, Caterina Aurilio

Ore 14.30-15.00 Anatomia e fisiologia delle vie afferenti e del sistema inibitore F. Ambrosio

Ore 15.00-15.30 Anamnesi del dolore e metodi di stima del dolore M.B. Passavanti

Ore 15.30-16.00 Il dolore riferito: Dolore Viscerale M.C. Pace

Ore 16.00-16.30 COFFEE BREAK

Ore 16.30-17.00 Gli Oppioidi D. Fornasari

Ore 17.00-17.30 Meccanismi molecolari di iperalgesia e tolleranza V.A. Peduto

Ore 17.30-18.00 I FANS M. Evangelista

Ore 18.00-18.30 L’importanza della differenziazione e specificità del dolore post-operatorio nelle varie specialità, l’analgesia multimodale F. Petrini

SECONDO GIORNO

Ore 08.30-09.00 La prevenzione del dolore cronico post operatorio in chirurgia to racica G. De Cosmo

Ore 09.00-09.30 Il dolore post operatorio in chirurgia toracica F. Piccioni

Ore 09.30-10.00 Il dolore postoperatorio in chirurgia maggiore e vascolare B. Samolsky

Ore 10.00-10.30 Il TAP BLOCK A. Fanelli


Ore 11.00-11.30 Il razionale del dolore post-operatorio nel taglio cesareo: dal do lore acuto al dolore cronico P. Sansone

Ore 11.30-12.00 Dolore post operatorio in pediatria F. Borrometi

Ore 12.30-13.00 L’analgesia post operatoria: vecchie molecole nuove opportuni tà terapeutiche C. Aurilio

Ore 13.00-13.30 Gruppi di lavoro con discussione interattiva R. Vellucci

Ore 13.30-14.00 Conclusioni e questionario ECM

PROGRAMMA SCIENTIFICO

1. Linee guida2. APS/protocolli 3. Real Life:

• Chir. Maggiore• Chir. vascolare • Osservazioni

Guidelines on the Management of Postoperative Pain

Management of Postoperative Pain: A Clinical Practice GuidelineFrom the American Pain Society, the American Society of RegionalAnesthesia and Pain Medicine, and the American Society ofAnesthesiologists’ Committee on Regional Anesthesia, ExecutiveCommittee, and Administrative Council

Roger Chou,* Debra B. Gordon,y Oscar A. de Leon-Casasola,z Jack M. Rosenberg,x

Stephen Bickler,{ Tim Brennan,k Todd Carter,** Carla L. Cassidy,yy Eva Hall Chittenden,zz

Ernest Degenhardt,xx Scott Griffith,{{ Renee Manworren,kk Bill McCarberg,***Robert Montgomery,yyy Jamie Murphy,zzz Melissa F. Perkal,xxx Santhanam Suresh,{{{

Kathleen Sluka,kkk Scott Strassels,**** Richard Thirlby,yyyy Eugene Viscusi,zzzz

Gary A. Walco,xxxx Lisa Warner,{{{{ Steven J. Weisman,kkkk and Christopher L. Wuzzz

*Departments of Medicine, andMedical Informatics and Clinical Epidemiology, Oregon Health and Science University,Pacific Northwest Evidence Based Practice Center, Portland, Oregon.yDepartment of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.zDepartment of Anesthesiology and Pain Medicine, Roswell Park Cancer Institute and University at Buffalo School ofMedicine and Biomedical Sciences, Buffalo, New York.xVeterans Integrated Service Network, Department of Veterans Affairs and Departments of Physical Medicine andRehabilitation and Anesthesiology, University of Michigan, Ann Arbor, Michigan.{Pediatric Surgery, University of California, San Diego, San Diego, California.kDepartment of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa.**Department of Anesthesia, University of Cincinnati, Cincinnati, Ohio.yyDepartment of Veterans Affairs, Veterans Health Administration, Washington, DC.zzDepartment of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts.xxQuality Management Division, United States Army Medical Command, San Antonio, Texas.{{Critical Care Medicine, Walter Reed Army Medical Center, Bethesda, Maryland.kkDepartment of Pediatrics, University of Connecticut School of Medicine, Mansfield, Connecticut.***American Academy of Pain Medicine, San Diego, California.yyyDepartment of Anesthesiology, University of Colorado, Denver, Denver, Colorado.zzzDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.xxxDepartment of Surgery, Veterans Affairs Medical Center, West Haven, Connecticut.{{{Department of Pediatric Anesthesia, Children’s Hospital of Chicago, Chicago, Illinois.kkkDepartment of Physical Therapy and Rehabilitation, University of Iowa, Iowa City, Iowa.****College of Pharmacy, University of Texas at Austin, Austin, Texas.yyyyBariatric Weight Loss Surgery Center, Virginia Mason Medical Center, Seattle, Washington.zzzzDepartment of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania.xxxxDepartment of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Washington.{{{{Department of Veteran Affairs, Phoenix, Arizona.kkkkDepartment of Anesthesiology, Children’s Hospital of Wisconsin, Wauwatosa, Wisconsin.

Received October 28, 2015; Revised December 11, 2015; AcceptedDecember 14, 2015.Funding for this guideline was provided by the American Pain Society.The guideline was submitted for approval by the partnering organiza-tions, but the content of the guideline is the sole responsibility of the au-thors and panel members.All panelists were required to disclose conflicts of interest within the pre-ceding 5 years at all face-to-face meetings and before submission of theguideline for publication, and to recuse themselves from votes if a

conflict was present. Conflicts of interest of the authors and panelmembers are listed in Supplementary Appendix 1.Supplementary data accompanying this article are available online atwww.jpain.org and www.sciencedirect.com.Address reprint requests to Roger Chou, MD, 3181 SW Sam Jackson ParkRoad, Mail code BICC, Portland, OR 97239. E-mail: [email protected]

1526-5900/$36.00

ª 2016 by the American Pain Society

http://dx.doi.org/10.1016/j.jpain.2015.12.008

131

The Journal of Pain, Vol 17, No 2 (February), 2016: pp 131-157Available online at www.jpain.org and www.sciencedirect.com

Racc.# Thepanelrecommends Racc. Evid.Qual.

1 Provide patient andfamily-centered,individually tailored education tothepatient..,including informationonpostoperative pain treatment….

S M

2 Instruction forparents (orother adult caregivers)ofchildren .. onappropriatemethods forassessing pain… andadministration ofanalgesics andmodalities .

S M

3 Conduct apre-operativeevaluation including assessment ofmedical andpsychiatriccomorbidities,concomitant medications,history ofchronic pain,substance abuse,andpreviouspostoperative treatmentregimens

S M

4 Adjust thepain managementplan onthebasis ofadequacy ofpain relief andpresence ofadverse events

S L

5 useavalidated pain assessment tool totrack responses topostoperative paintreatments andadjust treatmentplans accordingly

S L

6 Offermulti-modal analgesia,ortheuseofavariety ofanalgesic medications andtechniques combined withnon-pharmacological interventions,forthetreatmentofpostoperative pain inchildren andadults

S H

7 consider transcutaneous electrical nerve stimulation (TENS)as anadjunct toother postoperative pain treatments (weak recommendation,moderate-quality evidence).

W M

8 Neither recommend nor discourage acupuncture,massage,orcold therapy asadjuncts toother postoperative pain treatments

Insuff Insuff

9 Consider theuseofcognitive–behavioral modalities inadults as partofamultimodal approach

W M

R. Chou et al. American Pain Society. The Journal of Pain 2016


10 Oral overintravenous (i.v.)administration ofopioids forpostoperativeanalgesiainpatients who canusetheoral route

S M

11 Avoid using theintramuscular route fortheadministration ofanalgesics formanagementofpostoperative pain

S M

12 i.v.patient-controlled analgesia(PCA)tobeused forpostoperative systemicanalgesiawhen theparenteral route is needed

S M

13 Against routinebasal infusion ofopioids withi.v.PCAinopioid-naive adults

S M

14 Appropriatemonitoring ofsedation,respiratory status,andotheradverse events inpatients who receive systemic opioids

S L

15 Provide adults andchildren withacetaminophen and/orNSAIDs as partofmultimodal analgesia.. inpatients without contraindications

S M

16 Consider apreoperative doseoforal celecoxib inadult patients withoutcontraindications

S M

17 Consider useofgabapentin orpregabalin as acomponentofmultimodal analgesia

S M

18 consider i.v.ketamine as acomponentofmultimodal analgesiainadults

W M

19 consider i.v.lidocaineinfusions inadults who undergo openandlaparoscopic

abdominal surgery who donot have contraindications .W M



20 Consider surgical site-specific local anesthetic infiltration forsurgi-cal procedures withevidence indicating efficacy.

W M

21 Usetopical local anesthetics incombination withnerve blocksbefore circumcision

S M

22 NOintrapleural analgesiawithlocal anesthetics forpain controlafterthoracic surgery

S M

23 Consider surgical site-specific peripheral regional anesthetictechniques … forprocedures withevidence indicating efficacy

S M

24 usecontinuous,LA–based peripheral regional analgesictechniques when theneed foranalgesiais likely toexceed theduration ofeffect ofasingleinjection

S M

25 consider theaddition ofclonidine as anadjuvant forprolongation ofanalgesiawithasingle-injection peripheral neural blockade.

W M

26 offer neuraxial analgesiaformajorthoracic andabdominalprocedures,particularly inpatients at risk forcardiac complications,pulmonarycomplications,orprolonged ileus .

S M

27 avoid theneuraxial administration ofmagnesium,benzodiaze-pines,neostigmine,tramadol,andketamine

S M

28 provide appropriatemonitoring ofpatients who have receivedneuraxial interventions forperioperative analgesia

S M



29 have anorganizational structure inplace todevelop andrefinepolicies andprocesses forsafe andeffective deliveryofpostoperative pain control

S L

30 access toconsultation withapain specialist forpatients withinadequatelycontrolled postoperative pain orat highrisk ofinadequately controlled postoperative pain .

S L

31 neuraxial analgesiaandcontinuous peripheral blocks ..havepolicies andprocedures tosupport their safe deliveryandtrained individuals tomanage these procedures .

S L

32 provide education toall patients (adult andchildren)andprimarycaregivers onthepain treatmentplan including tapering ofanalgesics after hospitaldischarge.

S L


APSUOAnestesiologiaeTerapiadelDoloreDir.ProfRMMelotti

AziendaOspedaliero– UniversitariadiBologna

A. Applicare,inlineacoiprincipietici,leraccomandazioniscientificheeconledirettiveaziendali,un’adeguataterapiaantalgicaalpazienteospedalizzato;

P. Promuoverelasensibilizzazionetraglioperatorisanitari,atuttiilivellienellevariediscipline,circal’importanzadiun’adeguataterapiaantalgicanelpazientecondolore;

S. Sviluppare laricercascientificainterapiaantalgicapermigliorareleprestazionierogate.

APS

Mission

1. Valutazioneregolareecontinuativadelpazientecondoloreedeltrattamentoantalgicoapplicato,pertuttaladuratadelladegenza;

2. Applicazioneeadeguamentoad-personam diprotocolliditerapiaantalgicapost-operatorianeirepartichirurgici;

3. Consulenzaantalgicaepresaincaricodipazienticondoloreneirepartichirurgicienonchirurgici;

4. AmpliamentodellaresponsabilitàedelcoinvolgimentodelmedicoinformazioneinA&Rneiprocessivalutativiedecisionalirelativialpazientecondolore;

5. Revisioneeauditsull’attivitàdell’APS.

APS

Percorsi



APS

Struttura

Medici in formazione in A&RCultori della materia (Medici in formazione)

Personale:

7/7 giorni settimanali08:00 – 20:00

Attività:

Luogo: Reparti chirurgici afferenti all’ UO AnestesiologiaReparti non chirurgici in regime di consulenza.

Coordinamento Dirigente medico: Specialisti in A&R



Database delle prestazioni

APS,flow-chartattività

Pz. Chirurgico

Pz. non Chirurgico

Operato Non operato*

Protocollo terapia antalgica post-operatoria

Valutazione e adeguamento dell’analgesia, TID.Gestione di tecniche antalgiche complesse.

Visita e applicazione di terapia antalgica

Intervento Dimissione

Consulenzaantalgica

Visita pre-antalgica

Pz. Esterno

Visita ambulatoriale

Terapia, Controlli e tecniche antalgiche

Complesse.

Chirurgia,doloreattesoeprotocollo

ChirurgiaGenerale ChirurgiaVascolare Doloreatteso* Protocollo

Tiroidectomia,Quadrantectomia,Appendicectomia,Ernioplastica.

Safenectomia, TEA,Carotide,Fogarty

Lieve A - B

Chir.Proctologica,Ernioplastica bilaterale,mastectomia,chir.Videolaparo,emicolectomia dx.

By-passperiferici,Axillo-femorale ecarotido-succlavio.

Lieve/moderato

B- C

ResezioneGastro-intestinali,Miles,chir.Esofago,Chir.epaticaedelleviebiliari,Chir delPancreas.

AneurismaAortaaddominale,By-passaorto-bisiliaco ebifemorale

Severo C- D

Doloreatteso?

• Inter-individualvariability:– Surgerytype– Heterogeneityofpopulation

• Intra-individualvariability:– Increasedrequierment :ambulation,dressing,physicaltherapy,

bedrest,• Surgeon,• Context.

D. Odedra F. Gamlin. Anaesthesia And Intensive Care Medicine 2010

SchematerapeuticoI(Dolorelieve)

Protocollo A Starter fine intervento Protocollo prime 48 ore Post-Op

RescueNRSs>3

Boli EV Paracetamolo1g ev (in 15 min)

Paracetamolo 1 g/8h ev (in 15 min)

Tramadolo 100mg + metoclopramide 10mg in SF 100ml.(in 30 min max TID)OppureKetoprofene 50mg (max TID)

Controindicazione al paracetamolo

Tramadolo 100mg + metoclopramide 10mg in SF100ml.(in 30 min)

Tramadolo 100mg + metoclopramide 10mg in SF 100ml.(in 30 min TID)

Ketoprofene 50mg (max TID)

Protocolli A, B, C, e D per le prime 48 ore post-op

SchematerapeuticoII(Doloremoderato)Protocollo B Terapia Starter

fine interventoTerapia prime 48 ore Post-Op

RescueNRSs>3

Cont. Tramadolo EV*1,2,3 ml/ora

Paracetamolo 1 g ev (in 15 min)

§ Tramadolo 400mg + metoclopramide 30mg in SF 100ml

Velocità 2ml/ora.§ Paracetamolo

1 g/8h ev (in 15 min)

Ketoprofene 50mgOppureKetorolac 30mg(max TID)

*elastomero


Tramadolo 100mg + metoclopramide 10mg in SF100ml.(in 30 min)

§ Tramadolo 400mg + metoclopramide 30mg in SF 100ml Velocità 2ml/ora.

§ Ketoprofene 100mg BID


Protocollo B Terapia Starter fine intervento

Terapia prime 48 ore Post-Op

RescueNRSs>3

Cont.* Morfina EV1,2,3 ml/ora

Morfina 0,1mg/Kg 30 min prima del risveglio)


§ Morfina 50mg + metoclopramide 40mg in SF 100ml Velocità 2ml/ora.

§ Paracetamolo 1 g/8h ev (in 15 min)

Ketoprofene 50mgOppureKetorolac 30mg

*elastomero


Morfina 0,1mg/Kg 30 min prima del risveglio)

Ketoprofene 50mg

§ Morfina 50mg + metoclopramide 40mg in SF 100ml Velocità 2ml/ora.


Ketoprofene 50mgOppureKetorolac 30mg

SchematerapeuticoIII(DoloreSevero)

Protocollo C Terapia Starter fine intervento


RescueNRSs>3

1. Morfina EV PCA Morfina 00,1-0,1mg/Kg + Metoclopramide ev 10mg in SF 100 (30 min prima del risveglio)


§ Morfina 50mg in SF 50ml (1mg/ml)

Velocità 1ml/ora.Lock out 5-10 minMax dose 4-6 mg/h.

§ Metoclopramide ev 10mg in SF 100 TID




Morfina 0,1mg/Kg + Metoclopramide ev 10mg in SF 100 (30 min prima del risveglio)

Ketoprofene 50mg

§ Morfina 50mg in SF 50ml Velocità 1ml/ora.Lock out 5-10 minMax dose 4-6 mg/h.




2. Ketamina Cont. EV bolo induzione 0,1-0,5 mg/Kg seguito da infusione di 1-3 mcg/Kg/min o 3 mg/h durante l’intervento

§ Ketamina 1,5-2 mcg/Kg/min per 48 ore


2. Morfina PCA EV § Morfina (1mg/ml) Velocità 1ml/ora.Lock out 5-10 minMax dose 4-6 mg/h.



SchematerapeuticoIII(DoloreSevero)

Protocollo DPeridurale

(AL + oppiaceo)


RescueNRSs>3

Infusione continua(Elastoemro)

§ AL (Ropivacaina 0,2% oppure levobupivacaina 0,125%) + Sufentanil 0,2-0,4 mcg/ml Velocità 5ml/ora


Ketoprofene 50mgOppureKetorolac 30mg(max TID)Per insufficienza copertura dermatomerica associare schema II.


§ Ketoprofene 100mg BID Ketoprofene 50mgOppureKetorolac 30mg(max TID)

PCEA § AL (Ropivacaina 0,2% oppure levobupivacaina 0,125%)

+ Sufentanil 0,2-0,4 mcg/mlVelocità 5ml/orabolo 1-1,5 mlLock out 20 min.


Per insufficienza copertura dermatomerica associare schema II.


§ Ketoprofene 100mg BID Ketoprofene 50mgOppureKetorolac 30mg(max TID)

ParavertebraleInfusione continua(Elastoemro)

§ AL (Ropivacaina 0,2% oppure levobupivacaina 0,125%) Velocità 0,1 ml/Kg/ora


Per insufficienza copertura dermatomerica associare schema II.

Schema terapeutico III (Dolore Severo)

APS, Protocolli di Terapia Antalgica Postoperatoria (48h)

A

B

C

D

APSeprotocollidianalgesiapost-operatoria (2004-2014)N =10461(≃34383valutazioni)

A

25%

B

50%

C

10%

D

15%

A B C D

2,5

1,4 1,3 1,1 1,0 0,9 0,8

3,73,1

2,4 2,2 2,1 2,0 1,9

012345678910

1H 8H 16H 24H 32H 40H 48H

NRS

VASS

VASDNRS (S)

NRS (D)

Endpoints:

NRS (S) ≤ 3

NRS (D) ≤ 4

†La soddisfazione dei pazienti era:buona nel 41,6% e ottima nel 58,1%.

20,1

56,1

13,97,8

A B C D

Chirurgia Maggiore e protocolli di analgesia (2004-2014)N = 6990 (≃20970 valutazioni)

2,9

1,91,5 1,3 1,2 1,0 0,9

4,1

3,32,9 2,7 2,5 2,4 2,2

0123456789

10

1H 8H 16H 24H 32H 40H 48H

NRS

VASS

VASD

NRS (S)

NRS (D)

Endpoints:

NRS (S) ≤ 3

NRS (D) ≤ 4

Chirurgiavascolare eprotocollidianalgesia(2004-2014)N =2032(≃6096valutazioni)

A

46%

B

21%

D

33%

A B C D

1,6 1,4 1,3 1,1 1,0 0,9 0,8

2,3 2,4 2,4 2,2 2,1 2,0 1,9

0,0

1,0

2,0

3,0

4,0

5,0

6,0

7,0

8,0

9,0

10,0

1H 8H 16H 24H 32H 40H 48H

NRS

VASSVASD

NRS (S)

NRS (D)

Endpoints:

NRS (S) ≤ 3

NRS (D) ≤ 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

98,5

51,7

5,5

38,5

95,7

10,8

58,5 60,772,3

40,0

1,5

17,2

91,4 26,9

4,3

21,4

6,6 6,6

1,2

26,5

31,0

3,1

34,6

67,6

34,9 32,826,5

33,5

A B C D

OSSERVAZIONICHIRURGIAVASCOLARE

1.Analgesiaforvascular patients

• Systemic Analgesia(oral,Intravenous),• Regional anaesthetic techniques

– Neuraxial techniques– Peripheral nerve blocks– Lower/Upper limb blocks:– Cervical plexus blocks:

• Withtheincreasing useofultrasound thesafety ofthese techniques hasimproved.

• provide excellent postoperative analgesia,andmay also reducetheincidence ofphantom limb-associated symptoms following amputation.

D. Odedra F. Gamlin. Anaesthesia And Intensive Care Medicine 2010

Technique Advantages Disadvantagesspinal Rapid,intenseanalgesia Bilateraleffects,shortlasting,

coagulationandinfectionconsiderations

Epidural(lumbar) Cathetertop-upsforprolongedperipheralsurgery

Epiduralhaematoma/abscess,bilateral,impairsmobilization

Epidural(thoracic) Excellentanalgesia,reducedileusandchestinfections

Epiduralhaematoma/abscess,bilateral,impairsmobilizationEpiduralhaematoma/abscess

Sciaticnerveblock Easy,prolongedanalgesia,unilateral

Prolongedonset,noteasytouseassoletechniqueforsurgery

Femoralnerveblock Easy,adjuncttosciaticforlegsurgery/amputation

Notforfootsurgery

Ankleblock Footsurgery,avoidsgeneralanaesthesia,prolongedanalgesia

Difficultifoedema/infectionpresent

Metatarsal block Asanadjuncttoankleblock,easy

Deepcervicalplexusblock

Sensoryandmotorblocktoneck Vertebralarteryinjection/damage,notstrictlyneeded,phrenicnerveblock,recurrentlaryngealnerveblock

Superficialcervicalplexusblock

Easy,goodanalgesiaaftersurgerywithgeneralanaesthesia

Externaljugularveininjection

Local anaesthetic techniques for vascular surgery

• Practice guidelines orrecommendations summarize evidence-based reviews;however,therarity ofspinalhematoma defies prospective-randomized study,andthere is nocurrent laboratory model.

• Thus,these consensus statements represent thecollective experience ofrecognized experts inneuraxialanesthesia andanticoagulation.

• While acookbook approach is not appropriate,understanding ofthecomplexity ofthis issue is essential topatient management;

• Thedecision toperform spinal orepidural anesthesia/analgesiaandthetimingofcatheter removal inapatient receiving antithrombotic therapy should bemadeonanindividual basis.

• Thepatient’s coagulation statusshould beoptimized at thetimeofspinal orepidural needle/catheterplacement,andthelevel ofanticoagulation mustbecarefully monitored during theperiod ofepiduralcatheterization.

• Indwelling catheters should not beremoved inthepresence oftherapeutic anticoagulation.• Identification ofrisk factors andestablishmentofguidelines will not completely eliminatethe

complication ofspinal hematoma.• Vigilance inmonitoring is critical toallow early evaluation ofneurologic dysfunction andprompt

intervention.

Copyright @ 2009 . Unauthorized reproduction of this article is prohibited.American Society of Regional Anesthesia and Pain Medicine

Regional Anesthesia in the Patient Receiving Antithromboticor Thrombolytic Therapy

American Society of Regional Anesthesia and Pain Medicine Evidence-BasedGuidelines (Third Edition)

Terese T. Horlocker, MD,* Denise J. Wedel, MD,* John C. Rowlingson, MD,Þ F. Kayser Enneking, MD,þSandra L. Kopp, MD,* Honorio T. Benzon, MD,§ David L. Brown, MD,|| John A. Heit, MD,*

Michael F. Mulroy, MD,¶ Richard W. Rosenquist, MD,L Michael Tryba, MD,**and Chun-Su Yuan, MD, PhDÞÞ

Abstract: The actual incidence of neurologic dysfunction resultingfrom hemorrhagic complications associated with neuraxial blockade isunknown. Although the incidence cited in the literature is estimated tobe less than 1 in 150,000 epidural and less than 1 in 220,000 spinalanesthetics, recent epidemiologic surveys suggest that the frequency isincreasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, thepresence of an underlying coagulopathy, difficulty during needle place-ment, and an indwelling neuraxial catheter during sustained antico-agulation (particularly with standard heparin or low-molecular weightheparin). The need for prompt diagnosis and intervention to optimizeneurologic outcome is also consistently reported.

In response to these patient safety issues, the American Society ofRegional Anesthesia and Pain Medicine (ASRA) convened its ThirdConsensus Conference on Regional Anesthesia and Anticoagulation.Practice guidelines or recommendations summarize evidence-basedreviews. However, the rarity of spinal hematoma defies a prospectiverandomized study, and there is no current laboratory model. As a re-sult, the ASRA consensus statements represent the collective experi-ence of recognized experts in the field of neuraxial anesthesia andanticoagulation. These are based on case reports, clinical series, phar-macology, hematology, and risk factors for surgical bleeding. Anunderstanding of the complexity of this issue is essential to patientmanagement.

(Reg Anesth Pain Med 2010;35: 64Y101)

Improvement in patient outcomes, including mortality, majormorbidity, and patient-oriented outcomes, has been demon-

strated with neuraxial techniques, particularly with epiduralanesthesia and continued epidural analgesia.1Y5 A major com-ponent of the decreased morbidity and mortality is due to theattenuation of the hypercoagulable response and the associatedreduction in the frequency of thromboembolism after neuraxial

blockade. Although this beneficial effect of neuraxial techniquescontinues to be recognized, the effect is insufficient as the solemethod of thromboprophylaxis. Consequently, anticoagulant,antiplatelet, and thrombolytic medications have been increas-ingly used in the prevention and treatment of thromboembolism.For example, the initial recommendations in 1986 by the Amer-ican College of Chest Physicians (ACCP) stated that patientsundergoing hip arthroplasty receive dextran, adjusted-dosestandard heparin (approximately 3500 U every 8 hrs), warfarin(started 48 hrs postoperatively to achieve a prothrombin time[PT] 1.25Y1.5 times baseline), or dextran plus intermittent pneu-matic compression (IPC).6 Two decades later, these patients arestill identified as among the highest risk for thromboembolismand receive prophylaxis with lowYmolecular weight heparin(LMWH), fondaparinux (2.5 mg started 6Y24 hrs postopera-tively) or warfarin (started before or after operation with a meantarget international normalized ratio [INR] of 2.5).7 However,adjusted-dose heparin, dextran, and venous foot pumps are nolonger recommended as sole methods of thromboprophylaxis,although IPC is considered appropriate for patients at a high riskfor bleeding. Importantly, the duration of thromboprophylaxis iscontinued after hospital discharge for a total of 10 to 35 days.

The development (and evolving status) of standards for theprevention of perioperative venous thromboembolism (VTE), aswell as the introduction of increasingly more potent antithrom-botic medications, resulted in concerns regarding the heightenedrisk of neuraxial bleeding. Trends in patient management in-cluded not only in the avoidance of neuraxial techniques butalso in the search for alternative therapies and likely playeda prominent role in the resurgence of peripheral blockade. Al-though meta-analyses have reported improved surgical out-comes (without a reduction in mortality or morbidity) associatedwith single-injection and continuous plexus and peripheral anal-gesic techniques,1,8 serious hemorrhagic complications havealso occurred.9,10

In response to these patient safety issues, the AmericanSociety of Regional Anesthesia and Pain Medicine (ASRA)convened its Third Consensus Conference on Regional Anes-thesia and Anticoagulation. Portions of the material presentedhere were published as the proceedings of the 1997 and 2002ASRA Consensus Conferences.11Y16 The information has beenupdated to incorporate additional data available since the time ofits publication. Variances from recommendations contained inthis document may be acceptable based on the judgment of theresponsible anesthesiologist. The consensus statements are de-signed to encourage safe and quality patient care, but they cannotguarantee a specific outcome. They are also subject to timelyrevision as justified by evolution of information and practice.

ASRA PRACTICE ADVISORY

64 Regional Anesthesia and Pain Medicine & Volume 35, Number 1, January-February 2010

From the *Mayo Clinic, Rochester, MN; †University of Virginia HealthScience Center, Charlottesville, VA; ‡University of Florida, Gainesville, FL;§Northwestern University, Chicago, IL; ||Anesthesiology Institute, ClevelandClinic, Cleveland, OH; ¶Virginia Mason Medical Center, Seattle, WA;LUniversity of Iowa, Iowa City, IA; **Kassel, Germany; and ††Universityof Chicago, IL.Accepted for publication July 20, 2009.Address correspondence to: Terese T. Horlocker, MD, Department of

Anesthesiology, Mayo Clinic, Rochester, MN 55905(e-mail: [email protected]).

Copyright * 2010 by American Society of Regional Anesthesia and PainMedicine

ISSN: 1098-7339DOI: 10.1097/AAP.0b013e3181c15c70

TT.Horlocker etal.Regional Anesthesia andPain Medicine2010

Anticoagulation 3rd Edition Regional Anesthesia and Pain Medicine: January/February 2010 -

2004 - 2017 0.0 % ematoma neuro-assiale!!

Ematoma neuro-assiale

2.Attivitàextra48hpost-operatorie(2011)

N° pazienti N° visite N° medio gg di presa in carico

PRE-OPERATORIO 205 3578 6,6

POST- 48h 813 10361 5,1

Totale 1018 13939 5,8

N=1997pazientiseguitinelleprime48hpost-operatorie

Author's personal copy

Data Presentation and Statistical Analysis

All analyses were conducted using StatView for Windows(SAS Institute Inc., Cary, NC, USA). Pain intensity scoreswere reported as median, interquartile range, 5% and 95%centiles and range. Differences between VAS scores wereanalysed using a paired t-test. Statistical significance wasdefined as P< 0.01.

Results

Over 1 year, group LRA (n Z 13) and group OX (n Z 18)patients were identified and included in the study. Table 1shows these patients’ demographic characteristics, Fontainstage, the applied pain treatment and the clinical outcomesof both groups. Except for the pain treatment used, the twogroups were homogeneous.

Figure 1 shows box and whisker plots of the median,interquartile range and range of the VAS scores during the 21pain evaluations. In group LRA, the median score of VASs was2.0 (interquartile range, 1.0e2.0; 5% and95% centiles, 0.0 and3.0, respectively; range, 0.0e8.0) and that of VASd was 3.0(interquartile range, 2.0e3.0; 5% and 95% centiles, 1.0 and4.0, respectively; range, 0.0e10.0). In group OX, the medianscore of VASs was 2.0 (interquartile range and 5% and 95%centiles, 0.0 and3.0, respectively; range,0.0e9.0)andthatofVASd was 3.0 (interquartile range, 2.0e5.0; 5% and 95%centiles, 2.0 and 6.0, respectively; range, 0.0e9.0).

Statistically significant differences between the twogroups were observed under dynamic conditions as, underthese conditions, pain control was better in the LRA group(P< 0.01).

Treatment side effects were relatively rare in bothgroups. In group OX, only one patient reported transient(<24 h) somnolence (Ramsey scale 2e3); in group LRA, onepatient reported lower limb hypoaesthesia and hypostheniain the first 4 h after the positioning of the epidural catheter.

Rescue dose was administered in five patients (n Z 3 ingroup LRA and n Z 2 in group OX). In these patients, treat-ment was hence optimised as follows: in the LRA group, L-bupivacaine 0.25% boluses were increased from 4 to 5 ml

(12.5 mg); in the OX group, the daily dose of oxycodone wasdoubled. Finally, most patients (n Z 30) found the appliedpain treatment good or excellent and only one patientdescribed it as sufficient.

Discussion

Pain management in the growing substantial population ofpatients with PAOD is a major issue both in the perioperativesetting and for outpatients. ‘Non-surgical’ pain managementmodalities for these patients may include neurolytic orradiofrequency lumbar sympathetic block and electricalspinal-cord stimulators. These modalities tend to be effec-tive in and indicated for ischaemic conditions with a majorvasospastic component. Often, patients’ compliance,availability of technology, operator experience and comfortlevel influence the selection of one of these expensivemodalities. Our findings suggest that epidural analgesia withboluses of L-bupivacaine provides robust pain relief underboth static and dynamic conditions. Alternatively, for long-term treatments and for patients who cannot be treatedwith ‘non-surgical’ pain management modalities or epiduralanalgesia, oral slow-release oxycodone may provide optimalanalgesia under static conditions and to lesser extent, yetsatisfactory, under dynamic conditions.

Pain management in PAOD patients with severe ischae-mic pain of the lower limbs is scantily addressed. In thesepatients, the two major objectives of treatment are: (1) toprevent ischaemic attacks and (2) to improve QOL. Whenmaking medical decisions, it is generally accepted thatpatients are as much concerned by QOL as by life expec-tancy, particularly with regard to chronic diseases for whichthe aim of therapy is not only to treat the disease but alsoto relieve pain or restore function.8

Chronic severe pain, like that of PAOD patients, is char-acterised by three elements: (1) lack of direct or exclusiverelationship between the extension of the tissue lesion andpain intensity; (2) a personal and subjective experience witha variable association of sensory, emotional and cognitivefactors; and (3) the concomitant activation of peripheralnociceptors due to tissue lesion (i.e., nociceptive pain) and

Table 1 Demographic characteristics, Fontain stage, pain treatment and clinical outcomes split by the study groups. OS, oral;bid, twice daily; SR, slow release; IR, immediate release.

Group n Female/Male

Age Fontain stage Analgesia applied Clinical result

n Mean(!SD)

III IV Main treatment Rescue dose Surgery Discharge

LRA 13 3/10 74.4(!9.5)

n Z 4 n Z 9 Epidural boluses:L-Bupivacaine0.25% 4 ml/6 h

L-Bupivacaine 0.25% 4 ml,max 3 boluses/24 h

n Z 7 n Z 6

OX 18 3/15 73.3(!6.3)

n Z 6 n Z 12 OS bid:OxycodoneSR Dailymean dose:27.8 (!12.2) mg

(Oxycodone 5 mgþparacetamol 375 mg IR)max 6 times/24 h

n Z 8 n Z 10

Total 31 6/25 73.8(!7.7)

n Z 10 n Z 21 n Z 15 n Z 16

776 B.G. Samolsky Dekel et al.


the aberrant activity or pathology of the nervous system(i.e., neuropathic pain). In PAOD patients, both types of painmay co-exist given the presence of both tissue and periph-eral nervous system lesions due to the frequent ischaemiaand, eventually, to diabetic neuropathies. Evidence showsthat opiates give good response rate in nociceptive andneuropathic pain states in patients with chronic pain of non-cancer origin.11,12

Chronic severe pain compromises physical activity, sleepand sexual activities and leads to changes in mood, reducedself-esteem and negative feelings, such as despair; inaddition, pain causes alterations in patients’ family, workand leisure relationships. The intensity and frequency ofpain may exceed its function as a protective indicatorand may seriously compromise the QOL of affectedindividuals.6e8

Physiological responses to postoperative pain may alterorgan functions (cardiovascular, pulmonary, coagulation,endocrine, gastrointestinal, central nervous system, etc.).Pain alleviation not only improves patients’ comfort, butalso may minimise perioperative stress response, physio-logical responses and postoperative organ dysfunction,assist postoperative nursing and physiotherapy, enhanceclinical outcome and potentially shorten the hospital stay.

Potent postoperative analgesia, especially by theepidural route, may be associated with reduction in inci-dence and severity of many perioperative dysfunctions.13e15

Epidural analgesia using local anaesthetics is the best tech-nique for decreasing postoperative stress after lowerabdominal or lower limb surgery. Analgesia using eitherepidural or high doses of opiates may improve some cardiacvariables such as tachycardia and ischaemia, but does notchange the incidence of severe cardiac complications inpatients with pre-existing high cardiac risk. For patientsundergoing vascular or orthopaedic surgery, epidural anal-gesia can improve clinical outcome by preventing thedevelopment of arterial or venous thrombo-emboliccomplications16 as during LRA, unlike during general anaes-thesia, the fibrinolytic system is not inhibited.17

In this study, we used L-bupivacaine for LRA. L-Bupivacainehas been developed to offer a safer alternative to bupiva-caine, having the desirable blocking properties of racemicbupivacaine with a greater margin of safety due to its reduced

toxic potential. In particular, L-bupivacaine provides a long-lasting block with a clinical profile characterised by a finedifferentiation between sensory and motor blocks. This isparticularly useful when recovery of motor function and earlymobilisation is important to accelerate postoperativerecovery. The reduced toxic potential of L-bupivacaine isstrongly supported by animal and volunteer studies. It ischaracterised not only in higher plasma concentrations anddoses before signs of systemic toxicity occur, but also in nocardiovascular toxicity or only minimal signs of cardiac effectsafter central nervous system toxicity occurs in case of eitheroverdosing or unintended intravascular injection.18

Guidelines for chronic pain management consideropiate medications as effective analgesics with a well-established role in the management of severe pain.11

These potent medications require a thorough under-standing of their risks and benefits, along with a basic skillset to assess and manage risk and titration. With appro-priate diagnosis and monitoring, they are tools that can beemployed effectively with other management techniquesfor the treatment of acute and chronic pain.19 Morphine isconsidered as the gold standard of opiate prescription forsevere pain. Among the newer available opiates,compared to oral morphine, oral slow-release oxycodone,at equal analgesic doses, is thought to have a better bio-disposability, fewer itching, hallucinogenic and otherside effects and the ability to control painful diabeticneuropathies.20 Evidence shows that post-retropubicprostatectomy pain control with oral slow-release oxy-codone is preferable to epidural analgesia.21 In thepresent study, the initial dose of oxycodone was 10e20 mgtwice a day; titration to higher doses was based on therescue dose consumption in 24 h.

The main limitations of the study are its retrospectivenature and the small sample size. Such limitations imposecaution before taking the study’s results as definitive.However, the study results may be considered sufficient towarrant further prospective and randomised studies to verifythe generalisation of the findings as (1) both treatmentsappear to be satisfactory with the only advantage for theLRA group under dynamic conditions and (2) the statisticaldifference between the groups was of high significance(P< 0.01), thus limiting the risk of type II error. Further

Figure 1 Box and whisker plots of the median, interquartile range and range of the VAS scores during the 21 pain evaluations.*P< 0.01.

Pain Management in PAOD 777


Pain Management in Peripheral Arterial ObstructiveDisease: Oral Slow-Release Oxycodone VersusEpidural L-Bupivacaine

B.G. Samolsky Dekel a,*, R.M. Melotti a, M. Gargiulo b,A. Freyrie b, A. Stella b, G. Di Nino a

a Department of Surgery and Anaesthesiology Sciences, Head Prof. GF Di Nino, Anaesthesiology Section,University of Bologna, Via Massarenti 9, 40138 Bologna, Italyb Department of Surgery and Anaesthesiology Sciences, Head Prof. GF Di Nino, Vascular Surgery Section,University of Bologna, Bologna, Italy

Submitted 5 December 2009; accepted 23 February 2010Available online 23 March 2010

KEYWORDSPain management;Peripheral ArterialObstructive Disease;Epidural;Opiates;Oxycodone

Abstract Objectives: To compare the effectiveness of oral slow-release oxycodone (groupOX, n Z 18) with that of epidural L-bupivacaine (group LRA, n Z 13) for the control ofmoderate/severe pain of advanced-stage peripheral arterial obstructive disease (PAOD)patients.Design: Observational and retrospective analysis of advanced stage and hospitalised PAODpatients treated for pain management for at least 7 days prior to surgery or discharged fromthe hospital without surgery.Methods: The outcome measures were pain intensity using the visual analogue scale under static,(VASs) and dynamic (VASd) conditions; vital signs, treatment side effects and patient satisfaction.Results: In both groups, pain control was satisfactory and VAS scores median were VASs< 3 andVASd< 4; under dynamic conditions, pain control was better in the LRA group (p< 0.01). Againstfewandtransientsideeffects,mostpatients (n Z 30) foundbothpaintreatmentsgoodorexcellent.Results should be confirmed by studies with larger samples.Conclusions: In the perioperative setting, the epidural infusion of local anaesthetics, such as L-bu-pivacaine, is an effective technique for pain control in PAOD patients; for patients with contraindi-cation for this technique or for non-surgical or outpatients, slow-release oxycodone is suggested asa possible alternative for the control of severe pain in these patients.ª 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ39 051 6363087; fax: þ39 051 6364333.E-mail address: [email protected] (B.G. Samolsky Dekel).

1078-5884/$36 ª 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.ejvs.2010.02.016

Eur J Vasc Endovasc Surg (2010) 39, 774e778

Pain Management in Peripheral Arterial ObstructiveDisease: Oral Slow-Release Oxycodone Versus Epidural L-BupivacaineB.G. Samolsky Dekel, R.M. Melotti, M. Gargiulo, A. Freyrie, A. Stella, G. Di Nino

3.ILPAZIENTECONNEUROPATIADIABETICA

• Gestionedeldoloreprimadellachirurgiavascolare

– Igieneescarpeadatte,– Controlloottimaledellaglicemiaprevienelaprogressionedellaneuropatia

periferica,– Antidepressivitriciclici,– Inibitoriselettividellarecaptazione dellaserotonina,– Anticonvulsivanti(carbamazepina,gabapentin,pregabalin),– Applicazionelocaledicapsaicina (deplezionedellasostanzaP),– Stimolatorimidollari,– Peridurale.

Diabetes Research Group N Engl J Med 1993

4.Doloredaartofantasma• Fattoridirischioperdoloreda’artofantasna’:

– Generefemminile;– Amputazionedegliartisuperiori;– Presenzadidolorepre-amputazione;– Doloreresiduonelmoncone;– Tempodall’amputazione(entro1mese;entro1anno).

• Teoriepatogenetiche:

SNperifericoIperattivitànervosamoncone/neurinoma

Meccanismipsicogenetici

SNcentraleSensibilizzazioneMS

Riorganizzazionecorticaleedissociazionesensorio-

motoriacorticaleAlterazionedelloschema

corporeoKehlet H. et al. Lancet; 2006;

B. Subedi and GT. GrossbergPain Res Treatment; 2011

4 Pain Research and Treatment

Table 3: Treatments for phantom limb pain.

Pharmacotherapy Surgical/invasive procedures Adjuvant therapy

Opioids Stump revision Transcutaneous nerve stimulation

Morphine Nerve block Mirror therapy

Tramadol Neurectomy Biofeedback

Tricyclic Antidepressants Rhizotomy Temperature biofeedback

Amitriptyline Cordotomy Electro myographic biofeedback

Nortriptyline Lobectomy Massage

Imipramine Sympathectomy Ultrasound

Desipramine CNS stimulation Physiotherapy

AntiConvulsants Spinal cord stimulation Sensory discrimination training

Carbamazepine Deep brain/thalamus stimulation Prosthesis training

Oxcarbazepine Cortical stimulation Cognitive behavioral pain management

Gabapentin Electroconvulsive therapy

Pregabalin

Sodium channel blockers

Lidocaine

Bupivacaine

Mexiletine

NMDA receptor antagonist

Memantine

Ketamine

Adapted from [4, 41].

to effectively control the pain. [49, 52]. Nortriptyline anddesipramine have been found to be equally effective andwith less side effects compared to amitriptyline [53]. A smallcase series demonstrated the effectiveness of mirtazapine,an alpha 2 receptor antagonist with fewer side effects thantricyclic antidepressants in the treatment of PLP [54]. Thereare case reports relative to the efficacy of duloxetine, a NE andserotonin receptor inhibitor, in the treatment of PLP [55].Even though there may be a role for the use of SSRI andSNRI in the treatment of neuropathic pain, the evidence isvery limited and further research is needed [56].

3.1.5. Anticonvulsants. Gabapentin has shown mixed resultsin the control of PLP with some studies showing positiveresults while others not showing efficacy [57–59]. Carba-mazepine has been reported to reduce the brief stabbingand lancinating pain associated with PLP. Oxcarbazepine andpregabalin may also play a role in the treatment of PLP, butfurther studies are required [4, 60].

3.1.6. Calcitonin. The mechanism of action of calcitonin intreatment of PLP is not clear. Studies relative to its therapeu-tic role have been mixed [61, 62].

3.1.7. NMDA Receptor Antagonist. The mechanism of actionof NMDA receptor antagonism in PLP is not clear. Meman-tine has shown some benefits in some case studies but con-trolled trials have shown mixed results [63, 64]. A review

concluded that memantine may be useful soon after ampu-tation rather than for use in chronic neuropathic pain condi-tions [65].

3.1.8. Other Medications. The beta blocker propranolol andthe calcium channel blocker nifedipine have been used forthe treatment of PLP [60]. However, their effectiveness isunclear and further studies are needed. Flupirtine, an NMDAantagonist and potassium channel agonist, has been reportedto be effective when used together with opioids in cancer-related neuropathic pain but needs further studies for otheretiologies [66].

3.2. Nonpharmacological Treatment

3.2.1. Transcutaneous Electrical Nerve Stimulation (TENS).Transcutaneous electrical nerve stimulation has been foundto be helpful in PLP [40]. Historically, there have beenmultiple studies showing the effectiveness of TENS of thecontralateral limb versus ipsilateral to decrease PLP [67].Though there is no strong evidence, low-frequency and high-intensity TENS is thought to be more effective than otherdoses [68]. TENS devices are portable, are easy to use, andhave few side effects or contraindications.

3.2.2. Mirror Therapy. Mirror therapy was first reported byRamachandran and Rogers-Ramachandran in 1996 and issuggested to help PLP by resolving the visual-proprioceptive

Efficace controllo del dolore peri-amputazione!!!

B. Subedi and GT. Grossberg. Pain Res Treatment; 2011

OSSERVAZIONICHIRURGIAMAGGIORE

a retrospective analysis of the pain therapy prescriptions at the endof the first 48 postoperative hours. The analysis included allpatients who underwent major abdominal surgery between January1 and December 31, 2006, and were followed by the APS for POPCover the first 48 postoperative hours. With respect to the appliedPOPC protocol, pain therapy after the first 48 hours could havebeen: (1) perpetuation of the same protocol with or withoutvariations of the analgesic drug or its doses; (2) application of adifferent administration route and analgesic drug; or (3) interrup-tion of POPC because it was not necessary or for other reasons,such as a surgeon’s decision to interrupt pain therapy.

RESULTS

In the examined period, the APS followed 1170 surgicalpatients including 485 who underwent major abdominalsurgery. Among the latter, the mean age was 61.5 (! 14.8)years. Among this group, the distribution of protocols forthe first 48 postoperative hours were: protocol A, 15.5%(n " 75); protocol B, 74.6% (n " 362); protocol C, 5.6%(n " 27); and protocol D, 4.3% (n " 21).

Percentile box plots and pain evaluation scores in thefirst 48 postoperative hours are shown in Fig 1 Panels Aand B. From the eighth postoperative hour onward, the50th percentile or median value of all evaluations of bothstatic and dynamic pain scores were lower than thedesired outcomes both for VAS(s) and VAS(d), respec-tively.

Table 1 describes the proportions of actions taken by theAPS after the first 48 postoperative hours. Regardless ofthe type of protocol applied after surgery pain control wasstill needed in 79.6% of the cases. In about half of the cases,pain control was perpetuated with only drug category ordosage modifications, while in roughly one third of thecases, both drug and administration route changes wereadopted. These changes were made by the APS after athorough evaluation of the patients’ conditions and needs interms of analgesia. Interestingly, in approximately 5% ofthe cases, the surgeon was the physician who decided tointerrupt pain therapy.

Fig 1. A and B are 10th, 25th, 50th, 75th, and 90th (circles) percentiles box plots of pain evaluation’s scores (VAS) in the first 48postoperative hours.

Table 1. Proportions of the Actions Taken by the APS After the First 48 Postoperative Hours

Protocol Perpetuation After theFirst 48 Hours

First Postoperative 48 Hours Protocol

An (%)

Bn (%)

Cn (%)

Dn (%) Total

Not necessary 44 (58.7) 31 (8.6) 1 (4.8) 76 (15.7)Without modifications 20 (5.5) 4 (14.8) 3 (14.3) 27 (5.6)With drug modifications 9 (12.0) 190 (52.5) 10 (37.0) 16 (76.2) 225 (46.4)With drug and administration

route modifications10 (13.3) 110 (30.4) 13 (48.1) 1 (4.8) 134 (27.6)

Interrupted by surgeon 12 (16.0) 11 (3.0) 23 (4.7)

Total 75 (100.0) 362 (100.0) 27 (100.0) 21 (100.0) 485 (100.0)

PAIN CONTROL AFTER ABDOMINAL SURGERY 1219

a retrospective analysis of the pain therapy prescriptions at the endof the first 48 postoperative hours. The analysis included allpatients who underwent major abdominal surgery between January1 and December 31, 2006, and were followed by the APS for POPCover the first 48 postoperative hours. With respect to the appliedPOPC protocol, pain therapy after the first 48 hours could havebeen: (1) perpetuation of the same protocol with or withoutvariations of the analgesic drug or its doses; (2) application of adifferent administration route and analgesic drug; or (3) interrup-tion of POPC because it was not necessary or for other reasons,such as a surgeon’s decision to interrupt pain therapy.

RESULTS

In the examined period, the APS followed 1170 surgicalpatients including 485 who underwent major abdominalsurgery. Among the latter, the mean age was 61.5 (! 14.8)years. Among this group, the distribution of protocols forthe first 48 postoperative hours were: protocol A, 15.5%(n " 75); protocol B, 74.6% (n " 362); protocol C, 5.6%(n " 27); and protocol D, 4.3% (n " 21).

Percentile box plots and pain evaluation scores in thefirst 48 postoperative hours are shown in Fig 1 Panels Aand B. From the eighth postoperative hour onward, the50th percentile or median value of all evaluations of bothstatic and dynamic pain scores were lower than thedesired outcomes both for VAS(s) and VAS(d), respec-tively.

Table 1 describes the proportions of actions taken by theAPS after the first 48 postoperative hours. Regardless ofthe type of protocol applied after surgery pain control wasstill needed in 79.6% of the cases. In about half of the cases,pain control was perpetuated with only drug category ordosage modifications, while in roughly one third of thecases, both drug and administration route changes wereadopted. These changes were made by the APS after athorough evaluation of the patients’ conditions and needs interms of analgesia. Interestingly, in approximately 5% ofthe cases, the surgeon was the physician who decided tointerrupt pain therapy.

Fig 1. A and B are 10th, 25th, 50th, 75th, and 90th (circles) percentiles box plots of pain evaluation’s scores (VAS) in the first 48postoperative hours.

Table 1. Proportions of the Actions Taken by the APS After the First 48 Postoperative Hours

Protocol Perpetuation After theFirst 48 Hours

First Postoperative 48 Hours Protocol

An (%)

Bn (%)

Cn (%)

Dn (%) Total

Not necessary 44 (58.7) 31 (8.6) 1 (4.8) 76 (15.7)Without modifications 20 (5.5) 4 (14.8) 3 (14.3) 27 (5.6)With drug modifications 9 (12.0) 190 (52.5) 10 (37.0) 16 (76.2) 225 (46.4)With drug and administration

route modifications10 (13.3) 110 (30.4) 13 (48.1) 1 (4.8) 134 (27.6)

Interrupted by surgeon 12 (16.0) 11 (3.0) 23 (4.7)

Total 75 (100.0) 362 (100.0) 27 (100.0) 21 (100.0) 485 (100.0)

PAIN CONTROL AFTER ABDOMINAL SURGERY 1219

Major Abdominal Surgery and Postoperative Pain Control:Are Protocols Enough?

B.G. Samolsky Dekel, R.M. Melotti, F. Carosi, F.D. Spinelli, R. D’Andrea,and G. Di Nino

ABSTRACTSuitable postoperative pain control (POPC) requires both the application of appropriatepain therapy and the continuous supervision of its therapeutic effects. In our hospital,POPC was, until recently, limited to the first 48 postoperative hours. The purpose of thisretrospective study was to assess, the evolution of POPC at the end of the firstpostoperative 48 hours among major abdominal surgery patients using the Acute PainService (APS) database. Further we sought to establish the indications to extend POPC tothe entire postoperative period. Regardless of the type of protocol applied after surgery,79.6% of cases showed pain control was still needed after the 48th hour. In about half ofthe cases, POPC was perpetuated with only the drug category or by dosage modifications,while in roughly one third of the cases we adopted both drug and administration routechanges. These changes were made by the APS after a thorough evaluation of the patients’conditions and needs in terms of analgesia. Interestingly, in approximately 5% of cases thesurgeon decided to interrupt pain therapy.

When applying evidence-based guideline protocols, organizational issues are important aswell as a better definition of the APS role in POPC, at least from the timing point of view.

TTHE AMERICAN PAIN SERVICE (APS) recom-mendations to improve the quality of acute and cancer

pain management have specified that efforts to improve thequality of pain management must move beyond assessmentand communication of pain to implementation and evalu-ation of improvements in pain treatment that are timely,safe, evidence based, and multimodal.1 Indeed, evidencefrom the literature has shown that suitable postoperativepain control (POPC) requires both the application of anappropriate pain therapy and the continuous supervision ofits therapeutic effects.2–6 The “Hospital Without Pain”committee of our teaching hospital, elaborated four proto-cols to apply for POPC. The protocols consider the admin-istration of analgesics and adjuvant drugs intravenously orvia the epidural route in the first postoperative 48 hours. Inparticular, these protocols are classified into four maingroups according to the administration regime: intravenousas fixed-hour boluses (protocol A); continuous administra-tion through elastomeric pumps (protocol B); patient con-trolled analgesia (PCA, protocol C); and, continuous/bo-luses epidural administration (protocol D). The evaluationof pain and the effectiveness of treatment is monitoredevery 8 hours during the first 48 postoperative hours. The

desired outcomes are that pain on rest [Static VisualAnalogue Scale, VAS (s)] should not exceed score point 3and pain on movement [Dynamic Visual Analogue Scale,VAS (d)], not exceed 4. The purpose of this report was toassess, the evolution of POPC at the end of the first 48hours after major abdominal surgery. In addition, we soughtto establish the indications for the extension of the POPC tothe entire postoperative hospitalization.

METHODS

The POPC protocols, evaluation, and the prescription of paintherapy were recorded on dedicated forms attached to the patient’sclinical chart as he left the operating theatre as well as stored in theAcute Pain Service (APS) database. Using the latter, we performed

From the University of Bologna, Department of Surgical andAnesthesiological Sciences (B.G.S.D., R.M.M., F.C., F.D.S.,R.D., G.D.N.) and Azienda Universitario-Ospedaliera di Bologna,Policlinico S. Orsola-Malpighi, UO Anestesiologia, (B.G.S.D.,R.M.M., F.C., R.D., G.D.N.), Bologna, Italy.

Address reprint requests to Boaz G. Samolsky Dekel, Depart-ment of Surgical and Anesthesiological Sciences, University ofBologna,� Via� Massarenti� 9,� 40138� Bologna,� Italy.� E-mail:� [email protected]

0041-1345/08/$–see front matter © 2008 by Elsevier Inc. All rights reserved.doi:10.1016/j.transproceed.2008.03.074 360 Park Avenue South, New York, NY 10010-1710

1218 Transplantation Proceedings, 40, 1218–1220 (2008)

Major Abdominal Surgery and Postoperative Pain Control:Are Protocols Enough?

B.G. Samolsky Dekel, R.M. Melotti, F. Carosi, F.D. Spinelli, R. D’Andrea,and G. Di Nino

ABSTRACTSuitable postoperative pain control (POPC) requires both the application of appropriatepain therapy and the continuous supervision of its therapeutic effects. In our hospital,POPC was, until recently, limited to the first 48 postoperative hours. The purpose of thisretrospective study was to assess, the evolution of POPC at the end of the firstpostoperative 48 hours among major abdominal surgery patients using the Acute PainService (APS) database. Further we sought to establish the indications to extend POPC tothe entire postoperative period. Regardless of the type of protocol applied after surgery,79.6% of cases showed pain control was still needed after the 48th hour. In about half ofthe cases, POPC was perpetuated with only the drug category or by dosage modifications,while in roughly one third of the cases we adopted both drug and administration routechanges. These changes were made by the APS after a thorough evaluation of the patients’conditions and needs in terms of analgesia. Interestingly, in approximately 5% of cases thesurgeon decided to interrupt pain therapy.

When applying evidence-based guideline protocols, organizational issues are important aswell as a better definition of the APS role in POPC, at least from the timing point of view.

TTHE AMERICAN PAIN SERVICE (APS) recom-mendations to improve the quality of acute and cancer

pain management have specified that efforts to improve thequality of pain management must move beyond assessmentand communication of pain to implementation and evalu-ation of improvements in pain treatment that are timely,safe, evidence based, and multimodal.1 Indeed, evidencefrom the literature has shown that suitable postoperativepain control (POPC) requires both the application of anappropriate pain therapy and the continuous supervision ofits therapeutic effects.2–6 The “Hospital Without Pain”committee of our teaching hospital, elaborated four proto-cols to apply for POPC. The protocols consider the admin-istration of analgesics and adjuvant drugs intravenously orvia the epidural route in the first postoperative 48 hours. Inparticular, these protocols are classified into four maingroups according to the administration regime: intravenousas fixed-hour boluses (protocol A); continuous administra-tion through elastomeric pumps (protocol B); patient con-trolled analgesia (PCA, protocol C); and, continuous/bo-luses epidural administration (protocol D). The evaluationof pain and the effectiveness of treatment is monitoredevery 8 hours during the first 48 postoperative hours. The

desired outcomes are that pain on rest [Static VisualAnalogue Scale, VAS (s)] should not exceed score point 3and pain on movement [Dynamic Visual Analogue Scale,VAS (d)], not exceed 4. The purpose of this report was toassess, the evolution of POPC at the end of the first 48hours after major abdominal surgery. In addition, we soughtto establish the indications for the extension of the POPC tothe entire postoperative hospitalization.

METHODS

The POPC protocols, evaluation, and the prescription of paintherapy were recorded on dedicated forms attached to the patient’sclinical chart as he left the operating theatre as well as stored in theAcute Pain Service (APS) database. Using the latter, we performed

From the University of Bologna, Department of Surgical andAnesthesiological Sciences (B.G.S.D., R.M.M., F.C., F.D.S.,R.D., G.D.N.) and Azienda Universitario-Ospedaliera di Bologna,Policlinico S. Orsola-Malpighi, UO Anestesiologia, (B.G.S.D.,R.M.M., F.C., R.D., G.D.N.), Bologna, Italy.

Address reprint requests to Boaz G. Samolsky Dekel, Depart-ment of Surgical and Anesthesiological Sciences, University ofBologna,� Via� Massarenti� 9,� 40138� Bologna,� Italy.� E-mail:� [email protected]

0041-1345/08/$–see front matter © 2008 by Elsevier Inc. All rights reserved.doi:10.1016/j.transproceed.2008.03.074 360 Park Avenue South, New York, NY 10010-1710

1218 Transplantation Proceedings, 40, 1218–1220 (2008)

1. Sono sufficienti rigidi protocolli?

2.LaChirurgiaMaggiorenelpazienteconmorbodiCrohn

• LachirurgiaaddominaleneipazienticonmorbodiCrohn èfrequente:

– Serveperlagestionedellecomplicazionidellamalattiaedeifallimentiterapeutici.

• FrequentiunascadenteQualitàdivitaericorrentistatidolorosiacutiecronici.

• Ipazientisperimentanodolorevisceraleinvariefasidellamalattiaedolorepost-operatorioamplificatosecondariacronichealterazionidelsistemasomato-sensorialeenocicettivo;

• Spesso,nelpost-operatorioèpresenteiperalgesiasecondariaadunostatoinfiammatoriocronico;

• Ilconsumodiopiacei nelpost-operatorio,neipazienticonIBDèmaggiorerispettoapazientisottopostiaprocedurechirurgichesimilimasenzalamalattiadiCrohn.

• IpazienticonlamalattiadiCrohn presentanounabitus psicologicopeculiare,spessoconILC.

Poggioli G,etal.Aliment.Pharmacol.Ther. 2002;Gazzard BG.ThequalityoflifeinCrohn'sdisease.Gut 1987;

CameronCA.Medsurg.Nurs. 2008;Fleyfel MDetal.Eur.J.Anaesthesiol. 2008;Gesink-vanBJ,etal.Br.J.Anaesth. 1993;

Analisidell’efficaciadeiprotocollidiTp Antalgicapost-opinn=197pazienticonilmorbodiCrohn

Protocol Surgery-typegroup

Ia IIb IIIc IVdTotalof

Protocols

n(%) n(%) n(%) n(%) n(%)

A 1(0.6) 2(18.2) 0(0.0) 3(27.3) 6(3.1)

B 54(32.3) 9(81.8) 1(12.5) 6(54.5) 70(35.5)

C 84(50.3) 0(0.0) 6(75.0) 1(9.1) 91(46.2)

D 28(16.8) 0(0.0) 1(12.5) 1(9.1) 30(15.2)

Totalofsurgerygroup 167(84.8) 11(5.6) 8(4.1) 11(5.6) 197(100.0)0

1

2

3

4

5

6

7

8

9

10N

RS

NRS 1 s NRS 8h s NRS 16h s NRS 24h s NRS 32h s NRS 40h s NRS 48h s 1 8 16 24 32 40 48 post-operative hours

(a)

(b)

*

*

Protocol % Compound % Dose(mg/mla ormcg/mlb)

Mean±SD

Adm.rate(ml/h)Mean±SD

Dailydose(mg)

Mean±SD

A 3.1 Paracetamol 66.7 10.00a 8-hourly3500.0±577.35

Tramadol 16.7 50.00a 12-hourly 100.0Oxycodone(OS) 16.7 10.00mgs 12-hourly 20.0

B 35.5 Morphinechlorhydrate

87.1 0.6±0.2a 2.0±0.423.9±7.7

Tramadol 7.1 5.6±0.6a 2.0±0.5268.8±26.3

Remifentanyl 5.7 0.066±0.03c 4.6±1.7 7.5±4.9

C 46.2 Morphinechlorhydrate

100.0 1.0a 1.29±0.39 1.8±0.4c

D 15.2 L-bupivacaine 30.0 0.127±0.0083b 6.22±2.33

L-bupivacaine+Fentanyl

6.7 L-bupivacaine(0.11±0.02)bFentanyl(400.0±141.42)b

7.0±0.5

Ropivacaine+Fentanyl

16.7 Ropivacaine(0.18±0.04)bFentanyl(500.0±70.71)b

6.2±1.095

L-bupivacaine+Sufentanyl

36.7 L-bupivacaine(0.127±0.0075)bSufentanyl(159.09±43.69)b

5.90±1.044

Ropivacaine+Sufentanyl

10.0 Ropivacaine (0.175±0.04)bSufentanyl (120±72.11)b

5.66±1.155

c, On demand boluses (mg)

post-optime(hours) Protocol NRSs NRSd

Mean(CI) Fisher’sPLSD,Pvalue Mean(CI) Fisher’sPLSD,Pvalue

B/C B/D C/D B/C B/D C/D

1st B 4.4(3.8-5.1) 0.09 0.62 0.34 6.0(5.3-6.1) 0.13 0.42 0.66

C 3.9(3.3-4.5) 5.4(4.8-6.0)

D 4.8(3.5-6.1) 6.0(4.8-7.2)

8th B 2.8(2.2-3.3) 0.06 0.27 0.01 4.1(3.5-4.7) 0.28 0.33 0.048

C 2.1(1.7-2.4) 3.6(3.1-4.0)

D 3.6(2.4-4.8) 4.8(3.7-5.9)

16th B 1.8(1.4-2.3) 0.63 0.17 0.06 3.2(2.7-3.7) 0.97 0.07 0.046

C 1.8(1.5-2.1) 3.1(2.8-3.5)

D 2.7(2.0-3.4) 4.3(3.4-5.1)

24th B 1.6(1.1-2.0) 0.97 0.06 0.04 3.1(2.6-3.6) 0.53 0.19 0.048

C 1.6(1.3-1.9) 2.8(2.5-3.2)

D 2.3(1.6-3.0) 3.9(3.1-4.7)

32nd B 1.4(1.0-1.8) 0.96 0.35 0.33 2.9(2.4-3.4) 0.53 0.19 0.048

C 1.2(0.9-1.5) 2.5(2.2-2.9)

D 1.7(1.2-2.2) 3.5(2.7-4.3)

40th B 1.2(0.8-1.5) 0.97 0.01 0.01 2.7(2.3-3.1) 0.61 0.02 0.004

C 1.1(0.8-1.3) 2.4(2.0-2.7)

D 1.8(1.3-2.4) 3.3(2.6-3.9)

48th B 1.0(0.6-1.4 0.77 0.14 0.17 2.4(2.0-2.7) 0.92 0.01 0.004

ConclusioniAnalisidell’efficaciadeiprotocollidiTpAntalgicapost-opinpazienticonilmorbodiCrohn

• Multiplifattoricomplicanolagestionedeldolorepost-opnellachirurgiaaddominaledelpazienteconmorboCrohn.

• Inquestipazienti,perlagestionedeldolorepost-op.,lasomministrazionee.v. dimorfinaconlametodicaPCAèsuperioreallasomministrazionee.v.continuadimorfinaedall’analgesiaperidurale.

59

TABELLA VII- modalità di somministrazione con PCA.

Comuni regimi di PCA-ev con oppioidi per pazienti naive

Oppioide Dose bolo Intervallo (min) Infusione basale *

Morfina 1-2 mg 6 -10 0-2 mg/h

Fentanyl 20-50 mcg 5 -10 0-60 mcg/h

Sufentanil 4 – 6 mcg 5 -10 0-8 mcg/h

Tramadolo 10-20 mg 6 -10 0-20 mg/h

* L’infusione continua basale non è raccomandata nella programmazione iniziale

298 ETCHES

PHARMACOLOGIC RATIONALE

To understand the rationale for PCA, one must first appreciate the problems of between-patient and within-patient variability in the response to opioids, and one must understand the concept of the sigmoidal dose-response curve as it relates to the minimum effective analgesic concentration (MEAC). In a relatively homogeneous group of patients undergoing similar surgical procedures, the postoperative opioid requirements typically vary by a factor of four or more. In a nonhomoge- neous group undergoing disparate surgical procedures, requirements may vary 10-fold. This is what is meant by between-patient variability. Similarly, a patient's analgesic requirements vary. In particular, analgesic requirements decrease over time but increase transiently in response to specific events, such as dressing changes, mobilization, physiotherapy, and other causes of so-called "incident pain." Good evidence of circadian variation also exists, with analgesic requirements typically greater in the morning, around the hours of 6 AM to 10 AM. This is known as within- patient variability.

The dose-response plot for opioid analgesia is best described not as a linear relationship but as a steep sigmoidal curve3 (Fig. 1). This means that for a given painful stimulus, little analgesia results until a threshold serum (and central nervous system [CNS]) concentration is reached.

c ._ a"

Serum Opioid Concentration (Arbitrary units)

Figure 1. The steep sigmoidal dose-response curve for opioid analgesics. The MEAC is the lowest serum opioid concentration at which the patient obtains effective analgesia. Increasing the serum opioid concentration above MEAC does not significantly improve analgesia, but does increase the incidence of unwanted side effects. The analgesic threshold is the serum concentration at which a small increase in serum concentration greatly increases the quality of analgesia.

Ferrante FM, Covino BG. Patient-controlled analgesia. Boston: Blackwell Scientific Publications, 1990

Analgesia with 1. intermittent bolus administration; 2. PCA.

• Minimum Effective Analgesic Concentration (MEAC) is achieved with titration of opioid until the MEAC is achieved

• The background or continuous infusion is a constant rate infusion that is administered regardless of whether the patient activates demand doses.

• Continuous basal infusion plus PCA is best reserved for opioid tolerant patients (e.g., chronic pain) and those who need it as judged by a management algorithm.

Jeffrey A. Grass Anesth Analg 2005;

Complex management of PCA

4.Ketamina

17,0

47,2

55,8

64,4 62,4 67,1

7,5

33,9

52,4 52,2 53,3

64,9

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

1 8 16 24 32 40h postoperatoria

mg

mor

fina

Gruppo PCA

Gruppoketamina

Consumo di morfina (mg) nei gruppi PCA e Ketamina

Campionemedia(±DS)

GruppoKetaminamedia(±DS)

GruppoPCAmedia(±DS)

Infusionecontinuamg/ml 1,6(± 0,62) 1,6(± 0,3) 1,6(± 0,7)

Dosebolomg 1,9(± 0,35) 2,0(± 0,1) 1,8(± 0,4)

Tempodibloccomin 14,7(± 3,96) 11,2(± 2,7) 15,5(± 3,8)

Limite4oremg 19,2(± 4,29) 20,6(± 3,7) 18,8(± 4,4)

Parametri di impostazione della PCA nel campione e nei due gruppi

P> 0.05

NRS(S) campione Ketamina (n=19) PCA(n=93) T-StudentPOra

post–operatoria

Media (IC,Inf-sup)

Media (IC,Inf-sup)

Media (IC,Inf-sup)

1^h 3,6 3,2– 4,0 3,7 2,4- 4,9 3,6 3,2– 4,0 0,842

8^h 2,4 2,1– 2,7 2,5 1,7– 3,3 2,4 2,1– 2,7 0,766

16^h 1,8 1,6– 2,0 1,6 1,3– 2,0 1,8 1,6– 2,1 0,498

24^h 1,6 1,4– 1,8 1,6 1,0– 2,2 1,6 1,4– 1,8 0,858

32^h 1,3 1,1– 1,5 1,2 0,9– 1,6 1,3 1,1– 1,5 0,695

40^h 1,3 1,1– 1,5 1,4 0,9– 2,0 1,3 1,1– 1,4 0,512

48^h 1,1 0,9– 1,3 1,3 0,8– 1,9 1,1 0,9– 1,3 0,362

NRS (D) campione Ketamina (n=19) PCA(n=93) T-Student

POra

post–operatoria

Media (IC,Inf-sup)

Media (IC,Inf-sup)

Media (IC,Inf-sup)

1^h 5,3 4,9– 5,7 5,3 4,0– 6,5 5,3 4,9– 5,7 0,923

8^h 3,9 3,6– 4,3 3,9 3,1– 4,8 3,9 3,6– 4,3 0,971

16^h 3,1 2,9– 3,3 2,8 2,3– 3,2 3,2 2,9– 3,4 0,205

24^h 2,9 2,7– 3,1 2,7 2,1– 3,3 2,9 2,7– 3,2 0,509

32^h 2,6 2,4– 2,9 2,4 2,0– 2,8 2,7 2,4– 2,9 0,432

40^h 2,6 2,4– 2,9 2,5 1,8– 3,2 2,7 2,4– 2,9 0,734

48^h 2,3 2,1– 2,4 2,3 1,8– 2,9 2,2 2,1– 2,4 0,740

Medie ed Intervalli di Confidenza dei valori della NRS.

NRSd

NRSs

0

1

2

3

4

5

6

7

8

9

10

VAS

VASs

1

VASd

1

VASs

8h

VASd

8h

VASs

16h

VASd

16h

VASs

24h

VASd

24h

VASs

32h

VASd

32h

VASs

40h

VASd

40h

VASs

48h

VASd

48h

PCA

KetaminaMediana e interquartile range della NRS,nelle prime 48 h post-op, in condizioni statiche e dinamiche.

Percentuale degli effetti collaterali.

Gruppo ‘K’ vs gruppo ‘PCA’.

5.Pazientitollerantiaglioppiaceiecondolorecronico• Opioid tolerance andchronic pain increase IV-PCAopioid requirements.• Although IV-PCAcanbeused successfully inthepostoperative setting inopioid-

tolerant patients,useofregional analgesiatechniques andadjuvant therapiesshould beconsidered inthese patients.

• Attention mustbegiven tosupplying patients who have been onchronic opioidsat least that same dosebefore beginning toconsider their additionalpostoperative analgesic requirements.

• Patients withchronic pain consistently reporthigher pain scores inthepostoperative setting than patients without chronic pain.

M.J. Hughes et al., JAMA Surg. 2014Magnani B. et al., Pain 1989;

policies and processes and health systems are encouragedto standardize and use valid and reliable measures.

Recommendation 30

! The panel recommends that facilities in which sur-gery is performed provide clinicians with access toconsultation with a pain specialist for patients withinadequately controlled postoperative pain or athigh risk of inadequately controlled postoperativepain (eg, opioid-tolerant, history of substance abuse)(strong recommendation, low-quality evidence).

Management of postoperative pain can be a chal-lenge, and require advanced assessment and manage-ment skills available from pain specialists. In somecases, postoperative pain might be inadequatelycontrolled despite the use of standard multimodal in-terventions. Consultation or referral to a painspecialist might be necessary to assist in the manage-ment of such patients, to assist with diagnosis, inter-ventional treatment, or management of comorbidconditions. Facilities in which surgery is performedshould ensure that access to such expertise is readilyavailable when needed.Consultative expertise might also be required in pa-

tients with opioid tolerance, particularly in those witha history of substance abuse or addiction.120,144,244

Adequate pain treatment should not be withheld frompatients with active or previous opioid addictionbecause of fears of worsening addiction orprecipitation of relapse. In addition to the ethicalrequirement to address postoperative pain, poorlytreated pain can be a trigger for relapse. Successfultreatment of such individuals might include measuresto prevent relapse and require the involvement of aspecialist trained in the assessment and managementof chemical dependency and addiction disorders. Theclinical problems of underlying chronic pain, persistentacute pain, and addiction are each complex entitieswith biological, psychosocial, and functionalcomponents.134 An interdisciplinary approach usingpharmacologic and nonpharmacologic interventionsmight be required to achieve successful postoperativeoutcomes and should be considered as part of the peri-operative management plan in these patients (Table 4).

Recommendation 31

! The panel recommends that facilities in which neu-raxial analgesia and continuous peripheral blocksare performed have policies and procedures to sup-port their safe delivery and trained individuals tomanage these procedures (strong recommendation,low-quality evidence).

Providers managing regional or neuraxial techniquesshould have the commensurate education, training,oversight, and experience to assure safe and effectivetherapy. Facilities that provide regional or neuraxialtechniques should have clearly defined policies and pro-cedures in place for appropriate patient monitoring andcompetency based training and education for staffinvolved in caring for these patients. This should includeclear and reliable means for hospital and nursing staff toreach the specialists managing these techniques.

Transitioning to Outpatient Care

Recommendation 32

! The panel recommends that clinicians provide edu-cation to all patients (adult and children) and pri-mary caregivers on the pain treatment planincluding tapering of analgesics after hospitaldischarge (strong recommendation, low-quality evi-dence).

Research onmethods and outcomes of discharge plan-ning and follow-up are scarce and insufficient to providestrong guidance on optimal methods.240 Nonetheless,anecdotal reports and clinical experience suggest theneed for appropriate discharge teaching and coordina-tion of transition to themedical home as part of the post-operative pain management plan. A coordinatedapproach to discharge instruction is important, includingadvice from prescribers, nurses, physiotherapists, andpharmacists. Clarity should be established about withwhom and when to follow-up for questions and transi-tion of care back to the primary provider.Patients should be counseled on how to take pain

medications safely and to manage side effects to opti-mize pain control and recoverywith return to usual activ-ities. This might be particularly important for the

Table 4. Management of Postoperative Pain in Patients Receiving Long-Term Opioid Therapy

! Conduct preoperative evaluation to determine preoperative opioid use and doses! Provide education regarding use of opioids before surgery! Recognize that postoperative opioid requirements will typically be greater and that pain might be more difficult to control! Consider pain specialty consultation (and in some cases behavioral and/or addiction consultation) for pain that is difficult tomanage and complexcases

! Consider nonpharmacological interventions! Transcutaneous electrical nerve stimulation! Cognitive–behavioral therapies

! Consider nonopioid systemic medications! Gabapentin or pregabalin! Ketamine

! Consider local anesthetic-based peripheral regional and neuraxial local analgesic techniques! Consider PCA with basal infusion of opioids for difficult to manage pain with appropriate monitoring! Provide education and instructions on tapering opioids to target dose after discharge

144 The Journal of Pain Management of Postoperative Pain

conclusioni• Ilcontrollodeldolorepost-opnellachirurgiamaggioreequellavascolareè

funzionesiadilineeguidamaanchedelcontesto(limitipersonali,strumentali)edaun’efficienteedattivomonitoraggioperi-operatorio(APS);

• Lasceltadelprotocolloantalgicoèfunzionesiadifattoriinter- cheintra-individualilegatialpaziente,alcontestoedaglioperatoricoinvolti.

• Doveèpossibilemegliofavorireapprocciantalgicimultimodali,PCAeprocedureantalgicheloco-regionaliadattialpazienteedallesuecondizionicliniche.

• Lasomministrazionedianalgesiamultimodalepuòessereassociataacomplicanze,percuiilmonitoraggioregolareecorrezioniinitineredellatecnicaanalgesicasonounaparteessenzialedellagestionedeldolorepostoperatorio.

• Attenzionevarivoltaaidettagli,asottopopolazioniconparticolaricomrbidità,terapieassociateetoleranti aglioppiacei.

GRAZIEPERL’ATTENZIONE!!!PRO VITA CONTRA DOLOREM SEMPER!

GRAZIE !!!

Boaz Samolsky-Dekel

IL DOLORE POST-OPERATORIO

CORSOSIAARTI

RazionaleIl dolore post-operatorio è una tipologia di dolore che insorge come conseguenza diretta di un intervento chirurgico, caratterizzato da un’intensità variabile che dipende dalla soglia individuale di percezione del dolore. Questo corso SIAARTI nasce dall’esigenza di migliorare la qualità della cura e della degenza del paziente attraverso una migliore conoscenza ed approfondimento delle diverse tipologie di dolore associate all’atto chirurgico. Il principio fondamentale di questo approccio mira a prevenire, monitorare e curare questo tipo di dolore attraverso le conoscenze della valutazione e rilevazione corretta dell’intensità del dolore, l’aggiornamento continuo e costante dei protocolli d’avanguardia come l’analgesia epidurale e plessica continua, l’infusione dei farmaci con l’analgesia controllata dal paziente con il fine di diminuire la sofferenza ed assicurare un trattamento del dolore che consenta di ridurre i tempi di ricovero.

PRIMO GIORNOOre 14.00-14.15 Registrazione dei partecipantiOre 14.15-14.30 Introduzione, obiettivi e finalità del corso Antonio Corcione, Caterina Aurilio

Ore 14.30-15.00 Anatomia e fisiologia delle vie afferenti e del sistema inibitore F. Ambrosio

Ore 15.00-15.30 Anamnesi del dolore e metodi di stima del dolore M.B. Passavanti

Ore 15.30-16.00 Il dolore riferito: Dolore Viscerale M.C. Pace


Ore 16.30-17.00 Gli Oppioidi D. Fornasari

Ore 17.00-17.30 Meccanismi molecolari di iperalgesia e tolleranza V.A. Peduto

Ore 17.30-18.00 I FANS M. Evangelista

Ore 18.00-18.30 L’importanza della differenziazione e specificità del dolore post-operatorio nelle varie specialità, l’analgesia multimodale F. Petrini

SECONDO GIORNO

Ore 08.30-09.00 La prevenzione del dolore cronico post operatorio in chirurgia to racica G. De Cosmo

Ore 09.00-09.30 Il dolore post operatorio in chirurgia toracica F. Piccioni

Ore 09.30-10.00 Il dolore postoperatorio in chirurgia maggiore e vascolare B. Samolsky

Ore 10.00-10.30 Il TAP BLOCK A. Fanelli


Ore 11.00-11.30 Il razionale del dolore post-operatorio nel taglio cesareo: dal do lore acuto al dolore cronico P. Sansone

Ore 11.30-12.00 Dolore post operatorio in pediatria F. Borrometi

Ore 12.30-13.00 L’analgesia post operatoria: vecchie molecole nuove opportuni tà terapeutiche C. Aurilio

Ore 13.00-13.30 Gruppi di lavoro con discussione interattiva R. Vellucci

Ore 13.30-14.00 Conclusioni e questionario ECM

PROGRAMMA SCIENTIFICO

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