POST OPERATION PAIN MANAGEMENT.pptx

8/18/2019 POST OPERATION PAIN MANAGEMENT.pptx

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Dr. Andrian AliSuperviser

Dr. Purwito Sp.An

POST OPERATIONPAIN MANAGEMENT



DEFINITION• The International Association for the Study of Pain

(IASP)

Pain is defined as a sensory and emotional experience

which participate in occuring tissue damage or potentially

destroy the tissue.



PHYSIOLOGY MECHANISM OF

PAIN

1. Nociceptie !sensory" is an inflammation pain which

related to chemical stimulation# mechanic# and thermal

at nociceptie receptor !nere that respons to painstimulation"

$. Neuropatic is pain that is related to periferal nere

damage or in the central nerous system"



PAINMECHANISMS

PATWAY



POST OPERATION PAIN

There are 2 types of pain : acute and chronic

• Acute pain

Immediatey occur after sur!ery "more than #

days$• Chronic pain

Pain that sette more than % months aftersur!ery$



POST OPERATION PAIN’S

THERAPY

General principle to blokade nociceptor are :1. The giving of peripheral anti inflammator agent

!. "lokade peripheral nociceptor#topical

$. "lokade peripheral nerve

%. "lokade spinal nerve

&. Spinal antinociceptive 'narcotic and non narcotic(

). *entral antinociceptive 'brain stem or upper(

+. *ombination of all above





A,A-GT/* A-T0,AT/ 230 P3ST 3P0AT/3, PA/,

Non&opioidana!etic

ParacetamoNSAI's( incudin! C)*&2 inhi+itors

,a+apentin( pre!a+ain

Wea- opioid Codeine

TramadoParacetamo com+ined .ith codeine or Tramado

Stron! opioid Morphine

/entany

Pethidine

Ad0u1ant etamine

Conidine



Morphine and Wea- )pioid

Morphinei3 PCA +ous 4&2 m!

SC 5(4&5(4 m!6-!

IM 7&45 m!( e1ery %&8 0am "not recommendated +ecause of the painfu$

Codein)ra %m!6-!6day com+ine .ith paracetamo

Tramado I3(IM()ra 75&455 m!6 9 hours

Non opioidParacetamo

I3 "%5 min after the end of sur!ery$

)ra ; 8<4 !r6day "hepar insu=ciency %<4 !r6day$

com+ination

paracetamo 755m! > Codein %5m!

8<4 !r6day paracetamo



NSAI'

I3 "%5&95 min +efore the end of sur!ery$

etoroac % < %5&85 m!6day

'i-ofenac 2 < #7 m!6day

etoprofen 8 < 75 m!6day

Meo<icam 47 m! 4<6day

Pareco<i+ 85 m!( foo. .ith 4&2 < 85m!6day



ALTERNATIVE THERAPY FOR POST OPERATIONPAIN APPROPIATE WITH THE TYPE OFOPERATION

?o. Intencity ofPainE<ampe :

In!uina Hernia3arices?aparascopy

4; Paracetamo and .ound in=tration .ith oca anesthesia;2; NSAI' "e<cept contraindication$( and%; @e!iona anesthesia .ith .ea- opioid ad0u1ant or sta!in! rescue

ana!esia or intra1enous stron! opioid if needed

?o. Intencity of

PainE<ampe :

Hip @epacementHisterectomy a. Sur!ery

4; Paracetamo and .ound in=tration .ith ocaanesthesia;

2; NSAI' "e<cept contraindication$( and

%; Periphera ner1e +oc- "sin!e shot orcontinuous infusion$ or opioid in0ection "i1 PCA$;

Hi!h Intencity of PainE<ampe :

ThoracotomyBpper A+domina Sur!ery

Aortanee @epacement Sur!ery

4; Paracetamo and .oundin=tration .ith oca anesthesia;

2; NSAI' "e<cept contraindication$(and

%; ?oca epidura ana!esia orpe<us +oc- or ma0or peripheraner1e or opioid in0ection "i1 PCA$



BALANCED ANALGESIA

Balanced Analgesia (ulti!odal Analgesia"

Two or more analgesia drug that wor% at different mechanism to

get the superior analgesia effect without significant side effect.

&ome examples from 'alanced analgesia are (

• The com'ination of epidural opioid with epidural anestetic )

• The com'ination of intraenous opioid with N&*IDs that hae

+sparing effect, with systemic effect of opioid.



PAT/,T *3,T03- A,A-GS/A 'P*A (

*ccording to premis that hae negatie trac%) when pain

is concerned# analgetic therapy is gien their own# and

when the pain decrease# there is no necessity more.



• P-* euipment can programmed to some aria'le) include dose necessity

!'olus"# interal# and infuse.

• Optimal necessity for integrated dose in efication of intraenous P-*

• *lthough optimal dose necessity doen/t assured

data that show optimal dose necessity is 1 mg for morphine and 0 2g for

fentanyl in lay person) 'ut# actual dose for fentanyl !13$ 2g" sometimes lac% in

clinical practice.





REGIONAL ANALGESIA

*ontinous *entral ,euroa4is "lockade '**,"(

*ontinous Peripheral ,erve "lockade '*P,"(

Continous Central Neyroaxis lo!"a#e $CCN %

*nalgesi which more efectie for pot operation pain although inasie# 'ut also still 'e the first

choise for a'dominal operation# thorax and orthopedy# if there is not improement of the pain with

another analgesia.

-an 'e with epidural lane !first choice" or spinal.

Epidural ussually with long acting local anesthesia !less ta%ifila%sis" and deep opioid in dulition

concentration.

Epidural local anestetic dose and opioid (

4opiacaine #$5 ! $mg6m1 " or leo'upiacine6'upiacaine #13 #$5&ulfentanil #131 ug6ml or

fentanyl $30 ug6day



Patient Control E"idural Analgesia

(PCEA)

The use of infuse continue or as ad7uant for

dose which need in general with P-E*

compare to intraenous P-* and can gie

superior analgesia for the usefull dose.





Drugs that used at epidural catheter :

8etamine

There is no sensory# motory# and anatomic 'lo%age# pruritus and urinary retention moreoer can/t cause

depresion. 0 mg dose dissoled with 1 ml dextrose 1. more short acting compare to morphine.

Opioid

*lternatie drug for terminally ill cancer patient. 9etter gie per orally opioid one wee% 'efore. :ore

efectie if com'ined with 'upiacaine.

:orphine

;ery hydrophilic so it will stay in <-& in long period of time# duration =31$ hours.

onset >3? minutes. Dose ( #1 mg6%g in Na-I #?5. :ore adantageous for chronis pain and release

isceral pain after a'sominal and thoracal surgery .

Fentanyl.

Dose ( $@ ug6hour mixed with Na-< #?5 or 4< eery ml ( @ug# com'ined with 'upiacaine #@5

9upiacaine

Dose #13#1$@5 se'esar 0 ml6hour can 'lo%ade segmental for A one dermatome.



Continous Peri&'eral Ner(e lo!"a#e

$CPN%

• -PN9# nowadays used more often 'ecause more selectie

and still gie good postoperatie analgesia so can decrease

the utiliBing of opioid.• Peripheral nere 'loc% humiliate the side effect which occur at

neuroaxial central 'loc%#as hypotention# wide motoric 'loc%

and complication as epidural hematom# epidural a'scess# and

panparesis.



CATETE@ ?)CATI)N ?)CA? ANESTESIA ')SES

@o+i1acaine 5(2

Dupi1acaine 5(4 & 5(427

?e1o+i1acaine 5(4 & 5(2

Interscaeni

Infraca1i-uer

A<iary

/emoraPopitea

7 & m6hour

7 & m6hour

7 F 45 m hour

# F 45 m hour% F # m hour



THAN) YO*

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