Pain relief after major oncologic surgery
Ksenija Mahkovic HergouthOnkološki inštitut
Surgical procedures for
GIT carcinomas
Retroperitoneal sark.
Liver metastases
Sarkomas of thoracic/ abdominal wall with reconstruction
Peritonectomies, cyto- reductive surgery
Urologic,gynec.carcin.
Postoperative pain is Postoperative pain is due todue to
Surgical woundSurgical wound (laparatomy – (laparatomy – somatic pain; organ resections – somatic pain; organ resections – visceral, sympatic pain)visceral, sympatic pain)
Analgesia during operationAnalgesia during operation (opioid, (opioid, LA consumptionLA consumption
Genetic determination of Genetic determination of analgesic requirements analgesic requirements (gene (gene polymorphism for opioid receptors)polymorphism for opioid receptors)
Havashida M, Pharmacogenomics 2008Havashida M, Pharmacogenomics 2008
Good pain relief after surgery is important part of quick and
successfull recovery
It diminishes perioperative stress response to surgery
Pain relief after major Pain relief after major oncologic surgeryoncologic surgery
1.1. Continuous/PCEA epidural analgesia – Continuous/PCEA epidural analgesia – based on long acting local anestheticsbased on long acting local anesthetics
2.2. Continuous/PCA intravenous analgesia Continuous/PCA intravenous analgesia – based on opioids– based on opioids
3.3. Continuous drip of local anesthetics by Continuous drip of local anesthetics by the catheter in the surgical wound ?the catheter in the surgical wound ?
All ways effective when proper used and with PCA All ways effective when proper used and with PCA technicktechnick
Mann C et all, Anesthesiology 2000Mann C et all, Anesthesiology 2000
Epidural analgesia – golden standard, insertion of epidural catether (EK) in
the thoracic region (most of the abdominal wall and organs are
inervated from Th6–Th12)
Physiologic effects of epidural analgesia
Blocade of aferent pain impulses Blocade of aferent pain impulses
Blokade of aferent sypmatic impulses from Blokade of aferent sypmatic impulses from intestine intestine
of pain and of pain and sympatic nerves activity in GIT sympatic nerves activity in GIT
↓ ↓ stress and inflammatory response to surgerystress and inflammatory response to surgery
of postoperative ileus, shortens time to passing of postoperative ileus, shortens time to passing stoolsstools
Improves mobilisation after surgeryImproves mobilisation after surgery
Clemante A,Carli F. Minerva Anesthesiol 2008Clemante A,Carli F. Minerva Anesthesiol 2008
1. group.:general anesthesia + piritramid i.v. postoperatively
2. group.: general + toracic epidural anesth. + piritramid i.v. postoperatively
3. group.: general + toracic epidural anesth. + epidur. analgesia postoperatively
Hormonal and inflammat.response and recovery after radical cystectomy
Results
↑Cortisol and epinephrin: no difference among groups
group 3 ↓less inflammatory response (↓CRP, ↑albumini)
group 3 ↓less fatigue
group 3 ↓less postoperative pain
group 3 ↑better enteral feeding and passing stools sooner Brodner G et al. Multimodal perioperative management- combining thoracic epidural analgesia, forced mobilisation and oralnutrition-reduces hormonal and metabolic stress after major urologic surgery.AnesthAnalg 2001;92:1594-1600.
Stress response I
Stress response IIStress response II
study of 45 patients on hormonal and study of 45 patients on hormonal and inflammatory stress responce to major inflammatory stress responce to major abdominal surgery abdominal surgery
1st group: epidural analgesia during surgery
2nd group: i.v. opioid analgesia during surgeryResult
s Epidural group: lower plasma epinephrine and cortisol higher lymphocyte number and T-helper cells no difference in IL 12 and clinical course
Ahlers O et al. Intraoperative thoracic epidural anesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-7.
Advantages of epidural analgesia to systemic analgesia
• Better analgesia (still and moving) than with systemic Better analgesia (still and moving) than with systemic opioids (1,2,3)opioids (1,2,3)
• Less adverse events than with opioids –Less adverse events than with opioids –↓↓ nausea,vomiting, sedation (2,3,4)nausea,vomiting, sedation (2,3,4)
• Less paralytic ileus, less respiratory complications (5)Less paralytic ileus, less respiratory complications (5)• But no difference in mortality compared to systemic But no difference in mortality compared to systemic
opioid analgesia (3)opioid analgesia (3)• Low incidence of motor block with thoracic epidurals Low incidence of motor block with thoracic epidurals
compared to lumbal epidurals(2)compared to lumbal epidurals(2)• Importance of the LA dose compared to volume or Importance of the LA dose compared to volume or
concentration (6)concentration (6)
1.Nishimori M et al. Cochrane Data Base Rev 20062.Flisberg P et al..Acta Anaesthesiol Scand 2003;47:457-653.Rudin A et al. J Cardiothorac Vasc Anesth 2005;19:350-74.Saeki H et al. Surgery Today 2009.5..Popping DM et al .Arch Surg 20086..Dernedde M et al. Anaesth Intensive Care 2008
ASAASA EK working EK working VASVAS mgmg of of piritramid in piritramid in 48 h 48 h ((rescue.analrescue.analg.g.))
34 34 patientspatients
2 2 0,7 0,7 In In 31 31 patientspatients
2 2 1,6 1,6 3 3 4 4
Random group of our patients after abdominal surgery in year 2006 with
epidural analgesia
Dg.: 6 colon carcinoma,7 carcinoma of sygmoid colon, 9 rectum carcinoma, 5 stomac carcinoma, 7 retroperitoneal sarcoma
Postoperative pain relief by epidural analgesia (we practice)
48h after surgery:48h after surgery: continuous epidural infusion of local anesthetic continuous epidural infusion of local anesthetic (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, LO 30 – 60 min. Sometimes combined with low dose opioid LO 30 – 60 min. Sometimes combined with low dose opioid epiduraly or in i.v. infusion (< 30%)epiduraly or in i.v. infusion (< 30%)
Metamizol 2,5g/12 h i.v.Metamizol 2,5g/12 h i.v. Piritramid 3 – 5mg i.v. when VAS>4Piritramid 3 – 5mg i.v. when VAS>4
3.-5. day:3.-5. day: 10 ml boluses of 0,25% levobupivacain /6–8h into EK 10 ml boluses of 0,25% levobupivacain /6–8h into EK ±±opioids p.os (oksicodon) opioids p.os (oksicodon)
after 5th day removal of epidural catheter.after 5th day removal of epidural catheter.
from 5th day on:from 5th day on: analgesic drugs p.o. (oksicodon, tramadol, NSAID, analgesic drugs p.o. (oksicodon, tramadol, NSAID, paracetamol)paracetamol)
Complications with epidural catheters
Punction of dura (incidence 0,3 – 1,2%) Transitory neropathy (0,01 – 0,02%) Punction of epidural vein (3 – 12%), epidural
hemmatoma very rare (1:150 000) Infection: local on insertion site 4%,
epidural absscess: 0,05 – 0,1% (perioperative epidural catheters)
Migration of the catheter into spinal space (0,18%)
Postoperative pain relief by systemic opioid analgesia
(we practice)
Systemic opioid analgesia – when epidural analgesia is containdicated, Systemic opioid analgesia – when epidural analgesia is containdicated, technically not possible or refused by the patient. technically not possible or refused by the patient. PPump needed.ump needed.
Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses
Sufentanil 50–100 Sufentanil 50–100 μμg/24h in continuous i.v. infusion + PCA bolusesg/24h in continuous i.v. infusion + PCA boluses
Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses s.c./i.v.s.c./i.v.
I.v.analgesia up to 3 days+metamizol/neodolpasseI.v.analgesia up to 3 days+metamizol/neodolpasseAfter 2-3-days analgetic drugs in tablets by mouth (oxicodon,After 2-3-days analgetic drugs in tablets by mouth (oxicodon,tramadol, paracetamol, NSAID)tramadol, paracetamol, NSAID)
Monitoring pain (VAS) and side effects
Monitoring of the patient
Day of surg.: pulse oximetry, blood pressure, VAS. Day of surg.: pulse oximetry, blood pressure, VAS. Broader monitoring according to patient’s state.Broader monitoring according to patient’s state.
Next days: blood pressure /1-2 h, pulse oximetry, Next days: blood pressure /1-2 h, pulse oximetry,
VAS. 50 – 100 VAS. 50 – 100 μμg/24 h. Broader monitoring g/24 h. Broader monitoring according to patient’s state.according to patient’s state.
Patient can be moved to the ward when Patient can be moved to the ward when cont.epidural infusion is stopped and regular cont.epidural infusion is stopped and regular epidural boluses given. Time of epidural catheter epidural boluses given. Time of epidural catheter removal should be planned. removal should be planned.
Bolnica 3.dan po op ca recti Bolnica 3.dan po op ca recti (LAR,TME)(LAR,TME)
54 let, ASA 154 let, ASA 1
94 bolnik Dg: Ca cekuma,eksulceriran. Op: desna hemikolektomija
3. dan po operaciji
Hvala za Hvala za pozornost!pozornost!
Vloga sester in tehnikov
poznati morajo delovanje EK kot tudi poznati morajo delovanje EK kot tudi kontinuirano i.v. analgezijo kontinuirano i.v. analgezijo
Redno morajo spremljati pooperativno Redno morajo spremljati pooperativno bolečino z merjenjem bolečine po VAS bolečino z merjenjem bolečine po VAS
Redno meriti bolnikove vitalne znake. Redno meriti bolnikove vitalne znake. Pomembna je tudi tudi odzivnost na Pomembna je tudi tudi odzivnost na
bolnikovo bolečino ali neželjene učinke in bolnikovo bolečino ali neželjene učinke in ukrepanje v okviru možnosti in navodil.ukrepanje v okviru možnosti in navodil.
Multimodalno perioperativno okrevanje
Predoperativno informiranje in priprava bolnika Predoperativno informiranje in priprava bolnika na opna op
↓ ↓ kirurškega stresa (krg. tehnika, anestezija)kirurškega stresa (krg. tehnika, anestezija) Optimalna pooperativna epidural. Optimalna pooperativna epidural.
analgezija z LA analgezija z LA ((torakalni EKtorakalni EK)) Hitra mobilizacija Hitra mobilizacija Zgodnje enteralno hranjenjeZgodnje enteralno hranjenje
Pooperativni problemi po operacijah v trebuhu
Bolečina Bolečina Pooperativni ileusPooperativni ileus Okužbe kirurške rane & druge Okužbe kirurške rane & druge
okužbeokužbe intraabdomin.pritiskintraabdomin.pritisk Motnje v delovanju organovMotnje v delovanju organov