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Peri operative pain

What is Pain ?
According to the International Association for the Study of Pain (IASP),pain is defined as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." (IASP 1979)

Undertreated Pain The Silent Epidemic .


Barriers for proper pain management  • Limited training in medical schools  • Lack of up to date knowledge  • Pain management not seen as a priority in the     disease-centered model of care • Lack of consultation and treatment resources • Time consuming • Biases and fears about use of opioid analgesics •Too many patients. not enough time .

addiction to therapeutic opioids  • Poor pain management is accepted as normal . tolerance vs.Patient and family barriers  • Communication problems in a stressed health care system  • Fear of taking opioids – biased media reports  • Confusion regarding: dependence.

The More It Should Hurt….. And the Greater Amount of Pain Medicine You Should Receive .“Pain Well” Thinking The Bigger the Surgery You Experience….

What’s A “Really Big” Surgery? .

A “Really Big Surgery” is any one that happens to ME! .

How does pain arise? .

Pain involves four physiological processes     Transduction Transmission Modulation Perception .

Why should treat post-operative pain? 1) Respiratory effects 2) Cardiovascular effects 3) Neuroendocrine 4) Effects on mobilization .

Pain associated with different surgerical procedures.decreasing order of severity: 1 thoracic 2 upper abdominal 3 lower abdominal 4 inguinal 5 head/ neck/ limb .

g. none. moderate. mild.e.Monitoring of pain :  Verbal rating scale. severe  Numerical rating scale (NRS)  Visual analogue scale(VAS)  Faces scale .

Methods available to treat post-operative pain:   A) pre operative counselling 1) Non-pharmacological –  B) transcutanous electrical nerve stimulation(TENS)  C) acupuncture .

for administration of analgesia: Minor pain – PCM. tramadol Severe pain – Opioids( morphine. diamorphene. NSAIDs Moderate pain – codene. oxycodone. propoxyphene. etc. buprenorphin.) .2) Pharmacological Simple pain ladder (WHO).

. NSAIDs :- Inhibit COX enzymes Do not relieve severe pain when used alone but they are valuable in multimodal analgesia because they decrease opioid requirement and improve the quality of opioid analgesia.

The Role of Cyclo-oxygenase (COX) Arachidonic acid Cyclo-oxygenase activity of COX PGG2 Peroxidase activity of COX PGH2 PGD2 PGF2 PGE2 PGI2 TXA2 .

pain.Two Forms of Cyclooxygenase (COX) COX-1  Constitutive  Mediate homeostatic functions  Especially important in:  –Gastric mucosa  –Kidney  –Platelets  –Vascular endothelium COX-2  Inducible (in most tissues)  Mediate inflammation. and fever  Induced mainly at sites of inflammation by cytokines .

impaired haemostasis  4.Adverse effects of NSAIDS : 1. Gastric ulcerations  2. nephrotoxicity  3. aspirin induced asthma .

remifentanyl. propoxyphene.  Intermediate opioids. OP3  Minor opioids. sulfentanyl.buprenorphin  Major opioids. fentanyl.codene.morphine. OP2. diamorphine.Opioids  Act at spinal and supraspinal levels  OP1. tramadol. .

IM  3. oral  2. rectal  7. transdermal  5.regional . nebulizer  9. subcutenous  8.Routes of administration : 1. sublingual  6. IV  4.

naloxone . nausea. vomiting.3-6 hrs  Dosage.Morphine :  IM.05 – 0. respiratory depression Requires monitoringSpO2 Sedation score Antagonist .0. itching.traditional method of administration.1 mg/kg  Side effects.  Duration of action.sedation.

procain.cocaine.Local anaesthetics :  1. tetracaine . Amide class – lidocaine. chlorprocaine. Ester class. bupivacaine.ropivacaine. prilocaine.levobupivacaine .  2.

touch.Mode of action : Membrane stabilization  Na+ channel blockade – inhibits transmission of impulses. Differential blockade :autonomic(sympathetic) > sensory(pain. temp)> motor Systemic absorption :Intercostal> epidural>brachial>sciatic .

 Contraindicationsend arteries unstable angina uncontrolled HTN cardiac . Prolongation of action with epinephrine.

numbness of tongue. muscular twitching. arrhythemias.lightheadedness. sedation. acute cardiovascular collapse .  Cardiotoxicity –hypotension. seizures.Side effects : CNS toxicity.

 Microprocessor control pump  Loading dose Relative contraindications :drug abusers major metabolic disorders end-stage renal or hepatic disease COPD sleep apnoea .allows the patient to self administer small doses of opioid when pain occurs.Patient controlled analgesia(PCA) :  Superior.

1% and opioid e. bupivacaine 0.  Low dose LA e.0002%.g.Epidural analgesia :  Injection of LA into epidural space. fentanyl 0.g. Advantages : effective analgesia reduced opioid requirement reduction in stress response after surgery early return of GI function after abdominal surgery reduction in mortality and serious morbidity .block nerve root transmission .

neurological disease.Absolute contraindications Patient refusal  allergy to LA drugs  Local infections Relative contraindicationshypovolaemia. coagulopathy .

post duralpuncture headache  Infection  Spinal haematoma .sympathetic blockade. Late onset of respiratory blockade of morphine  Dural spinal block.motor blockade.Complications :  Cardiovascular.T1 to T4  Respiratory.

Relative efficacy of analgesics. NNT <2-3 .numbers needed to treat (NNT)  It is the number of patients who need to receive the active drug for one to achieve at least 50% relief of pain compared with placebo over a period of 6hrs.  Effective analgesics.

Pre-emptive analgesia:  Surgery. by providing per surgery/ pre emptive analgesia these sensitizing neuroplastic changes can be prevented – diminished post operative pain sensation .  So.pain signals-priming of CNS-enhanced postoperative pain.

many die in pain and even more live in pain .Although few people die of pain.