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J Bone Joint Surg 2007;89:1343-58 By Scott S. Reuben, MD et al.

Preventing the Development of Chronic Pain After Orthopaedic Surgery with Preventive Multimodal Analgesic Techniques. J Bone Joint Surg 2007;89:1343-58 By Scott S. Reuben, MD et al. R2 신승호. Current Concept. Persistent postoperative pain 3-6 개월 이상 지속 Risk factor Preoperative pain

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J Bone Joint Surg 2007;89:1343-58 By Scott S. Reuben, MD et al.

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  1. Preventing the Development of Chronic Pain After Orthopaedic Surgery with Preventive Multimodal Analgesic Techniques J Bone Joint Surg 2007;89:1343-58 By Scott S. Reuben, MD et al. R2 신승호

  2. Current Concept • Persistent postoperative pain • 3-6 개월 이상 지속 • Risk factor • Preoperative pain • Intensity of acute postoperative pain • Physiologic factor, operative approach • Genetic factor • Chronic postoperative pain syndrome • Mechanism, treatment 에 대한 response 등 알려진 바가 거의 없음 • Central plasticity • Different neurotransmitter, chemical substrate, different anatomical location

  3. Mechanism of postoperative pain • Peripheral sensitization • Primary hyperalgesia • Secondary hyperalgesia • Central sensitization • pph neuron 의 지속적인 afferent input • Activity 에 의존적인, spinal neuron 의 excitability 증가  “Spinal wind up”

  4. Preemptive & Preventive analgesia • Preemptive analgesia • 단순한 Sx 호전이 목적이 아님 • “Wind up”방지 • Preventive analgesia • Entire perioperative period • Noxious input 의 차단 • Central sensitization 감소 • Central neuroplasticity 에 중점을 둔 개념

  5. Multimodal analgesia (1) • Opioid • Major role in the management of pain • Adverse event • N/V, resp. depression, sedation, pruritis, urinary retension • Hospital morbidity & health cost

  6. Multimodal analgesia (2) • Concept • Analgesic effect 개선 • Opioid related adverse event 의 감소 • 여러 약물에 의한 additive & synergistic effect • 입원 기간 단축, recovery & function 개선, cost benefit • 현재 OS 수술에 쓰이는 multimodal analgesic regimens • Local anesthetics, α2 agonist, NSAIDs, acetaminophen, ketamine, α2-δ ligand, Opioid

  7. Clonidine & other α2 agonist • 작용부위 • pph, spinal, brainstem site  α2 adrenoceptors on primary afferent terminals • Peripheral nerve block 을 enhance • α2-δ, C fiber 의 selective block • Local vasoconstriction • Release enkephalin-like substance • Pre-junctional α2 adrenoceptor • Norepinephrine secretion 억제 • Central neuraxial block with Clonidine & local anesthetics • Intrathecal clonidine & morphine (TKR OP) • Epidural infusion of a local anesthetics & clonidine & fentanyl (TKR) • Clonidine (1 μg/kg), 0.5 % lidocaine for intravenous regional anesthesia for hand surgery • pph mediated, not d/t central redistribution • Intra-articular route • Morphine & bupivacaine

  8. Nonsteroidal Anti-Inflammatory Drugs and Acetaminophen (1) • Tissue trauma • Arachidonic metabolism 에 의해 pain & hyperalgesia 유발

  9. Nonsteroidal Anti-Inflammatory Drugs and Acetaminophen (2) • NSAIDs • pph, spinal cord 에서 PG 합성을 억제 • Surgical trauma 에 의한 hyperalgesia 억제 • Sole analgesic after minor op • Opioid-sparing effect after major op • Recent practice guide (post op. setting) • “특별한 금기 사항이 아니라면, 모든 환자에게 규칙적인 시간에 NSAIDs, COXIB, acetaminophen 을 투여함” • Acetaminophen • Aspirin 과 유사한, analgesic, antipyretic property • CNS 에서, PG 합성을 억제 • Serotonergic mechanism • Antinociceptive activity

  10. Nonsteroidal Anti-Inflammatory Drugs and Acetaminophen (3) • Acetaminophen • Major Os surgery 에서 analgesic efficacy 가 NSAIDs 와 유사 • NSAIDs 에 비해, 적은 adverse effect • Viable alternative to NSAIDs in high risk pt. • NSAIDs 혹은 COX-2 inhibitor 와 병용 시, additive, synergistic effects

  11. Nonsteroidal Anti-Inflammatory Drugs and Acetaminophen (4) • COX-2 inhibitors • Traditional NSAIDs 와 유사한 equipotent analgesic efficacy after minor & major op procedure • Low G-I side effects, absence of anti-platelet effect • 일반적인 NSAIDs 에 비해, OS 수술 에서, perioperative bleeding risk 감소 • Cardiovascular morbidity • Valdecoxib, parecoxib 의 supramaximal dose 에서 MI 발생 증가가 보고 • Therapeutic dose 에서는 cardiovascular event 증가가 없음 • Conventional NSAIDs • Diclofenac, indomethacine, naproxen  cardiovascular event 증가 • Celecoxib 의 cardiovascular risk 는 일반적인 NSAIDs 와 유사 • 결론적으로, 모든 NSAIDs 및 COX-2 inhibitor lowest effective dose 사용이 권장 • IHD, stroke, CHF, PTCA Hx 등의 환자에게는 금기

  12. Ketamine • Noncompetitive NMDA receptor antagonist • 2 mg/kg 이상의 high dose • Psychomimetic effects (sedation, cognitive dysfunction, hallucination, nightmare) • Subanesthetic dose < 1 mg/kg • Analgesic efficacy without side effects • Respiratory, cardiovascular, G-I function 에 미치는 영향 없음 • 투여 경로 • Iv, IM, subcutaneous  sole analgesic effect • Low dose epidural  단독 사용시, little effect • Adjunct to opioid or local anesthetics • Opioid sparing effect, 를 가지지만, opioid 에 연관된 side effect 에는 영향이 없음 • Wound infiltration with local anesthetics • Intraoperative single injection (0.15 mg/kg) • Improved analgesia & passive knee movement (ACL op) • Improved functional outcome after outpatient knee arthroplasty • Conjunction with epidural anesthesia, continuous femoral nerve block

  13. Local Anesthetics and Regional Analgesia • Genera anesthesia and local regional block • Improved analgesia and enhanced prognosis

  14. Wound Infiltration • Infiltrating local anesthetics into the skin and subcutaneous tissue • Skin incision 이전에 시행  가장 간단한 형태의 preemptive analgesia • Safe procedure with few side effect & toxicity • Pre-incisional vs. Post-incisional wound infiltration • No difference in analgesic efficacy (Moiniche et, al) • Analgesic consumption 과 환자가 진통제를 요구 하는 최초의 시간에서 preemptive local infiltration 이 우수, 하지만 pain intensity 는 차이가 없음 (Ong et al.) • Continuous infusions of bupivacaine • Intra-articular, into wound, local nerve block 등의 다양한 방법들이 사용 (ACL 수술 시, intra-articular, infrapatellar fat, shoulder operation, hand surgery) • Pain 감소, opioid use 감소 • TKR • Pain management 에 큰 효과 없음 • d/t drug loss from the knee drainage • Possibility of infection and chondrotoxicity • 동물실험 결과, hand 등의 small joint 에서 조직학적 변화 및 infection 증가 • Efficacy 와 safety 에 대한 human study 필요

  15. Peripheral Nerve Blocks • Attractive method of providing postoperative analgesia for many OS procedure • G/A 와 비교하여 • Same-day recovery 우수, hospital readmission 감소 • Single injection regional anesthesia • Effective for early analgesia • Long-term benefit ? • Continuous peripheral nerve block • Opioid 단독 사용에 비해 • Superior analgesia and reduce opioid use • Reduce opioid related side effect • Long-term functional outcome ?

  16. Epidural Blocks • OS 수술 후, 발생하는 neuroendocrine stress response • Hypercatabolism, hypercoagulability, inflammation • Somatic & autonomic response • Parenteral opioid vs. epidural technique • Epidural analgesia • Superior to pph nerve block or PCA • Hip Fx, THR • Neuraxial block • Deep vein thrombosis, pulmonary embolism, intraoperative blood loss, blood transfusion requirement 측면에서 G/A 에 비해 우수 • 1 yr mortality rate ? • Early administration (pre op) continuous epidural analgesia • High risk Pt • Preoperative stressful period  cardiac event 발생 감소 • Continuous epidural anesthesia, continuous femoral nerve block, IV PCA • TKR • Multimodal analgesics (lidocaine, clonidine, morphine) 을 이용한 epidural anesthesia 나 femoral nerve block 이 진통효과가 더 우수 • Neuraxial hematoma

  17. Opioid (1) • Preoperative opioid use • Effective analgesic technique for management of postoperative pain • Postoperative opioid 사용량 감소 • Multimodal analgesic regimen • Opioid-induced hyperalgesia • Long-term administration • Enhanced pain sensitivity • Short-term use of opioid (abdominal op, OS) • Hyperalgesia, allodynia 등의 발생 • 수술 중 opioid 사용량이 증가 할 수록, 수술 후 opioid requirement 증가 • Short-term tolerance to an opioid • Not pharmacological tolerance • Hyperalgesia : pain sensitivity 의 증가가 원인 • NMDA and COX pro-nociceptive system • Multimodal adjuvant drugs for postoperative pain • Opioid induced hyperalgesia 감소 • Ketamine (NMDA receptor antagonist) • NSAIDs

  18. Opioid (2) • Peripheral mechanism of opioid • Antinociception effect in pph • Intra-articular, perineural, iv regional route • Arthroscopic surgery : intra-articular administration of morphine • Preemptive peripheral administration of morphine • Small, systemically inactive dose • 충분한 진통효과 발휘, minimal side effects

  19. Gabapentin and Pregabalin (α2-δ ligand) • Anticonvulsants 로 개발 • α2-δ subunit of voltage-gated calcium channel 에 결합 • nociceptive neurotransmitter (Glutamate, substance P, noradrenalin) 분비 억제 • pph, primary afferent neuron, spinal neuron, supra spinal site • Morphine, NSAIDs, COX-2 inhibitor 등의 analgesic effect 강화 • Preemptive use (Preoperative administration) • Neuropathic, chr. pain syndrome • Postoperative analgesia • Single preoperative 1200 mg dose of pregabalin (ACL Op) • Reduce preoperative anxiety, postoperative pain score, opioid use • Improve ROM, • Synergistic effect with NSAIDs • NSAIDs 의 Antihyperalgesia effect 증가 • Pregabalin and celecoxib (spinal fusion) • Long-term use • Dizziness, somnolence, pph edema • 최근의 연구 결과에서 perioperative treatment with gabapentin • Moderate increase in sedation

  20. Overview on Multimodal Analgesia • 여러 analgesic adjuvant medication 은 단독 사용시, opioid sparing effect 를 가지고 있지만, opioid-related side effect 를 효과적으로 줄이지는 못함 • NSAIDs 는 multiple dose가 single dose에 비해 postoperative pain management 에 효과적 • Multimodal approach • Bimodal approach 에 비해 opioid-related adverse event 를 감소 시키고, functional outcome 을 증가 • Spinal fusion study • Celecoxib, pregabalin 단독 투여 • Morphine 사용량 감소, 부작용 감소 없음 • 이 두 가지 약물의 병행 사용은 morphine 사용량 감소 뿐 아니라, adverse effect 의 severity 및 빈도 감소 • TKR • COX-2 inhibitor • Epidural analgesic use 감소, opioid use 감소, pain score, PONV, 수면장애 등에 효과적 • ACL operation • Perioperative acetaminophen, rofecoxib, intra-articular analgesics (bupivacaine, clonidine, morphine), femoral nerve block • Prevalence of pain, opioid use, PONV 등 감소

  21. Prevention of Chronic Postoperative Pain Syndrome

  22. Complex Regional Pain Syndrome • 발생율 • Arthroscopic knee surgery : 2.3~4 % • Carpal tunnel syndrome : 2.1 ~ 5 % • Ankle surgery : 13.6 % • TKR : 0.8 ~ 13 % • Wrist Fx : 7 ~ 37 % • Dupuytren contracture : 4.5 ~ 40 %

  23. Complex Regional Pain Syndrome • Regional nerve block • Perioperative sympathectomy effect • CRPS Hx 환자의 OS surgery • SGB • Upper Ext. surgery with CRPS pt • 수술 후, SGB 시행한 환자에게서 CRPS 재발 확률이 감소 • BPB, iv regional anesthesia with clonidine (1 μg/kg) • Dupuytren contracture surgery 시 CRPS 발생 률 • BPB< iv regional anesthesia with lidocaine & clonidine < iv regional anesthesia with lidocaine =G/A • Vit C • Perioperative acetaminophen, rofecoxib, intraarticular analgesics, femoral nerve block, postoperative cryotherapy

  24. Phantom Limb Pain • Experience the loss of a limb • 50 ~ 80 % 의 prevalence • Risk factor • Degrees of preoperative pain • Magnitude of intraoperative noxious input • Intensity of postoperative pain, psychological factor • Preventive regional analgesic technique • Epidural bupivacaine & morphine • Epidural infusion of bupivacaine, diamorphine, clonidine • Phantom limb pain 감소 효과 • Continuous postoperative regional analgesia with a nerve sheath block • Controversial

  25. Chronic Donor-Site Pain • Not an uncommon complication following spinal fusion • Ileum : autogenous bone graft • Donor site pain : 39 %  3개월, 38 % 6개월, 19 % 2년 • 원인 • Muscular or periosteal pain • Donor site nerve damage • Neuropathic in origin • Local application of analgesics • Low dose of morphine • Bupivacaine & morphine with 17 gauge catheter • Preemptive COX-2 administration • CNS, pph sensitization • Acute pain  chronic pain 과정을 억제 • 저자 권고 사항 • 1000 mg acetaminophen, 400mg celecoxib, 150mg pregabalin • 수술 1-2 시간 전 투여 • 20 mg ketamine iv, graft harvest site (10 ml/0.25% bupivacaine, 5mg morphine, 50 μg clonidine ) infiltration • 수술 중 • 200 mg celecoxib, 75 mg pregabalin , 10 mg of controlled released oxycodone ,bid • 1000 mg of acetaminophen qid • 수술 후 1주일간 지속

  26. Chronic Pain After Total Joint Arthroplasty • THR surgery • 28.1 % 의 환자가, 12-18 개월간, ipsilateral hip pain 호소 • 12.1 % 의 pt  moderate ~ severe pain • TKR surgery • 18.4 % 의 환자가 수술 후 6 개월간 moderate ~ severe pain 호소 • Preoperative pain • Total arthroplasty 의 primary indication • Primary indicator of chronic postoperative pain • Longer hospital stay, longer rehabilitation • High pain ratings • Treatment failure 증가, poor outcome • Risk factor • Preoperative depression, anxiety • Higher Chronic pain & CRPS • Psychological & pharmacological intervention

  27. OVERVIEW • Chronic pain • Major source of morbidity after opthopaedic surgical procedure • Preventive multimodal analgesic technique • Reducing the prevalence of certain chronic postoperative pain syndrome • Analgesic intervention 의 적절한 timing 의 이해가 중요 • Central neuroplasticity development 예방 • Regional blockade 자체 만으로는, 완전한 pain relief, central sensitization 예방에 불충분 • Adequate neural blockade • Central neuroplasticity ? • Multimodal analgesic regimen • Regional blockade, NSAIDs, other central & pph acting analgesics • Entire perioperative period • 정형외과적 수술 후, acute & chronic pain 감소에 가장 효과적인 방법

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