Lecturer name: Dr. Salah N EL- Tallawy Prof . of Anesthesia and Pain Management

1. بسم الله الرحمن الرحيم Lecture Title: Acute Pain Management Lecturer name:Dr.SalahN EL-Tallawy Prof. of Anesthesia and Pain Management Lecture date:

2. Lecture Objectives.. Students at the end of the lecture will be able to: • Learn a common approach to emergency medical problems encountered in the postoperative period. • Study post-operative respiratory and hemodynamic problems and understand how to manage these problems. • Learn about the predisposing factors, differential diagnosis and management of PONV. • Understand the causes and treatments of post-operative agitation and delirium. • Learn about the causes of delayed emergence and know how to deal with this problem. • Learn about different approaches of post-Operative pain management

3. Postoperative care- Post Anesthesia Care Unit“PACU”

4. PACU • Design should match function • Location: • Close to the OR. • Access to x-ray, blood bank & clinical labs. • Monitoring equipment • Emergency equipment • Personnel

5. Admission to PACU Steps: • Coordinate prior to arrival, • Assess airway, • Administer oxygen, • Apply monitors, • Obtain vital signs, • Receive report from anesthesia personnel.

6. PACU - ASA Standards • Standard I All patients should receive appropriate care • Standard II All patients will be accompanied by one of anesthesia team • Standard III The patient will be reevaluated & report given to the nurse • Standard IV The patient shall be continually monitored in the PACU • Standard V A physician will signing for the patient out of the PACU

7. Patient Care in the PACU • Admission • Apply oxygen and monitor • Receive report • Monitor & Observe & Manage  To Achieve • Cardiovascular stability • Respiratory stability • Pain control • Discharge from PACU

8. Monitoring in the PACU • Baseline vital signs. • Respiration • RR/min, Rythm • Pulse oximetry • Circulation • PR/min & Blood pressure • ECG • Level of consciousness • Pain scores

9. Initial Assessment • Color • Respiration • Circulation • Consciousness • Activity

10. Aldrete Score

11. Common PACU Problems • Bleeding • Agitation • Delayed recovery • “PONV” • Pain • Oliguria • Airway obstruction • Hypoxemia • Hypoventilation • Hypotension • Hypertension • Cardiac dysrhythmias • Hypothermia

12. 1. Airway Obstruction • Most common: tongue fall back  posterior pharynx • May be foreign body • Inadequate relaxant reversal • Residual anesthesia

13. Management of Airway Obstruction • Patient’s stimulation, • Suction, • Oral Airway, • Nasal Airway, • Others: • Tracheal intubation • Cricothyroidotomy • Tracheotomy

14. 2. Hypoventilation • Residual anesthesia • Narcotics • Inhalation agent • Muscle Relaxant • Post oper - Analgesia • Intravenous • Epidural

15. Treatment of Hypoventilation • Close observation, • Assess the problem, • Treatment of the cause: • Reverse (or Antidote): • Muscle relaxant  Neostigmine • Opioids  Naloxone • Midazolam  Anexate

16. 3. Hypertension • Common causes: e.g. • Pain • Full Bladder • Hypertensive patients • Fluid overload • Excessive use of vasopressors

17. Treatment of Hypertension • Effective pain control • Sedation • Anti-hypertensives: • Beta blockers • Alpha blockers • Hydralazine (Apresoline) • Calcium channel blockers

18. 4. Hypotension • Decreased venous return • Hypovolemia, •  fluid intake •  losses • Bleeding • Sympathectomy, • 3rd space loss, • Left ventricular dysfunction

19. Treatment of Hypotension • Initially treat with fluid bolus, • + Vasopressors, • + Correction of the cause

20. 5. Dysrhythmias • Secondary to • Hypoxemia • Hypercarbia • Hypothermia • Acidosis • Catecholamines • Electrolyte abnormalities.

21. Treatment of Dysrhythmia • Identify and treat the cause, • Assure oxygenation, • Pharmacological

22. 6. Urine Output • Oliguria • Hypovolemia, • Surgical trauma, • Impaired renal function, • Mechanical blocking of catheter. • Treatment: • Assess catheter patency • Fluid bolus • Diuretics e.g. Lasix

23. 7. Post op Bleeding Causes: • Usually Surgical Problem, • Coagulopathy, • Drug induced

24. Treatment of Post op Bleeding • Treatment: • Start i.v. lines  push fluids • Blood sample, • CBC, • Cross matching, • Coagulopathy • Notify the surgeon, • Correction of the cause

25. 8. Hypothermia • Most of patients will arrive cold • Treatment: • Get baseline temperature • Actively rewarm • Administer oxygen if shivering • Take care for: • Pediatric, • Geriatric.

26. 9. Altered Mental Status • Reaction to drugs? • Drugs e.g. sedatives, anticholinergics • Intoxication / Drug abusers • Pain • Full bladder • Hypoventilation • Low COP • CVA

27. Treatment of Altered Mental Status • Reassurances, • Always protect the patient, • Evaluate the cause, • Treatment of symptoms, • Sedatives / Opioids if necessary.

28. 10. Delayed Recovery • Systematic evaluation • Pre-op status • Intraoperative events • Ventilation • Response to Stimulation • Cardiovascular status

29. Delayed Recovery • The most common cause: • Residual anesthesia  Consider reversal • Hypothermia, • Metabolic e.g. diabetic coma, • Underlying psychiatric problem • CVA

30. 11. Postoperative Nausea & Vomiting “PONV” • Risk factors • Type & duration of surgery, • Type of anesthesia, • Drugs, • Hormone levels, • Medical problems, • Autonomic involvement.

31. Prevention of PONV • NPO status • Dexamothasone, • Droperidol, • Metoclopramide, • H2 blockers, • Ondansetron, • Acupuncture

32. 12. Postoperative Pain

33. 12. Postoperative Pain • Causes: • Incisional Skin and subcutaneous tissue • Laparoscopy Insuflation of Co2 • Others: • Deep cutting, coagulation, trauma • Positional nerve compression, traction & bed sore. • IV site needle trauma, extravasation, venous irritation • Tubes drains, nasogastric tube, ETT • Surgical complication of surgery • Others cast, dressing too tight, urinary retention

34. PAIN MEASUREMENTS

35. Pain Scores • Visual Analogue Scale (VAS) • 0 10 Numeric Rating Scale (NRS)

36. Verbal scale Wong-Baker “Faces Scale”

37. ACUTE POSTOPERATIVE MANAGEMENT TOOLS Pharmaco - Therapy Regional Techniques • Non Opioid Analgesics • NSAADs • Analgesic /Antipyretic • Analgesic/Anti-inflam/Antipyretic • NSAIDs • Non-selective COX inhibitors • Selective COX-2 inhibitors • Opioids • Weak Opioids. • Strong Opioids. • Mixed agonist-antagonists • Adjuvants • -2 Agonists • LA • SP inhibitors • NMDA inhibitors • Anticonvulsant / Antidepressants • Calcitonin • Relaxants • Cannabinoids • Others • Local infiltration • Wound perfusion • Intra-abdominal inj. of LA/Analg. • Intercostal & Interpleural • Paravertebral • USG-RA: e.g. TAP • Neuraxial: • Epidural: • Thoracic • Lumbar • Spinal • Single shot • CSA • CSE

38. WHO IVInterventional WHO LadderUpdated Severe pain (7-10) WHO IIIStrong opioids ± Adjuvant Pain Persists or Increases Moderate pain (4-6) WHO class IIWeak opioids ± Adjuvant • By the mouth • By the clock • By the ladder Mild pain (0-3) WHO class I NSAIDs ± Adjuvant

39. WHO (I) Non Opioid Analgesics • Non Opioid Analgesics • NSAADs • Analgesic / Anti-inflam / Antipyretic / Anticoagulant • ASA • Analgesic /Antipyretic • Paracetamol • NSAIDs • Non-selective COX inhibitors: • Diclofenac & Ketoprofen • Selective COX-2 inhibitors • Celecoxib & Rofecoxib WHO IIIStrong opioids ± Adjuvant Severe pain (7-10) Moderate pain (4-6) WHO class IIWeak opioids ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant

40. Scientific Evidence – NON OPIOID ANALGESICS • Paracetamol: • is an effective analgesic for acute pain; the incidence of adverse effects comparable to placebo (Level I [Cochrane Review]). • Paracetamol / NSAIDs given in addition to PCA Opioids   Opioid consumption (Level I). • NSAIDs: • are effective in the treatment of acute postoperative (Level I ). • With careful patient selection and monitoring, the incidence of renal impairment is low (Level I [Cochrane Review]). • NSAIDs + Paracetamol improve analgesia compared with paracetamol alone (Level I). Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

41. WHO Ladder II - Weak Opioids: • Tramadol: • Tramadol : Morphine: • Parenteral = 1 : 10 & Oral = 1 : 5 • Dose: 200 – 400 mg/d • Codeine: • Metabolized to morphine. • Codeine : Morphine = 1 : 10 • Dextro-propoxyphene: • Methadone Derivative • Prolongation of Q-T interval. WHO IIIStrong opioids ± Adjuvant Severe pain (7-10) Moderate pain (4-6) WHO class IIWeak opioids ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant

42. Scientific Evidence – WEAK OPIOIDS • Tramadol: • has a lower risk of respiratory depression & impairs GIT motor function < other opioids (Level II). • is an effective treatment for neuropathic pain (Level I [Cochrane Review]). • Dextropropoxyphene: • has low analgesic efficacy (Level I [Cochrane Review]). Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

43. WHO Ladder III - Strong Opioids • Morphine: • Sedation • PONV • Respiratory Depression • Fentanyl • Rapid action, Short duration. • Fentanyl : Mophine = (1:10) • Pethidene: • Active metabolite:  t½ . • Prolongs Q-T interval. • Pethidine : Mophine = (1:10) • Hydromorphone: • Powerful, rapidly acting. • Release is in distal gut. • Hydromorphone : Morphine = 1 : 5 WHO IIIStrong opioids ± Adjuvant Severe pain (7-10) Moderate pain (4-6) WHO class IIWeak opioids ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant

44. WHO IVInterventional Severe pain (7-10) WHO IIIStrong opioids ± Adjuvant Moderate pain (4-6) WHO class IIWeak opioids ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant WHO Ladder IV – Regional Anesthetic Techniques • Local infiltration • Wound perfusion • Intra-abdominal LA • Intercostal • Interpleural • Paravertebral • USG - RA: e.g. TAP • Neuraxial: • Epidural: • Thoracic • Lumbar • Spinal • Single shot • CSA • CSE

45. Neuraxial (Spinal / Epidural)(LA / Opioids / others) • Advantages: • Provide prolonged & effective analgesia • Side effects • Respiratory depression. • N/V. • Pruritis. • Urinary retention.

46. WHO Algorithm for Management of Pain • + Multidisciplinary: • Adjuvant therapy. • Psychotherapy. • Physioltherapy. • Causal diag. & ttt. Neuraxial LA Opioids WHO IIIStrong opioids Plexus block Paravertebral / PNB WHO class IIWeak opioids Non-pharmacological LA infiltration WHO class INSAIDs

47. Management Algorithm for Postoperative Pain Diagnosis Preventive / Preemptive Procedure Specific Pain manag. Pain Assessment ttt of Pain and Co morbidities 1ry Treatment Supportive Treatment Psychological ttt. Pharmacotherapy Physical / Rehab. Interventional

48. PACU Discharge Criteria • Fully Awake, • Patent airway, • Good respiratory function, • Stable vital signs, • Patency of tubes, catheters, IV’s • Pain free, • Reassurance of surgical site.

49. Postanesthesia Discharge Scoring System

50. Reference book and the relevant page numbers..