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OPIOIDS AND POST OPERATIVE PAIN MANAGEMENT

OPIOIDS AND POST OPERATIVE PAIN MANAGEMENT. DR S NAIDOO ANAESTHESIOLOGY KALAFONG . WHAT IS PAIN?. Not only sensory Unpleasant and emotional experience Associated with tissue damage. NOCICEPTION. Latin for damage or injury Only refers to the neural response to injury

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OPIOIDS AND POST OPERATIVE PAIN MANAGEMENT

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  1. OPIOIDS AND POST OPERATIVE PAIN MANAGEMENT DR S NAIDOO ANAESTHESIOLOGY KALAFONG

  2. WHAT IS PAIN? • Not only sensory • Unpleasant and emotional experience • Associated with tissue damage

  3. NOCICEPTION • Latin for damage or injury • Only refers to the neural response to injury • All nociception causes pain • BUT • Other things also cause pain!!!

  4. Nociception causes ACUTE PAIN – nociceptive pain • Nociception and psycho-behaviouristic factors cause CHRONIC PAIN – neurogenic pain

  5. THE TRANSMISSION OF PAIN

  6. THE BASIC PAIN PATHWAY

  7. Tissue injury stimulate free nerve endings • NOCICEPTORS • Afferent nerve fibres (A∂ and C) conduct stimuli centrally • Peripheral afferents project into the DORSAL HORN and other areas in the SPINAL CORD • SYNAPSES extend over to the SPINOTHALAMIC TRACT and up to the THALAMUS and to the CEREBRAL CORTEX

  8. MODULATION OF PAIN

  9. FACTORS RESPONSIBLE

  10. PERIPHERAL MODULATION • Locally secreted substances • Sensitises the nociceptors • Site of action for NSAIDs, glucocorticoids, opioids

  11. SPINAL MODULATION • Neurotransmitters like glutamate, aspartate and substance P • SUPRASPINAL MODULATION • Descending inhibition in the dorsal horn • These inhibitory tracts are opioid and ἀ-adrenergic

  12. COGNITIVE MODULATON • Distraction of attention • Therefore appropriate treatment agents best suited for various types of pain can be determined from causative agents

  13. PAIN • Requires treatment • Accompanied by unwanted side effects • Acute pain untreated adequately becomes chronic in nature and even more difficult to treat • And has a high morbidity

  14. SO…WHY TREAT PAIN?

  15. SIDE EFFECTS OF PAIN

  16. DRUG THERAPY FOR ACUTE PAIN

  17. NON-OPIATES NSAIDS AND PARACETAMOL Useful when prostaglandins contribute to the injury ASPIRIN IBOPROFEN DICLOFENAK KETOROLAC PARACETAMOL-CODEINE COMBINATIONS

  18. ἀ₂ AGONISTS • KETAMINE – 0,25mg/kg • REGIONAL ANAESTHESIA • The only way to blunt the afferent sympathetic influence therefore the stress response • Analgesia for hours

  19. OPIOIDS momor

  20. OPIOID RECEPTORS • 3 MAIN CLASSES • Mu main pharmacological effects of morphine analgesia, dependence & resp depression • Kappa analgesia, resp depression, gastrointestinal effects • Delta

  21. RECEPTOR PROFILE • ANTAGONISTS • FULL OR PARTIAL AGONISTS

  22. CENTRAL EFFECTS OF OPIOIDS • Analgesia • Anaesthesia • Muscle rigidity • Pupils • Thermoregulation • Euphoria

  23. OPIOIDS • Drugs of choice for the treatment of severe pain • Patients do not get addicted to opioids, they become tolerant • Besides analgesia, opioids are sedating, suppress ventilation, alleviates coughing and can cause bronchospasm

  24. EXAMPLES OF OPIOIDS • NATURAL OCCURRING • MORPHINE, CODEINE • PAPAVERINE, NOSCARPINE • SYNTHETIC • PHENYLPIPERIDINES egfentanyl, sufentanil, etc • PENTAZOCINE, BUPRENORPHINE

  25. SYSTEMIC EFFECTS OF OPIOIDS

  26. CARDIOVASCULAR • DECREASED SYMPATHETIC OUTFLOW • HISTAMINE RELEASE – CVS COLLAPSE • BLUNTS THE SYMPATHETIC RESPONSE TO INTUBATION

  27. RESPIRATORY SYSTEM • DECREASED SENSITIVITY TO AN INCREASED PaCO₂ • HYPOXIC DRIVE DECREASES • CHEST WALL RIGIDITY • BLUNTS THE RESPONSE TO INTUBATION • BRONCHOSPASM

  28. CENTRAL NERVOUS SYSTEM • REDUCED CEREBRAL O₂ CONSUMPTION, BLOOD FLOW AND INTRACRANIAL PRESSURE • LITTLE EEG CHANGES • MIOSIS • STIMULATES THE CETZ

  29. GASTROINTESTINAL SYSTEM • DECREASED GASTRIC EMPTYING • SPASM OF THE SPHINCTER OF ODDI • CONSTIPATION

  30. ENDOCRINE SYSTEM • DECREASED RELEASE OF STRESS HORMONES • ATTENUATES THE INTUBATION RESPONSE

  31. OTHER SIDE EFFECTS OF OPIOIDS • NAUSEA • VOMITING • CONSTIPATION • PRURITIS • URINE RETENTION • HISTAMINE RELEASE • CHEST WALL RIGIDITY

  32. MULTIMODAL ANALGESIA

  33. The application of several modalities to alleviate pain • Used in combination with regional anaesthesia

  34. PRE-EMPTIVE ANALGESIA

  35. Administration of analgesia BEFORE surgery • Found to be less effective in man than animal

  36. HIGH TECHNOLOGY METHODS

  37. Including nerve blocks with or without • Infusions of local anaesthesia • Neuraxial blocks (spinal, epidural block and paravertebral blocks) • Patient controlled analgesia

  38. Nerve Blocks

  39. NeuraxialBlocks

  40. Patient controlled analgesia

  41. So... Please remember: • PAIN IS NOT AN OPTION WHEN WE AS PHYSICIANS HAVE SUCH A WIDE RANGE OF MODALITIES TO TREAT IT!

  42. THANK YOU

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