1 / 29

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

vine
Download Presentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related