Surviving Surgerys Aftermath Judith Handley MD Assistant Professor OUHSC October 5, 2012 Disclosures I have no disclosures
Objectives Discuss basic pathophysiology of acute pain Identify options in treatment of acute post operative pain Discuss a multi-modal approach to pain management in the post operative patient
Pain: Definition The IASP defines pain as Unpleasant sensory and emotional experience associated with real or perceived tissue injury Whatever the person says it is, wherever the person says it is
Impact on Healthcare Pain is the most common reason a patient seeks healthcare The cost in healthcare dollars in significant annually Acute Pain Sudden onset
Usually lasts < 6months Has a known cause/circumstance Surgery Burns/cuts Broken bones, pulled muscles Labor and childbirth Post-Operative Pain
You wake up from surgery hurting, why? - Skin/Incision Pain - Muscle Pain - Bone Pain - Tendon/Ligament Pain - Movement Pain - Throat Pain
Pathophysiology Pathophysiology Why is it so important to control and treat Post-Op pain? Good Post-Op Pain Control = Faster recovery and discharge
Ability to utilize deep breathing exercises Decrease post-op pneumonia/collapsed lung Decrease O2 requirements Ability to sit up, get out of bed, walk sooner Decreases decubitis ulcers and blood clot formation Active participation in Physical Therapy
Comfortable and satisfied patient Unrelieved Post-Op Pain Poor Post Op Pain Control = Increases risk of post operative morbidity and mortality Pneumonia Decubitis Ulcers
Blood Clots Increases hospitalization and costs of care Can develop into chronic pain Unnecessary patient suffering, unsatisfied patient Other Thoughts To control pain post-operatively, you need to
know information pre-operatively. Allergies Does the patient take any pain medication at home regularly or intermittently? Where is current pain? Introduce and educate about pain scales Post-Op Pain Control Options
Regional Anesthesia/Analgesia Peripheral Nerve Blocks Single Injection Intrathecal/Caudal Analgesia Epidural Analgesia Non-Opioids Opioids IV vs. PO
PRN vs. PCA Adjuvants Regional/Neuraxial Anesthesia Administration of local anesthetics (often with other drugs) into the epidural space, around a peripheral nerve plexus, or into the intrathecal space to block pain transmission.
Types: 1. Peripheral Nerve Blocks 2. Epidural Analgesia 3. Single Injection Intrathecal/Caudal Analgesia Regional Anesthesia: Nerve Blocks Commonly used for surgery involving the
upper or lower extremities Types: Interscalene, Axillary, Femoral, Sciatic, Caudal Typically used for outpatient procedures (although can be used inpatient and as a continuous infusion) Nerve stimulators and ultrasound guided Typically lasts 4-24 hours
Regional Anesthesia: Nerve Blocks Advantages: Reduced amount of additional systemic opioids Reduction of side effects Nausea/vomiting Puritis
Drowsiness Epidural Anesthesia A thin catheter that is threaded into the epidural space which provides anesthesia by continuous infusion via an epidural pump Indications: Thoracic/heart surgeries, abdominal surgeries, limb amputation, thoracotomies, urology
surgeries Epidural Analgesia Drugs infused through an epidural catheter Local Anesthetics (Bupivacaine, Ropivacaine) Opioids (fentanyl, hydromorphone) All are preservative free
Advantages of Epidural Analgesia Local Anesthetics via Epidural= can prevent the pain response with minimal physiologic alterations Opioids via Epidural= can provide prolonged analgesia at low doses Systemic Opioids= modify perception of nociceptive input so patients are better able to tolerate pain
GOAL: Reduction of systemic opioids, better pulmonary profile, better OOB and PT profile Single Injection Analgesia Caudal Intrathecal Duramorph Extended Release morphine Peaks in 6 hrs and lasts 18-24
Single Injection Analgesia Intrathecal Duramorph 3:1 ratio or PICU admit Caudal Duramorph Dosing: Less than 15mcg/kg discharge home 15-45mcg/kg admitted, 3:1 ratio or PICU
Greater than 45mcg/kg automatic PICU Opioids Drug options Morphine Fentanyl Hydromorphone
PRN Bolus or PCA Patient Controlled Analgesia (PCA) Common agents used Morphine Hydromorphone Fentanyl
PCA demand dose Basal Rate Non-Opioids and Adjuvants Drug Options Ketoralac Acetaminophen Ibuprofen
Route of administration options Other adjuvants Post-Op Pain Management Care Plans Individualized Tailored to the specific surgical procedure Perioperative pain control optimized
Utilize a multi-modal approach Multi-Modal Approach Outpatient Cyst removal right elbow Regional, opioid with adjuvant medications Inpatient
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