Post operative pain management has no specific criteria. Lots of methods and procedures are suggested with various types of drugs. It is just a guideline for management of pain after surgery.
3. Pain is a Sensory and Emotional experience
associated with tissue damage or described
in terms of such damage
(I.A.S.P)
(The International Association for the
Study of Pain)
8. How Pain Occurs
Tissue damage
prostaglandins,
releases bradykinin and
which activate or sensitize
nociceptors.
Activation of nociceptors
leads to the release of
substance P and calcitonin gene related peptide
(CGRP).
Substance P
acts on mast cells in the vicinity of
sensory endings and release of histamine, which
directly excites nociceptors.
Substance P and CGRP produces dilation of
peripheral blood vessels. The resultant edema causes
additional liberation of bradykinin.
Thus Nociceptors activate and cause pain.
12. Pathophysiology
⢠The generation of pain
involves interaction
between all parts of the
nervous system.
Pain ultimately transmitted to:
⢠Thalamus
⢠Medulla oblongata
⢠Cerebral cortex.
13. Types of Pain
Fast Pain: Felt within 0.1 second after
painful stimulus.
Also called: sharp pain, pricking pain,
electric pain and acute pain.
Slow Pain: Felt within 1.0 second or
more after painful stimulus.
Also called: dull pain and chronic pain.
14. Types of Pain
1. Nociceptive pain- Direct stimulation of intact
nociceptors
⢠Transmission along normal nerves
⢠Sharp, aching, throbbing
â somatic
⢠easy to describe, localize
â visceral
⢠difficult to describe, localize
15. 2. Neuropathic pain . . .
⢠Disordered peripheral or central nerves
⢠Compression, transection, infiltration,
ischemia, metabolic injury
⢠Varied types
â peripheral, deafferentation, complex regional
syndromes
⢠Pain may exceed observable injury
⢠Described as burning, tingling, shooting, stabbing,
electrical
⢠Mx: opioids, adjuvant / coanalgesics often req.
25. Pre-emptive Analgesia
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Pre-emptive analgesia can be achieved
by:
local anesthetic infiltration of the skin
Effective dose of systemic opioids
Systemic nonsteroidal anti-inflammatory
drugs (NSAIDs)
Neuroaxial opioids or local anesthetic
Peripheral nerve blocks
26. Patient Controlled Analgesia
PCA
1. Increase patient satisfaction
2. Decrease side effects and
complications
3. Decrease sedation
4. Decrease total amount of daily
opioids
5. Avoid Basal rate in the Elderly
6. PCA Flowsheets
41. NSAID's
⢠Blocks the production of
Prostaglandin
⢠Very effective in pain control, Alone
or in Combination with Narcotics
⢠Ketorolac is My drug of choice as
an adjunct therapy in acute pain
⢠Use p.o. forms âCox2 inhibitorsâ
when possible in combination with
Epidural,
IV,or oral narcotics
42. Practical guide for NSAIDâs
Usage
⢠Pre-op administration significantly decreases
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post-op pain and cramps
Toradol 30mg, IV or Celebrex 400mg, P.O. preop
For sever acute pain Celebrex 400mg, P.O. bid
X one week the 200 P.O., bid. Bextra 20mg,
bid X one week the 20mg, QD
PPI are the drugs of choice to treat gastric
complications. H2 blockers only mask the
disease
Please check the patient renal function
routinely prior to administration
COX2 inhibitors doesnât affect the platelet
43. Practical guide for NSAIDâs
Usage
(Continuum)
All specific or non-specific NSAIDâs may
cause:
⢠water retention and edema
⢠Hypertension
⢠Renal dysfunction
⢠May delay bony fusion in chronic usage ?
44. Clonidine
⢠Alpha2 agonist with outstanding
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properties when administered
intrathecally:
Pain control properties by itself
Decrease the requirement of narcotics
Decrease tolerance
Great for neuropathic pain control
Adding 1mcg/kg for children caudal
block will extend pain relief up to 24h
45. Clonidine
Oral or transdermal Clonidine:
ď§ Enhance the effect of narcotics
ď§ Decreases the daily narcotic requirement
ď§ Excellent Adjuvant therapy for narcotic
dependent patients
ď§ Effective for neuropathic pain
47. Ketamine
⢠NMDA receptors antagonist â
Neuropathic pain
⢠Potent analgesic effect
⢠Small doses in combination of opioids
substantially improve pain control
⢠Bolus dose of 100 mcg/kg followed by a
continuous drip of 1-3 mcg/kg/min is ideal
for chronic opioid users postoperatively
49. Usage of Anti-Epileptic Drugs in
Acute Pain
⢠Every surgical incisional pain has Neuropathic
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component
Studies showed giving 1200 mg of Gabapentin
1 h prior to surgery decreases the opioids
requirement post-op and results in better pain
control without increased sedation
Combining Gabapentin with opioids is ideal for
re-do back surgery cases with chronic opioids
usage
These class of drugs are also mode stabilizers
50. Non Chemical Techniques
⢠Psychological treatments:
Relaxation, hypnosis Cognitive
therapy etc..
⢠TENS Units
⢠Physiotherapy
54. Pain after surgery
Inflammatory pain
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Inflammatory pain
Nociceptive painpain
Nociceptive
Neuropathic pain
Neuropathic pain
55. Chronic post surgical pain
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Pain developed after a surgical procedure
At least 2 month duration
Other causes excluded (malignancy, chronic
infection)
⢠Possibility of continuous pain of pre-existing
problem
Macrae 2001
56. Principles of analgesic Plan
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Balanced analgesia
Opioids: First line morphine
Regional analgesia
Actual dose of analgesics will not be discussed
Regular and breakthrough prescription including
night-time