Perioperative pain management toni hundle the arm clinic 2019
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Peri-operative pain management from Anaesthetist, Dr Toni Hundle for The Arm Clinic at HCA The Wilmslow Hospital 2019
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Perioperative pain management toni hundle the arm clinic 2019
- 9. Acute vs Chronic • 3 months • Biology changes quickly • Presentation differs • Management is also different
- 10. Acute Pain • Nociceptor response from trauma, injury, surgery etc. • Classic Inflammatory response – • rubor (redness) • tumor (swelling) • calor (increased heat) • dolor (pain) • Treat with R.I.C.E, drugs, injections, slings and supports, psychology
- 13. Paracetamol • Acetaminophen, Tylenol, Panadol etc. • 500mg UK, vs 375mg U.S.A • 60-90% bioavailability orally and onset 35-40 minutes • 8 minutes IV • Metabolised in liver; excreted by kidneys, relatively safe in pregnancy • Under 50kg – 500mg, QDS • Over 50kg – 1gm, QDS • Still kills a lot of people after deliberate or accidental overdose!
- 14. NSAIDs •Salicylates – Aspirin •Proprionic Acid – Ibuprofen, naproxen, ketoprofen •Acetic Acid – Indomethacin, ketorolac, diclofenac •Enolic Acid – Piroxicam, meloxicam, tenoxicam •Selective COX2 inhibitors – Celecoxib, parecoxib
- 15. Phospholipid Arachidonic Acid Prostaglandins Cyclo-oxygenase 1 and 2 Phospholipase Corticosteroids NSAIDs Vascular Cell Walls etc.
- 18. NSAIDs • Balance risk vs benefit • Controversy of COX specific inhibitors and cardiac risk • Now seems to be an issue with all NSAIDs • Use the lowest dose possible for least amount of time. • Wean off first. • Review after 2 weeks, especially in at risk groups. • Stop immediately if any side-effects at all. • Prefer Ibuprofen, 400mg TDS – protect stomach.
- 19. Opiates and Opioids - Morphine • Morphine oral bioavailability is about 23% • Peak levels after 45 minutes in liquid form • Hepatic metabolism to an active metabolite • 5-10mg (10mg in 5ml) oromorph, 4 hourly prn. • S/E constipation, nausea, itching, urinary retention, sedation • BUT, no organ toxicity, unlike NSAIDs
- 20. Opiates and Opioids - Codeine • Codeine has more predictable oral bioavailability, 90% • 15-30 minute onset • Metabolised to morphine in liver • Cytochrome P450 enzyme is gene sensitive. Some can and others can’t metabolise. Variability in effectiveness. • Used with paracetamol and NSAIDs • S/E limit usage • Max 60mg QDS daily
- 21. Opiates and Opioids - Tramadol • Not a purely opioid mechanism • Has 5HT (serotonin) and Noradrenaline actions • 15-30 minute onset • Metabolised to morphine in liver • Cytochrome P450 enzyme is gene sensitive. Some can and others can’t metabolise. Variability in effectiveness. • Used with paracetamol and NSAIDs • S/E limit usage • Max 100mg QDS daily