Postoperativ smertelindring

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Post-operativ smertelindring

• -----------------------------
• Johan Ræder
• Anestesiavdelingen,
• Ullevål Universitets Sykehus
• Oslo
• Mail johan.rader_at_ioks.uio.no

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Post-operative recovery Day-surgery patients
preferencesJenkins K. et al. Br J Anaesth
200186272-4

• 355 patients What will you prefer to avoid from
• 10 possible post-operative problems?
• 1) Pain
• 2) Sore throat (from tubings)
• 3) Nausea and vomiting
• 4)..
• 5)..

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Major ambulatory surgery (n178)- laparoscopy,
hernia rep. ()

• In hospital lt24 h 24-72 h
• Pain 40 73 64
• Nausea/
• vomiting 30 38 28
• Steine S, Ræder J Submitted Br.J.An, 2002

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Chronic Pain as an Outcome of SurgeryPerkins
and Kehlet, Anesthesiology 931123, 2000
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Surgical trauma - Nerve stimulation - Nerve
(cell) damage - Tissue cell damage -
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Peripheral nerve-ending
NERVE CELL DAMAGE Nevropatic pain
TRAUMA
VR1 vanilloid (pepper, heat, cold)

• STIMULATION
• Mechanical
• Temperature
• Chemical

TTx resistant sodium channel
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• Surgical trauma
• - Nerve stimulation
• - Nerve (cell) damage
• - Tissue cell damage
• - Reduce trauma !!!
• - local anaestesia
• NSAID
• opioid ?

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Pain fibers - local anaesthesia
Trauma Periphery
A-delta fibers
Dorsal horn
C-fibers
( A-beta fibers)
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• Surgical trauma
• - Nerve stimulation
• - Nerve (cell) damage
• - Tissue cell damage
• - Reduce trauma !!!
• - local anaestesia
• NSAID
• opioid ?

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Dorsal Horn
FROM PERIPHERY
C fiber
Inter-neuron
GABA Glycine Opioid
Glutamate
()
PGE2
NMDA
Substance P
Descending control
AMPA
PGE2
Ca
()
Noradrenaline Serotonine
()
COX-2 induction
()
Na
PGE2
PGE2
TO CORTEX
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Descending Inhibitory Pathways - noradrenaline
(alfa-2-ag) acetylcholine - serotonine Spinal
Amplification NMDA glutamate prostaglandin
(cox-II) Spinal Inhibition - opioid -
local anaestesia
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COX II and CENTRAL PAIN
Trauma (periphery Interleukin (in
blood) blood brain barrier cyclo
oxygenase II phosholipase Brain
prostaglandin synthase prostaglandin
PAIN interleukin cyclo oxygenase
II Nature 2001410 Ek et al430-1 Samad
TA474-5
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Normal pain
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Pain sensitisation
Trauma
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Tissue damage
Pain

• Superficially, cutaneous precise, sharp, many
  receptors
• Deep somatic aching, less localized
• Visceral few receptors, diffuse, somatic
  projection

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Tissue damage
The pain experience
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Situation
Tissue damage
The pain experience
Existential pain
Previous pain
Psychogenic influence
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Somato-sensory (localize) Limbic
(emotional) Temporal (memory) Cognitive
(evaluation, action taking)
Cerebral cortex
Pain stimuli
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PAIN TREATMENT4 GENERAL PRINCIPLES

• 1) Opioid minimization
• 2) Multimodal approach
• 3) Loco/regional
• 4) Timing

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ING. FIELD BLOCK vs. GENERAL AN.for Hernia
repair, 60 patients(Aasbø V, Thuen A,Ræder J.
Acta Anaesth Scand 200246674-678 )
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ING. FIELD BLOCK vs. GENERAL AN.for Hernia
repair, 60 patients Aasbø V, Thuen A,Ræder J.
Acta Anaesth Scand 200246674-678 )

• Sign. better with reg.field block (ropiva. 0,5
  50ml)
• analgesia at 0, 1h, 2h, 48h
• less analgesics day 1, 2 and 2-7
• recovery unit
• able to sit at 18 min (vs. 72)
• able to stand/walk at 33 min (vs. 115)
• discharge ready at 102 min (vs. 280)
• better daylife function at 24 and 48 h
• more satisfied patients at 48h and day 7

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PAIN PREVENTION, TIMING

• 1) Post-operative pain starts on the op.table!
• - propofol, renifentanil, desflurane,sevoflurane
• no post.op. analgesia
• 2) Preventive analgesia
• - analgesia before the pain starts
• 3) Pre-emptive analgesia
• - analgesia before the trauma starts

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A qualitative and quantitative systematic review
of preemptive analgesia for postoperative pain
relief.Moiniche S, Kehlet H, Dahl JB.
Anesthesiology 200296725-41

• No pre-emptive effect
• opioids
• NSAID
• ketamine
• alfa-2 agonists
• local anaesthesia
• Possible pre-emptive effect
• continous epidural anaesthesia

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The preemptive analgesic effect of rofecoxib
after ambulatory knee surgeryReuben SS et al.
Anesth Analg 20029455-9

• 60 patients, meniscectomy, local an. (bupi)
  sedation (propofolmidazolam)
• rofecoxib 50 mg preop (1h) or end of surgery or
  placebo
• First rescue
• pre-op 803 min gt post-op 461 min gt placebo 318
  min
• Pre-op versus post-op
• less pain on movements, less 24 h opioid need

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DIFFICULT BALANCE MINIMIZE OPIOID NEED!
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New opioids?

• Tramadol
• no resp.depression
• medium analgesia
• nausea
• Oxycodone
• strong analgesia
• 60-87 bioavailable (oral)
• tablets or slow release tablets
• 12 h effect -gt less break-through pain

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MULTIMODALITY
drug C
drug A
side-effects
side-effects
ANALGESIA
side-effects
drug B
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TISSUE (trauma)
PHOSFOLIPID
CORTICO STEROID
phosfolipase
pain inflammation
ARACHIDONIC ACID
PROSTAGLANDIN
Cyclo-oxygenase Cox-I Cox-III ?
?
substrate activator
Cox-II
LEUKOTRIEN
PROSTAGLANDIN
PARACETAMOL
NSAID COXIB
pain inflammation allergy?
TISSUE HOMEOSTASIS kidneys GI-mucosa platelets
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Paracetamol dose

• Children 1.dose oral 40 mg/kg or rectal 50
  mg/kg
• 100 mg/kg/day (including start dose) 1. and 2.
  day
• then reduce to 50 mg/kg/day
• Adults, oral
• start 1.0 - 2.0 g age, weight
• continue 1g x 3 - 6 (careful
  ethanol, antiepileptics)

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CODEINE (60mg) PARACET.(800mg)ORIBUPROFEN
(800mg) x 3 AT HOMERæder J, Steine S, Vatsgar
T. Anesth Analg 2001921470-2

• 104 pat, hernia/varic.v. gen.anestesia
• double-blindly for 3 days at home
• ----------------------------
• 10 pat denied participation due to distrust in
  codeineparacet.
• Identical analgesia in both groups
• 20 - 30 more nausea with codeineparacet. (ns)
• More obstipation with codeineparacet (23 no
  defec. for 3d)
• More general satisfaction with Ibuprofen

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NSAID, CODEINE AND/OR PARACETAMOLBreivik EK et
al. Clin Pharmacol Ther 199966625-35

• 120 pat. wisdom-teeth extr. pain 0-8h, single
  oral dose
• diclofenac 100 mg paracetamol 1 g better than
• paracetamol 1 g
• diclofenac 100 mg
• paracetamol 1 g codeine 60 mg
• paracet. 1g codeine 60 mg better than paracet 1
  g
• adding codeine 60 mg (to diclopara) increased
  side-effects, no additional analgesia

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KETOROLAC vs PETHIDINE(n210, hysterectomi,
cholecystect)

• KETOROLAC RESULTED IN (Plt0.05)
• less need of nursing care
• better function day 0-3
• faster gut function, oral inntake, ambulation
• less nausea, fatigue, somnolens
• less urinary retention
• faster discharge (cholecystect).
• ---------------
• same pain relief

Stahlgren L et al. Clin Ther 199315570-80
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Post-operative bleeding, tonsillectomy

• Blood-loss
• 2.2 ml/kg after ketorolac per-op.
• 1.3 ml/kg after codeine per- op. Plt0.05
• Splinter WM.Can J An19964356-63
• Major bleeding (intervention)
• 5 out of 49 after ketorolac
• 0 out of 47 after morphine Plt0.05
• Bleeding episodes, 0-24h
• 0.22 episodes per patient after ketorolac
• 0.04 episodes per patient after morphine Plt0.05
• Gunter JB. Anesth Analg 1995811136-41

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Mean Platelet Aggregation Response to Arachidonate
Platelet and Renal Function Study - 027
100
J
P
J
80
J
B
B
J
J
B
B
B
B
J
J
J

B
B
Aggregation (Mean SE)
60
40
P
P
P
P
P
20
P
P







0
4 hr
2 hr
4 hr
6 hr
Baseline
Pre-Dose
2 hr
6 hr
Day 1
Day 7
Change from baseline significantly different
from placebo and parecoxib P lt 0.05 Change
from baseline significantly different from
placebo P lt 0.05
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COX-II SELECTIVE NSAIDS

• no effect on platelets (i.e. bleeding)
• sign.reduced gastrointestinal ulcers
• stronger receptorbinding -gt prolonged effect
• ------------------------------
• still
• risk of renal failure,
• risk of hypertention / heart failure
• ( risk of anaphylactoid reactions ?)
• equiv.-analgesic efficacy (?)
• costs?

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COX-II SELECTIVE NSAIDS

• celecoxib
• rofecoxib
• parecoxib injection -gtvaldecoxib
• valdecoxib
• etoricoxib fast strong (?) durable

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COX-II SELECTIVE NSAIDS

• 226 dental patients, post.op. pain -gtsingle dose
• rofecoxib 50mg celecoxib 200mg ibuprofen
  400mg
• onset time (h) 0.5 1.0 0.4
• peak analg. score 2.8 2.3 2.9
• duration (h) gt24 5.1 8.9
• and sign. different from other groups
• Malmstrom K. Clin Ther 1999211653-63

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New magic bullets?

• Corticosteroids
• Ketamine (NMDA-block)
• Magnesium
• Gabapentin (neuropatic pain ? Acute pain?)

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BETAMETHASONE 8 mg i.m. (B) vs. PLACEBO (P)
(hemorrhoidectomy or osteocynthesis)
(mean SD) Group P(n40)
Group B(n38) VAS 3 h 32 23 19
17 VAS 4 h 28 24 15 18
Verbal Pain Score, 4-24 h post.op
(0-3) 1.9 1.0 1.2 0.1 Nausea or
vomiting 5-24 h () 38
11 Satisfaction, 24 h
(bad/medium/good) 9/9/22 1/5/30
Plt0.05, Plt0.01, Plt 0.001 Aasbø
V, Ræder JC, Grøgaard B. Anesth Analg
199887319-23
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Conclusion Post-operative pain4 GENERAL
PRINCIPLES

• 1) Opioid minimization
• - paracetamol
• - corticosteroid
• - NSAID -gt coxib
• 2) Multimodal approach
• 3) Loco/regional
• 4) Timing
• - before (?) / at emergence
• - adequate throughout post.op. period

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