Outline

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?????????????????????

• ????? ????????????

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Outline

• Pain pathway
• ??????????????????????????
• ??????????????????????????????????????????????????
  
• Pain assessment
• Drugs dose route

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central sensitization

• substance P
• calcitonin
• gene-related peptide

• Histamine
• Bradykinin
• Prostaglandins
• Nerve growth factor

Peripheral sensitization
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Pathophysiology of pain

• Systematic responses to surgery
• Sympathetic nervous system activation
• Neuroendocrine stress response
• Immunologicinflammatory changes
• Physiological disturbances
• Cardiovascular increased heart rate, blood
  pressure
• Gastrointestinal ileus
• Pulmonary decreased lung volumes
• Renal decreased renal blood flow

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?????????????????????????? (ACUTE PHASE)

• Hypercoagulability
• deep vein thrombosis
• vascular graft failure
• myocardial ischemia
• ???????????????????????????
• Hyperglycemia

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?????????????????????????? (ACUTE PHASE)

• Increase sympathetic tone
• CVS
• ?????????????????? O2 ???????
• ????????????????????????????????????????
• ?????????????????????????????????????????

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?????????????????????????? (Acute phase)

• Increase sympathetic tone
• Respiratory system
• phrenic nerve ????????????
• ???????????????????????? ??????????????
• ?????????????????????????????????????
• GI
• paralytic ileus

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Subacute phase
Inadequate pain control
Acute pain ? Chronic pain
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Plan for postop. Pain
Regional / peripheral nerve block
Preemptive analgesia
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??????????????????????????????????????????

• Preemptive analgesia
• Multimodal perioperative management
• Analgesic drugs
• Acetaminophen
• NSAIDs
• Opioids
• Regional / peripheral nerve block

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Pre-operative approach

• Education
• ??????????????????????????????????????????????????
  ?
• Pre-medications
• NSAIDs
• Opioids

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Intra - operative approach

• Systemic opioids during GA
• Regional
• Spinal / epidural block opioids
• Peripheral nerve block
• Local anesthetics
• Wound infiltration

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Post - operative approach

• Regional or peripheral nerve block
• single shot
• intermittent injection
• continuous infusion LA opioid

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POST - OPERATIVE APPROACH

• Systemic drugs
• Opioids
• Strong morphine, pethidine, fentanyl, ect.
• Weak tramadol, codiene
• Non-opioid
• Acetaminophen
• NSAIDs
• Alpha 2 agonist clonidine, dexmedetomidine
• Gabapentin
• Ketamine

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POST - OPERATIVE APPROACH

• Non-opioid
• Acetaminophen
• NSAIDs
• Alpha 2 agonist clonidine, dexmedetomidine
• Gabapentin
• Ketamine

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Acetaminophen

• Actions CNS by inhibit prostaglandin synthetase
  
• For mild pain, fever
• Increase effect when combined with NSAIDs
• Doses 325-1000 mg/ dose

Non-opioid Analgesics Time To Peak Levels (hr) Onset (hr) Half-Life (hr) Duration (hr) Maximum Recommended Daily Dose (mg)
Acetaminophen 0.51 1.4 0.5 24 1,200
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Acetaminophen sulfate / glucoronide
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ACETAMINOPHEN
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Nonsteroidal antiinflammatory drugs (NSAIDs)
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NSAIDS
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NSAIDS
Non-opioid Analgesics Time To Peak Levels (hr) Onset (hr) Half-Life (hr) Duration (hr) Maximum Recommended Daily Dose (mg)
Aspirin/salicylate 0.52 23 0.51 24 3,600
Ibuprofen 12 1.82.5 0.5 46 3,200
Indomethacin 12 4.5 0.5 46 200
Diclofenac 23 2 1 1.6 200
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ketamine

• adjuvant analgesic
• opioid-tolerant patients
• chronic pain or cancer pain
• surgical procedures
• higher incidences of persistent surgical pain
• Thoracotomy
• Mastectomy
• Limb amputations

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Gabapentin

• antihyperanalgesic effects
• Peripheral sodium channel activation
• Binding to a specific calcium channel subunit
• Oral1,200 mg gabapentin preoperative
• decreased opioid requirements
• improved pain scores both at rest and with
  movement (mod. pain sx)

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Dexmedetomidine

• highly selective alpha 2 agonist
• shorter half-life than clonidine
• sedation and analgesia with minimal respiratory
  depression
• infuse 1 hour before the end of surgery and
  continued in PACU
• Lower opioid requirements
• better pain control
• not associated with respiratory depression in the
  morbidly obese patients

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Systemic drugs weak opioids

• Tramadol
• synthetic opioid , weak µ-agonist activity
• inhibits reuptake of serotonin and norepinephrine
  
• effective for moderate pain
• Advantages
• lack of - respiratory depression
• - major organ toxicity
• - depression of gastrointestinal motility
• low potential for abuse
• Dose 100mg, total 600mg/day

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Tramadol

• Common side effects (incidence of 1.6 to 6.1)
• Dizziness , drowsiness , headache
• Sweating, dry mouth
• Nausea, vomiting
• Should be used with caution in
• Patients with seizures
• Increased intracranial pressure
• Contraindicated in
• Patients taking monoamine oxidase inhibitors

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Systemic drugs weak opioids

• Codeine
• Morphine like effect (1/10 )
• Increase dose not increase analgesia but
  increase side effect
• Side effects nausea, vomiting, constipation,
  lightheadedness, dizziness, drowsiness
• Combine with paracetamol increase efficacy

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Post - operative approach

• Systemic drugs opioids

Morphine ( route ) Dose (mg.) Onset (min) Peak effect (min) Duration (hr)
( IV ) 2.515 3-5 20 2-3
(IM) 1015 20 30-90 3-4
(PO) 3060 30-60 12 4
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Post - operative approach

• Systemic drugs

• Systemic drugs opioids

Opioids (route) Dose (mg) Onset (min) Peak effect (min) Duration (hr)
Meperidine (IV) 25-100 1-3 - 2-4
Codeine (IM) 1560 15-30 60 46
Codeine (PO) 1560 15-60 30-120 34
Tramadol (PO) 100 60 120-180 3-6
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Side effects of opioids

• Urinary retention
• Nausea vomiting
• Itching
• Sedation
• Respiratory depression

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????????????? Opioid... ??????? !!!

• ?????????????????? ???????????????????????

1. ?????????? pain score, sedation score
2. ???????????????? ??? O2saturation
3. ???????????????????????????????????????????????
4. Slow titration of opioid
5. ??????? pain score ??? sedation score
   ???????????? 5 ????
6. ??????????????????... ???????????,
   ????????Emergency ????? Naloxone (1-4 mcg/kg
   IV.)

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Sedation Score
Score ???????????????????????
0 ????? ?????????? ???????? ??????????????????????????? ?????????????????????
1 ????? ???????????? ????????????? ???????????? ???????????????????????
2 ????? ??????????????????????????????????? ??????????? ???????????????????????????????????????????????????????
3 ????? ???????????? ????????????????????????? ?????????
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Numeric rating scale

• ?????????????????????????????????? 6 ??- ???????
• ???????????????????????????
• 0 ?????????
• 10 ???? 100 ????????????

???? Pain scale Min-max ?????????????????????????????
6 ?? ?????? NRS 0-10 ????? 5 ?????
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Respiratory depression
Sedation
analgesia
Pain
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MEAC (minimum effective analgesia
concentration)
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Intramuscular injection

• ????? ???????????????
• ??????????? ??????????????????
• ???????????????? hypovolemia, hypothermia,
  hypotension
• ???????
• ??????????????????

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IM. prn.
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IM. around the clock

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Intravenous route?
Dose Interval
Sedation score 2
Pain score 5
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Intravenous infusion

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PCA (patient controlled analgesia)

• ?????
• ??????????????????????????????
• ????????????????????????????????????????
• ???????????
• ??????????????????????????????????
• ???????
• ?????????? ???????, ???????????????????????????,
  ??????????????

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PCA (patient controlled analgesia)
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PCA (patient controlled analgesia)

• Bolus dose, PCA dose ???? demand dose
• ??????/??????1?????
• Lockout Interval
• PCA 1 dose /????????
• Continuous Infusion, background infusion, basal
  rate
• ?????????????????????????????????
• 4-Hr Limit
• ???????????????????????????????????

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PCA (patient controlled analgesia)
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IV and intrathecal opioid

• Intrathecal opioid (spinal / epidural)
• Smaller dose
• Longer duration
• Comparable side effect

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Analgesic drugs

• Strong opioids moderate - severe pain
• Morphine
• Pethidine
• Fentanyl

• Weak opioids
• moderate pain
• Tramadol
• Codiene
• Non opioids
• mild - moderate pain
• NSAIDs
• Acetaminophen

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Intrathecal opioid
Intrathecal opioids Fentanyl, Sufentanil Morphine
????????? ???????????? ????????????????????
?????????????????????????????? ???? (5-10????) ??? (30-60????)
????????????????? ???? (2-4???????) ??? (6-24???????)
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Intrathecal opioid
??????????? fentanyl morphine
???????? ???????
???
?????????? ????????????????????????? ?????????????????? ?????????? ????????????????????????? 6 ???????
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Postoperative Analgesia Among Various Techniques Postoperative Analgesia Among Various Techniques
Epidural analgesia Parenteral opioids IV. PCA.with opioids
Continuous peripheral analgesia Systemic opioids
Continuous epidural infusions Patient-controlled epidural analgesia
Epidural analgesia local anesthetic Epidural analgesia opioids

• Lower PONV and sedation
• Greater risk of pruritus or motor block

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Post - operative approach

• How to give opioids in safe manner?
• How to detect and treat side effect of opioids?

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??????????????????????????????????????????????????

• ????????????????????
• Paracetamol
• 10 15 ??./??. Oral ???6??.
• ????????????? 100 ??./??./???
• ?????????????????????????????????5???
• NSAID (Ibuprofen)
• 6-10 ??./??. Oral ???8??.????????????? 40
  ??./??./???
• Platelet dysfunction and nephrotoxicity

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??????????????????????????????????????????????????

• ?????????? ?????????
• Fentanyl 0.5- 1 ???./??. IV.
• Morphine 0.05-0.1 ??./??. IV.
• Pethidine 0.5-1 ??./??. IV.

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?????????????????????????????????????
???? ????????????????????(?????/????)
0-1 ?? 30
1-3 ?? 25
3-6 ?? 20
6-13 ?? 15
gt13?? 10
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Ambulatory surgical patient

• Discharge criteria
• vital signs ???? , ?????????????,
  ???????????????????????????????,
  ??????????????????????????????????
• multimodal analgesia
• ?????????????, peripheral nerve block, weak
  opioids NSAIDs, acetaminophen
• moderate pain
• decrease side effect

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Elderly patient

• Inadequate pain relief
• ?????????????????????????????????????????
• ????????????????????????????????????
• Common postop. problem delirium associate with
  pain
• Titration technique
• ?????????????????????????????????????????????????
• ?????????????????????????????????????????????????
  ??????????????????????????

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Pediatric patient

• Main problems
• the myths children and infants do not feel
  pain,
• pain is not remembered
• there is no untoward consequence of experiencing
  pain
• communication barrier
• Pain assessment is essential in pediatrics

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?????????????????????????

• ??????????
• ?????????? pain score ??? sedation score
• ???????????????????????????????????????????????
• ??????????????????????????
• ???????????????????????????
• ??????? ??????????????????????????????????????????
  ????????
• ??????????????????????????????????????????????????
  ???????

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Neonatal Infant Pain Scale (NIPS)
???????????????????????????0 1 ??
?????????????????????????????
4 ?????
?????????? 0 ????? 1 ????? 2 ?????
?????? ???? ???? ?????????? ??????? ?????????? ????????? -
??????? ??????? ???????? ????????
???????? ???????? ?????????????/?????/?????????? -
??? ???????? ?? -
?? ???????? ?? / ?????? -
???????????? ???? / ???? ????????????? ??????? -
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Children Hospital of Eastern Ontario Pain Scale
(CHEOPS) ???????????????????????????1 6 ??
?????????????????????????????
8 ?????
?????????? 0 ????? 1 ????? 2 ????? 3 ?????
??????? - ??????? ????,??????? ????????
?????? ???? ??? ??? -
??????????? ?????????????? ?????????? ???????? (???,?????) ?????? ???????? -
?????? (?????) - ?????? ????? ????/?????/???? /???/????????? ?????????? -
????????? - ????????? ???????????/???????/????/ ??????????????????????? -
?? - ??????? ??????/???/????????/?????/???/??????????????????????? -
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????????????????????????????

• Oral medications
• Mild moderate pain
• Regional block / IV analgesics
• Moderate severe pain
• IM is not appropriate
• Afraid of needle
• Keep still.. Report No pain

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Morbid obese obstructive sleep apnea

• High risk to postop. hypoxemia and apnea
• opioids increase risk of respiratory depression
• Recommend to avoid opioids
• Non opioid drugs
• continuous epidural block without opioids
• If !!! Cannot avoid opioids
• titration technique
• Close monitor in ICU during 24 hr. postop.
• Nasal CPAP may be useful

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