The%20Post%20Anesthesia%20Care%20Unit

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Lecture Title Acute Pain Management
Lecture date
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Lecture Objectives..

• Students at the end of the lecture will be able
  to
• Learn a common approach to emergency medical
  problems encountered in the postoperative period.
• Study post-operative respiratory and hemodynamic
  problems and understand how to manage these
  problems.
• Learn about the predisposing factors,
  differential diagnosis and management of PONV.
• Understand the causes and treatments of
  post-operative agitation and delirium.
• Learn about the causes of delayed emergence and
  know how to deal with this problem.
• Learn about different approaches of
  post-Operative pain management

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Postoperative care- Post Anesthesia Care
UnitPACU
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PACU

• Design should match function
• Location
• Close to the OR.
• Access to x-ray, blood bank clinical labs.
• Monitoring equipment
• Emergency equipment
• Personnel

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Admission to PACU

• Steps
• Coordinate prior to arrival,
• Assess airway,
• Administer oxygen,
• Apply monitors,
• Obtain vital signs,
• Receive report from anesthesia personnel.

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PACU - ASA Standards

• Standard I
• All patients should receive appropriate care
• Standard II
• All patients will be accompanied by one of
  anesthesia team
• Standard III
• The patient will be reevaluated report given to
  the nurse
• Standard IV
• The patient shall be continually monitored in the
  PACU
• Standard V
• A physician will signing for the patient out of
  the PACU

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Patient Care in the PACU

• Admission
• Apply oxygen and monitor
• Receive report
• Monitor Observe Manage
• ? To Achieve
• Cardiovascular stability
• Respiratory stability
• Pain control
• Discharge from PACU

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Monitoring in the PACU

• Baseline vital signs.
• Respiration
• RR/min, Rythm
• Pulse oximetry
• Circulation
• PR/min Blood pressure
• ECG
• Level of consciousness
• Pain scores

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Initial Assessment

1. Color
2. Respiration
3. Circulation
4. Consciousness
5. Activity

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Aldrete Score
Score Activity Respiration Circulation Consciousness Oxygen Saturation
2 Moves all extremities Breaths deeply and coughs freely. BP 20 mm of preanesth. level Fully awake Spo2 gt 92 on room air
1 Moves 2 extremities Dyspneic, or shallow breathing BP 20-50 mm of preanesth. level Arousable on calling Spo2 gt90 With suppl. O2
0 Unable to move Apneic BP 50 mm of preanesth. level Not responding Spo2 lt92 With suppl. O2
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Common PACU Problems

• Airway obstruction
• Hypoxemia
• Hypoventilation
• Hypotension
• Hypertension
• Cardiac dysrhythmias
• Hypothermia

• Bleeding
• Agitation
• Delayed recovery
• PONV
• Pain
• Oliguria

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1. Airway Obstruction

• Most common tongue fall back
• ? posterior pharynx
• May be foreign body
• Inadequate relaxant reversal
• Residual anesthesia

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Management of Airway Obstruction

• Patients stimulation,
• Suction,
• Oral Airway,
• Nasal Airway,
• Others
• Tracheal intubation
• Cricothyroidotomy
• Tracheotomy

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2. Hypoventilation

• Residual anesthesia
• Narcotics
• Inhalation agent
• Muscle Relaxant
• Post oper - Analgesia
• Intravenous
• Epidural

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Treatment of Hypoventilation

• Close observation,
• Assess the problem,
• Treatment of the cause
• Reverse (or Antidote)
• Muscle relaxant ? Neostigmine
• Opioids ? Naloxone
• Midazolam ? Anexate

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3. Hypertension

• Common causes e.g.
• Pain
• Full Bladder
• Hypertensive patients
• Fluid overload
• Excessive use of vasopressors

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Treatment of Hypertension

• Effective pain control
• Sedation
• Anti-hypertensives
• Beta blockers
• Alpha blockers
• Hydralazine (Apresoline)
• Calcium channel blockers

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4. Hypotension

• Decreased venous return
• Hypovolemia,
• ? fluid intake
• ? losses
• Bleeding
• Sympathectomy,
• 3rd space loss,
• Left ventricular dysfunction

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Treatment of Hypotension

• Initially treat with fluid bolus,
• Vasopressors,
• Correction of the cause

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5. Dysrhythmias

• Secondary to
• Hypoxemia
• Hypercarbia
• Hypothermia
• Acidosis
• Catecholamines
• Electrolyte abnormalities.

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Treatment of Dysrhythmia

• Identify and treat the cause,
• Assure oxygenation,
• Pharmacological

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6. Urine Output

• Oliguria
• Hypovolemia,
• Surgical trauma,
• Impaired renal function,
• Mechanical blocking of catheter.
• Treatment
• Assess catheter patency
• Fluid bolus
• Diuretics e.g. Lasix

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7. Post op Bleeding

• Causes
• Usually Surgical Problem,
• Coagulopathy,
• Drug induced

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Treatment of Post op Bleeding

• Treatment
• Start i.v. lines ? push fluids
• Blood sample,
• CBC,
• Cross matching,
• Coagulopathy
• Notify the surgeon,
• Correction of the cause

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8. Hypothermia

• Most of patients will arrive cold
• Treatment
• Get baseline temperature
• Actively rewarm
• Administer oxygen if shivering
• Take care for
• Pediatric,
• Geriatric.

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9. Altered Mental Status

• Reaction to drugs?
• Drugs e.g. sedatives, anticholinergics
• Intoxication / Drug abusers
• Pain
• Full bladder
• Hypoventilation
• Low COP
• CVA

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Treatment of Altered Mental Status

• Reassurances,
• Always protect the patient,
• Evaluate the cause,
• Treatment of symptoms,
• Sedatives / Opioids if necessary.

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10. Delayed Recovery

• Systematic evaluation
• Pre-op status
• Intraoperative events
• Ventilation
• Response to Stimulation
• Cardiovascular status

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Delayed Recovery

• The most common cause
• Residual anesthesia ? Consider reversal
• Hypothermia,
• Metabolic e.g. diabetic coma,
• Underlying psychiatric problem
• CVA

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11. Postoperative Nausea Vomiting PONV

• Risk factors
• Type duration of surgery,
• Type of anesthesia,
• Drugs,
• Hormone levels,
• Medical problems,
• Autonomic involvement.

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Prevention of PONV

• NPO status
• Dexamothasone,
• Droperidol,
• Metoclopramide,
• H2 blockers,
• Ondansetron,
• Acupuncture

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12. Postoperative Pain
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12. Postoperative Pain

• Causes
• Incisional Skin and subcutaneous tissue
• Laparoscopy Insuflation of Co2
• Others
• Deep cutting, coagulation, trauma
• Positional nerve compression, traction bed
  sore.
• IV site needle trauma,
  extravasation, venous irritation
• Tubes drains, nasogastric tube,
  ETT
• Surgical complication of surgery
• Others cast, dressing too tight,
  urinary retention

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PAIN MEASUREMENTS
Subjective Objective
Uni-Dimensional Multidimentional Behavioral. Physiological. Neuro-endocrinal. Algometry.
VRS, VAS NRS. Facial expression. McGill P Q, Pain Inventory. Behavioral. Physiological. Neuro-endocrinal. Algometry.
ACUTE PAIN Chronic Pain Both
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Pain Scores
Visual Analogue Scale (VAS) 0
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Numeric Rating Scale (NRS)
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Verbal scale
Wong-Baker Faces Scale
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Pharmaco - Therapy
ACUTE POSTOPERATIVE MANAGEMENT TOOLS
Regional Techniques

• Local infiltration
• Wound perfusion
• Intra-abdominal inj. of LA/Analg.
• Intercostal Interpleural
• Paravertebral
• USG-RA e.g. TAP
• Neuraxial
• Epidural
• Thoracic
• Lumbar
• Spinal
• Single shot
• CSA
• CSE

• Non Opioid Analgesics
• NSAADs
• Analgesic /Antipyretic
• Analgesic/Anti-inflam/Antipyretic
• NSAIDs
• Non-selective COX inhibitors
• Selective COX-2 inhibitors
• Opioids
• Weak Opioids.
• Strong Opioids.
• Mixed agonist-antagonists
• Adjuvants
• ?-2 Agonists
• LA
• SP inhibitors
• NMDA inhibitors
• Anticonvulsant / Antidepressants
• Calcitonin
• Relaxants

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WHO Ladder Updated
WHO IV Interventional
Severe pain (7-10)
WHO III Strong opioids
Adjuvant
Pain Persists or Increases
Moderate pain (4-6)
WHO class II Weak opioids
Adjuvant

• By the mouth
• By the clock
• By the ladder

Mild pain (0-3)
WHO class I NSAIDs
Adjuvant
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WHO (I) Non Opioid Analgesics

• Non Opioid Analgesics
• NSAADs
• Analgesic / Anti-inflam / Antipyretic /
  Anticoagulant
• ASA
• Analgesic /Antipyretic
• Paracetamol
• NSAIDs
• Non-selective COX inhibitors
• Diclofenac Ketoprofen
• Selective COX-2 inhibitors
• Celecoxib Rofecoxib

Severe pain (7-10)
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Scientific Evidence NON OPIOID ANALGESICS

1. Paracetamol
2. is an effective analgesic for acute pain the
   incidence of adverse effects comparable to
   placebo (Level I Cochrane Review).
3. Paracetamol / NSAIDs given in addition to PCA
   Opioids ? ? Opioid consumption (Level I).
4. NSAIDs
5. are effective in the treatment of acute
   postoperative (Level I ).
6. With careful patient selection and monitoring,
   the incidence of renal impairment is low (Level I
   Cochrane Review).
7. NSAIDs Paracetamol improve analgesia compared
   with paracetamol alone (Level I).

Acute Pain Management - Scientific Evidence -
AAGBI Guidelines 2010
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WHO Ladder II - Weak Opioids

• Tramadol
• Tramadol Morphine
• Parenteral 1 10 Oral 1 5
• Dose 200 400 mg/d
• Codeine
• Metabolized to morphine.
• Codeine Morphine 1 10
• Dextro-propoxyphene
• Methadone Derivative
• Prolongation of Q-T interval.

Severe pain (7-10)
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Scientific Evidence WEAK OPIOIDS

• Tramadol
• has a lower risk of respiratory depression
  impairs GIT motor function lt other opioids
• (Level II).
• is an effective treatment for neuropathic pain
• (Level I Cochrane Review).
• Dextropropoxyphene
• has low analgesic efficacy
• (Level I Cochrane Review).

Acute Pain Management - Scientific Evidence -
AAGBI Guidelines 2010
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WHO Ladder III - Strong Opioids

1. Morphine
2. Sedation
3. PONV
4. Respiratory Depression
5. Fentanyl
6. Rapid action, Short duration.
7. Fentanyl Mophine (110)
8. Pethidene
9. Active metabolite ? t½ .
10. Prolongs Q-T interval.
11. Pethidine Mophine (110)
12. Hydromorphone
13. Powerful, rapidly acting.
14. Release is in distal gut.
15. Hydromorphone Morphine 1 5

Severe pain (7-10)
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WHO Ladder IV Regional Anesthetic Techniques

• Local infiltration
• Wound perfusion
• Intra-abdominal LA
• Intercostal
• Interpleural
• Paravertebral
• USG - RA e.g. TAP
• Neuraxial
• Epidural
• Thoracic
• Lumbar
• Spinal
• Single shot
• CSA
• CSE

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Neuraxial (Spinal / Epidural)(LA / Opioids /
others)

• Advantages
• Provide prolonged effective analgesia
• Side effects
• Respiratory depression.
• N/V.
• Pruritis.
• Urinary retention.

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WHO Algorithm for Management of Pain

• Multidisciplinary
• Adjuvant therapy.
• Psychotherapy.
• Physioltherapy.
• Causal diag. ttt.

Neuraxial LA Opioids
WHO III Strong opioids
Plexus block
Paravertebral / PNB
WHO class II Weak opioids
Non-pharmacological
LA infiltration
WHO class I NSAIDs
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Management Algorithm for Postoperative Pain
Diagnosis
Preventive / Preemptive
Procedure Specific Pain manag.
Pain Assessment
ttt of Pain and Co morbidities
1ry Treatment
Supportive Treatment
Psychological ttt.
Pharmacotherapy
Physical / Rehab.
Interventional
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PACU Discharge Criteria

• Fully Awake,
• Patent airway,
• Good respiratory function,
• Stable vital signs,
• Patency of tubes, catheters, IVs
• Pain free,
• Reassurance of surgical site.

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Postanesthesia Discharge Scoring System
Vital Signs (PR ABP) Activity PONV Pain Surgical Bleeding
2 Within 20 of preoperative baseline 2 Steady gait, no dizziness 2 Minimal treat with PO meds 2 Acceptable control per the patient controlled with PO meds 2 Minimal no dressing changes required
1 20-40 of preoperative baseline 1 Requires assistance 1 Moderate treat with IM medications 1 Not acceptable to the patient not controlled with PO meds 1 Moderate up to 2 dressing changes
0 gt40 of preoperative baseline 0 Unable to ambulate 0 Continues repeated treatment 0 Severe Uncontrolled pain 0 Severe more than 3 dressing changes
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Reference book and the relevant page numbers..
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Thank You ?

• Dr.
• Date