acute and chronic pain.pptx

7/25/2019 acute and chronic pain.pptx

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History

Dr Mehran Rezvani pain fellowship anesthesiologist& acupuncturist


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Acute E+ects

Attenuation of postoperative pain4 especially withtypes

of analgesic regi.ens4 .ay $ecrease perioperativ.or,i$ity an$

Mortality



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!he $o.inant neuroen$ocrine responses to pain i

Hypothala.icpituitary2a$renocortical

8y.pathoa$renal interactions



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!he stress response .ay also potentiate postopei..unosuppression3the e6tent of which correlates with the sesurgical in-ury 5

Hyperglyce.iafro. the stress response .ay co

to poor woun$ healing an$ $epression of i..unfunction



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8y.pathetic activation

Myocar$ial o6ygen consu.ption

Myocar$ial o6ygen supply

Paralytic ileus



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Nociceptors activation9

'2 Postoperative respiratory function is .ar%e$ly $ecre3 especially after upper a,$o.inal an$ thoracic surgery5

8pinal re/e6 inhi,ition of phrenic nerve activity is an ico.ponent of this $ecrease$ postoperative pul.onary

function

=2 postoperative pain is also i.portant ,ecause patien

.ay ,reathe less $eeply4 have an ina$e>uate cough4 a.ore suscepti,le to the $evelop.ent of postoperativepul.onary co.plications

?2 Initiate spinal re/e6 inhi,ition of gastrointestinal tra

function an$ $elay return of gastrointestinal .otility



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Preventive Analgesia



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Many options are availa,le for the treat.ent ofpostoperative pain9

8yste.ic 3ie4 opioi$an$ nonopioi$5 analgesics

Regional 3ie4 neura6ial an$ peripheral5 analgesictechni>ues



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Atropa .an$ragor



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Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist


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& acupuncturist


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P7A is ,ase$ on the pre.ise that a negative2fee$loop e6ists when pain is e6perience$4 analgesic.e$ication is self2a$.inistere$4 an$ when pain isre$uce$4 there are no further $e.an$s


& acupuncturist


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Although the opti.al $e.an$ $ose is uncertain4 tavaila,le suggest that the opti.al $e.an$ $ose i

' .g for .orphine an$ JB Kg for fentanyl in opioipatients however4 the actual $ose for fentanyl 3'Kg5 is often less in clinical practice


& acupuncturist


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When co.pare$ with tra$itional PRN analgesic re

Intravenous P7A provi$es superior postoperativeanalgesia

an$ i.proves patient satisfaction4 ,ut it is uncleawhether

intravenous P7A can provi$e any econo.ic ,ene"


& acupuncturist


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!he inci$ence of opioi$2relate$ a$verse events frointravenous

P7A $oes not see. to $i+er signi"cantly fro. thaopioi$s a$.inistere$ intravenously4 intra.usculasu,cutaneously

!he rate of respiratory $epression associate$ withintravenous P7A is low 3LB*C5an$ $oes not app,e higher than that with PRN syste.ic or neura6iopioi$s Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist


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; t f i t $ i ith i i$


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;actors for respiratory $epression with opioi$

se of a ,ac%groun$ infusion

A$vance$ age

7onco.itant a$.inistration of se$ative or hypnotic age

7oe6isting pul.onary $isease such as sleep apnea

Errors in progra..ing or a$.inistration 3ie4 operator e


& acupuncturist


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N8AID8


& acupuncturist

Nonsteroi$al Anti in/a..atory


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Nonsteroi$al Anti2in/a..atoryAgents!he pri.ary .echanis. ,y which N8AIDs e6ert thanalgesic e+ect is through inhi,ition of cycloo6yg37O5 an$ synthesis of prostaglan$ins4 which arei.portant .e$iators of peripheral sensitization anhyperalgesia

N8AIDs can also e6ert their analgesic e+ects throinhi,ition of spinal 7O


& acupuncturist


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!he $iscovery of at least two 7O isofor.s 3ie4 7constitutive an$ 7O2= is in$uci,le5 with $i+erentfunctions 3ie4 7O2' participates

in platelet aggregation4 he.ostasis4 an$ gastric .

protection4 whereas 7O2= participates in pain4

in/a..ation4an$ fever5 has le$ to the $evelop.ent of selectiveinhi,itors


& acupuncturist


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!he $iscovery of a 7O2? variant .ay represent apri.ary central .echanis.,y which aceta.inopother antipyretics $ecrease pain an$ fever

se$ as a sole agent4 N8AIDs generally provi$e e

analgesia for .il$ to .o$erate pain


& acupuncturist


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& acupuncturist


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Perioperative use of N8AIDs is associatwith a nu.,er of si$e e+ects9

Decrease$ he.ostasisRenal $ysfunction

Gastrointestinal he.orrhage

Deleterious e+ects on ,one healing a

osteogenesis


& acupuncturist


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Perioperative N8AID2in$uce$ renal in high2ris%pat

Hypovole.ia

A,nor.al renal function

A,nor.al seru. electrolyte


& acupuncturist


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N8AIDs .ay cause a clinically uni.portransient re$uction in renal function inearly postoperative perio$ in patientsnor.al preoperative renal function 3M$%%


& acupuncturist


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!here $oes notappear to ,e a ,ene"t in usin= inhi,itors instea$ of tra$itional nonselectiv

N8AIDs in re$ucing the inci$ence of renalco.plications

Preli.inary evi$ence suggests that 7O2= in

.ay ,e an alternative when atte.pting to avthe $etri.entale+ects of nonselective N8AID,one

healing


& acupuncturist


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Fronchospas. .ay ,e in$uce$ ,y N8A3inclu$ing aspirin5 or aceta.inophen

!here .ay ,e cross2sensitivity withaceta.inophen in aspirin sensitiveasth.atic su,-ects


& acupuncturist

7O2= inhi,itors are associate$ with a lower inci$


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7O = inhi,itors are associate$ with a lowerinci$gastrointestinal co.plications an$ e6hi,it .ini.aplatelet inhi,ition4 even when a$.inistere$ insupratherapeutic $oses

:ong2ter. use of 7O2= inhi,itors has ,een assocwith e6cess car$iovascular ris% such that rofeco6i

with$rawn fro. the .ar%et


& acupuncturist


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Although car$iovascular to6icity appears to ,e a c

e+ect of all 7O2= inhi,itors4 the car$iovascular ri7O2= inhi,itors appear to ,e heterogeneousan$in/uence$ ,y .any factors such as the speci"c.e$ication4 $osage4 an$ patient characteristics


& acupuncturist


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!he use of pareco6i, an$ val$eco6i,a7AFG was associate$ with an increaseinci$ence of car$iovascular events4 thearousing serious concern a,out the use

these $rugs in such circu.stances


& acupuncturist


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Ga,apentanoi$s3 only Miller =B'*5


& acupuncturist


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ral ga,apentin i.proves the analgesecacy of opioi$s ,oth at restan$ wit.ove.ent4 an$ re$uces opioi$ consu.an$ opioi$2relate$ si$e e+ects4 ,ut wit

increase$ inci$ence of si$e e+ects sucse$ation an$ $izziness


& acupuncturist


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Ga,apentin an$ prega,alin4 antiepileptic $rugs al

in the treat.ent of neuropathic pain

ral prega,alin is a,sor,e$ .ore rapi$ly an$ hasa,solute ,ioavaila,ility3(BC versus L)BC5 tha

ga,apentin



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A .eta2analysis 9

se of prega,alin was associate$ with a $ecrease

consu.ption an$ opioi$2relate$ si$e e+ects4 ,ut n$i+erence in pain intensity

Another .eta2analysis 9

Perioperative a$.inistration of prega,alin .ay pro

a$$itional analgesia in the short ter. ,ut also resuan increasein si$e e+ects such as$izzinessQlighthea$e$nessor visual $istur,ances



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Perioperative a$.inistration ofga,apentin an$ prega,alin .ay rethe inci$ence of 7P8P

37P8P 7hronic postsurgical pain



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#Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist


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SE!AMINE



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se of low2$ose %eta.ine for postoperative analg

$evelope$

NMDA2antagonisticproperties4 .ay ,e i.portant attenuating central sensitization an$ opioi$ tolera

Race.ic.i6tures of %eta.ine have ,een foun$ toneuroto6ic4an$ therefore the use of neura6ial %etis $iscourage$



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Perioperative %eta.ine re$uce$ =J2hour P7A .or

consu.ption an$ postoperativenausea or vo.iti

low2$ose %eta.ine infusion $oes not appear to cahallucinations orcognitive i.pair.ent4 an$ the in

of si$e e+ects4 such as $izziness4 itching4 nausea4vo.iting $onTt change



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!RAMAD:



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!ra.a$ol was launche$ an$ .ar%ete$ !ra.al ,y the Ger.an phar.aceuticalco.pany GrUnenthal G.,H in '( inGer.any4 an$ =B years later it was lauin countries such as the S4 84 an$Australia



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!ra.a$ol is a synthetic opioi$ that e6hi,its wea%

agonist activity an$ inhi,its reupta%e of serotoninnorepinephrine

Although tra.a$ol e6erts its analgesic e+ects prithrough

central .echanis.s4 it .ay have peripheral localanesthetic properties



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!ra.a$ol is e+ective in treating .o$erate

postoperative

Pain

7o.para,le in analgesic ecacy to aspirin.g5 with co$eine 3)B .g5 or i,uprofen 3JBB



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It is often co.,ine$ with paraceta.ol 3aceta.inophen

is %nown to i.prove the ecacy of tra.a$ol in relievin

!ra.a$ol is .eta,olise$ to 2$es.ethyltra.a$ol4 whic.ore potent opioi$

!he a$$ition of aceta.inophen to tra.a$ol 3versus traalone5 .ay $ecrease the inci$ence of tra.a$olTs si$e ewithout

re$ucing its analgesic ecacy 3Miller =B'*5



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Miller =B'*9

se of tra.a$ol in intravenous P7A results in si.scores when co.pare$ with that fro. intravenouopioi$s

however4 the si$e e+ect pro"le is $i+erent ,etweetwo groups 3ie4a.ore fre>uent inci$ence ofpostoperative nauseaQvo.iting

,ut lower pruritus with tra.a$ol5Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist


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A$vantages of tra.a$ol for postoperative analges

inclu$eRelativelac% of respiratory $epression

lac% of .a-or organ to6icity

lac% of $epression of gastrointestinal .otility

low potential for a,use



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7o..on si$e e+ects 3overall inci$ence of ')C to

inclu$eDizziness

Drowsiness

8weating

Nausea & vo.iting

Dry .outh

Hea$ache



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!ra.a$olshoul$ ,e use$ with caution in patients wseizures or increase$ intracranial pressure

!ra.a$olis contrain$icate$in those ta%ing .onoa.o6i$ase

inhi,itors



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!ra.a$ol is reco..en$e$ for the .anage.ent

in ",ro.yalgia ,y the European :eague AgainstRheu.atis.

Analgesic e+ects are only partially reverse$ ,y n



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Dosage 9

A$ult9 *B2'BB .g >)h po 3 in renal failure >'=h5

Ma6 $ose 9 JBB .g Q$ay or 3=BB .gQ$ay if creatclearance is L ?B .lQ.in5



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In Iran availa,le9

!a,let 9 *B & 'BB .g

!a,let 9 'BB3slow release5

7ap 9 *B .g

In-ction *B .g Q.l 3= .l5



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In general4 the analgesia provi$e$ ,y epi$ural an

peripheral techni>ues 3particularly when localanesthetics are use$5 is superior

to that with syste.ic opioi$s

se of these techni>ues .ay even re$uce .or,i$.ortality



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8ingle2Dose Neura6ial pioi$s



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A$.inistration of a single $ose of opioi$ .ay ,e

ecacious as a sole or a$-uvant analgesic agent wa$.inistere$ intrathecally or epi$urally

:ipophilicity or Hy$rophilicity ###


Hy$rophilic opioi$s 3ie4 .orphine an$hy$ro.orphone5 ten$ to re.ain within


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hy$ro.orphone5 ten$ to re.ain within78; an$ pro$uce a $elaye$ ,ut longer

$uration of analgesia4 along with a genhigher inci$ence of si$e e+ects ,ecausthe cephalic or supraspinal sprea$ of tco.poun$s



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se of a single2$ose hy$rophilic opioi$, i ll h l f l i i$i


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,e especially helpful in provi$ingpostoperative epi$ural analgesia when

epi$ural catheterTs location is not congwith the surgical incision 3eg4 lu.,arepi$ural catheter for thoracic surgery5



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An e6ten$e$2release for.ulation of 3single2$ose5

.orphine encapsulate$ within liposo.es that resup toJ

hours of analgesia has recently ,een intro$uce$

7oncurrenta$.inistration of liposo.al e6ten$e$2.orphinean$ local anesthetics .ay increase peaconcentrationsof .orphine



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!he .anufacturer has reco..en$e$ that clinicia

increase the interval ,etween a$.inistration of loanesthetic 3inclu$ing test $oses5 an$ liposo.al e6release .orphine to at least '* .inutes

to .ini.ize this phar.aco%inetic interaction

It shoul$ ,e a$.inistere$ within J hours after witfro. the vial



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:fgren & :un$>vist


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& acupuncturist


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Hor$eu. vulgare



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Analgesia $elivere$ through an in$welling epi$ura

catheter is a safe an$ e+ective .etho$ for .anagof acute postoperative pain



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It is i.portant to

realize that intraoperative use of the epi$ural catpart of

a co.,ine$ epi$ural2general anesthetic techni>uein less

pain an$ faster patient recovery i..e$iately aftesurgery than

general anesthesia followe$ ,y syste.ic opioi$s $



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Analgesic Drugs in Epi$ural infus



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Epi$ural infusion of local anesthetic alone is less e

in controlling pain 3in co.pare to local anestheticepi$ural analgesic co.,inations5

!he precise location of action of local anesthetics epi$ural space is not clear4 an$ potential sitesincspinal nerve roots4 $orsal root ganglion4 or spinal itself



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!he soleuse of local anesthetics is less

co..on than the use of a local anesthopioi$ co.,ination ,ecause of a signi"failure rate 3fro. regression of sensory,loc%a$e an$ ina$e>uate analgesia5 an

relatively high inci$ence of .otor ,lochypotension



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pioi$s for Epi$ural Infusio



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pioi$s.ay ,e use$ alone for postoperative epi$

infusion an$ $o not generally cause .otor ,loc% ohypotension fro. sy.pathetic ,loc%a$e


!he analgesic site of action 3spinal ersus s ste.


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!he analgesic site of action 3spinal versus syste.continuous epi$ural infusion of lipophilic opioi$s i

clear4 although several ran$o.ize$ clinical trials sthat it is syste.ic

!here were no $i+erencesin plas.a concentratio

e+ects4 or pain scores ,etween those who receiveintravenous or epi$ural infusion of fentanyl



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!he overall a$vantage of a$.inisteringcontinuouepi$ural infusion of

lipophilic opioi$s alone is .arginal



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!he analgesic site of action for continu

hy$rophilic opioi$ infusion is pri.arily

se of a continuous infusion rather thainter.ittent ,oluses of epi$ural .orph.ay result in superior analgesia with fesi$e e+ects



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:ocal AnestheticXpioi$

7o.,inations



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8uperior postoperative analgesia

3inclu$ing i.prove$ $yna.ic pain relli.its regression of sensory ,loc%a$e

possi,ly $ecreases the $ose of localanesthetic a$.inistere$


7 i $ f i


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7oncentrations use$ for postoperative

epi$ural analgesia 3YB'=*C ,upivacor levo,upivacaine or YB=C ropivacaare lower than those use$ forintraoperative anesthesia


Many clinicians prefer a lipophilic opioi3fentanyl4 = to * KgQ.:4 or sufentanil4 B' Q :5 t ll i$ tit ti f


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' KgQ.:5 to allow rapi$ titration of ana

se of a hy$rophilic opioi$ 3.orphine4 to B' .gQ.:5 as part of a local anesthopioi$ epi$ural analgesic regi.en .ayprovi$e e+ective postoperative analge


A$- t D


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A$-uvant Drugs


cloni$ine 3* to =B VgQhr5

Ris%s9


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Hypotension 3$ose $epen$ent5

Fra$ycar$ia 33$ose $epen$ent5

8e$ation

Other drugs:

Epinephrine 3= to * VgQ.l5

Seta.ine #


: ti f 7 th t I t


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:ocation of 7atheter Insert


Insertion of the epi$ural catheter congruent to theincisional $er.ato.e 9


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pti.al postoperative epi$ural analgesia

Mini.izing si$e e+ects 3eg4 lower e6tre.ity .oan$ urinary retention5

Decreasing .or,i$ity

:ower $rug re>uire.ents

Decrease$ .e$ication2relate$ si$e e+ects


:u.,ar epi$ural catheters9

Higher inci$ence of lower e6tre.ity .otor ,loc%


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Higher inci$ence of lower e6tre.ity .otor ,loc%

Earlier2than2anticipate$ ter.ination of epi$uralanalgesia

High thoracic epi$ural

Does not inhi,it sy.pathetic nerve activity in th

e6tre.ities4 3!( to :'5


se of thoracic epi$ural analgesia for a,$o.inal o


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se of thoracic epi$ural analgesiafor a,$o.inal othoracic surgery .ay result in a relatively low incof urinary Retention

Place.ent of thoracic epi$ural catheters appearsrelatively

safe4 an$ there is no evi$ence of a higher inci$enneurologic co.plications with place.ent of a tho3versus lu.,ar5 epi$ural catheter


RECOMMENDED CATHETER INSERTION SITESSURGICAL PROCEDURES:ocation of Incision E6a.ples of 8urgical Proce$ures Epi$

Plac

!horacic :ung re$uction !J2


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!horacic :ung re$uction4Ra$ical .astecto.y4 thoracoto.y4 thy.ecto.y

!J

pper a,$o.inal 7holecystecto.y4 esophagecto.y4 gastrecto.y4hepatic resection4 Whipple proce$ure

!)2

Mi$$le a,$o.inal 7ystoprostatecto.y4 nephrecto.y !2'

:ower a,$o.inal A,$o.inal aortic aneurys. repair4 colecto.yRa$ical prostatecto.y4

!otal a,$o.inal hysterecto.y

!2

:ower e6tre.ity ;e.oral2popliteal ,ypass4 total hip or total %neereplace.ent

:'2J


8i$e E+ects of Neura6ia


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8i$e E+ects of Neura6ia

Analgesic Drugs


Hypotension

Inci$ence of postoperative hypotension with


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Inci$ence of postoperative hypotension withpostoperative epi$ural analgesia .ay ,e as high

the average .ay ,e BC to ?C

oDecreasing the overall $ose of local anesthetica$.inistere$

oInfusing an opioi$ epi$ural alone

o!reating the un$erlying cause of the $ecrease inpressure


Motor Floc%

Inci$ence of lower e6tre.ity .otor ,loc% is =C to


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Inci$ence of lower e6tre.ity .otor ,loc% is=C topatients

!his .ay lea$ to the $evelop.ent of pressure sorthe heels

A lower concentration of local anesthetic

7atheter2incisionXcongruentplace.ent of epi$ucatheters


Motor Floc%

Motor ,loc% resolves in .ost cases after stoppin


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Motor ,loc% resolves in .ost cases after stoppinepi$ural infusion for appro6i.ately = hours

Persistent or increasing .otor ,loc% shoul$ ,eevaluate$ pro.ptly9

8pinal he.ato.a

8pinal a,scess

Intrathecal catheter .igration


Nausea an$


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Neura6ial a$.inistration of single $ose opioi$ oc=BC to *BC

Neura6ial opioi$Xrelate$ nausea an$ vo.iting is$epen$ent

se of epi$uralfentanyl infusion is associate$ wlower inci$ence of nausea an$ vo.iting than infof .orphine


Nausea an$


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Nalo6one

Droperi$ol

Metoclopra.i$e

De6a.ethasone

n$ansetron

!rans$er.al scopola.ine


PruritusPruritus is one of the .ost co..on si$e+ects of epi$ural or intrathecal


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a$.inistration of opioi$s4 with an inci$e

of appro6i.ately )BC versus a,out '*C'C for epi$ural local anesthetica$.inistration or syste.ic opioi$s

;entanyl appears have lower inci$encepruritus than .orphine



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Respiratory Depression


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Respiratory Depression


Neura6ial opioi$s use$ in appropriate $oses are n


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associate$ with a higher inci$ence of respiratory

$epression than that seen with syste.ic opioi$s

Inci$ence for Neura6ial opioi$s B'C to B(C

Neura6ial lipophilic opioi$s are thought to cause

$elaye$ respiratory $epression thanhy$rophilic


Delaye$ respiratory $epression is pri.arily


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y p y p p yassociate$ with the cephala$ sprea$ ofhy$rophilic opioi$s4 which typically occurs w'= hours after in-ection of .orphine

7linical assess.ents4 such as the respirato.ay not relia,ly pre$icta patientTs ventilatstatus or i.pen$ing respiratory $epression


Ris%s factors

Increasing $ose


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Increasing age

conco.itant use of syste.ic opioi$s or se$ative

Possi,ly prolonge$or e6tensive surgery

!he presence of co.or,i$ con$itions 3eg4 o,structiapnea5

!horacic surgery


!reat.ent9


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Nalo6one 3an$ airway .anage.ent if necessary

B'2 to BJ2.g incre.ents

7ontinuous infusion of nalo6one 3B* to * VgQ%gQ,e nee$e$


Although perioperative single2$ose e6ten$e$2rele


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epi$ural .orphine3versus intravenous opioi$ P7A

,e e+ective for postoperative pain relief for up to hours4 respiratory $epression .ay ,e .ore li%ely


rinary Retention

rinary retention associate$ with the neura6ial$ i i t ti f i i$ i th lt f i t


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a$.inistration of opioi$s is the result of an inter

with opioi$ receptors in the spinal cor$ that $ecrthe $etrusor .uscleTs strength of contraction

rinary retention $oes not appear to $epen$ on opioi$ $ose an$

se of low2$ose nalo6one4 though at the ris% ofreversing the analgesic e+ect .ay ,e useful


rinary Retention

Epi$ural a$.inistration of local anesthetics is alsoi t $ ith i t ti ith t $


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associate$ with urinary retention4 with a reporte$

appro6i.ately 'BC to ?BC

Higher epi$ural infusion rates of local anestheticsgreater e6tent of sensory ,loc% an$ a higher inci$

.otor ,loc%5 .ay ,e associate$ with a higher incof urinary retention



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Atropa ,ella$onna


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Atropa ,ella$onna



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!rige.inal Nerve Floc%


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g



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ANA!MZ



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A gasserian ganglion ,loc%4 approache$ classicallthrough


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through

the fora.en ovale4 is infre>uently use$ for pro$ucsurgical

anesthesia

In the past4 it was pri.arily applie$ for the $iagno

treat.entof trige.inal neuralgia however4 theincreasing

popularity an$ safety of ther.ocoagulation for a,of the Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist


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?J ol$ year Q .ale Q with J2* year


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sharp pain in .an$i,ular an$ .a6$er.ato. Qall$ynia \Q responsi,leprega,alin



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8IDE E;;E7!8 AND 7MP:I7A!I

8u,scleral he.ato.a of the eye are co..on se

!otal spinal anesthesia


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p

7orneal anesthesia

Postproce$ure $ysesthesia

wea%ness of the .uscles of .astication an$ facasy..etry


;A7IA: 8SIN ANE8!HE8


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;or re.oving a nevus on the chee% as in the pictuwhich nerve .ust ,e ,loc%e$#


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'28upratrochlear Nerves =2suprala,ial nerve

?2 Infraor,ital nerve

J2Ma6illary nerve


Infraor,ital Nerve

!he infraor,ital nerve can ,e ,loc%e$ to provi$eanesthesia of the


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upper lip an$ s%in of the chee%



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8upraor,ital an$ 8upratroch


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Nerves


8upraor,ital an$ 8upratrochlea

Nerves

!he supraor,ital notch can easily ,e palpate$

!his lan$.ar% lies on a vertical line with the pupi


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A =*2gauge4 =2c. nee$le is inserte$ i..e$iatelysuperior to the supraor,ital notch4 an$ = to J .:anesthetic solution

is in-ecte$

!he supratrochlear nerve can ,e ,loc%e$ ,y e6tenthe supraor,ital in-ection site .e$ially with an a$= to J .: of solution



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Mental Nerve


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Floc%a$e of the .ental nerve as it e6its the .entfora.en provi$es


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anesthesia to the lower lip an$ chin

!he fora.en is palpate$ in the .an$i,le4 an$ a =gauge4 ?2c. nee$le is inserte$ infero.e$ially In"

of = to J .: of solution afterelicitation of a paresthesia or in the region of the results

in anesthesia of the .ental nerveDr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist


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& acupuncturist

8tellate Ganglion Floc


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!he patient lies supine with the nec% e6ten$e$ sli

!he .ost pro.inent cervical transverse process[7hassaignac tu,ercle 37)5[is palpate$ ,etween t


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sternoclei$o.astoi$ .uscle an$ the trachea

!he 7) tu,ercle is palpate$ ,etween the in$e6 an.i$$le "ngers an$ the caroti$ artery is pushe$ la


A ==2 gauge4 J2c. short2,evele$ nee$le with a '=syringe attache$ is inserte$ in a perpen$icular $ir


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until the tip contacts the 7) transverse process

!he nee$le is then with$rawn ? .. an$ "6e$ Aftcareful aspiration4 to '= .: of local anesthetic sis in-ecte$


8igns of a successful stellate ganglion ,loc% 9

HornerTs syn$ro.e


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Anhi$rosis

In-ection of the con-unctiva

Nasal stuness


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8i$e E+ects an$ 7o.plicationsFloc% of the ,rachial ple6us

Floc% of recurrent laryngeal nerves


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He.ato.a for.ation

Intravascular In-ection resulting in convulsions

Epi$ural an$ su,arachnoi$ in-ection


7


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7ase report



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7eliac Ple6us Floc%


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!he ple6us lies in close relation to the :' verte,

!he vena cava lies anteriorly to the right4 an$ onanteriorly is the aorta

!he %i$neys lie laterally with the pancreas ante


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!he %i$neys lie laterally4 with the pancreas ante

!he nu.,er of ganglia varies fro. one to "ve4 aganglion is B* to J* c. in $ia.eter

:eft2si$e$ ganglia are usually lower than those oright



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A =B2gauge4 'B2 to '*2c. nee$le is inserte$ on tsi$e

!hrough a s%in wheal at a J* $egree angle towa


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!hrough a s%in wheal at a J*2$egree angle towa,o$y of !'= or :'

Fone contact shoul$ ,e .a$e at an average $ep

( c.



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8i$e E+ects an$ 7o.plications Hypotension

8pinal or epi$ural in-ection

Intravascular in-ection Pneu.othora6


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Pneu.othora6

Puncture of viscera 3%i$ney4 ureter4 or gut]5

Retroperitoneal he.ato.a


7ase report '


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7ase report =


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Di+erent case reports


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Patient27ontrolle$ Epi$uraAnalgesia


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;or P7EAas 7EI4 a$$ition of an opioi$ to the localanesthetic can provi$e analgesia superior to that either agent alone

A lipophilic opioi$ is usually chosen ,ecause its ra


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A lipophilic opioi$ is usually chosen ,ecause its raanalgesic e+ect an$ shorter $uration of action .a.ore suita,le for use with P7EA



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acute and chronic pain.pptx