Acute Post Operative Pain+PATHOS

8/2/2019 Acute Post Operative Pain+PATHOS

http://slidepdf.com/reader/full/acute-post-operative-painpathos 1/33

Acute Post Operative Pain Acute Post Operative Pain

Dr.Magdi Ramzi Iskander

MD, FFARCSI, FIPP

Professor of Anaesthesia & Algesiology

National Cancer Institute

Cairo University















Rationale for Active Treatment of

Post-Operative Pain Relief

Pulmonary function has

improved. Incidence of DVT is lower when epidural

anaesthesia used

Lessening immune suppression Decrease incidence and severity of

phantom limb pain.



Psychological Preparation

Some degree of post-operative pain is

inevitable.

Different choices of post-operative painmanagement.

Established pain is more difficult to

control than new pain.



Methods of Pain Relief Perioperatively

1.NSAID¶s(adult& paediatric)

2.Narcotics

Parentral IM by the clock

IV by continuous infusion

by PCA

3. Regional Block (Single or continuous)

Axillary in forearm surgery

Intercostal for subcostal incision in Cholecystectomy

Ileoinguinal & ileohypogastrlc in inguinal hernia

Thoracic epidural in upper GIT surgery

Lumbar epidural in Lower Limb surgery

Sacral epidural in pelvic operations esp. in children



Patient ± Controlled Analgesia

Avolds delay in administration of pain medication

Proper selection of patients not too old, too

confused, and not for short procedures

Microprocessor controlled pump programming:Requirements

- Dose

- Dose intervals

- Maximum dose per set time

- Back ground infusion rate

Example

Morphine 1 mg/ ml

5 min.10-12 mg/hour

0.5 mg/hour









Lumbar & Thoracic Epidurals

Patients having thoracic or upper abdominal surgery.

Patients having thoracic or upper & lower abdominalsurgery & who have significant pulmonary disease.

Patients having lower limb surgery or vascular by-pass inwhich sympathetic bloc is desirable.

Patients having orthopaedic surgery; e.g. total hip, & totalknee replacement.

Dose:

BUPIVACAINE 0.1%5-15 ml +2 g/ml FENTANYL/hourSide Effects:

Dizziness, nausea, & retention of urine

Indications



Infusion Rate

(ML/ HR)

Bupivacaine Load

(0.25-0.5% ML)

Morphine

Load (MG)

Patient

Age (yrs)

Bupivacaine

0.1%

Morphine 0.05

mg/ mL

Infusion

6-88-12315-44

4-66-8245-65

3-45-7166-75

2-33-60 ± 0.576+

Infusion Rate

(ML/ HR)

Bupivacaine Load

(0.25-0.5% ML)

Morphine

Load (MG)

Patient

Age (yrs)

Bupivacaine

0.1%

Fentanyl

2-5 mcg/ mL

Infusion

6-88-12100-20015-44

4-66-8100-15045-65

3-45-750-10066-75

2-43-625-5076+

Recommended Solutions for Thoracic Epidural Analgesia(Thoracic Epidural Catheters, T6 h T8)



Infusion Rate

(ML/ HR)

Bupivacaine Load

(0.25-0.5% ML)

Morphine

Load (MG)

Patient

Age (yrs)

Bupivacaine

0.1%

Morphine 0.05

mg/ mL

Infusion

6-810-15315-44

4-68-12245-65

3-46-10166-75

2-35-70 ± 0.576+

Infusion Rate

(ML/ HR)

Bupivacaine Load

(0.25-0.5% ML)

Morphine

Load (MG)

Patient

Age (yrs)

Bupivacaine

0.1%

Fentanyl

2-5 mcg/ mL

Infusion

6-1010-15100-20015-44

4-88-12100-15045-65

4-66-1050-10066-75

3-45-75076+

Recommended Solutions for Thoracic Epidural Analgesia(Thoracic Epidural Catheters, T8 h T12)



Preemptive Analgesia

Preventing the establishment of altered central

processing by analgesics (regional or systemic) that

covers incisional (intraoperative) and inflammatory

(postoperative) is clinically fruitful.

Maximal clinical benefit is observed when there is

complete blockade of noxious stimuli, with extensionof this block into the postoperative period.



Paediatric Patients

Children do feel, but cannot easily quantify their pain.

Rectal administration of acetaminophen at a higher

dose 40 mg/ kg followed by 3 doses of 20 mg/ kg at 6

hours interval result into proper serum analgesic

level.

Epidural through caudal approach with catheterdeposition in the proper dermatome (advanced easily

cephalad) is very effective.





This picture was coloured in by

AN YOU COLOUR IN THIS PICTURE OF HERBIE AND HIS FRIEND DR OWL?



Paediatric Sacral Epidural

Indication:

All pelvic and lower abdominal surgery

Analgesic Dose: 0.056 ml / segment / kg of 0.25%

BUPIVACAINE .

0.3 ml/ kg of 0.25% BUPIVACAINE

Side Effects:

Nausea, retention of urine,intravascular inject..















Elderly Patients

There is a clinically significant reduction in theintensity of pain perception or symptoms with

increasing age ± due to decrease in A and C-fiber

nociceptive function ± resulting into delay in central

sensitization, increase in pain thresholds and decreasein sensitivity to low intensity noxious stimuli.

Postoperative delirium is among the devastating

complications in the elderly:

- Uncontrolled postoperative pain may be a

contributing factor.

- Higher pain scores predict a decline in mental status

& an increased risk of delirium.







INPOS T ANAES TH. RECOVERY SCORE

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

43

21

Respirations:Able to breathe deeply & coughAble to breathe adequately

Limited respirationApnoea

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

Activity:No impaired muscle activityAble to move as directedLimited MobilityUnable to move

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

Color:

Normal for patientPale/ flushedDusky ² blotchyCyanotic

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

Circulation:B.P.=Pre-anaes. B.P +/- 20mm HgB.P.=Pre-anaes. B.P +/- 30mm HgB.P.=Pre-anaes. B.P +/- 40mm HgB.P.=Pre-anaes. B.P +/- 50mm Hg

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

4321

Consciousness:Awake & alertSleepyResponds to stimuliNo responding

Recovery score totals



Documents

Acute Post Operative Pain+PATHOS