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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Post Operative Pain Module
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Key Sections
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Overview of Acute Pain
Physiology of Post Operative Pain
Why is Post Operative Pain management important?
Chronic Post Operative Pain
Assessment Tools
Current Post Operative Pain Management
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Overview of Acute Pain
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Acute pain
Acute pain is caused by injury and/or trauma, infection, or surgery² It has an important warning function to protect us from further damage, and it
supports the healing process after injuries¹ Acute pain has sensory, cognitive and emotional components¹ Acute pain leads to motor reflexes, muscle tension and changes in the
autonomic/sympathetic nervous system¹ Acute pain is limited in time, and its location can be easily assessed¹
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1. Woolf CJ, et al. Ann Intern Med. 2004;140:441-51.2. Cavill G. Pain as a clinical entity. In: Hughes J, ed. Pain Management: from basics to clinical practice. London: Churchill Livingstone Elsevier; 2008
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Pain Classification: Acute - Chronic
Acute Pain Chronic Pain
<3 months duration >3 or 6 months duration
Physiological warning & protective function
No useful function
Caused by external/internal injury/damage
No relationship to causative event
Can be clearly located Becomes a disease in its own right
Pain pathway activity Changes in pain signalling and detection¹
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Table adapted from: Cavill G. Pain as a clinical entity. In: Hughes J, ed. Pain Management: from basics to clinical practice. London: Churchill Livingstone Elsevier; 2008.1 Woolf CJ, Costigan M. Proc Natl Acad Sci USA 1999;96:7723-30.
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Example Causes of Acute Pain
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Labour
Knee replacement
Tonsillectomy Bunionectomy
AbdominalChest painHeadachesCancer
LacerationBurnsFracture
Surgery Trauma
OtherPainfulpresentation
Painfulpresentations
National Health & Medical Research Council 2011, Emergency Care Acute Pain Management Manual
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Physiology of Post Operative Pain
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Normal Pain Processing
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1. Detection of pain
2. Communication of pain
3. Perception of pain
4. Regulation of pain12
3
4
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Pain Physiology Acute Pain
Peripheral
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Acute post-operative pain Direct activation and peripheral sensitization of nociceptors
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C-fibre C-fibre C-fibre
Substance P Substance P + CGRP + NK A
Capillary
Mast cell
Histamine
Prostaglandin, bradykinin, histamine, H-ions
Many receptors and channels involved
The afferent C-fibres react to the toxic
stimulus with a peripheral secretion of
neuropeptides (substance P, calcitonin gene-related peptide, and
neurokinin A)
= neurogenic inflammation
Furthermore, inflammation mediators
are released from the damaged tissue
Dublin & Patapoutin. J Clin Investigation 2010; 120 (11): 3760-72
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Operation: What happens to the nerve
Nervepain
C-fibre
Ab-fibre
Touch
Peripheral
Local
central
Nerve
Centralsensitization
Peripheralsensitization
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What is happening to the spinal cord?
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Glu
SP
CGRP
Ca2+
Ca channel
NMDA
Ca2+ reservoir
K+
Mg2+
α2 receptor
Noradrenaline (NA)
ATP cAMP
Reduction of endogenous inhibition in chronic pain
ATP
cAMP
Ca2+
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Why is Post Operative PainManagement Important?
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Why does Post Operative Pain Management require our attention?
In a survey of 250 adults who had undergone surgical procedures about perceptions around post-operative pain and pain medications¹
- Experiencing post operative pain was the most common concern (59%) of patients
- Almost 25% of patients who received pain medications experienced adverse effects
Pain scores were often at their worst for relatively small procedures² Patients undergoing minor surgeries typically receive no or low doses of opioids,
despite high indicated pain scores, which leads to insufficient analgesia²
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1. Apfelbaum, J.L., et al. 2003 Anesth Analg 97:534–402. Gerbershagen et al 2013.. Anesthesiology. 118(4): 934-944
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Post-Operative Pain in the UK
1 in 5 patients experiences severe pain, or poor or fair pain relief, after surgery1
Evidence to suggest that women experience more post-operative pain than men2
1. Dolin, S., et al. Br J of Anaes 2002; 89: 409-423.2. Zeidan, A., et al. Obes Surg 2013; 23: 1880-1884.
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Economic Burden of Post Operative Pain
Unrelieved postoperative pain has been shown to increase postoperative complications, prolong hospital stays, and increase the risk of chronic pain1,2
For 2004 - 2005, an episode of IV PCA therapy lasted a mean of 1.6 days and had a mean cost of pounds 60 in the UK3
Costs were attributed to staff time (79%), pump costs (11%) and consumable costs (11%)3
Substantial staff time and costs are associated with IV PCA treatment3
I. IASP: Pain - Clinical Updates 2011 Managing Acute Pain Vol. XIX Issue 32. Macrae. Br J Anaes. 2008; 101 (1): 77-863. Standl et al, EJHP Science 2010; 16: 1-10
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Quality of Life
Pain negatively impacts on physical function, independency and psychological state which may lead to depression, anxiety and a reduction in physical activity¹
EQ-5D™ index scores were substantially reduced 7 days after the operation, compared to the pre-operative period²
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1. Skevington et al Pain. 1998; 76(3): 395-406.2. Taylor et al Pain Pract. 2013; 13(7): 515-523.
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Recommended Pathway
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Pain Adequate Pain Control
Early rehabilitation
Recovery of function
Reduction of morbidity &
mortality
RCOA Acute Guidelines 2014
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Hospital Stays and Ambulation
Compared with patients reporting low pain scores, patients with higher pain scores demonstrate longer time to ambulation with longer stays in hospital*
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Outcomes
Significantly longer length of stay in hospital (p=0.02)
Took significantly longer to ambulate beyond a bedside
chair (p=0.001)
Were less likely to be ambulatory on
day 3
(p=0.001)
Had significantly lower locomotion
scores after 6 months (p=0.02)
Morrison et al. Pain. 2003; 103 (3): 303-311
LOS: Length of stay *Based upon a study of 411 older, cognitively-intact adults with hip fractures.
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Pain Management Goals
Early intervention, with prompt adjustments in the regimen for inadequate pain control
Reduce pain intensity to an acceptable level
Facilitate recovery from underlying disease or injury
Prevent development of chronic pain
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1. NPC. Pain: Current Understanding of Assessment, Management, and Treatments, 20012. Farrar JT et al. Pain 2001;94(2):149-583. Macrae. Br J Anaes. 2008; 101 (1): 77-86
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Risk factors
1,2,3
1. Ip et al.. Anesthesiology. 2009 111(3): 657-677;2. Liu et al.. Int Orthop. 2012 36(11): 2261-22673. Gerbershagen et al. Anesthesiology. 2014. 120(5): 1237-1245.
Risk factors for post-operative pain1-3
Demographics• Age• Gender • BMI
Psychological• Anxiety• Psychological
Stress• Catastrophisation
Pre-operative pain• Pre-operative
pain experience• Patients’
perception of pain
• Pain threshold
Surgical factors• Type of surgery• Surgery duration
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Persistent Post Operative Pain
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Persistent Post Operative Pain
10-50% of surgeries leave patients with Chronic Pain¹ Development of chronic pain is influenced by a variety of factors²
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1. Kehlet et al. Lancet. 2006.367(9522): 1618-16252. Macrae. Br J Anaes. 2008; 101 (1): 77-86
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Definition of Persistent Post Surgical Pain
Also known as Chronic Post Operative Pain or Chronic Pain After Surgery¹
Pain²
- That newly occurs after an operation
- That persists for >2-3 months after an operation
- For which other causes have been excluded and
- That is not the result of a continuous pre-existing problem
- Changes after 6 to 12 months are possible
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1. Macrae et al. Epidemiology of pain. Seattle: IASP Press; 1999; 125–42.2. Kehlet et al. Anesthesiology 2010;112.514-15
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Incidence of Persistent Post Operative Pain
Retrospective study of 3020 surgery patients (50% orthopaedic/trauma, 33% general surgery (abdominal/visceral) and 17% vascular surgery)
911 patients answered the PPSP questionnaire 214 chronic pain >3, 14.7% PPSP (joints (49.4%), surgical area/scar (37.7%) and
neuropathic pain (33.7%)
Summary: “There was a high rate of Chronic Post Surgical Pain (CPSP) after 2 years in general and especially in orthopaedic/trauma patients (57%). ʻMajor’ and ʻminor’ surgical procedures led to CPSP”.
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Simanski et al. Pain Med. 2014 Jul;15(7):1222-9
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Predictors and Causes of Persistent Post Operative Pain
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Post-operative pain
Paininhibition
(CMP/DNIC)
Pre-operativepain
Intra-operative nerve injury
Genetic factorsAge
Gender
Surgicaltechnique
Pre-operativepain thresholds
Psycho-social factors
Hypervigilance
Chronic pain after surgery/trauma
1. Ip et al.. Anesthesiology. 2009 111(3): 657-677;2. Liu et al.. Int Orthop. 2012 36(11): 2261-22673. Gerbershagen et al. Anesthesiology. 2014. 120(5): 1237-1245.
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Assessment Tools
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Importance of a Focussed Assessment
Capture an individual’s pain experience in a standardised way Identify type of pain and causes Impact pain has on the individual and their functionality Allows development of an appropriate treatment plan Facilitate communication between interdisciplinary teams
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Initial pre-operative
Initial post-operative
Ongoing, regular assessment and evaluation of pain management in acute and primary care
Pain Assessment
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Pain Measurement with rating scales
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Visual analogue scale (VAS):
Instruments for recording pain
Verbal rating scale (VRS):
Pain free Slight pain Moderate pain
Strong pain
Very strong pain
Unbearable pain
Numerical rating scale (NRS):
“Smiley face” scale:
Other scales e.g. Abbey Pain Scale, Pain AD
No painPain
insupportable
Pain insupportable
No pain
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Current Post Operative Pain Management
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Surgical treatment phases
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Before surgical incision
PREEMPTIVE
(Time/Dose/Effect)
Inci
sio
n High intensity noxious stimuli
PREVENTIVE
(Time/Dose/Effect)
Preoperative Perioperative
POSTOPERATIVE
Inci
sio
n
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Pre-emptive & Preventive Analgesia
Analgesia initiated before the surgical procedure¹ Treatments include COX inhibitors, Opiates, Epidurals, Neuropathic agents²
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1. Dahl & Kehlet. Curr Op in Anes. 2011; 24: 331-3382. Kehlet et al. Lancet. 2006.367(9522): 1618-1625
Pre-emptive analgesia¹
• Aims to reduce physiological consequences of afferent nociceptive transmission provoked by the procedure
• Timing is important
Preventive analgesia¹
• Aims to prevent central sensitization by blocking any pain and afferent signals from the surgical wound from the time of incision until final wound healing
UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Post Operative Pain Management
The primary aims are to¹:
In the short-term, acute post-operative pain can reduce mobility, delay time to hospital discharge, and decrease patient quality of life²
If pain persists, complications including hospital readmission and chronification may occur²
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Increase patient and
nurse satisfaction
Minimise adverse
events and complications
Aid rapid recovery
and mobility
Relieve post-operative pain
1. European Association of Urology 2014. Guidelines on pain management and palliative care.
2. Oderda et al. Pharmacotherapy. 2012 32(9 Suppl): 6S-11S.
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Selection of Pharmacological Post Operative Pain Management
Criteria for selecting a mode of application
- Clinical status of the patient
- Current symptoms
- Type of surgical intervention
- Local situation in the hospital
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Drug examples
• Paracetamol• NSAIDs• Coxibs• Opioids• Adjuvants• Local anaesthetics
Mode
• Oral• Intravenous• Local techniques• Regional techniques
Delivery
• IV infusion• Local anaesthetic
infusion• Epidural• Spinal
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Local Application
Local wound (margin) infiltration Administration of a local anaesthetic directly into the tissue that is to be
anaesthetised Infusion by means of catheter or repeated injection
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Regional application
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• Elimination of pain during operations• Post-operative analgesia• Mobilisation• Relief of pain during birth• Contra-indications for general anaesthesia
Application
• Refusal of the patient• Coagulation disorders• Anatomical conditions• Severe cardiovascular diseases
Contraindications
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Peripheral Nerve Block
Targeted blockade of individual peripheral nerves that serve a certain part of the body, while consciousness is maintained
Plexus analgesia
- Targeted blockage of a neural plexus that serves a certain part of the body, while consciousness is maintained
Orientation aids in location nerves:- Anatomical landmarks- Nerve simulator- Ultrasound monitoring
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e.g. axillary blockade of the brachial plexus e.g. blockade of the femoral nerve Intercostal block
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Central Regional Analgesia Methods
Temporary blockade of a nerve root emanating from the spinal cord Consciousness is maintained
Synonym: regional analgesia near the spinal cord
Neuroaxial regional analgesia
Methods used:
- Intrathecal application: Spinal analgesia
- Epidural application: Epidural analgesia (synonym peridural analgesia)
- Combined spinal and epidural analgesia (CSE)
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Epidural Analgesia
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Thoracic epidural analgesia
Procedures and pain in the chest and upper abdomen
Lumbar epidural analgesia
Procedures and pain in the lower abdomen, hips, pelvis, and lower extremities
Labour pains
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Summary of Regional and Local Treatment
Regional and local therapies limit the analgesic effect to a specific region¹ The most frequent forms of regional and local post operative pain management are
nerve blockade and wound infiltration:²
Regional and local POPM therapies are often initiated even before or during surgery¹
The selection of the therapy depends on the type of procedure and the individual patient situation²
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Regional Local
- Epidural analgesia- Spinal analgesia- Peripheral nerve blockade
- Wound (margin) infiltration
ANZCA acute pain management: scientific evidence. 2010. 3rd ed. Chelly JE, et al. Br J Anaesthesia. 2010;105:i86-i96.PROSPECT accessed via http://www.postoppain.org/frameset.htm. Last accessed: October 2015
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Oral/Sublingual/Buccal Application
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Immediate-release
Solution
Tablets
Capsules
Slow-release
Tablets
Capsules
Substances
ParacetamolNSAIDsCoxibs
Weak opioidsStrong opioids
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Intravenous Application
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With and without bolus
Administration with the help of infusion pumps
i.v.Injections
i.v. Infusions
Short infusionContinuous
infusionSubstances
includeParacetamol
Some NSAIDsOpioids
Patient-controlled
administration is possible
i.v. PCA
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Patient Controlled Analgesia (PCA)
Administration with the aid of electronically controlled pump systems
At the push of a button, the patient can call up a pre-programmed dose of pain medication
Can be used for various analgesics Methods of PCA include: Intravenous,
epidural, transdermal and sublingual
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UK/C15 0023(1) date of preparation Oct 2015 Provided as a service to medicine by Grünenthal Ltd
Summary of Post Operative Pain Management
1 in 5 patients experiences severe pain, or poor or fair pain relief after surgery¹ Measurement of pain is the pre-requisite for individual therapy Standardisation of pain therapy is important Early intervention, with prompt adjustments in the regimen for inadequate pain
control²
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1. Dolin, S., et al. British Journal of Anaesthesia 2002; 89: 409-423. 2. Zeidan, A., et al. Obes Surg 2013; 23: 1880-1884