Postoperative Pain Management in Ambulatory

patients

Arif H.M. Marsaban

Dept of Anesteshesilogy & Intensive Care

Univ of Indonesia, Dr Cipto Mangunkusuma Hospital

Introduction

• Incidence of PAIN in ambulatory patient:

• 30 – 40% mod to severe pain (24 – 48 hr)

• 50% in pediatric

• Postop PAIN is still inadequately managed

• Postop PAIN management for ambulatory patient is IMPORTANT

Ambulatory Discharge criteriaTanda Vital• TD ± 20 mmHg dari nilai pra-anestesia • TD ± 20-50 mmHg dari nilai pra-anestesia • TD ± 50 mmHg dari nilai pra-anestesia Aktivitas, status mental• Orientasi & berjalan stabil • Orientasi atau berjalan stabil • Tidak dua-duanya • NYERI, mual, muntah• Minimal • Sedang • Berat • Perdarahan surgical• Minimal • Sedang • Berat • Intake dan output • Minum dan BAK • Minum atau BAK • Tidak keduanya

PAIN causes :

• > 50% becomes chronic pain

• 47% pediatric : problematical behavioural changes

• PONV

• Delayed discharge

• Unanticipated readmission

• Increased costs

Severity of postop pain :

• Type of surgery (orthop, urol, ENT, cosmetic etc))

• Complexity of surgery (lap chol, hernia,tonsill etc)

• Type of anesthetic techniques (RA, GA + LA infiltration)

• Analgesics perioperative (RA, NSAID)

Pain control for ambulatory surgery

Should be :• Effective• Minimal side effects• Facilitate recovery• Easily managed by patients at home• Should permit normal activities• Started intra-operatively (GA with short-

acting opioids, NSAID or RA)

Assessment of pain

• Assess pain

• at rest in early recovery

• at rest and during activity at and after discharge

Type of anesthetic techniques(1)

GENERAL ANESTHESIA :

• Avoid opioid because of PONV

• The choice : alfentanil or fentanyl

• Add wound infiltration single shot or continuous with bupivacain or ropivavain

Type of anesthetic techniques (2)

REGIONAL ANESTHESIA (RA) & LOCAL ANESTHESIA (LA):

• Epidural• Spinal / CSE• Caudal (in pediatric)• Peripheral nerve block (one shot or continuous)• Intra-articular • Field block• Wound infiltration (one shot or continuous)• LA or RA can be used alone or combined with

GA /sedation

RA / LA

• Reduced pain score

• Prolonged postoperative analgesia

• Less analgesics in PACU

Strategies for postop pain management after ambulatory surgery (1)

Continuation from intraoperative with :

• Short-acting opioids i.v

• NSAID oral / i.v

• RA

• = balanced or multimodal techniques using combination of short-acting opioids, NSAID, & LA

Strategies for postop pain management after ambulatory surgery (2)

Oral analgesic after discharge

• Mild pain : paracetamol

• Mild to moderate pain : combination NSAID & weak opioids in addition to RA or LA

• Should provide rescue analgesia or instruction if still have pain (weak opioids)

Paracetamol• First line analgetic• Effective• Cheap • Safe• Ceiling effect• For mild to moderate pain• For mod to severe pain combine with NSAID and

weak opioid• For pediatric loading dose 40 mg/kg, regular dose 90

mg/kg/day oral• Now only oral preparation, coming soon intravanous

preparation

NSAID

• Mild to moderate pain

• Sole analgesic or Combined with paracetamol, weak opioids

• COX-2 fewer side effects

• Celecoxib etoricoxib, meloxicam, rofecoxib, parecoxib

• Choice of drug : availability, route of administration, duration, cost

NSAID

• Some NSAID & aspirin increased risk of post-tonsillectomy bleeding

Weak opioid

• Codeine : devoid of analgesic activity but because metabolism of codein to morphine

• Dextropropoxyphene : renally excreted, accumulation cause CNS, resp, cardiac depression

• Tramadol :opioid agonist & serotonin – noradrenalin reuptake inhibitor, potency = petidine, s.e : nausea-vomiting

Strategies for postop pain management after ambulatory surgery (3)

Continuous RA at home

Continous Peripheral nerve blocks Reduced analgesic consumption & reduce

sleep disturbance Complications :

• nerve injury

• Catheter migration LA toxicity,

• unintentional spinal / epidural spread

Strategies for postop pain management after ambulatory surgery (4)

Continuous RA at home

Infusion dose :

• Bupivacaine 0.5 % or ropivacaine 0.5 – 0.75 % 20 – 40 mL

• 5 mL / hr

Strategies for postop pain management after ambulatory surgery (5)

LA infiltration

Incisional & intra-articular LA drugs

• Is more preferred because simple, safe, low cost

• Single shot or continuous infiltration

Strategies for postop pain management after ambulatory surgery (6)

Continuous LA at home • Continuous wound infiltration several days of

analgesia , not as potent as continuous peripheral nerve blocks

• Can be combined with single-injection peripheral nerve blocks or with oral non-opioid analgesics

• Diposable pumps for continous infusion available with variety preset rates with/without patient-controlled boluses

Strategies for postop pain management after ambulatory surgery (6)

• Clear verbal & written instructions

• Follow-up call next day

Take home message

treat Postop Pain according to the intensity, start intraoperatively, continue postoperatively

intens introperative PACU Home Rescue

mild LA + sedation

GA + infiltration

NSAID iv or paracet iv

non-opiod

non-opiod

Weak opioid

Mod to

Sev

Pain

GA + single infiltration

GA

GA + single shot

RA

Single shot RA

Continous RA

NSAID iv or paracet iv

Cont infilt + NSAID iv

NSAID iv or tramadol iv

NSAID iv or tramadol iv

NSAID iv or paracet iv

NSAID or weak op + paracetamol

NSAID + paracetamol

NSAID or weak op + paracetamol

NSAID or weak op + paracetamol

NSAID or weak op /+ paracetamol

Weak opioid

SUMMARY

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