What`s the best pain medication for your patient? Ries Gisler Tobias, MNS Anesthesia Tobias.Ries-Gisler@usb.ch 11. June 2015

That depends on...

Postoperative Pain Kills Patients Postoperative Pain Kills Patients

Pain

• Is present when those affected say they are in pain • Is a subjective and emotional experience

(McCaffery & Ferrell, 1997)

Pain 1. Nociceptors

• Pain receptor • Impulse to CNS

2. Spinal cord • Relay station, modeling,

forwarding 3. Brain

• Perception, relay station • Hyperalgesia, pain

memory, chronicity

(Angster & Hainsch-Müller, 2005; Larsen, 2013; Isfort J., Koch M.B., & Koneczny N., 2005)

Acute Postoperative Chronic

• Physiological information about threat, injury

• Warning function • Is gone once the

injury has healed • Can be traced

• Pain caused by surgery or trauma

• Triggered by intraoperative surgical stimuli

• Very decisive • May become chronic

• Long-lasting • Recurring • Longer than normal • No relation to the

origin of the injury • Independent disease • Loss of “sense“ • Physiological and/or

psychological changes

Pain

(Angster & Hainsch-Müller, 2005; Larsen, 2013; Apfelbaum, Chen, Mehta, & Gan, 2003; Botti, Bucknall, & Manias, 2004; Schäfer & Eberhardt, 2002; Schweizer Gesellschaft zum Studium des Schmerzes, 2010).

Impact of pain

(Larsen, 2013)

Effect of insufficient analgesia

Pain

Activation of sympathetic NS

Chronic pain

Fear anxiety

Shallow breathing

O2 consumption

Immune response

Myocardial ischemia

HR, RR

Tissue damage

Loss of sleep, helplessness

Atelectasis/ hypoxia

Regulation of blood flow

Impaired recovery

Lung inflammation

Infection/ sepsis

Secondary hyperalgesia

Prevalence of postoperative pain

First 48 hours: ~ 83%

• Moderate to severe pain: ~ 26% • Pain on the Intensive Care Unit: ~ 77%

Rate of pain chronification: ~ 10-50%

• Strong chronic pain: ~ 2-10% • One year postoperatively: ~ 0.05% - 1.5%

(Angster & Hainsch-Müller, 2005; Wilder-Smith, 2011; Gelinas, Fillion, Viens, & Puntillo, 2007;)

Prevalence of chronic postoperative pain

(Stannard, Kalso, & Ballantyne, 2010)

What to do….

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Metamizol

• Paracetamol

• Opioids

• Local anesthetics

• Non-pharmacological treatments

Acute pain therapy

(Vargas-Schaffer, 2010)

Drug therapy (oral, s.c., i.v.)

Patient-controlled analgesia (PCA)

Patient-controlled epidural analgesia (PCEA)

Peripheral Nerve blockade (PNB)/EP

Pros • Quick, easy

administration Cons • Delayed onset of

effect

Pros • Various medications • Various programs • Dose distribution • Patient-controlled Cons • Requires intense

personal supervision

Pros: • Various medications • Various programs • Basic, dose distribution • Segmental analgesia Cons • Movement • Toxicity • Requires intense

personal supervision

Pros • Various flow rates • Segmental analgesia Cons • No history • Pressure alarm • Toxicity

NSAID: Ibuprofen (Brufen) Indications: • Traumatology • Bone pain • Infections • Fever • Inflammation • Tooth or headache • Rheumatism

(Herdegen, 2010; Derry, Derry, Moore, & McQuay, 2009; Documed Kompendium, 2013)

Contraindications: • Gastrointestinal bleeding • 3rd trimester pregnancy • Severe renal insufficiency (RI);

clearance <30 • Allergies • Heart failure

(NYHA III-IV) • Anticoagulation • Coagulation disorders

Metamizol (Novalgin)

Indications: • Visceral pain

− Abdominal/urology • Colic

− Bile/urinary ducts • Alternative to NSAIDs

Contraindications:

• Allergy/bronchospasm • Agranulocytosis (rare) • Severe hypotension • Patients undergoing

chemotherapy, or with bone marrow and stem cell transplantation

(Herdegen, 2010; Documed Kompendium, 2013; Ruppen, 2013)

Paracetamol (Dafalgan) Indications: • Moderate pain • No cardiovascular risk • Low gastrointestinal risk • No inhibition of T cell

aggregation

Contraindications: • Impaired liver function • Acute hepatitis • Hereditary (constitutional)

hyperbilirubinemia (Gilbert’s syndrome)

(Bandolier, 1994 – 2007; Herdegen, 2010; Documed Kompendium, 2013)

Non-opioid analgesics in comparison

(Bandolier, 2003; Derry, Derry, Moore, & McQuay, 2009; Edwards et al., 2010)

Medication Number needed to treat (NNT)

Max. dose/day

Ibuprofen 400 mg= 2.5 (2.4-2.6) 200 mg= 2.7 (2.5-3.0)

2400 mg

Metamizol 2.4 (1.9-3.2)

4000 mg

Paracetamol 3.8 (1000 mg) 4000 mg

Opioids

Opioids (morphine, oxycodone, methadone, fentanyl…) Effects and side effects by binding to receptor

• μ-MOR • κ-KOR • δ-DOR

Receptors are found in the central and peripheral NS • Analgesia • Resporatory depression • Euphoria, strong dependency (limbic system) • Bradycardia, hypothermia • Constipation, urinary retention • Miosis

(Herdegen, 2010)

Number needed to treat

(Bandolier, 2003)

Local anesthesia

Reversible blockade of impulse conduction • At the nerve endings • Peripheral nerves • Spinal root

Switch off sensory and motor nerves

(Larsen, 2013)

Alternative treatments

(Barandun Schäfer & Ries-Gisler, 2013; Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP), 2011)

Summary • Assessment, evaluation, reassessment • Involvement of patients • Individual approaches • Adjuvant therapy • Interprofessionel cooperation • Non-pharmacological interventions • Positive suggestions

(Barandun Schäfer & Ries-Gisler, 2013)

References Angster, R., & Hainsch-Müller, L. (2005). Postoperatives Schmerzmanagement. Anaesthesist. 16. April 2005. from cme.springer.de Apfelbaum, J. L., Chen, C., Mehta, S. S., & Gan, T. J. (2003). Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg, 97(2), 534-540, table of contents. Bandolier (Producer). (2003, 18. März 2013). The Oxford Pain Internet Site: Acute Pain. Retrieved from www.medicine.ox.ac.uk Bandolier (Producer). (1994 - 2007, 11. Januar 2013). Paracetamol in acute postoperative pain. Retrieved from www.medicine.ox.ac.uk Botti, M., Bucknall, T., & Manias, E. (2004). The problem of postoperative pain: issues for future research. International Journal of Nursing Practice, 10(6), 257-263. Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP). (2011). Expertenstandard Schmerzmanagement in der Pflege bei akuten Schmerzen (pp. 1-151). Osnabrück: Hochschule Osnabrück. Derry, C., Derry, S., Moore, R. A., & McQuay, H. J. (2009). Single dose oral ibuprofen for acute postoperative pain in adults. Cochrane Database Syst Rev(3), CD001548. doi: 10.1002/14651858.CD001548.pub2 Documed Kompendium. (2013). Arzneimittel-Kompendium. from Documed AG www.kompendium.ch Edwards, J., Meseguer, F., Faura, C., Moore, R. A., McQuay, H. J., & Derry, S. (2010). Single dose dipyrone for acute postoperative pain. Cochrane Database Syst Rev(9), CD003227. doi: 10.1002/14651858.CD003227.pub2 Gelinas, C., Fillion, L., Viens, C., & Puntillo, K. (2007). Management of pain in cardiac surgery ICU patients: have we improved over time? American Journal of Critical Care, 16(3), 311-311. Herdegen, T. (2010). Pharmakologie und Toxikologie (Vol. 2. Auflage). Stuttgar, New York: Georg Thieme Verlag. Isfort J., Koch M.B., & Koneczny N. (2005). Kopfschmerzen und Migräne (Patientenleitlinie). Retrieved 09. November 2012, from evidence.de www.patientenleitlinien.de Larsen, R. (2013). Anästhesie (Vol. 10. Auflage). München: Urban & Fischer Verlag. Schäfer, R., & Eberhardt, M. (Eds.). (2002). Klinikleitfaden Anästhesie (Vol. 4. Auflage). München, Jena: Urban & Fischer. SGSS. (2010). Chronische Schmerzen. Schweizerische Gesellschaft zum Studium des Schmerzes. Retrieved 06. November 2010, from www.pain.ch Stannard, C. F., Kalso, E., & Ballantyne, J. (2010). Evidence-based chronic pain management: Wiley Online Library. Vargas-Schaffer, G. (2010). Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician, 56(6), 514- 517, e202-515. Wilder-Smith, O. H. (2011). Chronic pain and surgery: a review of new insights from sensory testing. J Pain Palliat Care Pharmacother, 25(2), 146-159. doi: 10.3109/15360288.2010.505256