pain management after major orthopaedic surgery: current ...pain management after major orthopaedic...

Vol 10, No 2, March/April 2002

PathophysiologicResponses to Poor lyContr olled Pain

Abstract

Pain Management After Major Or thopaedic Sur gery:Curr ent Strategies and New Concepts

Raymond S. Sinatra MD, PhD, Jaime Torres, MD, and Arsenio M. Bustos, MD

Per ipheral Sensitization

Neuroendocr ine Responses

Sympathoadrenal Activation

Pain Management After Major Orthopaedic Surgery

Journal of the Amer ican Academy of Or thopaedic Surgeons

TISSUE INJURY

Atelectasis

Hypoxia

Na+

retention

Venousstasis

Plateletaggregation

Decreasedregional

blood flow

Neuroendocrinealterations

Increased cortisol,hyperglycemia,catabolic state

Immunosuppression,increased risk of

infection

Increasedoxygen

consumption

Sympathoadrenalactivation

Renin-angiotensinrelease

POOR WOUND HEALING

CORONARYISCHEMIA

DEEP VEINTHROMBOSIS

Tachycardia,hypertension

Diminishedpulmonary function

Neural plasticity(dorsal horn)

Neurohumeralalterations

Central processing(cognitive changes)

Facilitatednociceptive

transmission

Peripheralhyperalgesia

Increasedwound sensitivity

ANXIETY

Fear,helplessness

SleepdeprivationMUSCLE

SPLINTING

DEMORALIZATION

IMMOBILIZATION

PNEUMONIA

Chronic Pain

Var iables That InfluenceAcute Pain Management

Techniques of PainManagement

Raymond S. Sinatra, MD, PhD, et al

Vol 10, No 2, March/April 2002

Oral Analgesics

Pain Management After Major Orthopaedic Surgery

Journal of the Amer ican Academy of Or thopaedic Surgeons

PCA Nurse responds

Call for nurse

Screening

Sign outmedication

Preparemedication

Administermedication

PATIENTVARIABLES

NURSINGVARIABLES

UPTAKE/DISTRIBUTION

VARIABLES

Absorptionfrom site

Relief (analgesia)

Sedation

PAIN

Parenteral Therapy

Raymond S. Sinatra, MD, PhD, et al

Vol 10, No 2, March/April 2002

Intravenous Patient-ControlledAnalgesia

Pain Management After Major Orthopaedic Surgery

Journal of the Amer ican Academy of Or thopaedic Surgeons

140

120

100

80

60

400 5 7.5 10 12.5 15 30

Tota

l Mor

phin

e Do

se (m

g)

Ketorolac (mg)

Spinal Opioid Analgesia

Raymond S. Sinatra, MD, PhD, et al

Vol 10, No 2, March/April 2002

Conc

entra

tion

Pain

Seda

tion

Anal

gesia

1 20 3 4 5 6 7 8

Hour

Pain Management After Major Orthopaedic Surgery

Journal of the Amer ican Academy of Or thopaedic Surgeons

Neural Blockade for Acute PainManagement

Raymond S. Sinatra, MD, PhD, et al

Vol 10, No 2, March/April 2002

Other Analgesic Techniques

New Concepts in PainManagement

Pain Services

Pain Management After Major Orthopaedic Surgery

Journal of the Amer ican Academy of Or thopaedic Surgeons

*

60

50

40ControlFemoral nerve blockSciatic-femoral nerve block30

20

10

0Day of Surgery

Day

of S

urge

ry

POD 1 POD 2 POD 3

Preemptive Analgesia

Multimodal Analgesia

Pain Contr ol andPostoperative Outcome

Raymond S. Sinatra, MD, PhD, et al

Vol 10, No 2, March/April 2002

Summary

Pain Management After Major Orthopaedic Surgery

Journal of the Amer ican Academy of Or thopaedic Surgeons

Refer ences

Raymond S. Sinatra, MD, PhD, et al

Vol 10, No 2, March/April 2002