postoperative pain management in ambulatory patients,dr.arif
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Postoperative Pain Management in Ambulatory patienTRANSCRIPT
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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