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Postoperative Pain Management Doc 7648
Postoperative Pain Management Doc 7648
Categories Of Pain
Postoperative pain can be divided into acute pain and chronic pain: Acute pain is experienced immediately after surgery (up to 7 days); Pain which lasts more than 3 months after the injury is considered to be chronic.
Types Of Pain
Somatic (from skin, muscle, bone); Visceral (from organs within the chest and abdomen); Neuropathic (caused by damage or dysfunction in the nervous system). Patients can experience more than one type of pain.
Pain Pathway
Perception Modulation Transmission Transduction
Family members are involved when appropriate. Tools For Pain Assessment
Facial expressions; Verbal rating scale (VRS); Numerical rating scale (NRS); Visual analogue scale (VAS).
Currently the most frequently used approach to pain management is PRN based monotherapy. Whats wrong with this standard? Analgesic Gaps are specific periods of time when pain management is inadequate. By definition, PRN medications cause analgesic gaps (breakthrough pain).
Non-opioids: NSAIDs
Intravenous (30-60 min before end of surgery); Administration Intramuscular (painful); Oral (as soon as possible). Monitoring Renal function in patients with renal or cardiac disease, elderly patients, or patients with episodes of severe hypotension. Gastrointestinal side effects. Can be added to the premedication. Would be combined with proton inhibitors (i.e. Omeprasol) in patients at risk of gastrointestinal side effects.
Comments
Analgesia Ceiling effect; Effects are evident in 1-2 hr; Administration limited to 1-2 wks; If inadequate results, change to another NSAID.
Opioids
Opiate Receptors Q Mu H Delta O Kappa Mu most important for analgesic actions. Opioids: problems Side-effects: euphoria/dysphoria, constipation, respiratory depression, nausea/vomiting, urinary retention. Tolerance Definition: A change in the dose-response relationship induced by exposure to the drug and manifest as a need for a higher dose to maintain an effect. Develops at different rates to varying effects: respiratory depression, somnolence, nausea >> analgesia Analgesic tolerance is rarely a problem. Opioid doses remain relatively stable in the absence of worsening pathology and increased opioid requirements after stable periods is often a signal of disease progression. Dependence Definition: The development of a withdrawal syndrome following dose reduction or administration of an antagonist. Often develops after only a few days of opioid therapy. Not a clinical problem if drug is tapered before discontinuation. Taper by no more than 50% of the dose/day. Addiction Compulsive use; Loss of control; Continued use despite harm to self and others. Risk of iatrogenic addiction in patients with pain and no prior history of substance abuse is extremely small. Pseudoaddiction- behavior that resembles addiction, but is driven by pain and disappear4 with adequate analgesia.
Opioids: MORPHINE
Intravenous Administration Subcutaneous (by continuous infusion or intermittent boluses); Intramuscular (not recommended). IV: Bolus: 2-3 mg each 5-10 min, up to 0.1- 0.15 mg/kg. Dosage SC: 0.1- 0.15 mg/kg 4 - 6/h IM: 5-10 mg 3 - 4 hourly. Monitoring Sedation, respiratory rate, nausea, vomiting, urinary retention.
Transition From PCA To Orals Give ~2/3 of previous 24 hour morphine requirements as OxyContin; Oxycodone for breakthrough.
Opioids: CODEINE
Administration Dosage Comments Oral 3 mg/kg/day (combined with Paracetamol) Analgesic action is likely to be due to conversion to morphine. Part of patients derive no benefit due to absence of the converting enzyme.
Equianalgesic Doses of Opioid Analgesics PO / PR 200 30 20 Analgesic Codeine Morphine Oxycodone Fentanyl SC / IV / IM 10 0.1-0.25
Opioids: TRAMADOL Intravenous; Administration Intramuscular; Oral (as soon as possible). Dosage Mechanism of action Side effects Comments 50-100 mg 6h; reduces serotonin and norepinephrine reuptake and is a weak opioid agonist nausea and vomiting 100 mg is equivalent to 5-15 mg Morphine; ~ 7% is "poor metabolizers.
Epidural Analgesia
Dosage
The response is not the same if the same dose is used but in a different volume and concentration. A higher volume of a low concentration of LA will result in a larger number of segments blocked but with less dense sensory block and less motor block.
Better efficacy than parenteral opioids and comparable to epidural; Lower incidence of side effects than with epidural; Excellent pain control over an extended period.