Mastertitelformat bearbeiten 1 UK/C15 0023 date of preparation Oct 2015 Post Operative Pain Module

Mastertitelformat bearbeiten

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UK/C15 0023 date of preparation Oct 2015

Post Operative Pain Module


Key Sections

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Overview of Acute Pain

Physiology of Post Operative Pain

Why is Post Operative Pain management important?

Chronic Post Operative Pain

Assessment Tools

Current Post Operative Pain Management


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Overview of Acute Pain


Acute pain

Acute pain is caused by injury and/or trauma, infection, or surgery² It has an important warning function to protect us from further damage, and it

supports the healing process after injuries¹ Acute pain has sensory, cognitive and emotional components¹ Acute pain leads to motor reflexes, muscle tension and changes in the

autonomic/sympathetic nervous system¹ Acute pain is limited in time, and its location can be easily assessed¹

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1. Woolf CJ, et al. Ann Intern Med. 2004;140:441-51.2. Cavill G. Pain as a clinical entity. In: Hughes J, ed. Pain Management: from basics to clinical practice. London: Churchill Livingstone Elsevier; 2008


Pain Classification: Acute - Chronic

Acute Pain Chronic Pain

<3 months duration >3 or 6 months duration

Physiological warning & protective function

No useful function

Caused by external/internal injury/damage

No relationship to causative event

Can be clearly located Becomes a disease in its own right

Pain pathway activity Changes in pain signalling and detection¹

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Table adapted from: Cavill G. Pain as a clinical entity. In: Hughes J, ed. Pain Management: from basics to clinical practice. London: Churchill Livingstone Elsevier; 2008.1 Woolf CJ, Costigan M. Proc Natl Acad Sci USA 1999;96:7723-30.


Example Causes of Acute Pain

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Labour

Knee replacement

Tonsillectomy Bunionectomy

AbdominalChest painHeadachesCancer

LacerationBurnsFracture

Surgery Trauma

OtherPainfulpresentation

Painfulpresentations

National Health & Medical Research Council 2011, Emergency Care Acute Pain Management Manual


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Physiology of Post Operative Pain


Normal Pain Processing

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1. Detection of pain

2. Communication of pain

3. Perception of pain

4. Regulation of pain12

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4


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Pain Physiology Acute Pain

Peripheral


Acute post-operative pain Direct activation and peripheral sensitization of nociceptors

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C-fibre C-fibre C-fibre

Substance P Substance P + CGRP + NK A

Capillary

Mast cell

Histamine

Prostaglandin, bradykinin, histamine, H-ions

Many receptors and channels involved

The afferent C-fibres react to the toxic

stimulus with a peripheral secretion of

neuropeptides (substance P, calcitonin gene-related peptide, and

neurokinin A)

= neurogenic inflammation

Furthermore, inflammation mediators

are released from the damaged tissue

Dublin & Patapoutin. J Clin Investigation 2010; 120 (11): 3760-72


Operation: What happens to the nerve

Nervepain

C-fibre

Ab-fibre

Touch

Peripheral

Local

central

Nerve

Centralsensitization

Peripheralsensitization


What is happening to the spinal cord?

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Glu

SP

CGRP

Ca2+

Ca channel

NMDA

Ca2+ reservoir

K+

Mg2+

α2 receptor

Noradrenaline (NA)

ATP cAMP

Reduction of endogenous inhibition in chronic pain

ATP

cAMP

Ca2+


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Why is Post Operative PainManagement Important?


Why does Post Operative Pain Management require our attention?

In a survey of 250 adults who had undergone surgical procedures about perceptions around post-operative pain and pain medications¹

- Experiencing post operative pain was the most common concern (59%) of patients

- Almost 25% of patients who received pain medications experienced adverse effects

Pain scores were often at their worst for relatively small procedures² Patients undergoing minor surgeries typically receive no or low doses of opioids,

despite high indicated pain scores, which leads to insufficient analgesia²

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1. Apfelbaum, J.L., et al. 2003 Anesth Analg 97:534–402. Gerbershagen et al 2013.. Anesthesiology. 118(4): 934-944


Post-Operative Pain in the UK

1 in 5 patients experiences severe pain, or poor or fair pain relief, after surgery1

Evidence to suggest that women experience more post-operative pain than men2

1. Dolin, S., et al. Br J of Anaes 2002; 89: 409-423.2. Zeidan, A., et al. Obes Surg 2013; 23: 1880-1884.


Economic Burden of Post Operative Pain

Unrelieved postoperative pain has been shown to increase postoperative complications, prolong hospital stays, and increase the risk of chronic pain1,2

For 2004 - 2005, an episode of IV PCA therapy lasted a mean of 1.6 days and had a mean cost of pounds 60 in the UK3

Costs were attributed to staff time (79%), pump costs (11%) and consumable costs (11%)3

Substantial staff time and costs are associated with IV PCA treatment3

I. IASP: Pain - Clinical Updates 2011 Managing Acute Pain Vol. XIX Issue 32. Macrae. Br J Anaes. 2008; 101 (1): 77-863. Standl et al, EJHP Science 2010; 16: 1-10


Quality of Life

Pain negatively impacts on physical function, independency and psychological state which may lead to depression, anxiety and a reduction in physical activity¹

EQ-5D™ index scores were substantially reduced 7 days after the operation, compared to the pre-operative period²

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1. Skevington et al Pain. 1998; 76(3): 395-406.2. Taylor et al Pain Pract. 2013; 13(7): 515-523.


Recommended Pathway

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Pain Adequate Pain Control

Early rehabilitation

Recovery of function

Reduction of morbidity &

mortality

RCOA Acute Guidelines 2014


Hospital Stays and Ambulation

Compared with patients reporting low pain scores, patients with higher pain scores demonstrate longer time to ambulation with longer stays in hospital*

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Outcomes

Significantly longer length of stay in hospital (p=0.02)

Took significantly longer to ambulate beyond a bedside

chair (p=0.001)

Were less likely to be ambulatory on

day 3

(p=0.001)

Had significantly lower locomotion

scores after 6 months (p=0.02)

Morrison et al. Pain. 2003; 103 (3): 303-311

LOS: Length of stay *Based upon a study of 411 older, cognitively-intact adults with hip fractures.


Pain Management Goals

Early intervention, with prompt adjustments in the regimen for inadequate pain control

Reduce pain intensity to an acceptable level

Facilitate recovery from underlying disease or injury

Prevent development of chronic pain

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1. NPC. Pain: Current Understanding of Assessment, Management, and Treatments, 20012. Farrar JT et al. Pain 2001;94(2):149-583. Macrae. Br J Anaes. 2008; 101 (1): 77-86


Risk factors

1,2,3

1. Ip et al.. Anesthesiology. 2009 111(3): 657-677;2. Liu et al.. Int Orthop. 2012 36(11): 2261-22673. Gerbershagen et al. Anesthesiology. 2014. 120(5): 1237-1245.

Risk factors for post-operative pain1-3

Demographics• Age• Gender • BMI

Psychological• Anxiety• Psychological

Stress• Catastrophisation

Pre-operative pain• Pre-operative

pain experience• Patients’

perception of pain

• Pain threshold

Surgical factors• Type of surgery• Surgery duration


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Persistent Post Operative Pain


Persistent Post Operative Pain

10-50% of surgeries leave patients with Chronic Pain¹ Development of chronic pain is influenced by a variety of factors²

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1. Kehlet et al. Lancet. 2006.367(9522): 1618-16252. Macrae. Br J Anaes. 2008; 101 (1): 77-86


Definition of Persistent Post Surgical Pain

Also known as Chronic Post Operative Pain or Chronic Pain After Surgery¹

Pain²

- That newly occurs after an operation

- That persists for >2-3 months after an operation

- For which other causes have been excluded and

- That is not the result of a continuous pre-existing problem

- Changes after 6 to 12 months are possible

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1. Macrae et al. Epidemiology of pain. Seattle: IASP Press; 1999; 125–42.2. Kehlet et al. Anesthesiology 2010;112.514-15


Incidence of Persistent Post Operative Pain

Retrospective study of 3020 surgery patients (50% orthopaedic/trauma, 33% general surgery (abdominal/visceral) and 17% vascular surgery)

911 patients answered the PPSP questionnaire 214 chronic pain >3, 14.7% PPSP (joints (49.4%), surgical area/scar (37.7%) and

neuropathic pain (33.7%)

Summary: “There was a high rate of Chronic Post Surgical Pain (CPSP) after 2 years in general and especially in orthopaedic/trauma patients (57%). ʻMajor’ and ʻminor’ surgical procedures led to CPSP”.

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Simanski et al. Pain Med. 2014 Jul;15(7):1222-9


Predictors and Causes of Persistent Post Operative Pain

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Post-operative pain

Paininhibition

Pre-operativepain

Intra-operative nerve injury

Genetic factorsAge

Gender

Surgicaltechnique

Pre-operativepain thresholds

Psycho-social factors

Hypervigilance

Chronic pain after surgery/trauma

1. Ip et al.. Anesthesiology. 2009 111(3): 657-677;2. Liu et al.. Int Orthop. 2012 36(11): 2261-22673. Gerbershagen et al. Anesthesiology. 2014. 120(5): 1237-1245.


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Assessment Tools


Importance of a Focussed Assessment

Capture an individual’s pain experience in a standardised way Identify type of pain and causes Impact pain has on the individual and their functionality Allows development of an appropriate treatment plan Facilitate communication between interdisciplinary teams

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Initial pre-operative

Initial post-operative

Ongoing, regular assessment and evaluation of pain management in acute and primary care

Pain Assessment


Pain Measurement with rating scales

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Visual analogue scale (VAS):

Instruments for recording pain

Verbal rating scale (VRS):

Pain free Slight pain Moderate pain

Strong pain

Very strong pain

Unbearable pain

Numerical rating scale (NRS):

“Smiley face” scale:

Other scales e.g. Abbey Pain Scale, Pain AD

No pain Pain insupportable

Pain insupportable

No pain


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Current Post Operative Pain Management


Surgical treatment phases

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Before surgical incision

PREEMPTIVE

(Time/Dose/Effect)

Inci

sio

n High intensity noxious stimuli

PREVENTIVE

(Time/Dose/Effect)

Preoperative Perioperative

POSTOPERATIVE

Inci

sio

n


Pre-emptive & Preventive Analgesia

Analgesia initiated before the surgical procedure¹ Treatments include COX inhibitors, Opiates, Epidurals, Neuropathic agents²

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1. Dahl & Kehlet. Curr Op in Anes. 2011; 24: 331-3382. Kehlet et al. Lancet. 2006.367(9522): 1618-1625

Pre-emptive analgesia¹

• Aims to reduce physiological consequences of afferent nociceptive transmission provoked by the procedure

• Timing is important

Preventive analgesia¹

• Aims to prevent central sensitization by blocking any pain and afferent signals from the surgical wound from the time of incision until final wound healing


Post Operative Pain Management

The primary aims are to¹:

In the short-term, acute post-operative pain can reduce mobility, delay time to hospital discharge, and decrease patient quality of life²

If pain persists, complications including hospital readmission and chronification may occur²

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Increase patient and

nurse satisfaction

Minimise adverse

events and complications

Aid rapid recovery

and mobility

Relieve post-operative pain

1. European Association of Urology 2014. Guidelines on pain management and palliative care.

2. Oderda et al. Pharmacotherapy. 2012 32(9 Suppl): 6S-11S.


Selection of Pharmacological Post Operative Pain Management

Criteria for selecting a mode of application

- Clinical status of the patient

- Current symptoms

- Type of surgical intervention

- Local situation in the hospital

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Drug examples

• Paracetamol• NSAIDs• Coxibs• Opioids• Adjuvants• Local anaesthetics

Mode

• Oral• Intravenous• Local techniques• Regional techniques

Delivery

• IV infusion• Local anaesthetic

infusion• Epidural• Spinal


Local Application

Local wound (margin) infiltration Administration of a local anaesthetic directly into the tissue that is to be

anaesthetised Infusion by means of catheter or repeated injection

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Regional application

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• Elimination of pain during operations• Post-operative analgesia• Mobilisation• Relief of pain during birth• Contra-indications for general anaesthesia

Application

• Refusal of the patient• Coagulation disorders• Anatomical conditions• Severe cardiovascular diseases

Contraindications


Peripheral Nerve Block

Targeted blockade of individual peripheral nerves that serve a certain part of the body, while consciousness is maintained

Plexus analgesia

- Targeted blockage of a neural plexus that serves a certain part of the body, while consciousness is maintained

Orientation aids in location nerves:- Anatomical landmarks- Nerve simulator- Ultrasound monitoring

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e.g. axillary blockade of the brachial plexus e.g. blockade of the femoral nerve Intercostal block


Central Regional Analgesia Methods

Temporary blockade of a nerve root emanating from the spinal cord Consciousness is maintained

Synonym: regional analgesia near the spinal cord

Neuroaxial regional analgesia

Methods used:

- Intrathecal application: Spinal analgesia

- Epidural application: Epidural analgesia (synonym peridural analgesia)

- Combined spinal and epidural analgesia (CSE)

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Epidural Analgesia

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Thoracic epidural analgesia

Procedures and pain in the chest and upper abdomen

Lumbar epidural analgesia

Procedures and pain in the lower abdomen, hips, pelvis, and lower extremities

Labour pains


Summary of Regional and Local Treatment

Regional and local therapies limit the analgesic effect to a specific region¹ The most frequent forms of regional and local post operative pain management are

nerve blockade and wound infiltration:²

Regional and local POPM therapies are often initiated even before or during surgery¹

The selection of the therapy depends on the type of procedure and the individual patient situation²

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Regional Local

- Epidural analgesia- Spinal analgesia- Peripheral nerve blockade

- Wound (margin) infiltration

ANZCA acute pain management: scientific evidence. 2010. 3rd ed. Chelly JE, et al. Br J Anaesthesia. 2010;105:i86-i96.PROSPECT accessed via http://www.postoppain.org/frameset.htm. Last accessed: October 2015

http://www.postoppain.org/frameset.htm

http://www.postoppain.org/frameset.htm


Oral/Sublingual/Buccal Application

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Immediate-release

Solution

Tablets

Capsules

Slow-release

Tablets

Capsules

Substances

ParacetamolNSAIDsCoxibs

Weak opioidsStrong opioids


Intravenous Application

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With and without bolus

Administration with the help of infusion pumps

i.v.Injections

i.v. Infusions

Short infusionContinuous

infusionSubstances

includeParacetamol

Some NSAIDsOpioids

Patient-controlled

administration is possible

i.v. PCA


Patient Controlled Analgesia (PCA)

Administration with the aid of electronically controlled pump systems

At the push of a button, the patient can call up a pre-programmed dose of pain medication

Can be used for various analgesics Methods of PCA include: Intravenous,

epidural, transdermal and sublingual

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Summary of Post Operative Pain Management

1 in 5 patients experiences severe pain, or poor or fair pain relief after surgery¹ Measurement of pain is the pre-requisite for individual therapy Standardisation of pain therapy is important Early intervention, with prompt adjustments in the regimen for inadequate pain

control²

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1. Dolin, S., et al. British Journal of Anaesthesia 2002; 89: 409-423. 2. Zeidan, A., et al. Obes Surg 2013; 23: 1880-1884

Documents

Mastertitelformat bearbeiten 1 UK/C15 0023 date of preparation Oct 2015 Post Operative Pain Module