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8/18/2019 POST OPERATION PAIN MANAGEMENT.pptx
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Dr. Andrian AliSuperviser
Dr. Purwito Sp.An
POST OPERATIONPAIN MANAGEMENT
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DEFINITION• The International Association for the Study of Pain
(IASP)
Pain is defined as a sensory and emotional experience
which participate in occuring tissue damage or potentially
destroy the tissue.
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PHYSIOLOGY MECHANISM OF
PAIN
1. Nociceptie !sensory" is an inflammation pain which
related to chemical stimulation# mechanic# and thermal
at nociceptie receptor !nere that respons to painstimulation"
$. Neuropatic is pain that is related to periferal nere
damage or in the central nerous system"
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PAINMECHANISMS
PATWAY
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POST OPERATION PAIN
There are 2 types of pain : acute and chronic
• Acute pain
Immediatey occur after sur!ery "more than #
days$• Chronic pain
Pain that sette more than % months aftersur!ery$
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POST OPERATION PAIN’S
THERAPY
General principle to blokade nociceptor are :1. The giving of peripheral anti inflammator agent
!. "lokade peripheral nociceptor#topical
$. "lokade peripheral nerve
%. "lokade spinal nerve
&. Spinal antinociceptive 'narcotic and non narcotic(
). *entral antinociceptive 'brain stem or upper(
+. *ombination of all above
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A,A-GT/* A-T0,AT/ 230 P3ST 3P0AT/3, PA/,
Non&opioidana!etic
ParacetamoNSAI's( incudin! C)*&2 inhi+itors
,a+apentin( pre!a+ain
Wea- opioid Codeine
TramadoParacetamo com+ined .ith codeine or Tramado
Stron! opioid Morphine
/entany
Pethidine
Ad0u1ant etamine
Conidine
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Morphine and Wea- )pioid
Morphinei3 PCA +ous 4&2 m!
SC 5(4&5(4 m!6-!
IM 7&45 m!( e1ery %&8 0am "not recommendated +ecause of the painfu$
Codein)ra %m!6-!6day com+ine .ith paracetamo
Tramado I3(IM()ra 75&455 m!6 9 hours
Non opioidParacetamo
I3 "%5 min after the end of sur!ery$
)ra ; 8<4 !r6day "hepar insu=ciency %<4 !r6day$
com+ination
paracetamo 755m! > Codein %5m!
8<4 !r6day paracetamo
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NSAI'
I3 "%5&95 min +efore the end of sur!ery$
etoroac % < %5&85 m!6day
'i-ofenac 2 < #7 m!6day
etoprofen 8 < 75 m!6day
Meo<icam 47 m! 4<6day
Pareco<i+ 85 m!( foo. .ith 4&2 < 85m!6day
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ALTERNATIVE THERAPY FOR POST OPERATIONPAIN APPROPIATE WITH THE TYPE OFOPERATION
?o. Intencity ofPainE<ampe :
In!uina Hernia3arices?aparascopy
4; Paracetamo and .ound in=tration .ith oca anesthesia;2; NSAI' "e<cept contraindication$( and%; @e!iona anesthesia .ith .ea- opioid ad0u1ant or sta!in! rescue
ana!esia or intra1enous stron! opioid if needed
?o. Intencity of
PainE<ampe :
Hip @epacementHisterectomy a. Sur!ery
4; Paracetamo and .ound in=tration .ith ocaanesthesia;
2; NSAI' "e<cept contraindication$( and
%; Periphera ner1e +oc- "sin!e shot orcontinuous infusion$ or opioid in0ection "i1 PCA$;
Hi!h Intencity of PainE<ampe :
ThoracotomyBpper A+domina Sur!ery
Aortanee @epacement Sur!ery
4; Paracetamo and .oundin=tration .ith oca anesthesia;
2; NSAI' "e<cept contraindication$(and
%; ?oca epidura ana!esia orpe<us +oc- or ma0or peripheraner1e or opioid in0ection "i1 PCA$
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BALANCED ANALGESIA
Balanced Analgesia (ulti!odal Analgesia"
Two or more analgesia drug that wor% at different mechanism to
get the superior analgesia effect without significant side effect.
&ome examples from 'alanced analgesia are (
• The com'ination of epidural opioid with epidural anestetic )
• The com'ination of intraenous opioid with N&*IDs that hae
+sparing effect, with systemic effect of opioid.
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PAT/,T *3,T03- A,A-GS/A 'P*A (
*ccording to premis that hae negatie trac%) when pain
is concerned# analgetic therapy is gien their own# and
when the pain decrease# there is no necessity more.
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• P-* euipment can programmed to some aria'le) include dose necessity
!'olus"# interal# and infuse.
• Optimal necessity for integrated dose in efication of intraenous P-*
• *lthough optimal dose necessity doen/t assured
data that show optimal dose necessity is 1 mg for morphine and 0 2g for
fentanyl in lay person) 'ut# actual dose for fentanyl !13$ 2g" sometimes lac% in
clinical practice.
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REGIONAL ANALGESIA
*ontinous *entral ,euroa4is "lockade '**,"(
*ontinous Peripheral ,erve "lockade '*P,"(
Continous Central Neyroaxis lo!"a#e $CCN %
*nalgesi which more efectie for pot operation pain although inasie# 'ut also still 'e the first
choise for a'dominal operation# thorax and orthopedy# if there is not improement of the pain with
another analgesia.
-an 'e with epidural lane !first choice" or spinal.
Epidural ussually with long acting local anesthesia !less ta%ifila%sis" and deep opioid in dulition
concentration.
Epidural local anestetic dose and opioid (
4opiacaine #$5 ! $mg6m1 " or leo'upiacine6'upiacaine #13 #$5&ulfentanil #131 ug6ml or
fentanyl $30 ug6day
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Patient Control E"idural Analgesia
(PCEA)
The use of infuse continue or as ad7uant for
dose which need in general with P-E*
compare to intraenous P-* and can gie
superior analgesia for the usefull dose.
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Drugs that used at epidural catheter :
8etamine
There is no sensory# motory# and anatomic 'lo%age# pruritus and urinary retention moreoer can/t cause
depresion. 0 mg dose dissoled with 1 ml dextrose 1. more short acting compare to morphine.
Opioid
*lternatie drug for terminally ill cancer patient. 9etter gie per orally opioid one wee% 'efore. :ore
efectie if com'ined with 'upiacaine.
:orphine
;ery hydrophilic so it will stay in <-& in long period of time# duration =31$ hours.
onset >3? minutes. Dose ( #1 mg6%g in Na-I #?5. :ore adantageous for chronis pain and release
isceral pain after a'sominal and thoracal surgery .
Fentanyl.
Dose ( $@ ug6hour mixed with Na-< #?5 or 4< eery ml ( @ug# com'ined with 'upiacaine #@5
9upiacaine
Dose #13#1$@5 se'esar 0 ml6hour can 'lo%ade segmental for A one dermatome.
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Continous Peri&'eral Ner(e lo!"a#e
$CPN%
• -PN9# nowadays used more often 'ecause more selectie
and still gie good postoperatie analgesia so can decrease
the utiliBing of opioid.• Peripheral nere 'loc% humiliate the side effect which occur at
neuroaxial central 'loc%#as hypotention# wide motoric 'loc%
and complication as epidural hematom# epidural a'scess# and
panparesis.
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CATETE@ ?)CATI)N ?)CA? ANESTESIA ')SES
@o+i1acaine 5(2
Dupi1acaine 5(4 & 5(427
?e1o+i1acaine 5(4 & 5(2
Interscaeni
Infraca1i-uer
A<iary
/emoraPopitea
7 & m6hour
7 & m6hour
7 F 45 m hour
# F 45 m hour% F # m hour
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THAN) YO*