Post-operative analgesia Flashcards
Outline the major choices for post-operative analgesia
Parenteral opioids administered PRN Patient controlled analgesia Parenteral adjuncts - tramadol, NSAIDs, Clonidine Ketamine Regional anaesthetics Neuraxial anaesthetics PO adjuncts - Gabapentin
Which patients are at increased risk of inadequate analgesia
Extremes of age Critically ill Communication difficulties (language, sensory, cognitive) Hx of substance misuse Chronic pain pts already on opioids
What factors should be considered when planning post-op analgesia
Anticipated severity - site & size of incision, major vs minor surgery, day cases
Potential side effects
Patient factors - expectations, personality
Underlying medical conditions
What are the adverse effects of poorly controlled pain
Psychological distress Sleep disturbance Can undermine therapeutic relationship Inc sympathetic drive - HTN, tachycardia, vasoconstriction Hypermetabolic, catabolic state Inc risk of DVT and PE from immobility Dec chest expansion & poor cough -> basal atelectasis, hypoxia, resp infections Inc post-op ileus Delayed wound healing Conversion to chronic pain Prolonged hospital stay Delayed return to activities
What are the principles of a multimodal pain strategy
Control of postoperative pain to allow early mobilization, early enteral nutrition, education and attenuation of the perioperative stress response through the use of regional anaesthetic techniques and/or a combination of analgesic drugs
How is post-operative pain assessed
Take a NILDOCARF history
Use a scoring system such as 1-10, or VAS
Perform a focussed examination
What is the “pain ladder”, is it appropriate for post-op analgesia
The pain ladder was introduced as a guide for management of pts with cancer. It divides pain into 3 categories - mild, moderate and severe with each step increasing the amount of analgesia given.
In acute post-operative pain this approach can be followed, but it is probably better to start at the top of the ladder and progress downwards, rather than the traditional upwards approach
Outline a management plan for a patient with mild pain
Regular paracetamol +/- NSAID if not CI
Consider an adjuvant such as tramadol if pain not adequately managed
Outline a management plan for a patient with moderate pain
Regular paracetamol +/- NSAID if not CI
Low dose PO opioid -> oxycodone, buprenorphine for breakthrough
Add regular long-acting opioid (Targin) if not adequate
Consider adjuncts - tramadol, clonidine, gabapentin
Outline a management plan for a patient with severe pain
Regular paracetamol +/- NSAID if not CI
Regular opioid such as Targin with breakthrough opioid such as Endone, Buprenorphine
PCA if not adequate
Adjuncts as required - Ketamine infusion, Tramadol, Clonidine
Consider use of regional techniques
What are the benefits of PCA
Able to be programmed to the individual needs of the patient
Compensates for wide interpatient and intrapatient analgesic variability
Avoids administration delays
Lockout period should avoid undesirable side effects
Define opioid tolerance
A pt taking the equivalent of: 60mg PO Morphine 25mcg/hr Fentanyl patch 30mg PO Oxycodone 8mg PO Hydromorphone per day, for longer than a week
What principles are important when managing pain in pts with opioid tolerance
Expect high self-reported pain scores
Base treatment decisions on objective pain assessment (ability to cough, deep breath, walk)
Understand the need to maintain basal opioid requirements + control the new incisional pain
Recognize detoxification is not an appropriate goal in the perioperative period
Goal is also NOT to treat long-standing persistent pain managed as an outpatient
Outline some general post-operative pain treatment options for opioid tolerant patients
Create a treatment plan early and discuss it with the pt
Replace patient’s baseline opioid requirements post-op
Maximize the use of adjuvant drugs
Consider the use of regional analgesic techniques
Manage non-nociceptive sources of distress
DO NOT use PRN only regimes
How can you decrease the risk of respiratory depression in OSA pts with post-operative pain
Limit usage of morphine
Utilise non-opioid medications esp Tramadol, Dexmedetomidine
Regular NSAIDs and Paracetamol
Avoid benzodiazepines
Utilise epidurals and regionals with local only
Avoid basal infusions in PCAs
