Postoperative Pain Management Flashcards
Post-Op Pain Management
Students will:
* Understand the physiology of epidural vs spinal anaesthesia and PCA analgesia in the postop patient
- Understand key nursing assessments when delivering care to patients who have epidural or PCA analagesia
- Understand key nursing interventions when complications arise from patients who have epidurals or PCA analgesia pumps
- Understand the student and RN scope of practice around monitoring patients with epidurals and PCAs.
General Anesthesia
a reversible state of unconsciousness produced by drugs with sufficient depression of reflexes to allow a surgical procedure to be performed.
Unconsciousness
Analgesia
Muscle Relaxation
Depression of autonomic/ endocrine reflexes
x4 Phases:
- Pre-Operative
- Intra-Operative
a. Induction
b. Maintenance - Reversal
- Recovery
Phase 1: Preoperative
There are a number of medications that may be given to achieve the following:
Anxiety relief
Decreased risk of acid aspiration
Pre-emptive analgesia
Depress reflex activity
Lab work, when to go off anticoagulants, control BG, how you adjust glucose control = all to optimize pt so sx goes well
Phase 2: Intraoperative
Induction: during the induction of anaesthesia the patient is taken from an awake to an unconscious state using IV medications (ie Propofol, Midazolam – short acting)
Maintenance: once induced, the patient is maintained (via inhaled and IV meds) so that all the body systems are protected while allowing the surgery to be performed
Unconsciousness
Muscle relaxation
Analgesia
Induction: short acting med in Iv to get them unconscious, they get intubated, then get inhaled medication continuously thru ET tube
Maintenance: continuous inhalation or IV by titration
Phase 3: Reversal
PACU
The goal of the reversal phase is to return the patient to a conscious, spontaneously breathing state while maintaining a state of analgesia.
ET tube comes out post op, gases stop
Want to wake up without experiencing pain so doc titrates to find that balance
Phase 4: Recovery
surgical unit
Airway Maintenance and Adequate Ventilation
Cardiovascular Stability
Normothermia
Consciousness
Freedom from Nausea and Vomiting
Analgesia
Spinal Anesthesia
The injection of local anaesthetic and/or opioids into the CSF of the subarachnoid space, usually below the level of L2.
In adults, the spinal cord ends at L1-L2. A fine gauge spinal needle is inserted at the L2-3 level or lower to avoid the spinal cord.
A single dose of opioid and local anaesthetic is injected into the subarachnoid space producing an autonomic, sensory and motor blockade.
Vasodilation/ hypotension – autonomic block
No pain – sensory block
Unable to move – motor block
The dose of subarachnoid analgesia is only 1/10 of the dose used in epidural space
Spinal post op monitoring
-Vital Signs
-Motor and sensory block
-Urinary output/ bladder distention
-Headache assessment
Epidural Anesthesia
A catheter is placed in the epidural space just outside the dura (the special covering enclosing the spinal canal)
Local anaesthetic agents works by binding to nerve roots as they enter and exit the spinal cord
Catheter stays in.. Either goes in thoracic and lumbar. Better to go in thoracic spine because they don’t get bowel/bladder dysfunction. (less pain, less complications, increase mobility)
Epidural post op moitoring
-Headache assessment
-Urinary output/ bladder distention
-Asessment for pruritis, nausea, or vomiting
-Pain assessment
-Assessment for catheter migration (ie numbness or tingling)
-Assessment of dressing and insertion site
Regional Anesthesia (spinal and epidural)
order of nerve function disappearance:
- Sympathetic (vasomotor): dilation of skin and blood
vessels including arteries and veins - Temperature discrimination
- Pain recognition
- Touch and pressure sense
- Motor function
return in reverse order
Chronic post op pain
Incidence of chronic postoperative pain (CPOP)
Amputation: 50-85%
Thoracotomy: 5-65%
Cardiac surgery: 30-55%
Breast surgery: 20-50%
Risk Factors:
Having preop pain
Psychological factors
Female and younger age
Open surgical approach
Length of surgery > 3 hours
Intensity of pain in the immediate postop period (ie first few days)
Risks of acute pain:
CVS:
Tachycardia, hypertension, increased myocardial oxygen consumption, DVT, MI
RESP:
Decreased lung volumes, atelectasis, decrease cough, sputum retention, hypoxemia
GI and GU:
decreased gastric and bowel motility, urinary retention
Metabolic:
Increase catabolic hormones (cortisol) and decrease anabolic hormones (insulin)
Psychological:
Anxiety, fear and sleeplessness
What is Epidural Analgesia?
Epidural analgesia is the administration of opioids and/or local anesthetics into the epidural space.
It can be used to manage pain in pediatric, adult, and older adult patients on a short-term (hours to days) or long-term (weeks to months) basis.
Epidural space is a space so tiny air bubbles are not a danger and it is ok to stop infusions for hours and be ok to restart without catheter becoming occluded
Epidural shouldn’t impact Cranial nerves or cervical nerve function because Crainial nerves arise from the brain stem, don’t enter and exit spinal column.
Spinal cord – supply trunk and limbs
-sensory (dermatome) and motor (myatome)
Each spinal cord segment is referred to as a level and when blocked with local anesthetic results in characteristic decrease in sensory (dermatome) and occasionally motor (myotome) function.
Only nerves from the thoracic, lumbar and sacral levels are routinely affected by continuous epidural analgesia.
KEY POINT
EXAM
In most cases of CEA with a local anesthetic, it is desirable that the patient have a decrease in cold sensation (to ice test) in the dermatome of the surgical incision.
In LUMBAR CEA, the sensation level should NEVER be at or above the nipple line (T4).
In THORACIC CEA there should be a band of decreased sensation in the thorax with normal sensation in the lower abdomen. The upper aspect of the inner arm or 5th finger (T1) should NEVER be affected. THESE ARE INDICATORS OF A HIGH BLOCK!
-want sx incision to be in middle of upper and lower end of the freezing
lumbar: Don’t want freezing above T4 nipple line = Lose diaphragm func = affects breathing
thoracic: T1 fifth finger means it is too high, should never be affected = indication of a high block, too much med, catheter has migrated.
If above T4 or T1= pause epidural and call anaesthesiologist
Motor Nerve Assessment
The Motor Assessment Scale (MAS) is used to monitor the level of motor block in a patient receiving CEA with a local anesthetic.
As we document on acute pain management flowsheet, use 0, 1, 2, 3. for degree of block
Motor fibers are thickest and therefore most resistant to local anes
A myotome is a group of muscles innervated by a single spinal cord segment
**There should be NO upper or lower extremity weakness when a thoracic epidural catheter is used
-patient should be able to flex the knees and the ankles against gravity. The ideal CEA results in minimal or NO Motor Block.
