Surgery 2 Flashcards
Pain management - drug misusers
- Pain management is a basic human right.
- Regular doses of methadone/buprenorphine does not provide an effective analgesic profile.
- Additional pain medication is required.
Consequences of inappropriate pain management - drug misusers
- Relapse to addiction.
- Potentially fatal toxicity due to misjudged tolerance or drug interactions.
- Compromised medical care.
Monitoring - drug misusers
- Pain score
- Respiratory depression
Current guidlines - drug misuers
- Opioids are not contraindicated.
- Long-acting opioids are preferred.
- Wean as soon as possible.
- Buprenorphine can generally be continued
Use of opioids
- Former addicts = small risk of triggering relapse.
- Discuss with patient - they may prefer non-opioid analgesia.
- Support during and after discharge.
Buprenorphine OST
- Patients on buprenorphine OST may require alternative treatments to manage pain (non-opioid).
- Doses >12 mg may cause total blockage of µ-opioid receptor.
Alternative non-opioid approaches
- Paracetamol
- NSAIDs
- Adjuvant medications (tricyclic antidepressants)
Buprenorphine OST - incomplete blockage
- Opioids can be used, but higher doses required.
- If the patient wants to remain on buprenorphine = 6-8 hourly dosing regime to improve the pain management response.
Venous Thromboembolism (VTE)
- Blood clot forms in vein.
- Commonly occurs in the deep veins of the legs (DVT).
VTE - Clinical presentation
- Varies
- Often asymptomatic.
- Pain and swelling in the leg.
Complications of VTE
- Pulmonary embolism (PE)
- Chronic venous insufficiency
- Venous ulceration
- Post-thrombotic limb
Pulmonary embolism (PE)
- Thrombus dislodges from site of origin and travels in the blood, leading to more serious pulmonary embolisms (PE).
- Part or all of the thrombus
- Travel to the lungs = potentially fatal pulmonary embolism.
Post-thrombotic limb
- Chronic pain
- Swelling
- Skin changes
VTE - Pharmacological treatment
- LMWH
- Daltaparin
- Dabigatran
- Rivaroxaban
VTE - non pharmacological treatment
- TEDs
- Foot pumps
- Flowtron intermittent pneumatic compression (IPC)
VTE - NICE Guidelines
- Asses pt on admission for risk of VTE.
- Bleeding risk vs. thrombotic risk
- If needed, started pharmacological VTE prophylaxis ASAP.
Surgical patients - risk of VTE
Surgical patients at risk if:
- Surgical procedure of more than 90 mins or 60 mins involving pelvis or lower limb.
- Acute surgical admission with inflammatory or intra-abdominal condition.
- Expected significant reduction in mobility.
- One or more VTE risk factors.
Risk factors for VTE
- Cancer
- 60+
- Dehydration
- Obese
- One or more medical comorbidities
- History/family history of VTE
- HRT
- Pregnancy (or <6 weeks postpartum)
PONV - at risk groups
- Young, Female
- Non smoker
- History of PONV or motion sickness.
- Use of pre/post-op opioids.
PONV - risk factors
- Age
- Anxiety level
- Non-compliance with pre-op fasting recommendations
- Duration and type of surgery
- Anaesthetic factors
- Use of opioids
-Pre-op drug treatment
PONV - consequences
- Delayed administration of opioid analgesia.
- Wound disruption after abdominal/max fac surgery.
- Bleeding
- Dehydration and electrolyte imbalance.
- Interference with nutrition.
- Delay in mobilisation, recovery & discharge.
- Patient discomfort and distress.
PONV - drugs
- Cyclizine
- Ondansetron/Granisetron
- Dexamethasone
- Metoclopramide/Domperidone
- Hyoscine
- Prochlorperazine
- Droperidol
- Aprepitant
Cyclizine
- Antihistamine
- Antimuscarin properties
Ondansetron/Granisetron
- 5-HT3 antagonists.
- Licensed for treatment and prophylaxis.
- Short treatment for post surgery
- Usually recommended 2nd line after cyclizine.
- Post-op CV risk (QT interval prolongation).
Dexamethasone
- Generally not used unless there is significantly untreated nausea
Metoclopramide
- Dopamine antagonist
- Gastro patient s
- Max 5 days
- Risk of neurological SE
Domperidone
- Dopamine antagonist
- Max 7 days
- Risk of cardiac SE
Droperidol
- Butyrophenone
- Structurally related to haloperidol
- Blocks dopamine receptors in the chemoreceptor trigger zone.
Aprepitant
- NK1 antagonist
- NK1 is a G protein-coupled receptor in CNS and PNS.
- This receptor has a dominant ligand known as Substance P (SP).
- SP, when activated sends impulses to vomiting centre of the brain.
PONV - post op management
- Actively vomiting = avoid PO.
- Cyclizine (IV or IM)
- Metoclopramide (IV)
- Ondansetron (IV)
- Hyoscine (transdermal)
- Prochlorperazine (buccal)
Prochlorperazine - buccal
- Absorbed through the lining of mouth
- Direct absorption into the systemic circulation, avoids first-pass metabolism.
- Higher plasma conc.
Non-pharmacological
- Adequate hydration and pain management.
- Minimise use of GA/opioid
- Acupuncture
- Ginger/ Mint
- Wristbands
