Week 6- post operative analgesia part 2 Flashcards
what is patient controlled analgesia (PCA)?
• Process where patients can determine when and
how much analgesic medication they receive
• IV PCA containing opiates/opioids most common
• Requires balance of safety, efficacy and tolerability
• Patient understanding is important
• Common post-operative analgesic option
-patient presses button and pumps drug in
what is the drug delivery?
• Loading dose (programmed by nurse)
• Top ups thereafter (controlled by patient)
• Lock out to prevent overdose
• Adjuncts prescribed automatically for management of toxicity
Monitoring
• Pain scores
• AVPU – alert, voice, pain, unresponsive
whats the advantages of PCA?
Advangtages •Patient in control – can manage their own pain •Predictable pain relief •Active participants in their recovery •Faster alleviation of pain •Patient doesn’t have to wait for pain relief – reduced distress in waiting for pain relief •Less time consuming for nurse •Easy to titrate dose according to
whats the disadvantages of PCA?
Disadvantages • Patient may not be responsive enough to use •May be scared of self administration •Poor dexterity •Reduced mobility •Potential to increase length of stay •Liable to abuse •Patients lack of understanding on how to use PCA •SIDE EFFECTS
what is needed to be monitored during PCA?
- BP, pulse, respiratory rate, sedation, pain score, nausea
- Hourly for first 8 hours from initiation of PCA
- 2 hourly for subsequent 48 hours
- Then 4 hourly until discontinuation
how are side effects managed?
- Nausea/vomiting • Cyclizine 50mg TDS - Pruritis • Chlorphenamine 4mg TDS PO - Respiratory depression (RR < 8) • O2 • Turn off PCA • Monitor O2 SATs • Consider naloxone 200-400mcg IV - Excessive sedation • Remove PCA handset • Monitor O2 SATs, pain and sedation scores • Ensure adequate non opiate analgesia is prescribed regularly
what is some other post-operative analgesia?
- Multi-modal approach should be used offering analgesics with differing MOA
- Paracetamol should be offered post-operatively unless contraindicated
• Weight >50kg – 1g QDS
• Weight <50kg – dose reduction - Oral NSAID
• Ibuprofen should be offered for immediate post-operative pain (except after surgery for fractured hip)
• IV NSAIDs are not commonly used
• Beware age and co-morbidities – - Oral opioid
• If post-operative pain expected to be moderate to severe
• Not with PCA or opiate containing epidural – can be given orally once PCA or epidural discontinued
• Adjust the dose to help the person achieve functional recovery (such as coughing and mobilising) as soon as possible - Gabapentin
• If neuropathic post-operative pain expected
what are some factors to consider in the choice of post-operative analgesia?
- Patient factors including; • comorbidities • age • frailty • renal and liver function • allergies • current medicines • cognitive function - Whether the surgery is immediate, urgent, expedited or elective - Patient discussion to include; • likely impact of the procedure on the person's pain • person's preferences and expectations • pain history • potential benefits and risks, including long-term risks, of different types of pain relief • plans for discharge
what is epidural anaesthesia?
Epidural analgesia is the administration
of analgesics (with or without adjuvants)
into the epidural space. This technique
enables analgesics to be injected close to
the spinal cord and spinal nerves where
they exert a powerful analgesic effect.
-gives drug to exact target
what is the area of analgesic effect?
-should be able to still have sensation area above and below the area analgesia is given
what is the central nerve blockade?
- small unmyelinated fibres are the first to be activated from the infusion as the drugs can infuse into them quicker and block them
- the Autonomic preganglionic fibres
what is put into the bag of an epidural?
- opioid analgesic
- local anaesthtic
what does the opioid analgesic do?
- diffuses into CSF
- INHIBITS PAIN TRANSMISSION IN SPINAL CORD
- main site of action-spinal opiate receptors
- no effect motor or sensory function
- reversible
- doesn’t migrate
what does local anaesthetic do?
- diffuse across myelin sheath into nerve cell
- inhibit Na+ channels, present Na+ influx, reduce cell membrane excitability
- reversible
- doesn’t migrate
what are the advantages of epidural?
Advantages • High quality pain relief • ↓ need for gaseous anaesthesia • Reduced incidence of DVT • Less sedation • Left in situ for post-op analgesia • Improved pulmonary function • Reduced cardiac morbidity • Reduced sepsis/chest infection • Faster re-establishment of oral intake • Tiny opioid dose compared to systemic analgesia
