Surviving Surgery’s Aftermath
Judith Handley MD
Assistant Professor OUHSC
October 5, 2012
Disclosures
• I have no disclosures
Objectives
• Discuss basic pathophysiology of acute pain
• Identify options in treatment of acute post
operative pain
• Discuss a multi-modal approach to pain
management in the post operative patient
Pain: Definition
• The IASP defines pain as “Unpleasant sensory
and emotional experience associated with real
or perceived tissue injury”
“Whatever the person says it is, wherever the person says it is”
Impact on Healthcare
• Pain is the most common reason a
patient seeks healthcare
• The cost in healthcare dollars in
significant annually
Acute Pain
• Sudden onset
• Usually lasts < 6months
• Has a known cause/circumstance
– Surgery
– Burns/cuts
– Broken bones, pulled muscles
– Labor and childbirth
Post-Operative Pain
You wake up from surgery hurting, why?
- Skin/Incision Pain
- Muscle Pain
- Bone Pain
- Tendon/Ligament Pain
- Movement Pain
- Throat Pain
Pathophysiology
Pathophysiology
Why is it so important to control and
treat Post-Op pain?
Good Post-Op Pain Control =
› Faster recovery and discharge
› Ability to utilize deep breathing exercises
 Decrease post-op pneumonia/collapsed lung
 Decrease O2 requirements
› Ability to sit up, get out of bed, walk sooner
 Decreases decubitis ulcers and blood clot formation
› Active participation in Physical Therapy
› Comfortable and satisfied patient
Unrelieved Post-Op Pain
• Poor Post Op Pain Control =
– Increases risk of post operative morbidity and
mortality
• Pneumonia
• Decubitis Ulcers
• Blood Clots
– Increases hospitalization and costs of care
– Can develop into chronic pain
– Unnecessary patient suffering, unsatisfied patient
Other Thoughts
• To control pain post-operatively, you need to
know information pre-operatively.
– Allergies
– Does the patient take any pain medication at
home regularly or intermittently?
– Where is current pain?
– Introduce and educate about pain scales
Post-Op Pain Control Options
Regional Anesthesia/Analgesia
› Peripheral Nerve Blocks
› Single Injection Intrathecal/Caudal Analgesia
› Epidural Analgesia
Non-Opioids
Opioids
› IV vs. PO
› PRN vs. PCA
Adjuvants
Regional/Neuraxial Anesthesia
 Administration of local anesthetics (often with other drugs)
into the epidural space, around a peripheral nerve plexus, or
into the intrathecal space to block pain transmission.
 Types:
1. Peripheral Nerve Blocks
2. Epidural Analgesia
3. Single Injection Intrathecal/Caudal Analgesia
Regional Anesthesia:
Nerve Blocks
Commonly used for surgery involving the
upper or lower extremities
› Types: Interscalene, Axillary, Femoral, Sciatic, Caudal
Typically used for outpatient procedures
(although can be used inpatient and as a
continuous infusion)
 Nerve stimulators and ultrasound guided
Typically lasts 4-24 hours
Regional Anesthesia:
Nerve Blocks
• Advantages:
– Reduced amount of additional systemic opioids
– Reduction of side effects
• Nausea/vomiting
• Puritis
• Drowsiness
• A thin catheter that is threaded into the epidural
space which provides anesthesia by continuous
infusion via an epidural pump
• Indications: Thoracic/heart surgeries, abdominal
surgeries, limb amputation, thoracotomies, urology
surgeries
Epidural Analgesia
• Drugs infused through an epidural catheter
– Local Anesthetics (Bupivacaine, Ropivacaine…)
– Opioids (fentanyl, hydromorphone…)
– All are preservative free
Advantages of
Epidural Analgesia
 Local Anesthetics via Epidural= can prevent the pain
response with minimal physiologic alterations
 Opioids via Epidural= can provide prolonged analgesia at
low doses
 Systemic Opioids= modify perception of nociceptive
input so patients are better able to tolerate pain
 GOAL: Reduction of systemic opioids, better pulmonary
profile, better OOB and PT profile
Single Injection Analgesia
• Caudal
• Intrathecal
• Duramorph – Extended Release morphine
– Peaks in 6 hrs and lasts 18-24
Single Injection Analgesia
• Intrathecal Duramorph
– 3:1 ratio or PICU admit
• Caudal Duramorph Dosing:
– Less than 15mcg/kg – discharge home
– 15-45mcg/kg – admitted, 3:1 ratio or PICU
– Greater than 45mcg/kg – automatic PICU
Opioids
• Drug options
– Morphine
– Fentanyl
– Hydromorphone
• PRN Bolus or PCA
Patient Controlled Analgesia (PCA)
• Common agents used
– Morphine
– Hydromorphone
– Fentanyl
• PCA demand dose
• Basal Rate
Non-Opioids and Adjuvants
• Drug Options
– Ketoralac
– Acetaminophen
– Ibuprofen
• Route of administration options
• Other adjuvants
Post-Op Pain Management Care
Plans
• Individualized
• Tailored to the specific surgical procedure
• Perioperative pain control optimized
• Utilize a multi-modal approach
Multi-Modal Approach
• Outpatient
– Cyst removal right elbow
• Regional, opioid with adjuvant medications
• Inpatient
– Posterior Spinal Fusion
Thank You
• Questions