evidence-based postoperative pain management · 2019-05-27 · evidence-based postoperative pain...
TRANSCRIPT
Evidence-Based Postoperative Pain Management
Stephan A Schug
Anaesthesiology University of Western Australia
Pain Medicine Royal Perth Hospital
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Disclaimer
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http://www.iasp-pain.org/GlobalYear
http://www.iasp-pain.org/GlobalYear
http://fpm.anzca.edu.au/ Resources/Publications
APM:SE 4th edition
Endnote library: 8,598 references Pages: 647 Key Messages: 669
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA
Consequences of Unrelieved Pain
Myocardial ischaemia
Increased sympathetic
activity
Myocardial O2
consumption
GI effects Splinting shallow
breathing
Increased catabolic demands
Anxiety and fear
Peripheral/ central
sensitisation
GI motility Atelectasis hypoxaemia hypercarbia
Poor wound healing/muscle
breakdown
Sleeplessness, helplessness
Neuro- plasticity
Delayed recovery Pneumonia
Weakness and impaired
rehab.
Psycho- logical
distress
Chronic pain
Acute pain
GI = gastrointestinal
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA
Opioids – the Good
Opioids are very effective analgesics Opioids are necessary to provide pain relief in many
situations linked to severe pain: – postoperative – after severe trauma
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA
Opioids – the Bad
Opioids are often associated with adverse events including: – Opioid-Induced Ventilatory Impairment – Nausea and vomiting – Constipation – Urinary retention – Sedation – Confusion or agitation – Rash, itching, hives – Opioid-Induced Hyperalgesia
Opioid-related AEs increase length of stay and costs
Oderda GM, et al. J Pain Symptom Manage. 2003;25:276-83. TJ et al. Anesth Analg. 2004;98:1665-73.
What Can We Do About Adverse Effects of Postoperative Opioids?
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA
Acute Pain Management: Scientific Evidence 4th edition 2015
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA
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American Pain Society,
American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists
“The panel recommends that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).”
Note: Exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure.
Chou R, et al. J Pain. 2016;17:131-57.
Scientific Evidence: Multimodal Analgesia*
There is Level I evidence for the effectiveness of the following components of multimodal analgesia: – Regional anaesthesia (peripheral and epidural) – Paracetamol – NSAIDs/Coxibs – Alpha-2-Delta Ligands – Systemic Local Anaesthetics (lignocaine) – NMDA Receptor antagonists (ketamine, magnesium) – Alpha-2 Agonists (clonidine/dexmedetomidine) – Corticosteroids (dexamethasone)
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA
* Please note, not all medications listed here are approved for the stated use
Acute Pain Management: Scientific Evidence 4th edition 2015
Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA
Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.
Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.
Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.
Initiate multimodal analgesic techniques – Minimise use of opioids – Maximise use of non-opioid agents – Use regional anaesthesia whenever possible
• Superior to opioids, especially in orthopaedic patients
Use evidence-based, procedure-specific pain management
guidelines where available – http://fpm.anzca.edu.au/Resources/Publications – http://www.jpain.org/article/S1526-5900(15)00995-5/pdf – http://www.postoppain.org
Conclusions
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