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Noxious stimulus :

Is one that is painful and potentially damaging to


normal tissues
Stimuli that are painful can be thermal,
mechanical or chemical
Encyclopedia of Pain. G.F. Gebhart , Robert F. Schmidt . Springer; 2nd ed. 2013 edition
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Harmful stimuli activate the peripheral endings of


primary
afferent neurons, also called nociceptors
Their cell bodies lie in the dorsal root ganglia (DRG) or
the trigeminal ganglia
Encyclopedia of Pain. G.F. Gebhart , Robert F. Schmidt . Springer; 2nd ed. 2013 edition

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Noxious stimuli & Nociception :


1- Neurogenic inflammation (SP CGRP)
2- Descending modulatory input (i.e.,
serotonin,NEP, -aminobutyric acid, enKephalin)
3-Impulses pass to the ventral and ventrolateral
horns ((spinal) reflex responses)
4- Spinothalamic and spinoreticular tracts
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Continuous release of inflammatory mediators:


Sensitization of peripheral nociceptors may occur and is
marked by
Decreased threshold for activation
Increased rate of discharge with activation
Increased rate of basal (spontaneous) discharge

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Intense noxious input from the periphery may also result


in central
sensitization and hyperexcitability
Central sensitization:
Persistent post injury changes in the CNS that result in
pain hypersensitivity
Hyperexcitability:
Exaggerated and prolonged responsiveness of neurons to
normal afferent input after tissue damage
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

FACTORS for
PPP

Preoperative
Intraoperative
Postoperative

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

CPSP is relatively common after :


limb amputation (30% to 83%)
Thoracotomy (22% to 67%)
Breast surgery (11% to 57%)
Gallbladder surgery (up to56%)
Sternotomy (27%)
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Preventive Analgesia
This definition broadly includes any regimen
given at any time during the perioperative
period that is able to control pain-induced
sensitization

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Maximal clinical benefit is observed when complete


multisegmental blockade of noxious stimuli occurs, with
extension of this effect into the postoperative period

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The analgesic benefits of controlling


postoperative pain are generally
maximized when a multimodal
strategy to facilitate the patients
convalescence is implemented
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

SYSTEMIC ANALGESIC TECHNIQUES

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

OPIOIDS
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Opium
Opiates
Narcotic
Opioid

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The modern word opium is derived from the Greek


word opion (poppy juice)

Drugs derived from opium are referred to as opiates


(morphine is the best-known opiate)
Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters
Kluwer Health 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The term narcotic is derived from the Greek word for


stupor and traditionally has been used to refer to potent
morphine-like analgesics with the potential to produce
physical dependence

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters


Kluwer Health 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The development of synthetic drugs with morphine-like


properties has led to the use of the term opioid to refer to
all exogenous substances, natural and synthetic, that
produce at least some agonist (morphine-like) effects

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters


Kluwer Health 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

OPIOIDS
Opioid analgesics are one of the cornerstone options for
the treatment of postoperative pain
They generally exert their analgesic effects through receptors in the CNS, although opioids may also act at
peripheral opioid receptors

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters


Kluwer Health 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Opioids act as agonists at specific opioid receptors at


presynaptic and postsynaptic sites in the central nervous
system (mainly the brainstem and spinal cord) as well as
in the periphery
OPIOID RECEPTORS FUNCTION ?
These opioid receptors normally are activated by three
endogenous peptide opioid receptor ligands known as
enkephalins, endorphins, and dynorphins (Opioids mimic
the actions of these endogenous ligands)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Is analgesic ceiling for opioids ?


A theoretical advantage of opioid analgesics is that
there is no analgesic ceiling
Realistically, the analgesic efficacy of opioids is
typically limited by
Development of tolerance
Opioid-related side effects such as
Nausea, vomiting
Sedation
Respiratory depression
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Because analgesic and ventilatory effects of opioids


occur by similar mechanisms, it is assumed that
equianalgesic doses of all opioids will produce some
degree of ventilatory depression and reversal of
ventilator depression with an opioid antagonist always
involves some reversal of analgesia

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters Kluwer Health
2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Most common routes of postoperative


systemic opioid analgesic administration are
oral and intravenous

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

In general, opioids are administered


parenterally (intravenously or
intramuscularly) for the treatment of
moderate to severe postoperative pain, in
part because these routes provide a more
rapid and reliable onset of analgesic action
than the oral route does
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Oral opioids (typically formulated as part of


a combination product that includes an
adjuvant such as acetaminophen) are
generally prescribed on an as-needed (PRN)
basis postoperatively

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Although the traditional form (passive) of transdermal


fentanyl is not indicated for the routine treatment of
acute postoperative pain, a newer version involving
patient-activated electrically facilitated delivery of
transdermal fentanyl has been developed for use in
hospitalized adult patients

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

A single dose of sufentanil, 0.1 to 0.4 mg/kg IV,


produces a longer period of analgesia and less
depression of ventilation than does a comparable dose
of fentanyl (1 to 4 mg/kg IV)
Unique advantage of alfentanil compared with fentanyl
and sufentanil is the more rapid onset of action

Dr Mehran Rezvani
painphysiology
fellowship anesthesiologist
Stoeltings handbook of pharmacology
and
in anesthetic practice. Wolters
& acupuncturist
Kluwer Health 2015

Alfentanil, compared with equipotent doses of fentanyl


and sufentanil, is associated with a lower incidence of
postoperative nausea and vomiting in outpatients
The advantage of remifentanil possessing a short
recovery period may be considered a disadvantage if
the infusion is stopped suddenly
Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters
Kluwer Health 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Context-sensitive half-time for remifentanil is


independent of the duration of infusion and is
estimated to be about 4 minutes (rapid clearance is
responsible for the lack of accumulation even during
prolonged periods of infusion)

Dr Mehran Rezvani
painphysiology
fellowship anesthesiologist
Stoeltings handbook of pharmacology
and
in anesthetic practice. Wolters
& acupuncturist
Kluwer Health 2015

Anesthesiology.2003;98:312322

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

PATS
PatientActivated
Transdermal
System
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

PATS is a compact, needle-free analgesic delivery system


recently approved by the U.S. Food and Drug
Administration
The device is preprogrammed to iontophoretically
administer a 40-mcg dose of fentanyl (over a 10-minute
period) upon patient activation
The self-contained device is applied with adhesive to the
patients upper arm or chest for analgesic delivery
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The patient activates the system by pressing the


recessed dosing button twice within 3 seconds
Additional dosing requests are prevented by the system
during drug delivery
Thus patients may self-administer up to 6 doses per hour

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The fentanyl ITS operates for up to 24 hours or a


maximum of 80 doses (whichever occurs first), after
which it automatically shuts down.
The system may then be removed and discarded, and a
new system may be applied to a different skin site if
additional analgesia is required

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Med Devices (Auckl). 2008; 1: 4957


Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Kalia YN, Naik A, Garrison J, Guy RH. 2004. Iontophoretic drug delivery. Adv Drug Deliv Rev, 56:619
Dr Mehran Rezvani pain fellowship anesthesiologist
58. Copyright 2004 Elsevier
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Opioid induced hyperalgesia


(OIH)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The opioid-induced hyperalgesia resulted from


spinal sensitization to glutamate and
substance P
Cholecystokinin and the NMDAnitric oxide
system and spinal serotonin activity are
responsible for the development of acute
tolerance to opioids
Miller 8 chp 31
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Opioid-induced hyperalgesia and subsequent


acute opioid tolerance can be prevented by
ketamine
Methadone is unique in possessing both -opioid
and NMDA-antagonist properties

Miller 8 chp 31

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Opioid-induced hyperalgesia resulted


from the presence of l-methadone (opioid agonist) in the racemate and was
antagonized by the presence of dmethadone (NMDA antagonist)
Miller 8 chp 31
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

N2O is an effective NMDA antagonist


Intraoperatively, 70% N2O administration
significantly reduced postoperative opioid
induced hyperalgesia in one study
Miller 8 chp 31
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Hyperalgesia after 30-minute


intravenous infusion of remifentanil
(0.1 g/kg/minute) could be
prevented by the administration
of parecoxib, before remifentanil
infusion
suggesting the involvement of COX2 in opioid-induced hyperalgesia
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Postoperative hyperalgesia induced


by intraoperative remifentanil
infusion was significant with
sevoflurane anesthesia but not
apparent with propofol anesthesia
Miller 8 chp 31
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

In mice
Prevetion for OIH was done with :
Selective 2-adrenergic receptor antagonist

butoxamine
Systemic or intrathecal injection of the
ondansetron
Miller 8 chp 31

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

A potential connection between OIH and


PPP has been recently suggested as there
is a dose-dependent relationship between
intraoperative remifentanil use and PPP
after thoracic surgery
van Gulik L, Ahlers S J, van de Garde EM, et al. Remifentanil during cardiac surgery is
associated with chronic thoracic pain 1 yr after sternotomy. Br J Anaesth 2013; 109(4): 61622
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Decreasing the opioid dose (40% to 50%) and


adding adjuvants or a low dose of methadone can
be used to treat opioid-induced hyperalgesia

S. Waldman PAIN MANAGEMENT., Elsevire 2011


Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Indirectly, in comparison to general anesthesia, the


use of intraoperative neuraxial anesthesia reduces
the risk of severe PPP at one year after total hip and
knee replacement a benefit partly attributed to the
opioid-sparing effect of the analgesic technique

Liu SS. A cross-sectional survey on prevalence and risk factors for persistent postsurgical
pain 1 year after total hip and knee replacement. Reg Anesth Pain Med 2012; 37(4): 41522.
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Thereby, the concept of opioid-sparing


anesthesia (even more, opioid-free
anesthesia) may be a major step in the
prevention of PPSP
Liu SS. A cross-sectional survey on prevalence and risk factors for persistent postsurgical
pain 1 year after total hip and knee replacement. Reg Anesth Pain Med 2012; 37(4): 41522.

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Intravenous
Patient-Controlled
Analgesia
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

PCA is based on the premise that a negative-feedback


loop exists; when pain is experienced, analgesic
medication is self-administered, and when pain is
reduced, there are no further demands

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters


Dr Mehran Rezvani pain fellowship anesthesiologist
Kluwer Health 2015
& acupuncturist

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters


Dr Mehran Rezvani pain fellowship anesthesiologist
Kluwer Health 2015
& acupuncturist

Although some equipment-related malfunctions can


occur, the PCA
device itself is relatively free of problems, and most
problems
related to PCA use result from user or operator error

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

A PCA device can be programmed for several variables:


Demand (bolus) dose
Lockout interval
Background infusion

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Although the optimal demand (bolus) dose is uncertain,


the data available suggest that the optimal demand dose
is
1 mg for morphine and 40 g for fentanyl in opioid-naive
patients; however, the actual dose for fentanyl (10 to 20
g) is often less in clinical practice (bolus)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The lockout interval is a safety feature of intravenous


PCA, and although the optimal lockout interval is
unknown, most intervals range from 5 to 10 minutes,
depending on the medication in the PCA pump

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Initially, routine use of a background


infusion predicted certain advantages,
including improved analgesia, especially
during sleep; however, analgesic benefits of
a background infusion have not been
successful in opioid-nave patients

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

A background infusion only increases the analgesic


dosage used and the incidence of adverse respiratory
events in the postoperative period especially in adult
subjects
Furthermore, use of a nighttime background infusion
does not improve postoperative sleep patterns,
analgesia, or recovery profiles
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

A background infusion in opioid-tolerant


or pediatric patients may be effective

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Stoeltings handbook of pharmacology and physiology in anesthetic practice. Wolters Kluwer Health 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Meperidine ?
The clinical use of meperidine has declined greatly in
recent years PCA with meperidine cannot be
recommended because of possible
normeperidine toxicity
Large doses of meperidine result in decreases in
myocardial contractility, which, among opioids, is
unique for this drug
Dr Mehran Rezvani
painphysiology
fellowship anesthesiologist
Stoeltings handbook of pharmacology
and
in anesthetic practice. Wolters
& acupuncturist
Kluwer Health 2015

When compared with traditional PRN analgesic regimens,


Intravenous PCA provides superior postoperative
analgesia
and improves patient satisfaction, but it is unclear
whether
intravenous PCA can provide any economic benefits

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Patients usually prefer intravenous PCA over


intravenously, intramuscularly, or
subcutaneously administered PRN opioids

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Chronic Methadone Therapy ?


Patients on chronic methadone therapy should be restarted
on their oral methadone dose as soon as possible after
surgery to meet basal pain needs; any additional
postoperative analgesic requirements can be met via IV-PCA
Patients often require high doses and can usually receive
them safely due to individualized opioid tolerance
Perioperative Pain Management. Urman Oxford University Press 2013
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The incidence of opioid-related adverse events from


intravenous
PCA does not seem to differ significantly from that of PRN
opioids administered intravenously, intramuscularly, or
subcutaneously
The rate of respiratory depression associated with
intravenous PCA is low 1.5% and does not appear to be
higher than that with PRN systemic or neuraxial opioids
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Factors for respiratory depression with opioid IV PCA:


Use of a background infusion
Advanced age
Concomitant administration of sedative or hypnotic agents
Coexisting pulmonary disease such as sleep apnea
Errors in programming or administration (i.e., operator error)
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

NSAIDS
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Acetaminophen

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Acetaminophen (paracetamol) is an antipyretic as well as


an analgesic that acts centrally by inhibiting
prostaglandin synthesis
In a placebo-controlled study, patients receiving
paracetamol reported no difference in their pain when
compared with placebo only in the first 6 hours after
surgery, but the pain intensity was diminished in the
paracetamol group from 12 to 24 hours
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The lack of cardiovascular and hemorrhagic


complications
makes it an alluring option
It may be beneficial in reducing oral opiate requirements
in patients susceptible to respiratory complications from
opiates:
Obstructive sleep apnea
Increased intracranial pressure
Morbidly obese patients
Pediatric and elderly
populations
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Adult oral acetaminophen, 600 to 1,000 mg qid, is


effective as part of a multimodal regimen and is well
tolerated
The recommended dosage of IVA for adults and
adolescents weighing 50 kg or more is 1g every 6 hours
or 650 mg every 4 hours, with a maximum single dose of
1 g, a minimum dosing interval of 4 hours, and a
maximum daily dose of acetaminophen of 4 g
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Acetaminophen should be used cautiously in patients


with alcoholism, chronic malnutrition, severe
hypovolemia, or severe renal impairment
Patients with severe renal impairment (creatinine
clearance [CrCl] = 30 mL/min) require longer dosing
intervals and a reduced total daily dose of
acetaminophen
Perioperative Pain Management.
Urman
University
Press 2013
Dr Mehran
RezvaniOxford
pain fellowship
anesthesiologist
& acupuncturist

IVA may mask fever in patients treated for postsurgical pain due
to its antipyretic effect and consequently may mask the signs of
postoperative infection and sepsis
Acetaminophen has produced transient hypotension in critically ill
patients with fever
The hypotension is usually mild to moderate but transient, within
15 to 30 minutes after the beginning of an infusion, and with
maximal hypotension occurring between 1 and 2 hours after
dosing
Perioperative Pain Management. Urman Oxford University Press 2013
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Nonsteroidal Anti-inflammatory
Agents
The primary mechanism by which NSAIDs exert their
analgesic effect is through inhibition of cyclooxygenase
(COX) and synthesis of prostaglandins, which are
important mediators of peripheral sensitization and
hyperalgesia
NSAIDs can also exert their analgesic effects through
inhibition of spinal COX
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The discovery of at least two COX isoforms (i.e.,


COX-1 is constitutive and COX-2 is inducible) with
different functions (i.e., COX-1 participates in
platelet aggregation, hemostasis, and gastric
mucosal protection, whereas COX-2 participates in
pain, inflammation, and fever) has led to the
development of selective COX-2 inhibitors

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The discovery of a COX-3 variant may represent a


primary central mechanism by which acetaminophen and
other antipyretics decrease pain and fever
Used as a sole agent, NSAIDs generally provide effective
analgesia for mild to moderate pain
NSAIDs are also traditionally considered a useful adjunct
to opioids for the treatment of moderate to severe pain
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Nicholas J. H. Davies . Lee's Synopsis of Anaesthesia, 13e 2005


Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Several meta-analyses have examined the analgesic


efficacy of NSAIDs (including COX-2 inhibitors) and
acetaminophen when added to intravenous PCA with
opioids

NSAIDs , not acetaminophen, resulted in a


statistically significant reduction in pain
scores
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Although all regimens significantly


decreased morphine consumption, only
NSAIDs (but not acetaminophen)
reduced the risk for the opioid-related
side effects of nausea, vomiting, and
sedation
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

NSAIDs are particularly useful as


components of a multimodal analgesic
regimen by producing analgesia
through a different mechanism than
that of opioids or local anesthetics

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Perioperative use of NSAIDs is associated


with a number of side effects:
Decreased hemostasis
Renal dysfunction
Gastrointestinal hemorrhage
Deleterious effects on bone healing and
osteogenesis?

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Aspirin
and
diclofenac
are the
most
potentially
hepatotoxi
c
NSAIDs,
and should
be avoided
in patients
with
preexisting
hepatic
failure
Dr Mehran
Rezvani
pain fellowship anesthesiologist
H.Hemmings, PHARMACOLOGY
AND
PHYSIOLOGY
FOR ANESTHESIA, ELSEVIRE 2013
& acupuncturist

NSAIDs cause significant lengthening (by about 30%) of the


bleeding time, but usually still within the normal range
This can last for days with aspirin (10-14 D) but just for hours
with non-aspirin NSAIDs
Single 300 to 900 mg dose of ibuprofen can inhibit platelet
aggregation for 2 hours after administration, and the effect is
largely dissipated by 24 hours
1-WALL AND MELZACKS TEXTBOOK OF PAIN.2013
2-H.Hemmings, PHARMACOLOGY AND PHYSIOLOGY FOR ANESTHESIA, ELSEVIRE 2013
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Two recent systematic reviews indicated that when


examining the highest-quality there was no increased
risk of nonunion with NSAID
Certainly, a short-term NSAID regimen can be used for
treatment of postfracture pain without significantly
increasing the risk of disrupted
healing
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

A brief (<14 days) exposure to normal-dose NSAIDs (e.g.,


ketorolac <120 mg/day) was safe after spinal fusion;
however, use of large-dose ketorolac (>120 mg/day)
increased the risk of nonunion, suggesting a
dose-dependent effect of perioperative NSAIDs on spinal
fusion healing

Spine surgeons will more refuse to have postoperative


spine fusion patients receive NSAIDs
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Perioperative NSAID-induced renal in high-risk patients:


Hypovolemia
Abnormal renal function
Abnormal serum electrolyte
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

NSAIDs may cause a clinically unimportant


transient reduction in renal function in the
early postoperative period in patients with
normal preoperative renal function

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

There does not appear to be a benefit in using COX2 inhibitors instead of traditional nonselective
NSAIDs in reducing the incidence of renal
complications (miller7)
Preliminary evidence suggests that COX-2 inhibitors
may be an alternative when attempting to avoid
the detrimental effects of nonselective NSAIDs on
bone
Healing (miller7)
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Bronchospasm may be induced by NSAIDs


(including aspirin) or acetaminophen
There may be cross-sensitivity with
acetaminophen in aspirin sensitive
asthmatic subjects

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Acute pain management , Taylor


& Francis
CRC
press 2015
Dr Mehran
Rezvani Group.
pain fellowship
anesthesiologist
& acupuncturist

COX-2 inhibitors are associated with a lower incidence of


gastrointestinal complications and exhibit minimal
platelet inhibition, even when administered in
supratherapeutic doses

Long-term use of COX-2 inhibitors has been associated


with excess cardiovascular risk such that rofecoxib was
withdrawn from the market

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Although cardiovascular toxicity appears to be a class


effect of all COX-2 inhibitors, the cardiovascular risks of
COX-2 inhibitors appear to be heterogeneous and
influenced by many factors such as the specific
medication, dosage, and patient characteristics

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The use of parecoxib and valdecoxib after


CABG was associated with an increased
incidence of cardiovascular events, thereby
arousing serious concern about the use of
these drugs in such circumstances

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Subsequent randomized controlled trial


investigating the safety and efficacy of
parecoxib and valdecoxib after major
noncardiac surgery found that patients who
received the COX-2 inhibitors had similar
frequencies of predefined adverse events
compared with those who
received placebo
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

R.MendesI,.. Selective inhibition of cyclooxygenase-2: risks and benefits, Rev. Bras. Reumatol.
vol.52 no.5 So Paulo Sept./Oct. 2012
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Parecoxib, the only injectable coxib, is


particularly suitable for acute pain
management as it can be given as an IV or
intramuscular injection
It provides rapid onset of effective analgesia
within 1015 minutes and lasts 1224 hours
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Ketorolac, until recently, was the only parenteral NSAID available in


the United States and was therefore used quite extensively in the
perioperative period
A standard dose (30 mg) of ketorolac provides analgesia equivalent
to 6 to 12 mg of morphine but has a longer duration of action of 6
to 8 hours and lacks the respiratory depressant effect of morphine
Perioperative Pain Management. Urman Oxford University Press 2013
Pharmacology and physiology for anesthesia : foundations and clinical application, elsevire 2013

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Ketorolac
Gastrointestinal bleeding and operative site bleeding
have also been reported and are mostly associated with :
Advanced patient age
Duration of therapy beyond 5 days
Higher dosing regimens
Pharmacology and physiology for anesthesia : foundations and clinical application,
elsevire 2013
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Ketorolac
For a single dose :
30 mg IV
15 mg if patient age is greater than 65 or body weight
less than 50 kg
For multiple dosing:
30 mg every 6 hours, not to exceed 120 mg in a 24hour period
In older than 65 years or weighing less than 50 kg, the
dosing should be 15 mg every 6 hours, not to exceed 60
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
mg in 24 hours

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Gabapentanoids

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Oral gabapentin improves the analgesic


efficacy of opioids both at rest and with
movement, and reduces opioid consumption
and opioid-related side effects, but with an
increased incidence of side effects such as
sedation and dizziness

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Gabapentin and pregabalin, antiepileptic drugs also used


in the treatment of neuropathic pain
Oral pregabalin is absorbed more rapidly and has more
absolute bioavailability (90% versus <60%) than does
gabapentin

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

A meta-analysis :
Use of pregabalin was associated with a decrease in opioid
consumption and opioid-related side effects, but no
difference in pain intensity
Another meta-analysis :
Perioperative administration of pregabalin may provide
additional analgesia in the short term but also results in
an increase in side effects such as
dizziness/lightheadedness or visual disturbances
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Perioperative administration of
gabapentin and pregabalin may reduce
the incidence of CPSP

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

NMDA receptor antagonists

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Wind-Up Phenomenon?

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Repetitive stimulation of unmyelinated Cfibers can result in


prolonged discharge of dorsal horn cells, termed windup
Windup is a short-lived process, however, repetitive
Episodes may precipitate long-term potentiation (LTP),
which involves a long lasting increase in the efficacy of
synaptic transmission and thus alters synaptic plasticity
Both windup and LTP are believed to be important
components of central sensitization.
Encyclopedia of Pain. G.F. Gebhart , Robert F. Schmidt . Springer; 2nd ed. 2013 edition

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Neuroplasticity?

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Neuroplasticity is a general term referring to persistent


changes in neural activity or function
A neuroplastic change is caused by frequent usage of a
neuron or a
neuronal connection , which stays for a longer period of
time after the end of the neuronal activity that started
the change
Memory processes and the transition from acute to
chronic pain are examples of neuroplastic changes
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Surgery or trauma leading to tissue damage and


subsequent inflammatory responses causes nociceptive
stimuli to be carried along peripheral sensory nerves to
the spinal cord
The CNS responds to this persistent input from the
periphery with adaptive processes commonly described
as neuroplasticity
This leads to the development of spinal cord
hyperexcitability, a process referred to as central
sensitization
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The increased excitability is primarily the result of


increased excitatory amino acid (EAA) release, in
particular glutamate
It is mediated by glutamate activation of Nmethyl-Daspartate (NMDA) receptors in the dorsal
horn neurons of the spinal cord

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Acute pain management , Taylor & Francis Group. CRC press 2015

These changes happen in all patients after acute injury


and therefore central sensitization contributes
significantly to the pain experience after trauma or
surgery
In most patients central sensitization lessens as the
injury heals and acute pain resolves
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

In some patients, central sensitization persists beyond


healing and can then contribute to persistent pain states

Of note is that the mechanisms underlying


the development of tolerance to opioids and
opioid-induced hyperalgesia are similar to
central sensitization
Acute pain management , Taylor & Francis Group. CRC press 2015

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Medications that either :


Decrease EAA release
(gabapentin and
pregabalin)
or
Act as antagonists at
NMDA

Reduce the risk of


development of
windup and central
sensitization and
downregulate
hyperexcitability after
sensitization has
taken place

receptors
Mehran Rezvani pain fellowship anesthesiologist
Acute pain management , TaylorDr&
& acupuncturist
Francis Group. CRC press 2015

Therefore, NMDA receptor antagonist drugs show


effects that are best described as antiallodynic, anti-hyperalgesic, and toleranceprotective rather than as simply analgesic

Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

KETAMINE

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Use of low-dose ketamine for postoperative analgesia has


developed
NMDA-antagonistic properties, may be important in
attenuating central sensitization and opioid tolerance
Racemic mixtures of ketamine have been found to be
neurotoxic, and therefore the use of neuraxial ketamine
is discouraged
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

S-(+)-isomer, available as an enantiomerspecific product in some countries only


More potent analgesic (twofold) with a
shorter duration of action
It is said to produce fewer side effects
than the racemic mixture
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist


Ketamine acts at a number of receptors including
NMDA and opioid receptors

Norketamine, is also an NMDA receptor antagonist


and contributes to its analgesic

It is the only anesthetic agent that results in no or


only minimal opioid-induced ventilatory
impairment (OIVI) or airway compromise
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Perioperative ketamine reduced 24-hour PCA morphine


consumption and postoperative nausea or vomiting
low-dose ketamine infusion does not appear to cause
hallucinations or cognitive impairment, and the incidence
of side effects, such as dizziness, itching, nausea, and
vomiting dont change

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Low-dose pain setting use


Ketamine

Higher-dose

Prevention of central sensitization


and reduction of developed central
sensitization of tolerance and
Attenuation

Treatment of acute pain

setting use

Procedural pain (dressing chang

Ketamine
pain setting
uses

hyperalgesia

pain

emergency department procedure

Prehospital setting

Treatment of poorly opioid-responsive


pain
Anesthetic doses

Neuropathic pain
Ischemic pain
Pain in opioid-tolerant patients

Preventive analgesia in patients at


increased risk of developing persistent
pain

Dr Mehran
Rezvani pain
o After nerve injury (surgical,
traumatic,
orfellowship
other anesthesiologist
& acupuncturist
cause)

Dr MehranR.Gupta.
Rezvani pain
fellowship
anesthesiologist
A. Akhabahian.,
The
Anesthesia
Guide. McGraw-Hill Education 2013
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

TRAMAD
OL
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Tramadol was launched and marketed as


Tramal by the German pharmaceutical
company Grnenthal GmbH in 1977 in West
Germany, and 20 years later it was launched
in countries such as the UK, U.S., and
Australia

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Tramadol is a synthetic opioid that exhibits weak agonist activity and inhibits reuptake of serotonin and
norepinephrine

Although tramadol exerts its analgesic effects primarily


through
central mechanisms, it may have peripheral local
anesthetic properties
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Tramadol is effective in treating moderate


postoperative
Pain
Comparable in analgesic efficacy to aspirin (650
mg) with codeine (60 mg) or ibuprofen (400 mg)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

It is often combined with paracetamol (acetaminophen) as this


is known to improve the efficacy of tramadol in relieving pain
Tramadol is metabolised to O-desmethyltramadol, which is a
more potent opioid
The addition of acetaminophen to tramadol (versus tramadol
alone) may decrease the incidence of tramadols side effects
without

reducing its analgesic efficacy


Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Use of tramadol in intravenous PCA results in similar pain


scores when compared with that from intravenous PCA
opioids
However, the side effect profile is different between the
two groups (i.e.,a more frequent incidence of
postoperative nausea/vomiting
but lower pruritus with tramadol)
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Advantages of tramadol for postoperative analgesia


include
Relative lack of respiratory depression
lack of major organ toxicity
lack of depression of gastrointestinal motility
low potential for abuse

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Common side effects (overall incidence of 1.6% to 6.1%)


include
Dizziness
Drowsiness
Sweating
Nausea & vomiting
Dry mouth
Headache
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Tramadol". MedlinePlus. American


Society
ofpain
Health-System
Pharmacists. 1 September 2008.
Dr Mehran
Rezvani
fellowship anesthesiologist
& acupuncturist
Retrieved 29 September 2009.

Tramadol should be used with caution in patients with


seizures or increased intracranial pressure
Tramadol is contraindicated in those taking monoamine
oxidase
inhibitors

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Tramadol is recommended for the management of pain


in fibromyalgia by the European League Against
Rheumatism
Analgesic effects are only partially reversed by naloxone

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dosage :
Adult: 50-100 mg q6h po ( in renal failure q12h)
Max dose : 400 mg /day or (200 mg/day if creatinine
clearance is < 30 ml/min)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

In Iran available:
Tablet : 50 & 100 mg
Tablet : 100(slow release)
Cap : 50 mg
Injction 50 mg /ml (2 ml)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Regional Analgesic
Techniques

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

In general, the analgesia provided by epidural and


peripheral techniques (particularly when local
anesthetics are used) is superior
to that with systemic opioids
Use of these techniques may even reduce morbidity and
mortality

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Single-Dose Neuraxial Opioids

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Administration of a single dose of opioid may be


efficacious as a sole or adjuvant analgesic agent when
administered intrathecally or epidurally

Lipophilicity or Hydrophilicity ???

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Hydrophilic opioids (i.e., morphine and


hydromorphone) tend to remain within the
CSF and produce a delayed but longer
duration of analgesia, along with a generally
higher incidence of side effects because of
the cephalic or supraspinal spread of these
compounds

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Single-dose intrathecal administration of a lipophilic opioid


:in situations (e.g., ambulatory surgical patients) in which
rapid analgesic onset (minutes) combined with a moderate
duration of action (<4 hours) and minimal risk of respiratory
depression is needed.
Single-dose hydrophilic opioid administration provides
effective postoperative analgesia and may be useful in
patients monitored on an
inpatient basis, for whom a longer duration of analgesia
would be
beneficial
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Use of a single-dose hydrophilic opioid may


be especially helpful in providing
postoperative epidural analgesia when the
epidural catheters location is not congruent
with the surgical incision (e.g., lumbar
epidural catheter for thoracic surgery)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

An extended-release formulation of (single-dose) epidural


morphine encapsulated within liposomes that results in
up to 48
hours of analgesia has recently been introduced
Concurrent administration of liposomal extended-release
morphine and local anesthetics may increase peak
concentrations of morphine
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

The manufacturer has recommended that clinicians


increase the interval between administration of local
anesthetic (including test doses) and liposomal extendedrelease morphine to at least 15 minutes
to minimize this pharmacokinetic interaction
It should be administered within 4 hours after withdrawal
from the vial
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

MILLER 2015

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Continuous Epidural Analgesia

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Analgesia delivered through an indwelling epidural


catheter is a safe and effective method for management
of acute postoperative pain

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

It is important to
realize that intraoperative use of the epidural catheter as
part of
a combined epidural-general anesthetic technique results
in less
pain and faster patient recovery immediately after
surgery than
general anesthesia followed by systemic opioids does
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Analgesic Drugs in Epidural infusion

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Epidural infusion of local anesthetic alone is less effective


in controlling pain (in compare to local anestheticopioid
epidural analgesic combinations)
The precise location of action of local anesthetics in the
epidural space is not clear, and potential sites include the
spinal nerve roots, dorsal root ganglion, or spinal cord
itself
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The sole use of local anesthetics is less


common than the use of a local anesthetic
opioid combination because of a significant
failure rate (from regression of sensory
blockade and inadequate analgesia) and
relatively high incidence of motor block and
hypotension
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Opioids for Epidural Infusion

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Opioids may be used alone for postoperative epidural


infusion and do not generally cause motor block or
hypotension from sympathetic blockade

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The analgesic site of action (spinal versus systemic) of


continuous epidural infusion of lipophilic opioids is not
clear, although several randomized clinical trials suggest
that it is systemic
There were no differences in plasma concentrations, side
effects, or pain scores between those who received
intravenous or epidural infusion of fentanyl.

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The overall advantage of administering continuous


epidural infusion of
lipophilic opioids alone is marginal

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The analgesic site of action for continuous


hydrophilic opioid infusion is primarily spinal
Use of a continuous infusion rather than
intermittent boluses of epidural morphine
may result in superior analgesia with fewer
side effects
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Continuous infusion of a hydrophilic opioid may be


especially useful for providing postoperative analgesia
when the site of catheter insertion is not congruent with
the site of surgery or when side effects (e.g.,
hypotension, motor block) are attributed to the epidural
local anesthetic

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Local AnestheticOpioid
Combinations

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Superior postoperative analgesia


(including improved dynamic pain relief)
limits regression of sensory blockade
possibly decreases the dose of local
anesthetic administered

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Concentrations used for postoperative


epidural analgesia (0.125% bupivacaine
or levobupivacaine or 0.2% ropivacaine)
are lower than those used for
intraoperative anesthesia

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Many clinicians prefer a lipophilic opioid


(fentanyl, 2 to 5 g/mL, or sufentanil, 0.5 to
1 g/mL) to allow rapid titration of analgesia
Use of a hydrophilic opioid (morphine, 0.05
to 0.1 mg/mL) as part of a local anesthetic
opioid epidural analgesic regimen may also
provide effective postoperative analgesia
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Adjuvant Drugs

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

clonidine (5 to 20 g/hr)
Risks:
Hypotension (dose dependent)
Bradycardia ((dose dependent)
Sedation
Other drugs:
Epinephrine (2 to 5 g/ml)
Ketamine ?

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Location of Catheter Insertion

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Insertion of the epidural catheter congruent to the


incisional dermatome :
Optimal postoperative epidural analgesia
Minimizing side effects (e.g., lower extremity motor block
and urinary retention)
Decreasing morbidity
Lower drug requirements
Decreased medication-related side effects

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Lumbar epidural catheters:


Higher incidence of lower extremity motor block an
Earlier-than-anticipated termination of epidural
analgesia
High thoracic epidural
Does not inhibit sympathetic nerve activity in the lower
extremities, (T9 to L1)

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Use of thoracic epidural analgesia for abdominal or


thoracic surgery may result in a relatively low incidence
of urinary Retention
Placement of thoracic epidural catheters appears to be
relatively
safe, and there is no evidence of a higher incidence of
neurologic complications with placement of a thoracic
(versus lumbar) epidural catheter
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

RECOMMENDED CATHETER INSERTION SITES FOR SURGICAL


PROCEDURES
Location of Incision

Examples of Surgical Procedures

Epidural Catheter
Placement

Thoracic

Lung reduction,
Radical mastectomy, thoracotomy, thymectomy

T4-8

Upper abdominal

Cholecystectomy, esophagectomy, gastrectomy,


hepatic resection, Whipple procedure

T6-8

Middle abdominal

Cystoprostatectomy, nephrectomy

T7-10

Lower abdominal

Abdominal aortic aneurysm repair, colectomy


Radical prostatectomy,
Total abdominal hysterectomy

T8-11

Lower extremity

Femoral-popliteal bypass, total hip or total knee


replacement

L1-4

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Side Effects of Neuraxial


Analgesic Drugs

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Hypotension
Incidence of postoperative hypotension with
postoperative epidural analgesia may be as high as 7%,
the average may be 0.7% to 3%
o Decreasing the overall dose of local anesthetic
administered
o Infusing an opioid epidural alone
o Treating the underlying cause of the decrease in blood
pressure
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Motor Block
Incidence of lower extremity motor block is 2% to 3% of
patients
This may lead to the development of pressure sores in
the heels
A lower concentration of local anesthetic
Catheter-incisioncongruent placement of epidural
catheters
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Motor Block
Motor block resolves in most cases after stopping the
epidural infusion for approximately 2 hours
Persistent or increasing motor block should be
evaluated promptly:
Spinal hematoma
Spinal abscess
Intrathecal catheter migration

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Nausea and Vomiting


Neuraxial administration of single-dose opioid occurs in
20% to 50%
Neuraxial opioidrelated nausea and vomiting is dose
dependent
Use of epidural fentanyl infusion is associated with a
lower incidence of nausea and vomiting than infusions
of morphine
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Nausea and Vomiting


Treatment:
Naloxone
Droperidol
Metoclopramide
Dexamethasone
Ondansetron
Transdermal scopolamine

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Pruritus
Pruritus is one of the most common side
effects of epidural or intrathecal
administration of opioids, with an incidence
of approximately 60% versus about 15% to
18% for epidural local anesthetic
administration or systemic opioids
Fentanyl appears have lower incidence of
pruritus than morphine
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Pruritus
Treatments :
Intravenous naloxone
Naltrexone
Nalbuphine
Droperidol

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Respiratory Depression

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Neuraxial opioids used in appropriate doses are not


associated with a higher incidence of respiratory
depression than that seen with systemic opioids
Incidence for Neuraxial opioids = 0.1% to 0.9%
Neuraxial lipophilic opioids are thought to cause less
delayed respiratory depression than hydrophilic opioids

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Delayed respiratory depression is primarily


associated with the cephalad spread of
hydrophilic opioids, which typically occurs within
12 hours after injection of morphine
Clinical assessments, such as the respiratory rate,
may not reliably predict a patients ventilator
status or impending respiratory depression
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Risks factors
Increasing dose
Increasing age
concomitant use of systemic opioids or sedatives
Possibly prolonged or extensive surgery
The presence of comorbid conditions (e.g., obstructive sleep
apnea)

Thoracic surgery

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Treatment:
Naloxone (and airway management if necessary)
0.1- to 0.4-mg increments
Continuous infusion of naloxone (0.5 to 5 g/kg/hr) may
be needed

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Although perioperative single-dose extended-release


epidural morphine (versus intravenous opioid PCA) may
be effective for postoperative pain relief for up to 48
hours, respiratory depression may be more likely

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Urinary Retention
Urinary retention associated with the neuraxial
administration of opioids is the result of an interaction
with opioid receptors in the spinal cord that decreases
the detrusor muscles strength of contraction
Urinary retention does not appear to depend on the
opioid dose and
Use of low-dose naloxone, though at the risk of
reversing the analgesic effect may be useful
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Urinary Retention
Epidural administration of local anesthetics is also
associated with urinary retention, with a reported rate of
approximately 10% to 30%
Higher epidural infusion rates of local anesthetics (with a
greater extent of sensory block and a higher incidence of
motor block) may be associated with a higher incidence
of urinary retention
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

FACIAL SKIN ANESTHESIA

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The infraorbital notch lies on a line connecting the


supraorbital and mental foramina and the pupil of the
eye
The nerve can be blocked by advancing a 25- gauge, 3cm needle laterally and cephalad toward the foramen
from a point 1 cm inferior
A paresthesia is frequently elicited. When the needle tip
is in the region of the foramen, 3 to 4 mL of solution is
injected
Dr Mehranthe
Rezvani needle
pain fellowship anesthesiologist
It is not essential that
enter the foramen
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Supraorbital and Supratrochlear


Nerves

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Supraorbital and Supratrochlear


Nerves
The supraorbital notch can easily be palpated
This landmark lies on a vertical line with the pupil
A 25-gauge, 2-cm needle is inserted immediately
superior to the supraorbital notch, and 2 to 4 mL of local
anesthetic solution
is injected
The supratrochlear nerve can be blocked by extending
the supraorbital injection site medially with an additional
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
2 to 4 mL of solution

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Mental Nerve

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Blockade of the mental nerve as it exits the mental


foramen provides
anesthesia to the lower lip and chin
The foramen is palpated in the mandible, and a 25gauge, 3-cm needle is inserted inferomedially. Infiltration
of 2 to 4 mL of solution after
elicitation of a paresthesia or in the region of the foramen
results
Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist
in anesthesia of the mental
nerve

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Stellate Ganglion Block

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

The patient lies supine with the neck extended slightly


The most prominent cervical transverse processthe
Chassaignac tubercle (C6)is palpated between the
sternocleidomastoid muscle and the trachea
The C6 tubercle is palpated between the index and
middle fingers and the carotid artery is pushed laterally

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

A 22- gauge, 4-cm short-beveled needle with a 12-mL


syringe attached is inserted in a perpendicular direction
until the tip contacts the C6 transverse process
The needle is then withdrawn 3 mm and fixed. After
careful aspiration, 8 to 12 mL of local anesthetic solution
is injected

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Signs of a successful stellate ganglion block :


Horners syndrome
Anhidrosis
Injection of the conjunctiva
Nasal stuffiness
Vasodilation
Increased skin temperature
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Side Effects and Complications


Block of the brachial plexus
Block of recurrent laryngeal nerves
Hematoma formation
Intravascular Injection resulting in convulsions
Epidural and subarachnoid injection
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Patient-Controlled Epidural
Analgesia

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Epidural analgesia has traditionally been delivered at a


fixed rate or as a continuous epidural infusion (CEI);
however, the administration
of epidural analgesia through a patient-controlled device
(PCEA) has become more common
The optimal PCEA analgesic solution and delivery
parameters are unclear
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist

For PCEA as CEI, addition of an opioid to the local


anesthetic can provide analgesia superior to that with
either agent alone
A lipophilic opioid is usually chosen because its rapid
analgesic effect and shorter duration of action may be
more suitable for use with PCEA

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

Dr Mehran Rezvani pain fellowship anesthesiologist


& acupuncturist

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