Professional Documents
Culture Documents
FACTORS for
PPP
Preoperative
Intraoperative
Postoperative
Preventive Analgesia
This definition broadly includes any regimen
given at any time during the perioperative
period that is able to control pain-induced
sensitization
OPIOIDS
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Opium
Opiates
Narcotic
Opioid
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
Dr Mehran Rezvani
painphysiology
fellowship anesthesiologist
Stoeltings handbook of pharmacology
and
in anesthetic practice. Wolters
& acupuncturist
Kluwer Health 2015
Dr Mehran Rezvani
painphysiology
fellowship anesthesiologist
Stoeltings handbook of pharmacology
and
in anesthetic practice. Wolters
& acupuncturist
Kluwer Health 2015
Anesthesiology.2003;98:312322
PATS
PatientActivated
Transdermal
System
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
Miller 8 chp 31
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
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
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
NSAIDS
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Acetaminophen
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
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
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
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
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
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
Gabapentanoids
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
Wind-Up Phenomenon?
Neuroplasticity?
Acute pain management , Taylor & Francis Group. CRC press 2015
receptors
Mehran Rezvani pain fellowship anesthesiologist
Acute pain management , TaylorDr&
& acupuncturist
Francis Group. CRC press 2015
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
KETAMINE
Ketamine acts at a number of receptors including
NMDA and opioid receptors
Higher-dose
setting use
Ketamine
pain setting
uses
hyperalgesia
pain
Prehospital setting
Neuropathic pain
Ischemic pain
Pain in opioid-tolerant patients
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
TRAMAD
OL
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Tramadol is a synthetic opioid that exhibits weak agonist activity and inhibits reuptake of serotonin and
norepinephrine
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)
In Iran available:
Tablet : 50 & 100 mg
Tablet : 100(slow release)
Cap : 50 mg
Injction 50 mg /ml (2 ml)
Regional Analgesic
Techniques
MILLER 2015
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
Local AnestheticOpioid
Combinations
Adjuvant Drugs
clonidine (5 to 20 g/hr)
Risks:
Hypotension (dose dependent)
Bradycardia ((dose dependent)
Sedation
Other drugs:
Epinephrine (2 to 5 g/ml)
Ketamine ?
Epidural Catheter
Placement
Thoracic
Lung reduction,
Radical mastectomy, thoracotomy, thymectomy
T4-8
Upper abdominal
T6-8
Middle abdominal
Cystoprostatectomy, nephrectomy
T7-10
Lower abdominal
T8-11
Lower extremity
L1-4
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
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
Respiratory Depression
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
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
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
Mental Nerve
& acupuncturist
in anesthesia of the mental
nerve
Patient-Controlled Epidural
Analgesia