Documentos de Académico
Documentos de Profesional
Documentos de Cultura
MANAGEMENT OF
POSTOPERATIVE PAIN:
MULTIMODAL APPROACHES
IN CLINICAL PRACTICE
ACUTE PAIN EPIDEMIOLOGY
Centers for Disease Control and Prevention. National Center for Health Statistics.
www.cdc.gov/nchs/faststats/inpatient-surgery. Accessed July 8, 2015.
ACUTE PAIN SCOPE OF THE
PROBLEM
Almost all patients experience pain after surgery,
procedure, or injury
Survey of 300 US adults undergoing surgery:
86% experienced pain post surgery
75% had moderate to extreme pain in the immediate
postsurgical period
74% still had pain post discharge
Harstall C, Ospina M. Pain: American Association for Marriage and Family Therapy Clinical Updates.
2003;11(2):1-4.
World Health Organization. WHO guidelines on the pharmacological treatment of persisting pain in children
with medical illnesses. http://www.who.int/medicines/areas/quality_safety/children_persisting_pain/en/.
Accessed July 8, 2015.
CURRENT PROBLEMS WITH THE
ASSESSMENT OF ACUTE PAIN
When used alone, these taxonomies do not capture the
multidimensionality of pain or the dynamics of pain
over the course of a 24-hour day in an individual
patient
This approach may result in inadequate
individualization of pharmacologic pain management
Somatic vs neuropathic
Pitfalls in the implementation of therapy to treat these patients:
Multimodal therapy
Opioid metabolism
Drug-drug interactions
Preexisting pain
A. PAIN QUESTIONNAIRE
5 Questions
B. SENSORY TESTING
2 Questions
Yes= 1/No= 0
Does stroking the affected area of skin with a piece of cotton wool produce an unpleasant painful
sensation?
Yes= 5/No= 0
Does touching the affected area of skin with a sharp needle feel sharper or duller when compared
to an area of normal skin?
Yes= 3/No= 0
Bennett M. Pain. 2001;92(1-2):147-157.
CHALLENGES IN THE
MANAGEMENT OF ACUTE PAIN
Variable response to analgesics
Older age = more sensitivity to opioids
Ethnicity
Psychological issues
Type of surgical procedure
The use of pre-emptive analgesic techniques
Intraoperative anesthetic techniques:
Regional anesthetic procedures vs general
Ketamine use
Chronic pain
Chronic pain Clinically
Clinically Up to
Up to 50%
50% Effectively
Effectively
may develop
may develop meaningful,
meaningful, of patients
of patients managing
managing
after surgery
after surgery severe acute
severe acute reportedly suffer
reportedly suffer acute pain
acute pain can
can
as aa result
as result postoperative
postoperative from chronic
from chronic reduce the
reduce the risk
risk
of complex
of complex pain may
pain may bebe aa pain following
pain following for pain
for pain
biochemical and
biochemical and risk factor
risk factor for
for the
the common surgery
common surgery progression
progression
pathophysiologica
pathophysiologica development of
development of
ll mechanisms
mechanisms chronic pain
chronic pain
Rationale:
Targeting of different pathways
Synergism of multiple agents
Allows for dose reduction of individual agents,
reducing the risk for adverse effects
MULTIMODAL THERAPY
Sensory Cortex
Thalamus
Peripheral
Nociceptor
Ascending
Descending
Pathways
Pathways
Mid Brain
Sensory
Fiber Dorsal
Horn
Spinal Cord
Efferent
Fiber
Thalamus
Ascending
Nociceptor
Pathways
Mid Brain
Sensory
Fiber Dorsal
Horn
Spinal Cord
Efferent
Fiber
Multimodal N-methyl-D-aspartate
(NMDA) antagonists
Therapy
LA via peripheral
nerve catheters
Local anesthetics
Opioids
2-Agonists
NMDA antagonists
COX-2 Inhibitors
for 4 hours
Number needed to treat (NNT) based on dose:
acetaminophen
Adverse events were statistically similar for those taking a lower
Placebo: 91%
in frequency
Derry S et al. Cochrane Database Syst Rev. Published Online: 22 OCT 2013
MULTIMODAL APPROACHES:
EVIDENCE-BASED SUMMARY
Injectable NSAIDs
Ketorolac and ibuprofen studied in United States
Indicated for short-term moderate to severe acute pain
that requires analgesia at the opioid level
Studies (variety of surgery types) with ketorolac1,2 compared with
placebo suggest patients who received ketorolac:
Significant reduction in pain
and complications
Conclusions: Epidural local anesthetics:
Jorgensen H et al. Cochrane Database Syst Rev. Published Online: 22 JAN 2001
MULTIMODAL APPROACHES:
EVIDENCE-BASED SUMMARY
Continuous Epidural Analgesia
Cochrane database review1: 9 RCT comparing IV PCA and
continuous epidural analgesia (CEA)
CEA had better pain control in the first 72 hours after abdominal
surgery
There was no difference in length of hospital stay and adverse
opioids
Comparing PCA vs CEA in colorectal surgery2 showed that CEA
1
Werawatganon T, Charuluxanun S. Cochrane Database Syst Rev. 2005;(1):CD004088.
Marret E et al; Postoperative Pain Forum Group. Br J Surg. 2007;94(6):665-673.
2
MULTIMODAL APPROACHES:
EVIDENCE-BASED SUMMARY
Intrathecal (IT) Morphine + PCA Morphine vs PCA
Morphine Alone
Major
abdominal surgery, 60 patients
Summary
Analgesia at rest and while coughing was significantly better in the
IT+PCA morphine group on the first postoperative day only
Morphine consumption was lower in the IT+PCA morphine group
issue
Preoperative blockage superior to postoperative
Incidence of PONV
Oral route
NSAIDs
APAP
Local anesthetics
Wound site infiltration or perfusion
Peripheral nerve infusions via catheters
Epidural
IV
Preperitoneal catheters
CHRONIC PAIN
Chronic Pain Acute Surgical
Ladder Pain
De
it y cr
e ns ea
s
t in
In g
a in Step 4 (interventional)
Pa
P i n
i n g Step 3 (potent opioids) In
a s te
re n sit
c
In Step 2 (weak opioids) y
Step 1 (nonopioids)
No analgesics
TRANSITION FROM ACUTE SURGICAL PAIN
AND THE DEVELOPMENT OF CHRONIC PAIN
Decreasing
Surgery Pain Intensity Increasing Pain
Intensity
interventional
potent opioids
interventional
weak opioids
potent opioids
non-opioids
Nerve Injury
vs Central
Sensitization adjuvants
no medications
Time
TRANSITION FROM ACUTE SURGICAL
PAIN TO SUBACUTE (PERSISTENT) PAIN
Decreasing
Surgery Pain Intensity
Pain Intensity
Remains High
interventional
potent opioids
non-opioids adjuvants
no medications
Time 1 to 12 weeks
MULTIMODAL PAIN
MANAGEMENT:
STEP THERAPY
Severe Postoperative Pain
Step 3 Step 1 and Step 2 Strategies
AND
Local Anesthetic Peripheral Neural
Blockade
(with or without catheter)
AND
Use of Sustained-release Opioid
Analgesics
Step 2 Moderate Postoperative Pain
Step 1 Strategy
AND
Intermittent Doses of Opioid
Analgesics
Mild Postoperative Pain
Step 1 Nonopioid Analgesic
Acetaminophen, NSAIDs, or COX-2 Selective
Inhibitors
AND
Local Anesthetic Infiltration
Reprinted with permission. Copyright 2002
American Medical Association. All rights reserved.
Readmissions
TRANSITION FROM ACUTE SURGICAL
PAIN TO SUBACUTE (PERSISTENT) PAIN
Decreasing
Surgery Pain Intensity
Pain Intensity
Remains High
interventional
potent opioids
non-opioids adjuvants
no medications
Time 1 to 12 weeks
CLINICAL PEARLS
THANK YOU!