海外讲者：术后疼痛管理课件

1、Professor Narinder Rawal, MD, PhD, FRCA (Hon)Department of Clinical MedicineDivision of Anaesthesiology and Intensive Care University Hospitalrebro, SwedenPostoperative Pain Management* The following only stand by personal opinion. Naropin prescription should follow product instruction. Professor Na

2、rinder Rawal, MD,Postoperative Pain Continues To Be UndertreatedDespite nearly a decade of progress in pain research, 39% of patients reported severe-to-extreme postoperative pain in 2003 versus 31% in 19951Warfield CA, Kahn CH. Anesthesiology. 1995;83(5):1090-1094.2Apfelbaum JL, et al. Anesth Analg

3、. 2003;97(2):534-540.SevereExtremeModerateMild1995120032SevereExtremeModerateMild19%49%23% 8%47%21%18%13%Postoperative Pain Continues Symptoms at home after ambulatory surgery literature review1966-2000, 156 articles, (33 included)Wu CL et alAnesthesiology 2000;96:994-1003Symptoms at home after ambu

4、latPersistent postsurgical pain the incidenceCraniotomy 6-12 %Kaur 2000Harner 1993Leg amputation 50-80 %Finch 1980Fisher 1998Sherman 1984Thoracotomy50 %Bertrand 1996Katz 1996Breast surgery11-57 %Jung 2003Tasmuth 1996Lap cholecystectomy3-56 %Stiff 1994Ure 1995de Povourville 1997Inguinal hernia12 %Aas

5、vang 2005Persistent postsurgical pain Chronic postsurgical painPsychologicalPatient attiudesPreop anxietyExpectation of chronicityEnvironmentalPoor educationLow incomePoor self-rated healthSurgicalSeverity of postopertaive painSurgical factors- site and extent of surgery- damage to nerves- reoperati

6、ons- bleeding, infectionPreoperativeFemale genderYounger agePain before surgeryAnalgesic useGenetic predispositionChronic postsurgical painPsychPCA techniques for postoperative painEpidural PCA (PCEA)Perineural PCAIncisional and intraarticular (PCRA)Other routes of opioid PCA (intranasal, transderma

7、l)PCA techniques for postoperati海外讲者：术后疼痛管理课件Non-opioid analgesic techniquesAnalgesic drugsParacetamolNSAIDs (including COX-2-inhibitors)NMDA antagonists (ketamine, dextromethorphan)2 receptor agonists (clonidine, dexmedetomidine)others (gabapentin, corticosteroids, capsaicin, nicotine, neostigmine

8、etc.)Regional techniques (including catheter techniques)Central blocks (EDA, spinal, CSE)Peripheral blocksIncisionalIntraarticularNon-pharmacological techniquesNon-opioid analgesic technique37 RCTs, n= 2385, 5 subgroups: i.v. ketamine single dose, cont. Infusion, PCA, epidural, pediatricI.v. morphin

9、e + ketamine not better than i.v. MorphineI.v. ketamine infusion decreased i.v. and epidural opioid requirements in 6/11 studies*Single bolus ketamine decreased opioid requirements in 7/11 studies*Epidural ketamine beneficial in 5/8 trialsAdverse effects not increased with small dose (0.15-1 mg/kg b

10、olus, 0.12-0.6 mg/kg/h infusion”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*Anesth Analg 2004;99:482-95May prevent central sensitization and chronic neuropathic pain* No reduction of opioid adverse effects, * in 54 % studies37 RCTs, n= 2385, 5 subgroup37

11、RCTs, n= 2385, 5 subgroups: i.v. ketamine single dose, cont. Infusion, PCA, epidural, pediatricI.v. morphine + ketamine not better than i.v. MorphineI.v. ketamine infusion decreased i.v. and epidural opioid requirements in 6/11 studies*Single bolus ketamine decreased opioid requirements in 7/11 stud

12、ies*Epidural ketamine beneficial in 5/8 trialsAdverse effects not increased with small dose (0.15-1 mg/kg bolus, 0.12-0.6 mg/kg/h infusion”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*Anesth Analg 2004;99:482-95May prevent central sensitization and chronic

13、 neuropathic pain* No reduction of opioid adverse effects, * in 54 % studies37 RCTs, n= 2385, 5 subgroupBuvanendran A, Kroin J SBest Practice and Reasearch Clin Anaesthesiology 2007;21:31-49Buvanendran A, Kroin J SBestDespite much rhetoric about combining multiple analgesic techniques to provide mul

14、timodal* analgesia, only limited evidence suggests that this approach will improve pain control or perioperative outcomes. (Level Ia evidence from 3 metaanalyses and 2 systematic reviews)Reg Anesth Pain Med 2006;31:1-42* Current literature only on ”bimodal” therapy. (i.v. PCA+paracetamol or NSAIDDes

15、pite much rhetoric about coPerioperative EDA and outcome after major surgery Advantages of EDA Excellent analgesia - the best techniqueShorter duration of postoperative ilieusReduced risk of pulmonary complications (Ballantyne 1998)Reduced risk of postoperative myocardial infarction (Beattie 2001)Re

16、duced risk of persistent postoperative painSome evidence of reduced risk of cancer recurrence (?) Perioperative EDA and outcome 299 RCTsEpidural analgesia in every combination superior to i.v. PCA upto 3-days (exception epidural morphine alone)Continuous infusion superior to PCEA for pain at rest an

17、d activity (but more PONV and motor block, less pruritus)Epidural l.a. opioid better than epidural opioid alone”In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia c

18、ompared with intravenous patient-controlled analgesia”299 RCTs* These benefits may become irrelevant with adoption of minimally invasive techniques 3800 clinical trials (Medline 2006)18 metaanalyses, 10 systematic reviews, 8 additional RCTs, 2 observational database articlesEpidural with la*:a) Redu

19、ces postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patientsb) Reduces risk of postoperative ileus after major abdominal surgery (by 24-37 h)No effect on postoperative complications:a) Perineural analgesiab) Continuous wound cathetersc) I.v.

20、 PCAd) Multimodal systemic analgesics (some evidence of increased risk of severe bleeding, renal failure, and cardiovascular complications if NSAIDs and coxibs are used)”Overall, there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect postoperati

21、ve mortality or morbidity”* These benefits may become ir16 RCTs (1987 - 2005),n=406 in EA group and n=400 in parenteral group(control ) Epidural analgesia associated with: - reduced pain scores (WMD 15mm day1, 18mm day2) - shorter duration of ileus (WMD 1.6 days) - increased incidence of pruritus (O

22、R 4.8) - increased incidence of urinary retention (OR 4.3) - increased hypotension (OR 13.5) - no influence on duration of hospital stay”Despite improved analgesia and a decrease in ileus, EA has some adverse effects and does not shorten the duration of hospital stay after colorectalsurgeryMarret E

23、et alBr J of Surgery 2008;95:1331-133816 RCTs (1987 - 2005),n=406 inLow J et alVery few good RCTsLack of good evidence about complication rate of epiduralsUpto 50 % epidurals fail or give inadequate analgesiaIn patients with pre-existing respiratory disease NNT is 17 to avoid one episode of respirat

24、ory failure”Putting an epidural in is rarely a problem it is in determining what we do with it after it is sited that the problem starts”There is a significant lack of evidence supporting the use of epidural analgesia and we question the routine use of this mode of analgesia in the postoperative per

25、iod for patients having abdominal surgery”Low J et alVery few good RCTsRCT, n=188(1971 - 2006), n=5904 Epidural analgesia associated with: - decreased risk of pneumonia (OR 0.54) - incidence unchanged(8%) from 1971-2006 with EA but decreased (34% to 12%) with systemic analgesia - improved pulmonary

26、function - reduced risk of myocardial infarct (NNT 48) - increased risk of hypotension (OR 2.0), urinary retention(OR 2.2) and pruritus (OR 6.5 morphine,OR 3.1 fentanyl, OR 1.1 sufentanil)”Epidural analgesia protects against pneumonia following abdominal or thoracic surgery, although this beneficial

27、 effect has lessened over the last 35 years because of a decrease in the baseline riskPopping D Met alArch Surg 2008;143:990-999RCT, n=188(1971 - 2006), n=590Davies R.G.BJA 2006;96:418-2610 trials (none blinded), n = 520No differences in pain scores at 4-8, 24 or 48 hParavertebral block associated w

28、ith:-Less frequent pulmonary complications (OR 0.36)-Less urinary retention (OR 0.23)-Less nausea, vomiting (OR 0.47)-Less hypotension (OR 0.23)-Less failed blocks (OR 0.28)”PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and

29、 is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery”Davies R.G.BJA 2006;96:418-26Thoracic EDA, paravertebral, intrathecal, intercostal and interpleural compared to each other and to systemic opioidsAnalysis of: postoperative analgesia, analge

30、sic use, complications74 RCTsParavertebral block-as effective as TEDA but less hypotension-reduced pulm complications vs. systemic analg (TEDA did not)TEDA superior to intrathecal and intercostal (which were superior to systemic analgesiaInterpleural analgesia inadequate”Either thoracic epidural ana

31、lgesia with LA plus opioid or continuous paravertebral block with LA can be recommended”. If not possible or contraindicated ”intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia”.Anesth Analg 2008;107:1026-40Thoracic EDA, paravertebral, i8 studies

32、 (91 % TKR), n = 510. Anesthesia: GA (6 studies), spinal 1 study, EDA/PNB 1 studyPNB: Femoral catheter 4 studies, sciatic nerve block 3 studies (only 1 catheter technique), continuous lumbar plexus block 1 studyNo difference in pain scores between epidural and PNB at 0-12 or 12-24 h and no clinicall

33、y significant difference at 24-48 hNo difference in morphine consumptionHypotension more frequent with EDA, increased risk of urinary retentionPatient satisfaction better with PNB (2/3 studies that assessed it)”we believe that there is now sufficient evidence that lumbar epidural analgesia should no

34、t be used routinely and that PNB is appropriate for a multimodal analgesia care after routine major knee surgery”8 studies (91 % TKR), n = 510.Epidural LA and/or opiod (Grade B) (no advantage over femoral, increased risk)Femoral with sciatic or obturator (Grade D)Lumbar plexus block (Grade D)Intraar

35、ticular techniques (Grade D) - inconsistent resultsPROSPECT recommendations for total knee arthroplasty ()Not recommended:Epidural LA and/or opiod (GradAbout 478.000 TKAs in US in 2004, 59.000 in UK in 2005112 RCTs (135 studies excluded)Recommended:- femoral nerve block (LOE, grade A) or spinal bloc

36、k and morphine (LOE, grade A) combined with:- cooling and compression techniques (LOE, grade B)- paracetamol and NSAIDs (or coxibs) (LOE, grade A)- i.v. strong opioids for breakthrough pain (LOE, grade A)Not recommended:- epidural LA + opioid (not better than femoral block)- combined intraarticular

37、+ incisional promising, further studies necessary- other blocks (with sciatic or obturator) limited evidenceAbout 478.000 TKAs in US in 2海外讲者：术后疼痛管理课件Anesth Analg 2006;102:248-5719 RCTs (only 11 double-blind)Better analgesia for all time periods (mean and max VAS) at 24, 48 and 72 hSuperior analgesi

38、a for all catheter locations and time periodsReduction in opioid use with perineural analgesiaPONV (49 % vs. 21 %), sedation (52 % vs. 27 %), pruritus (27 vs. 10 %) more common with opioid analgesiaImproved patient satisfaction (4 RCTs only)”CPNB analgesia, regardless of catheter location, provided

39、superior postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia”Anesth Analg 2006;102:248-5719Rawal et alAnesth Analg 1998;86:86-9Rawal et alAnesth Analg 1998;J Am Coll Surg2006;203:914-93239 RCTs (n = 1761) qualitative analysis, 45 RCTs (n = 2031), qualita

40、tive analysisSurgical subgroups (abdominal, cardiothoracic, gynecologic, orthopedic, minor)Benefits of wound catheters:- decreased pain scores at rest and activity (32 % reduction)- decreased need for opioids (25 % reduction)- decreased risk of PONV (16 % reduction)- increased patient satisfaction (

41、30 % increase)- decreased LOS in hospitalized patients (limited data, 1 day, p = 0.01)No increase in adverse effectsQualititative systematic review supported same benefits”Continuous wound catheters appear to be an effective modality for management of postoperative pain”J Am Coll Surg2006;203:914-93

42、Wound catheters for postoperative analgesia - SummaryThe technique is well-established internationally Evidence-based data (Grade scoring) shows efficacy in following surgeries: - Orthopedic (shoulder, knee, hip, spine, iliac crest bone harvesting) - Abdominal (colorectal, hernia, hysterectomy, C.Se

43、ction) - Breast surgery - Sternotomy - Other surgeries (limited data) No major problems so far (1.5 million pumps sold by one company) Routine method for pain management after ambulatory surgery in many institutions Several questions unanswered - further studies necessaryWound catheters for postoper

44、atWhy decreasing use of postoperative epidural analgesia?No major advantages in outcome (some exceptions)Practical obstacles due to use of newer anticoagulantsOrganizational issues:- lack of trained staff on surgical wards (PACU/ICU)- analgesia not integrated into postop. rehabilitation protocols- ”

45、struggling” APS, audits rarely performedRisk of severe neurological complications greater than previously believedPrevious in-patient procedures now ambulatory (major orthopedic, abdominal)Simpler alternatives almost as effective:- peripheral n. blocks (orthopedic procedures, thoracotomy)- incisiona

46、l technique (lower abdominal, breast surgery, orthopedic, miscellaneous procedures)- intraarticular catheter techniques- non-regional techniques (i.v. PCA, ”multimodal” techniques)Why decreasing use of postoperChristopherson R et al Anesth Analg 2008;107:325-32GA combined with postop EA had 57 % low

47、er risk of cancer recurrence vs GA+postop systemic opioids (chemical markers)Postop epidural analgesia associated with enhanced survival among patients without matastasis before 1.46 years (no difference later)Christopherson R et al Anesth ANESTHESIA RA techniques Procedure specific () APS organizat

48、ionPHYSIOTHERAPY Pre-set mobilization routinesPATIENT ASA status Information, ”contract” pre-set goals Life style (smoking, alcohol)SURGERY High volume surgeon/hospital Skillful surgeon Surgery specific registersSURGICAL WARD Pain mgmt policy (VAS 3) Clinical pathways, pre-set goals Regular auditsMu

49、ltifactorial nature of postoperative outcomeANESTHESIAPHYSIOTHERAPYPATIENT20-40% reduction in operative mortality in high volume (vs low volume) hospitals (colon cancer, CABG, AAA resection) No benefit of operative drains* ( major liver, pancreas, gastric surgery) No benefit of perioperative nasogas

50、tric suctioning (may increase risk of pneumonia) No benefit of mechanical bowel prepration (colon resection) No benefit of routine parentral or enteral feeding* supported by data from PROSPECT recommendations ( )20-40% reduction in operative ?Prevention of cancer recurrence?Prevention of cancer recu

51、rrePerioperative EDA and outcome after major surgery Alternatives to EDA for major surgery Abdominal surgery ( iv lidocaine, WCI (preperitoneal), multimodal techniques)Thoracotomy (paravertebral block) (Davies 2006, Joshi 2008 (PROSPECT) Total knee arthroplasty ( spinal +opioid, femoral - (PROSPECT)

52、, LIA)Total hip replacement (spinal+opioid, femoral- (PROSPECT), LIA)Orthopaedic (shoulder,spine), abdominal (hysterectomy, C.section), breast, sternotomy . WCI Perioperative EDA and outcome Perioperative EDA and outcome after major surgery SummaryPerioperative EDA provides outstanding analgesiaNo m

53、ajor advantages in other outcomesAs good or better alternatives now available (major knee,hip, abdominal,thoracic surgery)Routine use of EDA decreasing (multiple reasons)May have a role in:- high risk patients undergoing major surgery- reducing risk of persistent post-surgical pain- reducing risk of

54、 cancer recurrenceStudies necessary to establish risk-benefit of this invasive and expensive technique Perioperative EDA and outcome Rawal N et al. Eur J Anaesthesiol 1998;15:35463A range of reasons for this dissatisfactionLack of organised APS Lack of qualified nursing staff for patient-controlled

55、analgesia (PCA) / epidural techniquesShortage of staffCost of PCA pumpsLack of post-anaesthesia care unitsPoor cooperation with surgeonsRestrictive opioid policies - Austria, Germany, Greece, Italy and SpainRawal N et al. Eur J AnaesthesAPS- what are the requirements? Assessment of pain at regular i

56、ntervals (at rest and on movement)Reassessment of pain after interventionDocumentation of pain scores (make pain visible”)Standerdized protocols for pain managementProtocols for monitoring routines (EDA, PCA, Perineural etc)Patient information routinesTeaching programmes (all personell categories)Re

57、gular audits (feedback to surgeons, anaesthesiologists, nurses, administrators) APS- what are the requirementsHospital-wide goal, at rebro University Hospital (since 1991)No patient who has undergone surgery shall have pain above VAS 3Hospital-wide goal, at rebro Pain assessment US (since 1991)VAS e

58、very 3 hours*VAS* before and after interventionVAS at rest and mobilizationDocumentation on patient chart*in some departments less (or more) frequent*verbal or observer scale if problem with VASPain assessment US (since 1Organization of Acute Pain Servicesrebro University HospitalAnesthesiologist (h

59、ospital wide)Section anesthesiologistAcute Pain Nurse (anesthesiologist supervision)Pain representatives (every ward)- one surgeon (named)- one day nurse (named)- one night nurse (named)Pain representative meeting every 3 monthsOrganization of Acute Pain Se* 1 nurse and 1-2 nurse assistants for 6-8

60、patients during regular hours. During nights and weekends the number of patients is 2-3 times more.Postoperative pain management - Role of ward nurses at rebro University Hospital*Injection of drugs into epidural cathetersAdministration of i.v. opioids.Increase or decrease epidural or i.v. doses wit