Post operative Pain and Regional Anaesthesia Dr Martin Rooms MB BS FRCA

Learning Objectives List 6 important reasons for post operative pain control Choose appropriate analgesic regimes Know when to call for senior advice

Why is it important to control pain? Divinum sedare dolorem Reduce Sympathetic activity ( ACS) Reduce respiratory complications Reduced chronic pain syndromes Improved mobilisation Improved patient satisfaction

Divinum sedare dolorem

Reduce respiratory complications

Reduce Sympathetic activity ( ACS)

Improved mobilisation

Reduce Chronic Pain Syndromes

Improved patient satisfaction

Case 1 It is your first on call as a Gas person. Bleeped about Mrs X DSU laproscopic cholesystectomy; admitted overnight for uncontrolled pain. PONV

Put the following in the right order A. d/w Spr B. management plan C. history and pain assessment D. check notes, anaesthetic and drug charts

D, C, B ,A D. check notes, anaesthetic and drug charts C. history and pain assessment B. management plan A. d/w Spr

Pain Assessment

Management Options A. regular oral analgesia eg paracetamol, diclofenac, prn Im morphine B. regular IV paracetamol, prn IM morph, IVF, antiemetic C. morphine PCA D.Immediate IV morphine 0.5-1mg/kg titrate in 2mg aliquots E. C +D+ IVF+ antiemetic.

WHO analgesic ladder....1, 2, 3

Analgesia Simple(mild) Paracetamol NSAIDs Moderate Codeine Tramadol Strong Fentanyl Morphine Adjuvants: ketamine, gabapentin

Ladder -Breakthrough pain - strong analgesics as per WHO pain ladder General points Ladder -Breakthrough pain - strong analgesics as per WHO pain ladder Oral -Regular oral analgesia ASAP Others -Treat co existing symptoms; fluids, antiemetic, laxatives , oxygen

CASE 2 57 y old 3d post laporotomy, thoracic epidural, can take free fluids Excruciating pain last 2 h A. Morphine PCA B. Notes, drug chart C. D/W SpR D. Hx, examination ( epidural site) E. Regular oral analgesia, breakthrough morphine F.Bolus/ top up

B, D, F, E, A, C B. Notes, drug chart D. Hx, examination ( epidural site) F. Bolus/ top up E. Regular oral analgesia, breakthrough morphine A. Morphine PCA C. D/W SpR

Regional analgesia Peripheral nerve block Epidural Spinal Mainly extremities, particularly orthopaedics Epidural Used as both analgesia and anaesthetic, usually catheter in situ for top ups Spinal Similar to epidural , but lower volumes required, rarely catheter in situ, continuous prolonged analgesia not appropriate

Peripheral Nerve Block Consent, performance and post-block care

Peripheral Nerve Block Techniques: Ultrasound Nerve stimulator Landmark

Spinal (A) v Epidural (B)

Summary – control of POP

General concepts pain treatment

General concepts pain treatment L (ladder) – WHO pain ladder ; stepwise increment of strength of analgesia; start at appropriate level O (oral) establish oral analgesics ASAP O (other assoc. symptoms ) Treat N & V, dehydration, constipation, anxiety.

Learning Objectives List 6 important reasons for post operative pain control Choose appropriate analgesic regimes Know when to call for senior advice