1. Pain relief after major oncologic surgery Ksenija Mahkovic Hergouth Onkološki inštitut

2. Surgical procedures for GIT carcinomas Retroperitoneal sark. Liver metastases Sarkomas of thoracic/ abdominal wall with reconstruction Peritonectomies, cyto- reductive surgery Urologic,gynec.carcin.

3. Postoperative pain is due to Surgical wound (laparatomy – somatic pain; organ resections – visceral, sympatic pain) Surgical wound (laparatomy – somatic pain; organ resections – visceral, sympatic pain) Analgesia during operation (opioid, LA consumption Analgesia during operation (opioid, LA consumption Genetic determination of analgesic requirements (gene polymorphism for opioid receptors) Genetic determination of analgesic requirements (gene polymorphism for opioid receptors) Havashida M, Pharmacogenomics 2008 Havashida M, Pharmacogenomics 2008

4. Good pain relief after surgery is important part of quick and successfull recovery It diminishes perioperative stress response to surgery

5. Pain relief after major oncologic surgery 1. Continuous/PCEA epidural analgesia – based on long acting local anesthetics 2. Continuous/PCA intravenous analgesia – based on opioids 3. Continuous drip of local anesthetics by the catheter in the surgical wound ? All ways effective when proper used and with PCA technick Mann C et all, Anesthesiology 2000

6. Epidural analgesia – golden standard, insertion of epidural catether (EK) in the thoracic region (most of the abdominal wall and organs are inervated from Th6–Th12)

7. Physiologic effects of epidural analgesia Blocade of aferent pain impulses Blocade of aferent pain impulses Blokade of aferent sypmatic impulses from intestine Blokade of aferent sypmatic impulses from intestine  of pain and  sympatic nerves activity in GIT  of pain and  sympatic nerves activity in GIT ↓ stress and inflammatory response to surgery ↓ stress and inflammatory response to surgery  of postoperative ileus, shortens time to passing stools  of postoperative ileus, shortens time to passing stools Improves mobilisation after surgery Improves mobilisation after surgery Clemante A,Carli F. Minerva Anesthesiol 2008

8. 1.group.:general anesthesia + piritramid i.v. postoperatively 2.group.: general + toracic epidural anesth. + piritramid i.v. postoperatively 3.group.: general + toracic epidural anesth. + epidur. analgesia postoperatively Hormonal and inflammat.response and recovery after radical cystectomy Results ↑ Cortisol and epinephrin: no difference among groups group 3 ↓ less inflammatory response (↓CRP, ↑albumini) group 3 ↓ less fatigue group 3 ↓ less postoperative pain group 3 ↑better enteral feeding and passing stools sooner Brodner G et al. Multimodal perioperative management- combining thoracic epidural analgesia, forced mobilisation and oralnutrition-reduces hormonal and metabolic stress after major urologic surgery.AnesthAnalg 2001;92:1594-1600. Stress response I

9. Stress response II study of 45 patients on hormonal and inflammatory stress responce to major abdominal surgery study of 45 patients on hormonal and inflammatory stress responce to major abdominal surgery 1st group: epidural analgesia during surgery 2nd group: i.v. opioid analgesia during surgery Results Epidural group: lower plasma epinephrine and cortisol higher lymphocyte number and T-helper cells no difference in IL 12 and clinical course Ahlers O et al. Intraoperative thoracic epidural anesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-7.

10. Advantages of epidural analgesia to systemic analgesia Better analgesia (still and moving) than with systemic opioids (1,2,3) Better analgesia (still and moving) than with systemic opioids (1,2,3) Less adverse events than with opioids – ↓ nausea,vomiting, sedation (2,3,4) Less adverse events than with opioids – ↓ nausea,vomiting, sedation (2,3,4) Less paralytic ileus, less respiratory complications (5) Less paralytic ileus, less respiratory complications (5) But no difference in mortality compared to systemic opioid analgesia (3) But no difference in mortality compared to systemic opioid analgesia (3) Low incidence of motor block with thoracic epidurals compared to lumbal epidurals(2) Low incidence of motor block with thoracic epidurals compared to lumbal epidurals(2) Importance of the LA dose compared to volume or concentration (6) Importance of the LA dose compared to volume or concentration (6) 1.Nishimori M et al. Cochrane Data Base Rev 2006 2.Flisberg P et al..Acta Anaesthesiol Scand 2003;47:457-65 3.Rudin A et al. J Cardiothorac Vasc Anesth 2005;19:350-7 4.Saeki H et al. Surgery Today 2009. 5..Popping DM et al.Arch Surg 2008 6..Dernedde M et al. Anaesth Intensive Care 2008

11. ASA EK working EK workingVAS mg of piritramid in 48 h ( rescue.analg. ) mg of piritramid in 48 h ( rescue.analg. ) 34 patients 2  0,7 In 31 patients 2  1,6 3  4 Random group of our patients after abdominal surgery in year 2006 with epidural analgesia Dg.: 6 colon carcinoma,7 carcinoma of sygmoid colon, 9 rectum carcinoma, 5 stomac carcinoma, 7 retroperitoneal sarcoma

12. Postoperative pain relief by epidural analgesia (we practice) 48h after surgery: continuous epidural infusion of local anesthetic (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, LO 30 – 60 min. Sometimes combined with low dose opioid epiduraly or in i.v. infusion (< 30%) Metamizol 2,5g/12 h i.v. Metamizol 2,5g/12 h i.v. Piritramid 3 – 5mg i.v. when VAS>4 Piritramid 3 – 5mg i.v. when VAS>4 3.-5. day: 10 ml boluses of 0,25% levobupivacain /6–8h into EK ±opioids p.os (oksicodon) after 5th day removal of epidural catheter. after 5th day removal of epidural catheter. from 5th day on: analgesic drugs p.o. (oksicodon, tramadol, NSAID, paracetamol) paracetamol)

13. Complications with epidural catheters Punction of dura (incidence 0,3 – 1,2%) Transitory neropathy (0,01 – 0,02%) Punction of epidural vein (3 – 12%), epidural hemmatoma very rare (1:150 000) Infection: local on insertion site 4%, epidural absscess: 0,05 – 0,1% (perioperative epidural catheters) Migration of the catheter into spinal space (0,18%)

14. Postoperative pain relief by systemic opioid analgesia (we practice) Systemic opioid analgesia – when epidural analgesia is containdicated, technically not possible or refused by the patient. Pump needed. Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses Sufentanil 50–100 μg/24h in continuous i.v. infusion + PCA boluses Sufentanil 50–100 μg/24h in continuous i.v. infusion + PCA boluses Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses s.c./i.v. Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses s.c./i.v. I.v.analgesia up to 3 days+metamizol/neodolpasse After 2-3-days analgetic drugs in tablets by mouth (oxicodon, tramadol, paracetamol, NSAID) Monitoring pain (VAS) and side effects

15. Monitoring of the patient Day of surg.: pulse oximetry, blood pressure, VAS. Broader monitoring according to patient’s state. Day of surg.: pulse oximetry, blood pressure, VAS. Broader monitoring according to patient’s state. Next days: blood pressure /1-2 h, pulse oximetry, VAS. 50 – 100 μg/24 h. Broader monitoring according to patient’s state. Next days: blood pressure /1-2 h, pulse oximetry, VAS. 50 – 100 μg/24 h. Broader monitoring according to patient’s state. Patient can be moved to the ward when cont.epidural infusion is stopped and regular epidural boluses given. Time of epidural catheter removal should be planned. Patient can be moved to the ward when cont.epidural infusion is stopped and regular epidural boluses given. Time of epidural catheter removal should be planned.

16. Bolnica 3.dan po op ca recti (LAR,TME) 54 let, ASA 1

17. 94 bolnik Dg: Ca cekuma,eksulceriran. Op: desna hemikolektomija 3. dan po operaciji

18. Hvala za pozornost!

21. Vloga sester in tehnikov poznati morajo delovanje EK kot tudi kontinuirano i.v. analgezijo poznati morajo delovanje EK kot tudi kontinuirano i.v. analgezijo Redno morajo spremljati pooperativno bolečino z merjenjem bolečine po VAS Redno morajo spremljati pooperativno bolečino z merjenjem bolečine po VAS Redno meriti bolnikove vitalne znake. Redno meriti bolnikove vitalne znake. Pomembna je tudi tudi odzivnost na bolnikovo bolečino ali neželjene učinke in ukrepanje v okviru možnosti in navodil. Pomembna je tudi tudi odzivnost na bolnikovo bolečino ali neželjene učinke in ukrepanje v okviru možnosti in navodil.

22. Multimodalno perioperativno okrevanje Predoperativno informiranje in priprava bolnika na op Predoperativno informiranje in priprava bolnika na op ↓ kirurškega stresa (krg. tehnika, anestezija) ↓ kirurškega stresa (krg. tehnika, anestezija) Optimalna pooperativna epidural. analgezija z LA (torakalni EK) Optimalna pooperativna epidural. analgezija z LA (torakalni EK) Hitra mobilizacija Hitra mobilizacija Zgodnje enteralno hranjenje Zgodnje enteralno hranjenje

23. Pooperativni problemi po operacijah v trebuhu Bolečina Bolečina Pooperativni ileus Pooperativni ileus Okužbe kirurške rane & druge okužbe Okužbe kirurške rane & druge okužbe  intraabdomin.pritisk  intraabdomin.pritisk Motnje v delovanju organov Motnje v delovanju organov