Dr. Sudheer Dara is a consultant anesthesiologist and pain specialist at Yashoda Hospital Secunderabad. He is the honorary treasurer of ISSP AP Chapter and founder of YAPM. His special interests include interventional pain management, ultrasound regional anesthesia, postoperative pain, acute pain services, and oral and injectable drugs. He discusses the need for improved postoperative pain management, highlighting issues like suboptimal analgesia, myths about pain relief, and inadequate assessment. He emphasizes the importance of multimodal analgesia using combinations of opioids, NSAIDs, paracetamol, nerve blocks, and the need for acute pain services with protocols and staff training to optimize postoperative pain management.
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Dr. Sudheer Dhara
1. Dr Sudheer Dara
• Consultant Anaesthesiologist & Pain specialist,
Yashoda Hospital Secunderabad.
• Hon. Treasurer of ISSP (AP Chapter)
• Faculty for “Traveling pain school” started by ISSP (AP Chapter)
• Founder of YAPM (Yashoda Academy of Pain Medicine)
• Special Interests:
Interventional Pain Management
Ultrasound Regional Anaesthesia
2. Post operative pain & acute pain services
DR.SUDHEER DARA
ANAESTHESIOLOGIST
PAIN SPECIALIST
YASHODA HOSPITAL
SECUNDERABAD
7. Questionnaire
1)The % of your patients comfortable in post
operative ward?
2)Are you satisfied with your post operative
rounds?
3)How frequently you use opioids in
postoperative period?
4) Do you have acute pain services?
8. Sub optimal analgesia
? lack of knowledge about drugs
?
? many myths associate with pain
? pain is not harmful to patient
? pain relief obscures signs of complications
?
? patient will become addicted to opioids
? risk of respiratory depression is high
? PRN: means
?
give as infrequently as possible’
9. Sources of postoperative pain
•Acute nociceptive pain from incision.
• Musculoskeletal pain from abnormal
body positioning and immobility during and
after surgery
• Neuropathic pain from excessive
stretching or direct trauma to peripheral
nerves
10. Postoperative pain is nociceptive
Perception
Modulation
Is responsive to NSAID’s,coxibs, paracetamol and
opiates
Transmission
Transduction
Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.
11. Pain pathway and modulation1
Ascending nociceptive pathways
Interpretation in
cerebral cortex:
pain
Stimulation of nociceptors
(A and C fibers) /
Release of
neurotransmitters and
neuromodulators (i.e. PG)
Descending inhibitory controls /
Diffuse noxious inhibitory controls
Activation of serotoninergic
and noradrenergic pathways
Release of
serotonin, noradrenalin and
enkephalins at spinal level
Injury
1. Adapted from: Bonica JJ. Postoperative pain. In Bonica JJ, ed. The management of pain. Philadelphia: Lea
and Febiger;1990:461-80.
13. Adverse Effects of Poor Pain Control
“… it remains a common misconception
amongst clinicians that acute
postoperative pain is a transient condition
involving physiological nociceptive
stimulation, with a variable affective
component, that differs markedly in its
pathophysiological basis from chronic pain
syndromes.”
Cousins MJ, Power I, and Smith G.
Regional Analgesia and Pain Medicine, 25 (2000) 6-21
22. Different modalities of pain
control
Drugs- oral,intramuscular,intravenous,rectal,
Epiduralanalgesia
Nerve blocks
Skin infiltration
Accessory methods: TENS, ACUPUNCTURE
COGNITVE THERAPIES
23. Modes of action of analgesics1,2,3,4
Paracetamol
Inhibition of central Cox-3 (?)
(Inhibition of PG synthesis)
Opioids
Activation of
opioid receptors
Paracetamol
Interaction with
serotoninergic descending
inhibitory pathway
NSAIDs / Coxibs
Inhibition of peripheral and
central Cox-1 / Cox-2
(Inhibition of PG synthesis)
1. D’Amours RH et al. JOSPT 1996;24(4):227-36.
2. Piguet V et al. Eur J Clin Pharmacol 1998;53:321-4.
3. Pini LA et al. JPET 1997;280(2):934-40.
4. Chandrasekharan NV et al. PNAS 2002;99(21):13926-31.
26. First contact (PAC)
Explaining about the nature of surgery
Explaining about the expected amount of
pain
Explaining the self assessment of pain
Explaining about the management offered
Explaining about the reassessment
Clearing the faulty thoughts (spiritual)
27. Operation theatre
Preemptive analgesia
Pre incision infiltration
Epidural analgesia (continous)
Parentral medication continuing into post
operative period (dosing)
Peripheral nerve blocks (technique ?)
Neuropathic pain
Patches ( fancy but questionable)
41. Principles of assessment of
pain
At rest and on movement
Evaluate before and after therapy
Character of the pain
Severe the pain more the evaluation
Document the response and adverse effects
Attention towards those unable to express
Family members are involved
50. BJA 2002
Comparative effect of
paracetomol(pct),NSAID,or their
combination
Systematic review of literature in medline
1996 to 2001
51. Bja 2002
Major abdominal surgeries:
Nsaid are superior to pct
Gynaecological :
Nsaid superior to pct
ENT:
pct = Nsaid
Dental: Nsaid superior to pct
53. Assessment of pain in
critically ill ( non verbal)
Critical care pain observation tool (CPOT)
Adult non verbal pain scale(NVPS)
Faces legs activity cry consolibility
scale(FLACC)
68. Transdermal fentanyl. A review of its pharmacological properties and therapeutic
efficacy in pain control.
Jeal W, Benfield P.
Source
Adis International Limited, Auckland, New Zealand. demail@adis.co.nz
69. Initially, much of the clinical experience with fentanyl TTS was obtained in
patients with acute postoperative pain. However, because of the increased risk
of respiratory complications, fentanyl TTS is contraindicated in this setting.
The most serious adverse event was hypoventilation, which occurred more
frequently in postoperative (4%) than in cancer patients (2%).
82. The important components of APS are as
follows:
(a)
Multidisciplinary committee comprising
anesthetists, surgeons, nurses and
pharmacists, supported by the secretarial
staff. The committee should define the needs
and suggest the equipments and
infrastructure besides providing guidance to
develop and manage the APS.
(b)
Acute pain management protocols and
modalities of APS.
(c)
Regular pain assessment methods and
guidelines to control pain within a defined
time scale.
(d)
Continuous professional development and
teaching programs.
(e)
Regular meetings, cooperation and
networking amongst the members
83. Guidelines for optimising
POP management1,2,3,4,5,6
Adequate and thorough patient information2,3,4,5,6
Use of written protocols1,3,4,5,6
Regular assessment of pain intensity1,2,3,4,5,6
Adequate medical and nursing staff training1,3,4,5,6
Use of balanced analgesia, PCA, and epidural drug
administration1,2,3,4,5,6
1. The Royal College of Surgeons of England and the College of Anaesthetists. Commission on the provision
of surgical services, report of the working party on pain after surgery. London, UK, HMSO.1990.
2. Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. Acute Pain Management in
Adults: Operative Procedures. Quick Reference Guide for Clinicians. AHCPR Pub. No. 92-0019. Rockville, MD.1992.
3. International Association for the Study of Pain, Management of acute pain: a practical guide. In: Ready LB, Edwards WT, eds. Seattle, 1992.
4. Wulf H et al. Die Behandlung akuter perioperativer und posttraumatischer Schmerzen Empfehlungen einer
interdisziplinaeren Expertenkommision. G. Thieme, Stuttgart, New York. 1997.
5. EuroPain. European Minimum Standards for the Management of Postoperative Pain.1998.
6. SFAR. Conférence de consensus. Prise en charge de la douleur postopératoire chez l’adulte et l’enfant.
Ann Fr Anesth Réanim 1998;17:445-61.
84.
85. Thanks for your patient
hearing
DR.SUDHEER DARA
ANAESTHESIOLOGIST & PAIN SPECIALIST
YASHODA HOSPITAL
SECUNDERABAD
Hinweis der Redaktion
Be sure to ask about pre-existing pain scores (ie. Pre-hospital)
Be sure to ask about pre-existing pain scores (ie. Pre-hospital)