海外讲者术后疼痛管理课件

Professor Narinder Rawal,MD,PhD,FRCA(Hon)Professor Narinder Rawal,MD,PhD,FRCA(Hon)Department of Clinical MedicineDepartment of Clinical MedicineDivision of Anaesthesiology and Intensive Care Division of Anaesthesiology and Intensive Care University HospitalUniversity Hospitalrebro,Swedenrebro,SwedenPostoperative Pain Management*The following only stand by personal opinion.Naropin prescription should follow product instruction.Professor Narinder 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.2003;97(2):534-540.SevereExtremeModerateMild1995120032SevereExtremeModerateMild19%49%23%8%47%21%18%13%Postoperative Pain Continues Symptomsathomeafterambulatorysurgery literature review1966-2000,156articles,(33included)1966-2000,156articles,(33included)Wu CL et alWu CL et alAnesthesiology 2000;96:994-1003Anesthesiology 2000;96:994-1003Symptoms at home after ambulatPersistent postsurgical pain the incidence CraniotomyCraniotomy6-12%6-12%Kaur2000Kaur2000Harner1993Harner1993 LegamputationLegamputation50-80%50-80%Finch1980Finch1980Fisher1998Fisher1998Sherman1984Sherman1984 ThoracotomyThoracotomy50%50%Bertrand1996Bertrand1996Katz1996Katz1996 BreastsurgeryBreastsurgery11-57%11-57%Jung2003Jung2003Tasmuth1996Tasmuth1996 LapcholecystectomyLapcholecystectomy3-56%3-56%Stiff1994Stiff1994Ure1995Ure1995dePovourville1997dePovourville1997 InguinalherniaInguinalhernia12%12%Aasvang2005Aasvang2005Persistent 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-reoperations-bleeding,infectionPreoperativeFemale genderYounger agePain before surgeryAnalgesic useGenetic predispositionChronic postsurgical painPsychPCA techniques for postoperative painEpiduralPCA(PCEA)PerineuralPCAIncisionalandintraarticular(PCRA)OtherroutesofopioidPCA(intranasal,transdermal)PCA techniques for postoperati海外讲者术后疼痛管理课件Non-opioid analgesic techniques AnalgesicdrugsAnalgesicdrugs ParacetamolParacetamol NSAIDs(includingCOX-2-inhibitors)NSAIDs(includingCOX-2-inhibitors)NMDAantagonists(ketamine,dextromethorphan)NMDAantagonists(ketamine,dextromethorphan)2 2 receptoragonists(clonidine,dexmedetomidine)receptoragonists(clonidine,dexmedetomidine)others(gabapentin,corticosteroids,capsaicin,nicotine,neostigmineetc.)others(gabapentin,corticosteroids,capsaicin,nicotine,neostigmineetc.)Regionaltechniques(includingcathetertechniques)Regionaltechniques(includingcathetertechniques)Centralblocks(EDA,spinal,CSE)Centralblocks(EDA,spinal,CSE)PeripheralblocksPeripheralblocks IncisionalIncisional IntraarticularIntraarticular Non-pharmacologicaltechniquesNon-pharmacologicaltechniquesNon-opioid analgesic technique 37RCTs,n=2385,5subgroups:i.v.ketaminesingledose,cont.Infusion,PCA,epidural,37RCTs,n=2385,5subgroups:i.v.ketaminesingledose,cont.Infusion,PCA,epidural,pediatricpediatric I.v.morphine+ketaminenotbetterthani.v.MorphineI.v.morphine+ketaminenotbetterthani.v.Morphine I.v.ketamineinfusiondecreasedi.v.andepiduralopioidrequirementsin6/11studies*I.v.ketamineinfusiondecreasedi.v.andepiduralopioidrequirementsin6/11studies*Singlebolusketaminedecreasedopioidrequirementsin7/11studies*Singlebolusketaminedecreasedopioidrequirementsin7/11studies*Epiduralketaminebeneficialin5/8trialsEpiduralketaminebeneficialin5/8trials Adverseeffectsnotincreasedwithsmalldose(0.15-1mg/kgbolus,0.12-0.6mg/kg/hinfusionAdverseeffectsnotincreasedwithsmalldose(0.15-1mg/kgbolus,0.12-0.6mg/kg/hinfusion”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*Anesth Analg 2004;99:482-95Anesth Analg 2004;99:482-95May prevent central sensitization and chronic neuropathic painMay prevent central sensitization and chronic neuropathic pain*No reduction of opioid adverse effects,*in 54%studies*No reduction of opioid adverse effects,*in 54%studies37 RCTs,n=2385,5 subgroup 37RCTs,n=2385,5subgroups:i.v.ketaminesingledose,cont.Infusion,PCA,epidural,37RCTs,n=2385,5subgroups:i.v.ketaminesingledose,cont.Infusion,PCA,epidural,pediatricpediatric I.v.morphine+ketaminenotbetterthani.v.MorphineI.v.morphine+ketaminenotbetterthani.v.Morphine I.v.ketamineinfusiondecreasedi.v.andepiduralopioidrequirementsin6/11studies*I.v.ketamineinfusiondecreasedi.v.andepiduralopioidrequirementsin6/11studies*Singlebolusketaminedecreasedopioidrequirementsin7/11studies*Singlebolusketaminedecreasedopioidrequirementsin7/11studies*Epiduralketaminebeneficialin5/8trialsEpiduralketaminebeneficialin5/8trials Adverseeffectsnotincreasedwithsmalldose(0.15-1mg/kgbolus,0.12-0.6mg/kg/hinfusionAdverseeffectsnotincreasedwithsmalldose(0.15-1mg/kgbolus,0.12-0.6mg/kg/hinfusion”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*Anesth Analg 2004;99:482-95Anesth Analg 2004;99:482-95May prevent central sensitization and chronic neuropathic painMay prevent central sensitization and chronic neuropathic pain*No reduction of opioid adverse effects,*in 54%studies*No reduction of opioid adverse effects,*in 54%studies37 RCTs,n=2385,5 subgroupBuvanendran A,Kroin J SBuvanendran A,Kroin J SBest Practice and Reasearch Clin Anaesthesiology 2007;21:31-49Best Practice and Reasearch Clin Anaesthesiology 2007;21:31-49Buvanendran A,Kroin J SBestDespitemuchrhetoricaboutcombiningmultipleanalgesictechniquesDespitemuchrhetoricaboutcombiningmultipleanalgesictechniquestoprovidemultimodal*analgesia,onlylimitedevidencesuggeststhattoprovidemultimodal*analgesia,onlylimitedevidencesuggeststhatthisapproachwillimprovepaincontrolorperioperativeoutcomes.thisapproachwillimprovepaincontrolorperioperativeoutcomes.(LevelIaevidencefrom3metaanalysesand2systematicreviews)(LevelIaevidencefrom3metaanalysesand2systematicreviews)Reg Anesth Pain Med 2006;31:1-42Reg Anesth Pain Med 2006;31:1-42*Current literature only on”bimodal”therapy.(i.v.PCA+paracetamol or NSAID*Current literature only on”bimodal”therapy.(i.v.PCA+paracetamol or NSAIDDespite much rhetoric about coPerioperative EDA and outcome after major surgery Advantages of EDA Advantages of EDA Excellentanalgesia-thebesttechniqueExcellentanalgesia-thebesttechnique ShorterdurationofpostoperativeilieusShorterdurationofpostoperativeilieus Reducedriskofpulmonarycomplications(Ballantyne1998)Reducedriskofpulmonarycomplications(Ballantyne1998)ReducedriskofpostoperativemyocardialinfarctionReducedriskofpostoperativemyocardialinfarction(Beattie2001)(Beattie2001)ReducedriskofpersistentpostoperativepainReducedriskofpersistentpostoperativepain Someevidenceofreducedriskofcancerrecurrence(?)Someevidenceofreducedriskofcancerrecurrence(?)Perioperative EDA and outcome 299RCT299RCTs s Epiduralanalgesiaineverycombinationsuperiortoi.v.PCAupto3-daysEpiduralanalgesiaineverycombinationsuperiortoi.v.PCAupto3-days(exceptionepiduralmorphinealone)(exceptionepiduralmorphinealone)ContinuousinfusionsuperiortoPCEAforpainatrestandactivity(butmoreContinuousinfusionsuperiortoPCEAforpainatrestandactivity(butmorePONVandmotorblock,lesspruritus)PONVandmotorblock,lesspruritus)Epidurall.a.Epidurall.a.opioidbetterthanepiduralopioidaloneopioidbetterthanepiduralopioidalone”In summary,almost without exception,epidural analgesia,regardless of analgesic”In summary,almost without exception,epidural analgesia,regardless of analgesic agent,epidural regimen,and type and time of pain assessment,provided superior agent,epidural regimen,and type and time of pain assessment,provided superior postoperative analgesia compared with intravenous patient-controlled analgesia”postoperative analgesia compared with intravenous patient-controlled analgesia”299 RCTs*These benefits may become irrelevant with adoption of minimally invasive techniques*These benefits may become irrelevant with adoption of minimally invasive techniques 3800clinicaltrials(Medline2006)3800clinicaltrials(Medline2006)18metaanalyses,10systematicreviews,8additionalRCTs,2observational18metaanalyses,10systematicreviews,8additionalRCTs,2observationaldatabasearticlesdatabasearticles Epiduralwithla*:Epiduralwithla*:a)a)ReducespostoperativecardiovascularandpulmonarycomplicationsReducespostoperativecardiovascularandpulmonarycomplicationsonlyonlyafteraftermajorvascularsurgeryorinhigh-riskpatientsmajorvascularsurgeryorinhigh-riskpatientsb)Reducesriskofpostoperativeileusaftermajorabdominalsurgery(by24-37h)b)Reducesriskofpostoperativeileusaftermajorabdominalsurgery(by24-37h)Noeffectonpostoperativecomplications:Noeffectonpostoperativecomplications:a)a)PerineuralanalgesiaPerineuralanalgesiab)b)ContinuouswoundcathetersContinuouswoundcathetersc)c)I.v.PCAI.v.PCAd)d)Multimodalsystemicanalgesics(someevidenceofincreasedriskofsevereMultimodalsystemicanalgesics(someevidenceofincreasedriskofseverebleeding,renalfailure,andcardiovascularcomplicationsifNSAIDsandcoxibsbleeding,renalfailure,andcardiovascularcomplicationsifNSAIDsandcoxibsareused)areused)”Overall,there is insufficient evidence to confirm or deny the ability of postoperative”Overall,there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect postoperative mortality or morbidity”analgesic techniques to affect postoperative mortality or morbidity”*These benefits may become ir 16RCTs(1987-2005),n=406inEAgroupandn=400inparenteral16RCTs(1987-2005),n=406inEAgroupandn=400inparenteralgroup(control)group(control)Epiduralanalgesiaassociatedwith:Epiduralanalgesiaassociatedwith:-reducedpainscores(WMD15mmday1,18mmday2)-reducedpainscores(WMD15mmday1,18mmday2)-shorterdurationofileus(WMD1.6days)-shorterdurationofileus(WMD1.6days)-increasedincidenceofpruritus(OR4.8)-increasedincidenceofpruritus(OR4.8)-increasedincidenceofurinaryretention(OR4.3)-increasedincidenceofurinaryretention(OR4.3)-increasedhypotension(OR13.5)-increasedhypotension(OR13.5)-noinfluenceondurationofhospitalstay-noinfluenceondurationofhospitalstay”Despite improved analgesia and a decrease in ileus,EA has some”Despite improved analgesia and a decrease in ileus,EA has some adverse effects and does not shorten the duration of hospital stay adverse effects and does not shorten the duration of hospital stay after colorectalsurgeryafter colorectalsurgeryMarret E et alMarret E et alBr J of Surgery 2008;95:1331-1338Br J of Surgery 2008;95:1331-133816 RCTs(1987-2005),n=406 inLow J et alLow J et al VeryfewgoodRCTVeryfewgoodRCTs s LackofgoodevidenceaboutcomplicationrateofepiduralsLackofgoodevidenceaboutcomplicationrateofepidurals Upto50%epiduralsfailorgiveinadequateanalgesiaUpto50%epiduralsfailorgiveinadequateanalgesia Inpatientswithpre-existingrespiratorydiseaseNNTis17toavoidoneepisodeInpatientswithpre-existingrespiratorydiseaseNNTis17toavoidoneepisodeofrespiratoryfailureofrespiratoryfailure”Puttinganepiduralinisrarelyaproblemitisindeterminingwhatwedo”Puttinganepiduralinisrarelyaproblemitisindeterminingwhatwedowithitafteritissitedthattheproblemstarts”withitafteritissitedthattheproblemstarts”There is a significant lack of evidence supporting the use of epidural analgesia”There is a significant lack of evidence supporting the use of epidural analgesia and we question theand we question the routine routine use of this mode of analgesia in the postoperative use of this mode of analgesia in the postoperative period for patients having abdominal surgery”period for patients having abdominal surgery”Low J et alVery few good RCTsRCT,n=188(1971-2006),n=5904Epiduralanalgesiaassociatedwith:-decreasedriskofpneumonia(OR0.54)-incidenceunchanged(8%)from1971-2006withEAbutdecreased(34%to12%)withsystemicanalgesia-improvedpulmonaryfunction-reducedriskofmyocardialinfarct(NNT48)-increasedriskofhypotension(OR2.0),urinaryretention(OR2.2)andpruritus(OR6.5morphine,OR3.1fentanyl,OR1.1sufentanil)”Epidural analgesia protects against pneumonia following abdominal or”Epidural analgesia protects against pneumonia following abdominal or thoracic surgery,although this beneficial effect has lessened over the thoracic surgery,although this beneficial effect has lessened over the last 35 years because of a decrease in the baseline risklast 35 years because of a decrease in the baseline riskPopping D Met alPopping D Met alArch Surg 2008;143:990-999Arch Surg 2008;143:990-999RCT,n=188(1971-2006),n=590Davies R.G.Davies R.G.BJA 2006;96:418-26BJA 2006;96:418-26 10trials(noneblinded),n=52010trials(noneblinded),n=520 Nodifferencesinpainscoresat4-8,24or48hNodifferencesinpainscoresat4-8,24or48h Paravertebralblockassociatedwith:Paravertebralblockassociatedwith:-LessfrequentpulmonarycomplicationsLessfrequentpulmonarycomplications(OR0.36)(OR0.36)-LessurinaryretentionLessurinaryretention(OR0.23)(OR0.23)-Lessnausea,vomitingLessnausea,vomiting(OR0.47)(OR0.47)-LesshypotensionLesshypotension(OR0.23)(OR0.23)-LessfailedblocksLessfailedblocks(OR0.28)(OR0.28)”PVB and epidural analgesia provide comparable pain relief after thoracic surgery,”PVB and epidural analgesia provide comparable pain relief after thoracic surgery,but PVB has a better side-effect profile and is associated with a reduction in but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications.PVB can be recommended for major thoracic surgery”pulmonary complications.PVB can be recommended for major thoracic surgery”Davies R.G.BJA 2006;96:418-26 ThoracicEDA,paravertebral,intrathecal,intercostalandinterpleuralcomparedtoThoracicEDA,paravertebral,intrathecal,intercostalandinterpleuralcomparedtoeachotherandtosystemicopioidseachotherandtosystemicopioids Analysisof:postoperativeanalgesia,analgesicuse,complicationsAnalysisof:postoperativeanalgesia,analgesicuse,complications 74RCTs74RCTs ParavertebralblockParavertebralblock-aseffectiveasTEDAbutlesshypotensionaseffectiveasTEDAbutlesshypotension-reducedpulmcomplicationsreducedpulmcomplicationsvs.vs.systemicanalg(TEDAdidnot)systemicanalg(TEDAdidnot)TEDAsuperiortointrathecalandintercostal(whichweresuperiortosystemicTEDAsuperiortointrathecalandintercostal(whichweresuperiortosystemicanalgesiaanalgesia InterpleuralanalgesiainadequateInterpleuralanalgesiainadequate”Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral”Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended”.If not possible or contraindicated”intrathecal block with LA can be recommended”.If not possible or contraindicated”intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of opioid or intercostal nerve block are recommended despite insufficient duration of analgesia”.analgesia”.Anesth Analg 2008;107:1026-40Anesth Analg 2008;107:1026-40Thoracic EDA,paravertebral,i 8studies(91%TKR),n=510.Anesthesia:GA(6studies),spinal1study,EDA/PNB18studies(91%TKR),n=510.Anesthesia:GA(6studies),spinal1study,EDA/PNB1studystudy PNB:Femoralcatheter4studies,sciaticnerveblock3studies(only1catheterPNB:Femoralcatheter4studies,sciaticnerveblock3studies(only1cathetertechnique),continuouslumbarplexusblock1studytechnique),continuouslumbarplexusblock1study NodifferenceinpainscoresbetweenepiduralandPNBat0-12or12-24handnoNodifferenceinpainscoresbetweenepiduralandPNBat0-12or12-24handnoclinicallysignificantdifferenceat24-48hclinicallysignificantdifferenceat24-48h NodifferenceinmorphineconsumptionNodifferenceinmorphineconsumption HypotensionmorefrequentwithEDA,increasedriskofurinaryretentionHypotensionmorefrequentwithEDA,increasedriskofurinaryretention PatientsatisfactionbetterwithPNB(2/3studiesthatassessedit)PatientsatisfactionbetterwithPNB(2/3studiesthatassessedit)”we believe that there is now sufficient evidence that lumbar epidural analgesia should”we believe that there is now sufficient evidence that lumbar epidural analgesia should not be used routinely and that PNB is appropriate for a multimodal analgesia care after not be used routinely and that PNB is appropriate for a multimodal analgesia care after routine major knee surgery”routine major knee surgery”8 studies(91%TKR),n=510.EpiduralLAand/oropiod(GradeB)(noadvantageoverEpiduralLAand/oropiod(GradeB)(noadvantageoverfemoral,increasedrisk)femoral,increasedrisk)Femoralwithsciaticorobturator(GradeD)Femoralwithsciaticorobturator(GradeD)Lumbarplexusblock(GradeD)Lumbarplexusblock(GradeD)Intraarticulartechniques(GradeD)-inconsistentresultsIntraarticulartechniques(GradeD)-inconsistentresultsPROSPECT recommendations for total knee arthroplasty(www.postoppain.org)Not recommended:Not recommended:Epidural LA and/or opiod(GradAbout 478.000 TKAs in US in 2004,59.000 in UK in 2005About 478.000 TKAs in US in 2004,59.000 in UK in 2005 112RCT112RCTs(135studiesexcluded)s(135studiesexcluded)Recommended:Recommended:-femoralnerveblock(LOE,gradeA)orspinalblockandmorphine(LOE,-femoralnerveblock(LOE,gradeA)orspinalblockandmorphine(LOE,gradeA)combinedwith:gradeA)combinedwith:-coolingandcompressiontechniques(LOE,gradeB)-coolingandcompressiontechniques(LOE,gradeB)-paracetamolandNSAID-paracetamolandNSAIDs(orcoxibs)(LOE,gradeA)s(orcoxibs)(LOE,gradeA)-i.v.strongopioidsforbreakthroughpain(LOE,gradeA)-i.v.strongopioidsforbreakthroughpain(LOE,gradeA)Notrecommended:Notrecommended:-epiduralLA+opioid(notbetterthanfemoralblock)-epiduralLA+opioid(notbetterthanfemoralblock)-combinedintraarticular+incisionalpromising,furtherstudiesnecessary-combinedintraarticular+incisionalpromising,furtherstudiesnecessary-otherblocks(withsciaticorobturator)limitedevidence-otherblocks(withsciaticorobturator)limitedevidenceAbout 478.000 TKAs in US in 2海外讲者术后疼痛管理课件Anesth Analg 2006;102:248-57Anesth Analg 2006;102:248-57 19RCTs(only11double-blind)19RCTs(only11double-blind)Betteranalgesiaforalltimeperiods(meanandmaxVAS)at24,48and72hBetteranalgesiaforalltimeperiods(meanandmaxVAS)at24,48and72h SuperioranalgesiaforallcatheterlocationsandtimeperiodsSuperioranalgesiaforallcatheterlocationsandtimeperiods ReductioninopioidusewithperineuralanalgesiaReductioninopioidusewithperineuralanalgesia PONV(49%PONV(49%vs.vs.21%),sedation(52%21%),sedation(52%vs.vs.27%),pruritus(2727%),pruritus(27vsvs.10%).10%)morecommonwithopioidanalgesiamorecommonwithopioidanalgesia Improvedpatientsatisfaction(4RCTsonly)Improvedpatientsatisfaction(4RCTsonly)”CPNB analgesia,regardless of catheter location,provided superior”CPNB analgesia,regardless of catheter location,provided superior postoperative analgesia and fewer opioid-related side effects when compared postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia”with opioid analgesia”Anesth Analg 2006;102:248-5719Rawal et alRawal et alAnesth Analg 1998;86:86-9Anesth Analg 1998;86:86-9Rawal et alAnesth Analg 1998;J Am Coll SurgJ Am Coll Surg2006;203:914-9322006;203:914-932 39RCT39RCTs(n=1761)qualitativeanalysis,45RCTs(n=2031),qualitativeanalysiss(n=1761)qualitativeanalysis,45RCTs(n=2031),qualitativeanalysis Surgicalsubgroups(abdominal,cardiothoracic,gynecologic,orthopedic,minor)Surgicalsubgroups(abdominal,cardiothoracic,gynecologic,orthopedic,minor)Benefitsofwoundcatheters:Benefitsofwoundcatheters:-decreasedpainscoresatrestandactivity(32%reduction)-decreasedpainscoresatrestandactivity(32%reduction)-decreasedneedforopioids(25%reduction)-decreasedneedforopioids(25%reduction)-decreasedriskofPONV(16%reduction)-decreasedriskofPONV(16%reduction)-increasedpatientsatisfaction(30%increase)-increasedpatientsatisfaction(30%increase)-decreasedLOSinhospitalizedpatients(limiteddata,1day,p=0.01)-decreasedLOSinhospitalizedpatients(limiteddata,1day,p=0.01)NoincreaseinadverseeffectsNoincreaseinadverseeffects QualititativesystematicreviewsupportedsamebenefitsQualititativesystemati