To improving postoperative pain management, we need to; - Always applies multi-modal analgesia. (get the advantages of multimodal analgesia) - Implementation of the existing EB regarding the use of non-opioid + opioid on as needed basis. - Use available specific evidence for optimizing multimodal pain management procedure (PROSPECT Web site).

1. Improving postoperative pain
management, what is unsolved?
Hasanuddin University Faculty of Medicine
Department of Anesthesiology, IC and
Pain Management
Makassar
A.Husni Tanra
ISAPM National Meeting, Manado 14-15 October 2015

2. Among nociceptive pain, postoperative
pain is well understood.
• We know what causes it
• We know the mechanism
• We know how to treat it
• We know the best drugs for it
• We know mostly self limited
(Lema MJ, Department of Anesthesiology, Buffalo State University )
So, no more reason to feel pain after surgey

3. Nature of post operative pain
• Four out or five patients undergoing surgery
experiences postoperative pain
– 86% of these patient rating
 Moderate
 Severe
 Extreme pain
• > 50% of patients report inadequate pain relief
• 10% to 50% acute post operative pain may become
chronic, depending on the surgical procedure
Pain, ASHP advantage E-NEWSLETTER, March 2014

4. • Why Management of postoperative
pain: still a long way to go?
Editorial Pain (2008) 233-234

5. Powel et al. Analyzed the obstacle in APS in UK.
• Dr. Powel AE et al. from UK explained:
“Misconception of the surgeon”
“ Acute pain vanishes in a few days, and as long as the
operation was successful the postoperative pain will
soon be forgotten”. So why bother with costly APS,
with epidural or peripheral nerve analgesia, which are
also not compleatly free of complication.
 They do not expect, acute pain may develop into chronic pain
 Every time this comes as a big surprise to them.
 They have never heard of this phenomenon, nor do they have
any idea how to treat it.
Editorial, Pain 137 (2008) 233:234

6. BSSP and SARPS - Dhaka 2006
What is
Traditional Postoperative Pain Management
 Unimodal analgesia, using Morphine
or Pethidine.
 10 mg morphine, or Pethidin im as
needed.
 done by SURGEON
 Applied by the nurses.
Courtesy S.A. Schug

7. Pain
Call for Nurse
Nurse Responds
Screening
Sign out Medication
Prepare Medication
Administer Med (im)
Absorption from site
Pain Relief
Sedation
PCA
Traditional pain relief vs PCA

8. After the Surgical injury
Peripheral
Sensitization
of Nociceptors
Primary
hyperalgesia
Surgical
Injury
Central
Sensitization
of Dorsal Horn
Secondary
Hyperalgesia
LTP
(Chronic pain)

9. Can be treated by Opioid, Ketamine, alpha2agonist,
gabapentinoid or continuous epidural with LA.
Problem of after surgery condition
Primary HYPERALGESIA
Can be easily treated by NSAID (Cox1 or Cox2)
Secondary HYPERALGESIA

10. PRIMARY HYPERALGESIA
• Rational treatment of primary hyperalgesia is
anti inflammatory agents;
 NSAID non selective
 Coxib (selective NSAID )
 Dexamethazone
 Infiltration of LA

11. In

12. Prostaglandins produced in
response to tissue injury;
increase sensitivity of
nociceptor (pain)
Nociceptor then releases
substance P, which dilates
blood vessels and increases
release of inflammatory
mediators, such as
Bradykinin (redness & heat)
Substance P also promotes
degranulation of mast cells,
which release histamine
(swelling)
1
2
3
Pain-sensitive tissue
Painful stimulus
Prostaglandin
Substance P
Histamine
Mast cell
Blood
vessel
Bradykinin
Nociceptor
Substance P
2
3
1
Peripheral sensitization
Infiltration of LA means blocking the
release of Subtance P

13. SECONDARY HYPERALGESIA
• Rational treatment of secondary hyperalgesia is
the drug/technique that can prevent the
occurrence of Central sensitization;
 Opioid (Mo, Fentanyl or Pethidine).
 Ketamine (NMDA antagonist).
 Gabapentinoid (Gabapentin or Pregabalin).
 Alpha2 agonist , Dexmetomidine.
 Continuous Epidural Block

14. 



Secondary Hyperalgesia
Commonly ignored or discounted in the evaluation
and treatment of postoperative pain
Neuroplastic changes in the CNS that may
amplify pain perception
Not relieved or may be worsened by conventional
medications
Persistence of CNS sensitisation may lead to chronic
post-surgical pain
Wilder-Smith OHG, Arendt-Nielsen L. Anesthesiology 2006;104:601-607

15. So what is unsolved issues?
• To improving postoperative pain management, we
need to;
1. Always applies multi-modal analgesia.
(get the advantages of multimodal analgesia)
2. Implementation of the existing EB regarding the
use of non-opioid + opioid on as needed basis.
3. Use available specific evidence for optimizing
multimodal pain management procedure (PROSPECT
Web site).

16. 1. What is multimodal analgesia?

17. Multimodal Analgesia is
• Administration of two or more drugs that act
by different mechanism it can be:
 The same or different routes
 Provide additive or synergic effect
 Minimal side effect
 Should be given by around the clock (ATC)
Main goals of Multimodal Analgsia is to
reduce the amount of Opioid

18. 1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
Potentiation
• Reduced doses of each
analgesic
• May reduce side effects
of each drug
• Improved pain relief due
to synergistic or additive
effects
Opioids
NSAIDs,
acetaminophen,
nerve blocks

19. Philosophy of Multimodal Analgesia
Not only just giving 2 or more drugs which different
mechanism, but;
• One drug should be effective at peripheral
sensitization and other at central sensitization.
• Combine drugs must be synergetic or addictive.
• Must be proven by laboratory or clinical data.
• Some drugs may act at several point at nociceptive
pathway.

20. Local anesthetics
Corticosteroids
NSAIDs
COXIBs
Local Anesthetic
DRG
Opioids
Gabapentinoids
Clonidine
Modify by AHT
Ketamin
Paracetamol
COXIBs
Transduction
TransductionModulation
Perception
Transmission
Modulation
Target Point of Analgesic Drugs

21. 2. Evidence based of the use of
nonopioid + opioid on an as needed
basis.

22. Efficacy of Postoperative Patient-Controlled
and Continuous Infusion Epidural Analgesia
vs Intravenous PCA with Opioids
• Meta-analysis of 299 RCTs
• Epidural analgesia in any combination (except
epidural morphine alone) > to IV PCA up to 3 days
• Continuous epidural analgesia > PCEA for pain at
rest and with activity but more PONV and motor
block, less pruritus
• Epidural LA + Opioid > Epidural Opioid alone
Wu et al Anesthesiology 2005
Regional Analgesia

23. Prevention
Andreae MH and Andreae DH. Br J Anaesth 2013.
• Paravertebral block may reduce the risk
of chronic pain after breast cancer
surgery in about 1 out of every 5 women
treated.
Conclusions:
• Epidural anesthesia may reduce the risk of
developing chronic pain after thoracotomy in
about 1 out of every 4 patients treated.
Regional Analgesia

24. Continuous Peripheral Nerve Blocks provide
superior pain control to opioids?
• Meta-analysis 12 studies [360 pts] lower limb
• Reduced Pain scores 24/48 hours ~ 50%
• Reduced side effects
Nausea/vomiting
Sedation
Pruritus
• ‘Perineural catheters provided superior
analgesia to opioids for all catheter locations
and times’
Continuous PNB
Richman et al Anesth Analg 2006
Peripheral Nerve Block

25. Efficacy of Continuous Wound Catheters Delivering
LA for Postoperative Analgesia: A Quantitative and
Qualitative Systematic Review of RCTs
• 39 RCTs (n=1761) quali analysis, 45 RCTs (n= 2031)
quantitative analysis
• Surgical subgroups: abdominal, gynaecologic,
cardiothoracic, urologic, orthopaedic
• Benefits of wound catheters:
– Decreased pain scores (32% reduction)
– Decreased opioid consumption (25% reduction)
– Decreased risk of PONV (16% reduction)
– Increased patient satisfaction (30%)
• No increase in adverse effects
Liu et al. J Am Coll Surg 2006
Wound Catheter Delivery

26. • IV Acetaminophen prolonged time to first
opioid administration
• Reduced nausea when given before surgery
or before arrival in PACU
• When given prophylactically, reduction of
nausea and vomiting correlated with the
reduction of pain

27. • Significant reduction in pain scores at 24 hrs
• Less PONV and pruritus
• Opioid sparing at 24 hours
• No significant differences in acute pain
outcomes with pregabalin 100-300mg between
single preop dose and additional doses postop
Prevention
Gabapentinoids

28. Prevention
A systematic review of intravenous
Ketamine for postoperative
analgesia
Laskowski et al. Can J Anaesth 2011
• IV Ketamine is an effective adjunct for postop
analgesia.
• Particular benefit observed in upper
abdominal, thoracic and major orthopaedic
surgeries.
• Analgesic effect of ketamine was independent
of the type of IV opioid, timing of ketamine
administration, and ketamine dose.
Ketamine

29. More Frequently Use in Postorthopedic Surgical Pain
Management
Arthroscopic Anterior Cruciate
Ligament Surgery
Outpatient Knee Arthroplasty
Total Knee Arthroplasty
A Single intraoperative injection of ketamin
(0,15 mg/kg) improved analgesia and passive
knee mobilization 24 hour after surgery
Improved Postoperative Outcome
When combine with epidural or femoral nerve
block, increase postoperative pain relief for total
knee arthroplasty.
•Menigaux C, Guignard B, Fletcher D, Dupont X, Guirimand F, Chauvin M. Anesth Analg. 2000;90:129–135.
•Menigaux C, Guignard B, Fletcher D, Sessler DI, Dupont X, Chauvin M. Anesth Analg. 2001;93:606–612.
•Himmelseher S, Ziegler-Pithamitsis D, Agiriadou H, Martin Jjelen-Esselborn S, Koch E. Anesth Analg. 2001;92: 1290–1295.
•Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Anesth Analg. 2005;100:475–480.

30. Conclusions:
• A single IV perioperative dose of dexamethasone
had small but statistically significant analgesic
benefits.
• There was no dose-response with regard to the
opioid-sparing effect
• There was no increase in infection or delayed
wound healing with dexamethasone, but blood
glucose levels were higher at 24 hrs.
Waldron et al. Br J Anaes 2013
Glucocorticoids

31. Effect of perioperative systemic α2 agonists
on postoperative morphine consumption
and pain intensity
Systematic review and meta-analysis of RCTs
• Periop systemic α2 agonists decrease postop
opioid consumption, pain intensity, and
nausea.
• Recovery times are not prolonged.
• Common AEs are bradycardia and arterial
hypotension.
Blaudszun et al. Anesthesiology 2012
α2 Agonists

32. 3. Specific evidence for optimizing
multimodal pain management procedure
(PROSPECT Web site)

33. Prevention
White P and Kehlet H. Anesthesiology 2010.

34. Take home message
• To improving postoperative pain management, we
need to;
1. Always applies multi-modal analgesia.
(get the advantages of multimodal analgesia)
2. Implementation of the existing EB regarding the
use of non-opioid + opioid on as needed basis.
3. Use available specific evidence for optimizing
multimodal pain management procedure (PROSPECT
Web site).