Postanesthetic care

2. POSTANESTHESIA CARE
 Pain
 Blood loss
 Hypothermia
 Residual effects of anesthesia

3. COMMON COMPLICATIONS
POSTANESTHESIA
 Nausea/vomiting 5%
 Unexpected alterations in mental state 5%
 Requirement for upper airway support 3.6%
 Hypotension 3%
 Dysrhythmias 2%
 Hypertension, myocardial ischemia, or a major
cardiovascular complication <1%

4. ASA SUMMARY TREATMENT
RECOMMENDATIONS
 Nausea and vomiting
 ondansetron, droperidol,
dexamethasone, or metoclopramide
when indicated.
 Supplemental oxygen for patients
at risk of hypoxemia.
 Fluids
 Postoperative fluids should be managed
in the PACU.
 Certain procedures may require
additional fluid management.
 Temperature
 Normothermia should be maintained.
 Forced-air warming systems are most
effective for treating hypothermia.
 Pharmacologic agents for the reduction of
shivering
 Meperidine is recommended.
 Antagonism of the effects of
sedatives, analgesics, and NMB
 Antagonism of benzodiazepines
 Antagonists should be available.
 Flumazenil should not be used routinely.
 Flumazenil may be administered to
antagonize respiratory
depression and sedation.
 Antagonism of opioids
 Antagonists (e.g., naloxone) should be
available but should not be used routinely.
Naloxone may be administered to antagonize
respiratory
depression and sedation.
 Reversal of neuromuscular blockade
 Specific antagonists should be administered
for reversal of
residual neuromuscular blockade as
indicated.
 After reversal, patients should be
observed to ensure that
cardiorespiratory depression does not
recur.

5. ROUTINE DISCHARGE CRITERIA
FROM PACU
 Vital signs satisfactory and stable
 Return to postoperative mental state
 Adequate pain control
 Immediate treatment of any complications
 Adequate treatment of nausea/vomiting
 Adequate function of all drains, tubes, catheters
 Surgical bleeding controlled or treated
 Postoperative orders reviewed and implemented
 Laboratory studies needed immediately obtained and
results reviewed

6. ALDRETE SCORING SYSTEM

8. “PAIN IS AN UNPLEASANT
SENSORY AND EMOTIONAL
EXPERIENCE ASSOCIATED WITH
ACTUAL AND POTENTIAL TISSUE
DAMAGE OR DESCRIBED IN
TERMS OF SUCH DAMAGE.”
International Association for the Study of Pain

9. POSTOPERATIVE PAIN
 Acute pain is experienced immediately after surgery
(up to 7 days).
 Chronic pain lasts more than 3 months after the
injury.

10. ACUTE POSTOPERATIVE PAIN
 Pain present in a surgical patient because of
preexisting disease, the surgical procedure (with
associated drains, chest or nasogastric tubes, or
complications), or a combination of disease-related
and procedure-related sources.

11. GOALS OF EFFECTIVE AND APPROPRIATE PAIN
MANAGEMENT
 lmprove quality of life for the patient
 Facilitate rapid recovery and return to full function
 Reduce morbidity
 Allow early discharge from hospital

12. PRINCIPLES OF PAIN ASSESSMENT
 Assess pain at rest and on
movement.
 The effect of treatment is evaluated
by assessing pain before and after.
 In the (PACU) or other
circumstances where pain is intense,
evaluate, treat, and re-evaluate
frequently (every 15 min initially,
then every 1-2 h as pain intensity
decreases).
 In the surgical ward, evaluate, treat,
and re-evaluate regularly (every 4-8
h) the pain and the patient's
response to treatment.
 Define the (intervention threshold).
For example, verbal rating score of 3
at rest and 4 on moving, on a 10-
point scale.
 Document pain and response to
treatment, including adverse effects.
 Patients who have difficulty
communicating their pain require
particular attention.
 Unexpected intense pain,
particularly if associated with
(hypotension, tachycardia, or fever),
is immediately evaluated.
 New diagnoses, e.g. wound
dehiscence, infection, or deep
venous thrombosis, should be
considered.
 Immediate pain relief without
asking for a pain rating is given to
patients in obvious pain who are not
sufficiently focused to use a pain
rating scale.
 Family members are involved when
appropriate.

13. CHOICE OF ASSESSMENT TOOL

14. THE OBJECTIVE PAIN SCALE
Blood Pressure/Heart Rate
+/- 10% of preoperative value 0
> 20% of preoperative value 1
>30% of preoperative value 2
Crying
Not Crying 0
Crying, responds to TLC 1
Crying, doesn't respond to TLC* 2
Movement
None 0
Restless 1
Thrashing around 2
Agitation
Asleep or calm 0
Mild Agitation 1
Hysterical 2
Verbalization of Pain
Asleep, states no pain 0
Vague, cannot localize pain 1
Localizes pain 2
For Pediatrics <3 years
For non-verbal who
cannot self-report

15. PHARMACOLOGICAL OPTIONS
OF PAIN MANAGEMENT
NON-OPIOID
ANALGESICS
WEAK OPIOIDS
STRONG OPIOIDS
ADJUVANTS
PARACETAMOL, NSAIDs, COX-2
SELECTIVE INHIBITORS, GABAPENTIN,
PREGABALIN
TRAMADOL, CODEINE,
DEXTROPROPOXYPHENE
MORPHINE, FENTANYL, OXYCODONE,
DIAMORPHINE, HYDROMORPHONE,
PETHIDINE,
KETAMINE, CLONIDINE,
DEXMEDETOMIDINE

16. MULTIMODAL ANALGESIA

17. BALANCED (MULTIMODAL) ANALGESIA
 Two or more analgesic agents act by different mechanisms to
achieve a superior analgesic effect without increasing
adverse events compared with increased doses of single
agents.
 Examples:
 Epidural opioids in combination with epidural local
anesthetics
 Intravenous opioids in combination with NSAIDs (dose
sparing effect)
 The method of choice wherever possible:
 Paracetamol and NSAIDs for low intensity pain
 Opioid analgesics and/or local analgesia techniques for
moderate and high intensity pain.

18. PARACETAMOL
Mechanisms:
 Inhibition of a COX-2 in the
CNS
 Inhibition of a COX-3
(selectively susceptible to
paracetamol)
 Modulation of inhibitory
descending serotonergic
pathways
 Prevents PG production at
the cellular transcriptional
level independent of COX
activity.
Efficacy:
 Effective for acute pain.
 Effective adjunct to opioids
reducing requirements by 20-
30%
 Addition of NSAID further
improves efficacy
 IV paracetamol as effective as
ketorolac
 Valuable component of MMA
Adverse effects:
 Fewer and can be used when
NSAIDS are contraindicated
 Caution with liver disease and
G6PD deficiency

19. NSAIDS
 Analgesic, anti-inflammatory, antipyretic
 Inhibits prostaglandin synthesis in peripheral tissues, nerves and CNS
 Non-selective COX inhibitors (inhibit both COX-1 and COX-2)
 Efficacy:
 Single doses effective for postoperative pain
 Inadequate alone for severe postoperative pain
 Useful adjuncts combined with opioids
 Integral components of MMA.
 NSAIDS given with paracetamol improves analgesia.
 Adverse effects: more common with long-term use; risk and severity
increase in the elderly
 Renal impairment
 Interference with platelet function
 Peptic ulceration
 Bronchospasm

20. COX-2 INHIBITORS
 Selectively inhibit the inducible COX-2 enzyme and spare the
constitutive COX-1(sparing physiological tissue PG production while
inhibiting inflammatory PG release)
 Available:Meloxicam, Celecoxib, Etoricoxib, Valdecoxib and Parecoxib
(injectible precursor of valdecoxib)
 Efficacy: Opioid-sparing in combination with opioids
 Adverse effects:
 Similar effects on renal function as NSAIDS
 Do not impair platelet function
 Short term results in gastric ulceration
 Analgesic doses do not produce bronchospasm

21. TRAMADOL
 Atypical centrally-acting due to combined effects as
opioid agonist and a serotonin and noradrenaline
reuptake inhibitor.
 Has a lower risk of respiratory depression and impairs
GIT motor function less than other opioids at
equianalgesic doses.
 Nausea and vomiting are the most common adverse
effects.

22. OPIOIDS
 Morphine
 The most widely used
opioid for the
management of pain and
the standard against
which others are
compared.
 Fentanyl
 Increasingly used for acute
pain due to lack of active
metabolites and fast onset.
 Oxycodone
 Commonly used for acute pain
management for patients able to
take opioids orally
 Immediate-release and controlled-
release formulations have been used
as “step-down” analgesia following
PCA
 Pethidine
 Synthetic opioid still widely used
despite multiple disadvantages
 Induces more nausea and vomiting
 Accumulation of active metabolite
associated with neuroexcitatory
effects
 Discouraged in favor of other
opioids

23. ADVERSE EFFECTS OF OPIOIDS Sedation
 Assessment of sedation level is a more reliable way of detecting
early opioid-induced respiratory depression than a decreased RR.
 Pruritus
 Nausea
 Vomiting
 Slows gastrointestinal function
 Urinary retention
 Adverse effects are dose-related; once a threshold dose is reached,
every 3-4mg increase of morphine-equivalent dose per day is
associated with one additional adverse event or patient-day with such
an event.

24. ADJUVANTS
 NMDA receptor antagonist:
KETAMINE
 Reduces opioid requirements in
opioid-tolerant patient
 Opioid-sparing effect in
postoperative pain
 Best effects as continuous IV
infusion
 Improves analgesia in patients with
severe pain poorly responsive to
opioids.
 Alpha-2 agonists: CLONIDINE
and DEXMEDETOMIDINE
 Decrease perioperative opioid
requirements
 Higher doses of clonidine
significantly reduce opioid
requirements but cause greater
degree of sedation and hypotension.
 Dexmedetomidine infusions to
sedate ventilated patients reduce
morphine requirements by 50%.

25. PATIENT CONTROLLED ANALGESIA
 Allows to self-administer small doses of analgesic as
required.
 Programmable PCA pump delivers opioid
medications IV or by other method and route of
delivery.
 Bolus dose
 Lockout interval
 Continuous infusions
 Dose limits
 Loading dose
 IV Opioid PCA
 Provides better analgesia than conventional parenteral
regimens.
 Patient preference is higher compared with conventional
regimens.
 PCEA decreases doses of local anesthetic, lessens
motor block and fewer anesthetic interventions
compared with epidural infusions.

26. REGIONAL ANALGESIA
 EPIDURAL ANALGESIA
 - continuous administration of
analgesic into the epidural space via
an indwelling catheter
 All techniques provide better
postoperative pain relief compared
with parenteral opioids.
 Low concentrations of local
anesthetics and opioids provide
better analgesia than either
component alone.
 Risk of permanent neurologic
damage is very low; higher when
delayed in diagnosis of an epidural
hematoma or abscess.

27. REGIONAL ANALGESIA
 INTRATHECAL ANALGESIA
 Local anesthetics intrathecally provide only short-term
postoperative analgesia.
 Intrathecal opioids provide prolonged postoperative
analgesia following a single dose.
 Combination of spinal opioids with local anesthetics
reduce dose requirements for either drug alone.
 Intrathecal morphine 100-200mcg offers effective
analgesia with low risk of adverse effects.

28. OTHER REGIONAL AND LOCAL
ANALGESIC TECHNIQUES
 Interscalene
 Axillary
 Femoral
 Fascia iliaca block
 Sciatic nerve
 Lumbar plexus
 Thoracic paravertebral blocks
 Intercostal and interpleural blocks

29. WOUND INFILTRATION
 Long-acting local anesthetics lengthen time until first
analgesic request, improve pain relief and decrease
opioid requirements after anterior cruciate ligament
reconstruction, shoulder surgery, spinal surgery and
median sternotomy after cardiac surgery.

30. TOPICAL APPLICATION OF LOCAL
ANESTHETICS
 Topical EMLA (Eutectic Mixture of Local Anesthetic)
cream is effective in reducing the pain associated with
venous ulcer debridement

31. NON-PHARMACOLOGICAL METHODS OF
PAIN MANAGEMENT
 Cold
 Iced-water after knee-surgery.
 Can be used both in the hospital and at home.
 There are commercial systems easy to use.
 Acupuncture
 There are no documented effects of acupuncture in postoperative
pain management. However, there may be an effect in reducing
nausea and vomiting.
 Relaxing therapy and distraction such as music, imagery or
hypnosis
 These may have a positive effect in individual cases.

32. TREATMENT OPTIONS IN RELATION TO MAGNITUDE OF
POSTOPERATIVE PAIN EXPECTED AFTER SURGERY

33. FACTORS INFLUENCING ANALGESIC
REQUIREMENTS
 Age: elderly patients require smaller doses.
 Sex.
 Pre-operative analgesic use.
 Past history of poor pain management.
 Coexisting medical conditions such as substance abuse or
withdrawal, hyperthyroidism, anxiety disorder, affective
disorder, hepatic or renal impairments.
 Cultural factors and personality. (e.g.intolerant of any
discomfort - surprising self-control - pain as normal part of life).
 Preoperative patient education (can improve expectations,
compliance and ability to effectively interact with pain
management techniques).
 Site of operation: thoracic and upper abdominal operations are
associated with the most severe pain.
 Individual variation in response and pain threshold.
 Attitude of the ward staff.

34. THANK YOU