Evidence-Based Postoperative Pain Management

Stephan A Schug

Anaesthesiology University of Western Australia

Pain Medicine Royal Perth Hospital

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Disclaimer

This presentation may include limited information about non-approved uses of certain pharmaceutical products for the purpose of scientific information sharing and discussion, which does not represent the opinion of Pfizer. Full prescribing information and primary references should be consulted for complete safety and efficacy information relating to the approved use of such products. Physicians have the professional responsibility to ensure that pharmaceutical products are prescribed and used appropriately, based on their own judgment and accepted standards of care. Images seen in this presentation either belong to the speaker or have been sourced by the speaker. Pfizer does not take responsibility for copyrights for the images

http://www.iasp-pain.org/GlobalYear

http://www.iasp-pain.org/GlobalYear

http://fpm.anzca.edu.au/ Resources/Publications

APM:SE 4th edition

Endnote library: 8,598 references Pages: 647 Key Messages: 669

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

Consequences of Unrelieved Pain

Myocardial ischaemia

Increased sympathetic

activity

Myocardial O2

consumption

GI effects Splinting shallow

breathing

Increased catabolic demands

Anxiety and fear

Peripheral/ central

sensitisation

GI motility Atelectasis hypoxaemia hypercarbia

Poor wound healing/muscle

breakdown

Sleeplessness, helplessness

Neuro- plasticity

Delayed recovery Pneumonia

Weakness and impaired

rehab.

Psycho- logical

distress

Chronic pain

Acute pain

GI = gastrointestinal

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

Opioids – the Good

Opioids are very effective analgesics Opioids are necessary to provide pain relief in many

situations linked to severe pain: – postoperative – after severe trauma

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZA

Opioids – the Bad

Opioids are often associated with adverse events including: – Opioid-Induced Ventilatory Impairment – Nausea and vomiting – Constipation – Urinary retention – Sedation – Confusion or agitation – Rash, itching, hives – Opioid-Induced Hyperalgesia

Opioid-related AEs increase length of stay and costs

Oderda GM, et al. J Pain Symptom Manage. 2003;25:276-83. TJ et al. Anesth Analg. 2004;98:1665-73.

What Can We Do About Adverse Effects of Postoperative Opioids?

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

Acute Pain Management: Scientific Evidence 4th edition 2015

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

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American Pain Society,

American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists

“The panel recommends that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).”

Note: Exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure.

Chou R, et al. J Pain. 2016;17:131-57.

Scientific Evidence: Multimodal Analgesia*

There is Level I evidence for the effectiveness of the following components of multimodal analgesia: – Regional anaesthesia (peripheral and epidural) – Paracetamol – NSAIDs/Coxibs – Alpha-2-Delta Ligands – Systemic Local Anaesthetics (lignocaine) – NMDA Receptor antagonists (ketamine, magnesium) – Alpha-2 Agonists (clonidine/dexmedetomidine) – Corticosteroids (dexamethasone)

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

* Please note, not all medications listed here are approved for the stated use

Acute Pain Management: Scientific Evidence 4th edition 2015

Schug et al. Acute Pain Management: Scientific Evidence 4th edition ANZCA&FPMANZCA

Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.

Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.

Procedure Specific Postoperative Pain Management (PROSPECT). Available from: http://www.postoppain.org. Accessed June 2017.

Initiate multimodal analgesic techniques – Minimise use of opioids – Maximise use of non-opioid agents – Use regional anaesthesia whenever possible

• Superior to opioids, especially in orthopaedic patients

Use evidence-based, procedure-specific pain management

guidelines where available – http://fpm.anzca.edu.au/Resources/Publications – http://www.jpain.org/article/S1526-5900(15)00995-5/pdf – http://www.postoppain.org

Conclusions

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