局麻技术与术后镇痛管理

Professor Narinder Rawal, MD, PhD, FRCA (Hon)Department of Clinical MedicineDivision of Anaesthesiology and Intensive Care University Hospitalrebro, Sweden,Postoperative pain management by regional analgesia techniques,Lecture outline,Why treat postoperative pain? (chronic postsurgical pain)Multimodal analgesic techniquesAdvantages and problems with epidural technique Alternative regional analgesia techniquesShould we stop using bupivacaine?Role of Acute Pain Services,Postoperative Pain Continues To Be Undertreated,Despite nearly a decade of progress in pain research, 39% of patients reported severe-to-extreme postoperative pain in 2003 versus 31% in 1995,1Warfield CA, Kahn CH. Anesthesiology. 1995;83(5):1090-1094.2Apfelbaum JL, et al. Anesth Analg. 2003;97(2):534-540.,19%,49%,23%,8%,47%,21%,18%,13%,Symptoms at home after ambulatory surgery literature review,1966-2000, 156 articles, (33 included),Wu CL et alAnesthesiology 2000;96:994-1003,Persistent postsurgical pain the incidence,Craniotomy 6-12 %Kaur 2000Harner 1993Leg amputation 50-80 %Finch 1980Fisher 1998Sherman 1984Thoracotomy50 %Bertrand 1996Katz 1996Breast surgery11-57 %Jung 2003Tasmuth 1996Lap cholecystectomy3-56 %Stiff 1994Ure 1995de Povourville 1997Inguinal hernia12 %Aasvang 2005,Chronic postsurgical pain,PsychologicalPatient attiudesPreop anxietyExpectation of chronicity,EnvironmentalPoor educationLow incomePoor self-rated health,SurgicalSeverity of postopertaive painSurgical factors- site and extent of surgery- damage to nerves- reoperations- bleeding, infection,PreoperativeFemale genderYounger agePain before surgeryAnalgesic use,Genetic predisposition,PCA techniques for postoperative painEpidural PCA (PCEA)Perineural PCAIncisional and intraarticular (PCRA)Other routes of opioid PCA (intranasal, transdermal),Non-opioid analgesic techniques,Analgesic drugsParacetamolNSAIDs (including COX-2-inhibitors)NMDA antagonists (ketamine, dextromethorphan)2 receptor agonists (clonidine, dexmedetomidine)others (gabapentin, corticosteroids, capsaicin, nicotine, neostigmine etc.)Regional techniques (including catheter techniques)Central blocks (EDA, spinal, CSE)Peripheral blocksIncisionalIntraarticularNon-pharmacological techniques,Improves quality of opioid analgesiaReduces opioid requirementsPrevents or reduces opioid toleranceRelieves anxiety,Rowbotham D J,37 RCTs, n= 2385, 5 subgroups: i.v. ketamine single dose, cont. Infusion, PCA, epidural, pediatricI.v. morphine + ketamine not better than i.v. MorphineI.v. ketamine infusion decreased i.v. and epidural opioid requirements in 6/11 studies*Single bolus ketamine decreased opioid requirements in 7/11 studies*Epidural ketamine beneficial in 5/8 trialsAdverse effects not increased with small dose (0.15-1 mg/kg bolus, 0.12-0.6 mg/kg/h infusion”small dose ketamine is a safe and useful adjuvant to standard practice opioid analgesia”*,Anesth Analg 2004;99:482-95,May prevent central sensitization and chronic neuropathic pain* No reduction of opioid adverse effects, * in 54 % studies,Buvanendran A, Kroin J SBest Practice and Reasearch Clin Anaesthesiology 2007;21:31-49,Perioperative EDA and outcome after major surgery,Advantages of EDA Excellent analgesia - the best techniqueShorter duration of postoperative ilieusReduced risk of pulmonary complications (Ballantyne 1998)Reduced risk of postoperative myocardial infarction (Beattie 2001)Reduced risk of persistent postoperative painSome evidence of reduced risk of cancer recurrence (?),299 RCTsEpidural analgesia in every combination superior to i.v. PCA upto 3-days (exception epidural morphine alone)Continuous infusion superior to PCEA for pain at rest and activity (but more PONV and motor block, less pruritus)Epidural l.a. opioid better than epidural opioid alone”In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared with intravenous patient-controlled analgesia”,16 RCTs (1987 - 2005),n=406 in EA group and n=400 in parenteral group(control ) Epidural analgesia associated with: - reduced pain scores (WMD 15mm day1, 18mm day2) - shorter duration of ileus (WMD 1.6 days) - increased incidence of pruritus (OR 4.8) - increased incidence of urinary retention (OR 4.3) - increased hypotension (OR 13.5) - no influence on duration of hospital stay,”Despite improved analgesia and a decrease in ileus, EA has some adverse effects and does not shorten the duration of hospital stay after colorectalsurgery,Marret E et alBr J of Surgery 2008;95:1331-1338,RCT, n=188(1971 - 2006), n=5904 Epidural analgesia associated with: - decreased risk of pneumonia (OR 0.54) - incidence unchanged(8%) from 1971-2006 with EA but decreased (34% to 12%) with systemic analgesia - improved pulmonary function - reduced risk of myocardial infarct (NNT 48) - increased risk of hypotension (OR 2.0), urinary retention(OR 2.2) and pruritus (OR 6.5 morphine,OR 3.1 fentanyl, OR 1.1 sufentanil),”Epidural analgesia protects against pneumonia following abdominal or thoracic surgery, although this beneficial effect has lessened over the last 35 years because of a decrease in the baseline risk,Popping D Met alArch Surg 2008;143:990-999,Davies R.G.BJA 2006;96:418-26,10 trials (none blinded), n = 520No differences in pain scores at 4-8, 24 or 48 hParavertebral block associated with:-Less frequent pulmonary complications (OR 0.36)-Less urinary retention (OR 0.23)-Less nausea, vomiting (OR 0.47)-Less hypotension (OR 0.23)-Less failed blocks (OR 0.28)”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 pulmonary complications. PVB can be recommended for major thoracic surgery”,Thoracic EDA, paravertebral, intrathecal, intercostal and interpleural compared to each other and to systemic opioidsAnalysis of: postoperative analgesia, analgesic use, complications74 RCTsParavertebral block-as effective as TEDA but less hypotension-reduced pulm complications vs. systemic analg (TEDA did not)TEDA superior to intrathecal and intercostal (which were superior to systemic analgesiaInterpleural analgesia inadequate”Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended”. If not possible or contraindicated ”intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia”.,Anesth Analg 2008;107:1026-40,8 studies (91 % TKR), n = 510. Anesthesia: GA (6 studies), spinal 1 study, EDA/PNB 1 studyPNB: Femoral catheter 4 studies, sciatic nerve block 3 studies (only 1 catheter technique), continuous lumbar plexus block 1 studyNo difference in pain scores between epidural and PNB at 0-12 or 12-24 h and no clinically significant difference at 24-48 hNo difference in morphine consumptionHypotension more frequent with EDA, increased risk of urinary retentionPatient satisfaction better with PNB (2/3 studies that assessed it)”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 routine major knee surgery”,About 478.000 TKAs in US in 2004, 59.000 in UK in 2005,112 RCTs (135 studies excluded)Recommended:- femoral nerve block (LOE, grade A) or spinal block and morphine (LOE, grade A) combined with:- cooling and compression techniques (LOE, grade B)- paracetamol and NSAIDs (or coxibs) (LOE, grade A)- i.v. strong opioids for breakthrough pain (LOE, grade A)Not recommended:- epidural LA + opioid (not better than femoral block)- combined intraarticular + incisional promising, further studies necessary- other blocks (with sciatic or obturator) limited evidence,Anesth Analg 2006;102:248-57,19 RCTs (only 11 double-blind)Better analgesia for all time periods (mean and max VAS) at 24, 48 and 72 hSuperior analgesia for all catheter locations and time periodsReduction in opioid use with perineural analgesiaPONV (49 % vs. 21 %), sedation (52 % vs. 27 %), pruritus (27 vs. 10 %) more common with opioid analgesiaImproved patient satisfaction (4 RCTs only)”CPNB analgesia, regardless of catheter location, provided superior postoperative analgesia and fewer opioid-related side effects when compared with opioid analgesia”,Rawal et alAnesth Analg 1998;86:86-9,J Am Coll Surg2006;203:914-932,39 RCTs (n = 1761) qualitative analysis, 45 RCTs (n = 2031), qualitative analysisSurgical subgroups (abdominal, cardiothoracic, gynecologic, orthopedic, minor)Benefits of wound catheters:- decreased pain scores at rest and activity (32 % reduction)- decreased need for opioids (25 % reduction)- decreased risk of PONV (16 % reduction)- increased patient satisfaction (30 % increase)- decreased LOS in hospitalized patients (limited data, 1 day, p = 0.01)No increase in adverse effectsQualititative systematic review supported same benefits”Continuous wound catheters appear to be an effective modality for management of postoperative pain”,Wound catheters for postoperative analgesia - Summary,The technique is well-established internationally Evidence-based data (Grade scoring) shows efficacy in following surgeries: - Orthopedic (shoulder, knee, hip, spine, iliac crest bone harvesting) - Abdominal (colorectal, hernia, hysterectomy, C.Section) - Breast surgery - Sternotomy - Other surgeries (limited data) No major problems so far (1.5 million pumps sold by one company) Routine method for pain management after ambulatory surgery in many institutions Several questions unanswered - further studies necessary,Christopherson R et al Anesth Analg 2008;107:325-32,GA combined with postop EA had 57 % lower risk of cancer recurrence vs GA+postop systemic opioids (chemical markers),Postop epidural analgesia associated with enhanced survival among patients without matastasis before 1.46 years (no difference later),ANESTHESIA RA techniques Procedure specific () APS organization,PHYSIOTHERAPY Pre-set mobilization routines,PATIENT ASA status Information, ”contract” pre-set goals Life style (smoking, alcohol),SURGERY High volume surgeon/hospital Skillful surgeon Surgery specific registers,SURGICAL WARD Pain mgmt policy (VAS 3) Clinical pathways, pre-set goals Regular audits,Multifactorial nature of postoperative outcome,20-40% reduction in operative mortality in high volume (vs low volume) hospitals (colon cancer, CABG, AAA resection) No benefit of operative drains* ( major liver, pancreas, gastric surgery) No benefit of perioperative nasogastric suctioning (may increase risk of pneumonia) No benefit of mechanical bowel prepration (colon resection) No benefit of routine parentral or enteral feeding,* supported by data from PROSPECT recommendations ( ),Needed the complete picture,?,?,Prevention of cancer recurrence?,Perioperative EDA and outcome after major surgery,SummaryPerioperative EDA provides outstanding analgesiaNo major advantages in other outcomesAs good or better alternatives now available (major knee,hip, abdominal,thoracic surgery)May have a role in:- high risk patients undergoing major surgery- reducing risk of persistent post-surgical pain- reducing risk of cancer recurrenceStudies necessary to establish risk-benefit of this invasive and expensive technique,Is bupivacaine pass?,Indications for chiral “caines” Pediatric regional techniques Use of large doses of local anesthetics Administration of local anesthetics in anesthetized patients Administration of local anesthetics by non-experts (surgeons) Pregnant patients - more vulnerable if cardiac arrest Use of local anesthetics outside hospital (day-care surgery) Intravascular injection risk relatively high (1:500) (Kopacz 1999) Incidence of seizures 1:4500 (Auroy 1997),Prospective. PCEA (n = 14,223), iv PCA (n = 1591), brachial plexus cath. interscalene or axillary (n = 1737), femoral/ sciatic catheter (n = 1374) pain scores significantly better for regional techniques Complications : - epidural haematoma 1:4741 (0.02 %), risk greater with lumbar (vs thoracic) - epidural abscess 1:7142 (0.01 %) - severe neurological complications of perineural catheters 2: 3111 (0.06 %) - infection (perineural catheter) 3.7 % (no abscess) - respiratory depression PCEA 1.1 %, iv PCA 0.7 %,PCEA, iv PCA and perineural catheter techniques - are safe and efficient, - close supervision of all these techniques by an acute pain service in the postoperative period is mandatory,Rawal N et al. Eur J Anaesthesiol 1998;15:35463,A range of reasons for this dissatisfaction with postoperative pain management,Lack of organised APS Lack of qualified nursing staff for patient-controlled analgesia (PCA) / epidural techniquesShortage of staffCost of PCA pumpsLack of post-anaesthesia care unitsPoor cooperation with surgeonsRestrictive opioid policies - Austria, Germany, Greece, Italy and Spain,APS- what are the requirements?,Assessment of pain at regular intervals (at rest and on movement)Reassessment of pain after interventionDocumentation of pain scores (make pain visible”)Standerdized protocols for pain managementProtocols for monitoring routines (EDA, PCA, Perineural etc)Patient information routinesTeaching programmes (all personell categories)Regular audits (feedback to surgeons, anaesthesiologists, nurses, administrators),Hospital-wide goal, at rebro University Hospital (since 1991)No patient who has undergone surgery shall have pain above VAS 3,Pain assessment US (since 1991)VAS every 3 hours*VAS* before and after interventionVAS at rest and mobilizationDocumentation on patient chart,*in some departments less (or more) frequent*verbal or observer scale if problem with VAS,Organization of Acute Pain Servicesrebro University Hospital,Anesthesiologist (hospital wide)Section anesthesiologistAcute Pain Nurse (anesthesiologist supervision)Pain representatives (every ward)- one surgeon (named)- one day nurse (named)- one night nurse (name