Abbas El Subai Medical University of Lodz

A variably unpleasant sensation associated with actual or potential tissue damage and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors

Short term effects : Emotional and physical suffering Sleep disturbance Cardiovascular effects Impaired bowel movement Effects on respiratory function Delayed mobilization, promotes thrombosis.

Long term effects : Acute pain can lead to chronic pain Behavioral changes in children for a prolonged period after surgical pain.

Improve quality of life for the patient Reduce morbidity Facilitate rapid recovery and return to full function Allow early discharge from hospital.

Postoperative pain can be divided into acute pain and chronic pain: Acute pain is experienced immediately after surgery (up to 1 month) Chronic (more than 1 month)

Somatic (from skin, muscle, bone) Visceral (from organs within the chest and abdomen) Neuropathic (caused by damage or dysfunction in the nervous system).

Patients can experience more than one type of pain.

Transduction Transmission Modulation Perception

 Assess

pain both at rest and on movement. Evaluate before treatment, than reevaluate after. If pain is intense, evaluate, treat, and re-evaluate frequently. On the ward, evaluate, treat, and re-evaluate regularly. Document pain and response to treatment, including adverse effects. Particular attention to patients who have difficulty communicating pain. Evaluate unexpected intense pain, particularly if associated with hypotension, tachycardia or fever.

 Facial

expressions Verbal rating scale (VRS) Numerical rating scale (NRS) Visual analogue scale (VAS)

 Proactiveness

Multimodal

approach Escalating approach Patient control

 Evaluate,

treat, and re-evaluate regularly. Define the intervention threshold. Give immediate pain relief without asking for a pain score to patients in obvious pain. Have predefined pain treatment plan ready and authorized.

Pain is complex and multifactorial, thus appropriate management requires a balanced therapeutic approach. Benefits of multimodal approach:

higher effectiveness due to synergism lower side effects due to lower doses used flexibility

PCA stands for Patient Controlled Analgesia the intermittent administration of analgesic drug under direct patient control (e.g: IV administration of Morphine).

Non-opioid analgesics: Paracetamol (Acamol), Dipyrone (Optalgin) NSAIDs (including COX-2 inhibitors) Weak opioids: Codeine Tramadol Strong opioids: Morphine Pethidine Oxycodone Adjuvant: Ketamine Gabapentine (Neurontin), Pregabalin (Lyrica) Clonidine, Dexmedetomidine (Precedex)

Euphoria/dysphoria Constipation respiratory depression nausea/vomiting urinary retention. Tolarace Addiction

Local anesthetics in epidural space produce three types of blocks: sympathetic; sensory; motor. The resulted block is concentration depended, the sympathetic block is been appearing first.

Postdural puncture headache (PDPH). Results from the tension force applied to meningeal and vascular structures. May herald incipient cerebrovascular accident. Treatment: simple analgesics; bed rest; fluid hydration; an epidural blood patch after 24 hours.

PNB is induced by injecting LA near the course of nerves or plexuses. Cervical plexus Brachial plexus Lumbar plexus Sacral plexus Cervical plexus The cervical plexus is formed from the first four cervical nerves (C1-C4). The most common clinical use for this block is for carotid endarterectomy. Phrenic Nerve from C3 & C4 & C5 Brachial Plexus Interscalene Supraclavicular Infraclavicular Axillary