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Pain Management

in Day Case Surgery


Sugeng Budi Santoso
Departement of Anesthesiology and Intensive Therapy
Sebelas Maret University/Dr. Moewardi General Hospital
Surakarta

ABSTRACT

*Advances
in
Anaesthetic
tehniques
*Escalalating healthy care
*Potential advatages of DCS :

&

surgical

In patient surgical ambulatory / DCS

Most DCS are associated with minor surgical trauma,


so discharge of patient depends of recovery from
anesthesia
Top priorities for successful DCS are the 4A

Ambulatio
Alertness
n

Unrelieved pain
Excessive Fatigue
Nausea & Vomiting

Analgesia

Alimentati
on

Delay discharge / unplanned


hospital admission

Potential cost saving of DCS may negated by poorly


treated of pain

DCS Minor surgical Trauma Mild Pain ?


Recent studies under treatment of pain is common

3040 % suffer moderate severe pain in first 24


48 (Beanregaan,et al, 1998; Rawal N, 2001)
40 % of patient experience severe pain despite
conventional treatment. ( Chung F, et al, 1997)

Effective & long lasting with minimal side effect


analgesia is
paramount importance in DCS

INTRODUCTION
Definition of DSC : Patient on elective surgery with one
workday (8-12 h) This includes admission, operation,
recovery and discharge ( Andi YM, Vickers AP, 2013)
Advantages of DCS :
Patient Preference
Timely Treatment
Reduced Risk of Nosocomial Infection
Earlier Return to Normal Activity
Possible Reduction of Postoperative Complication
Value for Money to Hospital Trusts
Reduce Surgery Waiting Times and Cost

Choice of anesthetic in DSC


Affect postoperative pain and morbidity
Basic : - Safety
- Rapid onset
- Excellent analgesia
- Good surgical condition
- Early recovery
Propofol, fentanyl, rocuronium, sevoflurane
RA : avoid the hazards of GA, provide analgesic
without sedation, early discharge & prolong
analgesia
Anesthesia > 90 min increased

Postoperative Analgesia in DCS


Impact of severe pain after DCS extreme
discomfort, sleep deprivation and suffering
Unplanned hospital admission
Analgesic should be effective, safe minimal side effect
facilitate
recovery and easily managed by patient at home
(Rawal N, 2001)

Started intra operatively by supplementing GA with


short-acting Opioid, NSAIDs or RA

Assesment & Documentation


Pain Intensity
Efficacy at rest & during
Side Effect

Must be assessed an
reassessed frequently
activityat least every hour and
documented in the bed
side chart

Pain assessment tools have been formulated and


validated for family
to use at home

Basic Principal of Good POA


Patient education about
peri-operative care &
Pain plays a very
important role in
managing expectations
and reducing anxiety
improves over all
outcome and patient
satisfaction

As with all surgical


procedure, a
multimodal approach
is paramount

Options For Postoperative Analgesia

Paracetemol

NSAIDs

Analgesic
adjustvants(gabape
ntin,
dexamethasone)

Opioids

Local anaesthetic
agents ( LIA,
Peripheral / Central
block )

Simple Analgesics : Paracetamol & NSAIDS


Should be the bedrock of an analgesic regimen
Paracetamol :
effective, cheap, save, having few side effects & contraindications, and reliable mild analgesic
The effectiveness of paracetamol is often underestimated
because it often doesnt administered correctly
Early dose 10-15 mg kg-1 as neccesarry failed to provide
therapeutic plasma concentrations and so was in
effective (Wolf AR, 1999)
In children : a loading dose of 40 mg kg-1 followed by
regular dosage of 90 mg kg-1 Day-1 to maintain theraupeutic
plasma concentrations is recommended (Wolf AR, 1999;
Zachrias M, et al, 1981)

NSAIDs
Basic of the most DCS analgesia
regiment
The inflammatory effects reduce
local oedema and minimize the
use of more potent drugs and
their side effects.
In 1998 the Royal College of
Anaesthetists state that in
situation where there arent
contraindication, NSAIDs are the
drugs of choice after many DCS
(Royal College of Anaesthetists, 1998)

Have significant GI, hematological and renal side effects


Risk of bronchospasm & bleeding
Ibuprofen is better CV side effects compare VS diclofenac

Oxford League Table of Analgesic Efficacy 2007

(Andy YM, Vickers AP,


2013)

OPIOIDs
The use opioids is protocol based and
limited to use where necessary
Work by activating inhibitory pathway
in descending spinal via opioid
receptors
Weak opioids + paracetamol has a
strong additive effects
Strong Opoids risk of unacceptable
side effects, especially nausea and
vomiting

Oxycodone
Synthetic Opioid with Higher Potency
Oral
Less Opioid Side effects
May have a role in Rescue analgesia in
DCS

Dexamethasone
Glucocorticoid without mineralocorticoid effect
Dual advantages in DCS : analgesic &
anti-emetic properties
of action is 1-2 h, act by peripheral
inhibition of phospholipase, which
decreases the procedures of pathways

Gabapentin
Better than as pre-emptive analgesia?
++channels to inhibits the release of
Binding to Ca++
nosiceptive neurotransmitter

Modify nosiceptive pathway within the CNS prior to a


noxious stimulus
The principle is not pre-empitve but anti-hyperalgesic &
there by to protect the CNS from pathological afferent &
sensitization
Pre-operative 600 mg gabapentin produce significant
reduction pain for 24 h ; opioid requirement anxiety, nausea
and vomiting (Turan A, et al , 2004)

For DCS, the dose of LA for SAB should be lower


& shorter duration of action , such as
Prilocain(Morris, et al, 2011)
Simple oral analgesia prior to discharge and at
home
Patient can be discharged with residual sensory or
motor deficit if the limb is protected and assistance is
available at home. Patients can be safely discharged
home with self administered LA wound-catether in
situ (Rawal N, et al, 1998)
PNB and LIA are very safe, less PONV and from an
effective form of multi-modal analgesia
LA intra joints and intra-peritonial

Regional Anesthesia

Advantages of Local / Regional


Anesthesia

Disadvantages of Local /
Regional Anesthesia

Plantar Flexion at preoperative level

Return of sensation S 4-5


( Perianal Sensation)

Discharge Criteria for


DC Spinal Anaesthesia
Not sedated or
hypovolaemia

Proprioception of big toe

o PDPH
- Minimize by small gauge, pencil point needles
- On discharge, patient should be given detailed
information about symptoms of PDPH and
have a point of contact should a problem occur
at home

Conclusions
DCS is a cost-effective
RA especially PNB alone or as part of GA, offer
many advantages for DCS
Success of DCS depend on effective control of PO
Pain and minimization of side effect, Fatigue and
PONV
DCS analgesia must be allow patient discharged
safety without delay
The unplanned hospital admission rate may well
reflect the quality of care in DCS.
Balanced analgesia in DCS commonly involves
intraop fentanyl, wound infiltration with LA at the
end of surgery and supplemented in PO period by
oral non opioid analgesi