DRMARTINROOMSConsultantinAnaesthesiaRoyalMarsdenHospital

REGIONALANAESTHESIA&PAIN

An Introduction to Anaesthesia 2019

Learning Objectives

•  List 6 important reasons for postoperative pain control

•  Choose appropriate analgesic regimes •  Know when to call for senior advice •  Understand principles and types of regional

anaesthesia

Why is it important to control pain?

Divinum sedare dolorem

“It is divine to alleviate pain”

Reduce respiratory complications

Reduce Sympathetic activity ( ACS)

Improved mobilisation

Reduce Chronic Pain Syndromes

Improved patient satisfaction

Why is it important to control pain?

•  Divinum sedare dolorem •  Reduce sympathetic activity ( ACS) •  Enhanced recovery •  Reduce respiratory complications •  Improved mobilisation •  Reduced chronic pain syndromes •  Improved patient satisfaction

Case 1

•  It is your first on call in anaesthetics •  Bleeped about Mrs X by DSU •  Laparoscopic cholecystectomy •  Being admitted overnight for uncontrolled pain •  PONV ++

Put the following in the right order

•  A. D/W SpR

•  B. Management plan

•  C. History and pain assessment

•  D. Check notes, anaesthetic and drug charts

D, C, B ,A

•  D. Check notes, anaesthetic and drug charts

•  C. History and pain assessment

•  B. Management plan

•  A. D/w Spr

Pain Assessment

Management Options

•  A. Regular oral analgesia eg paracetamol, diclofenac, prn IM morphine

•  B. Regular IV paracetamol, prn IM morphine, IVF, antiemetic

•  C. Morphine PCA

•  D. Immediate IV morphine 0.5-1mg/kg titrate in 2mg aliquots

•  E. C +D+ IVF+ antiemetic.

WHO analgesic ladder....1, 2, 3

Analgesia

Adjuvants: Ketamine, Gabapentin

Simple (mild) Paracetamol, NSAIDs

Moderate Codeine, Tramadol

Strong Fentanyl, Morphine, Oxycodone

General points

•  Ladder - Breakthrough pain - strong analgesics as per WHO pain ladder

•  Oral - Regular oral analgesia ASAP

•  Others - Treat co-existing symptoms; fluids, antiemetic, laxatives , oxygen

CASE 2

•  57 yr old 3d post laparotomy, thoracic epidural, taking free fluids

•  Excruciating pain last 2 h

•  A. Morphine PCA•  B. Notes, drug chart•  C. D/W SpR•  D. Hx, examination ( epidural site)•  E. Regular oral analgesia, breakthrough morphine •  F. Bolus/ top up

B, D, F, E, A, C

•  B. Notes, drug chart •  D. Hx, examination ( epidural site) •  F. Bolus/ top up •  E. Regular oral analgesia, breakthrough

morphine •  A. Morphine PCA •  C. D/W SpR

Regional analgesia

•  Peripheral nerve block –  Mainly extremities, particularly orthopaedics

•  Epidural –  Used as both analgesia and anaesthetic, usually catheter

in situ for top ups

•  Spinal –  Similar to epidural , but lower volumes required, rarely

catheter in situ, continuous prolonged analgesia not appropriate

Peripheral Nerve Block

Consent, performance and post-block care

Peripheral Nerve Block

Techniques: •  Ultrasound •  Nerve stimulator •  Landmark

Spinal (A) v Epidural (B)

Summary – control of POP

General concepts pain treatment

•  L

•  O

•  O

General concepts pain treatment

•  L (ladder) – WHO pain ladder ; stepwise increment of strength of analgesia; start at appropriate level

•  O (oral) establish oral analgesics ASAP

•  O (other assoc. symptoms ) Treat N & V, dehydration, constipation, anxiety.

Learning Objectives

•  List 6 important reasons for post operative pain control

•  Choose appropriate analgesic regimes •  Know when to call for senior advice

Further reading on the course website.

www.ucl.ac.uk/anaesthesia/education/AnaesthesiaIntroduction

•  Postoperative pain •  Pain in children •  Epidurals on the ward