Chair of Anesthesiology
Wake Forest University Baptist Medical Center
Winston-Salem, North Carolina 27157-1009
rroy@wfubmc.edu
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Techniques to reduce postoperative opioid requirements презентация
Содержание
- 1. Techniques to reduce postoperative opioid requirements
- 2. OVERVIEW Problems with opioids Hypothesis: if I
- 3. INTRAOPERATIVE TECHNIQUES Prevent opioid hyperalgesia Wound infiltration
- 4. PROBLEMS WITH OPIOIDS Pharmacogenetic Organ-specific side effects
- 5. PHARMACOGENETIC ISSUES WITH OPIOIDS Cytochrome P450 enzyme
- 6. ORGAN-SPECIFIC SIDE EFFECTS WITH OPIOIDS - 1
- 7. ORGAN-SPECIFIC SIDE EFFECTS WITH OPIOIDS - 2
- 8. ORGAN-SPECIFIC SIDE EFFECTS WITH OPIOIDS - 3
- 9. REVERSING OPIOID SIDE EFFECTS - 1 Symptomatic
- 10. REVERSING OPIOID SIDE EFFECTS - 2 Systemic
- 11. UNDESIRABLE PHYSIOLOGIC EFFECTS OF OPIOIDS Hyperalgesia NMDA receptor Tolerance NMDA receptor Addiction
- 12. PATIENT PERCEPTION of PAIN after OUTPATIENT SURGERY
- 13. EXCESSIVE PAIN after AMBULATORY SURGERY Chung
- 14. POSTOPERATIVE CHRONIC PAIN STATES - 1 Perkins,
- 15. POSTOPERATIVE CHRONIC PAIN STATES - 2 Perkins,
- 16. PAIN PHYSIOLOGY REVIEW Potential sites of
- 17. PERIPHERAL NERVE ENDINGS Pain receptor (nociceptor) stimulation
- 18. PERIPHERAL NERVE TRANSMISSION Normal A-δ fibers (sharp)
- 19. DORSAL HORN Termination of nociceptor input Lamina
- 20. SPINAL CORD Ascending tracts Supraspinal reflexes –
- 21. OPIOID HYPERALGESIA Vinik. Anesth Analg 1998;86:1307 Rapid
- 22. PREVENT OPIOID HYPERALGESIA Luginbuhl. Anesth Analg 2003;96:726
- 23. Koppert. Anesthesiology 2003;99:152
- 24. WOUND INFILTRATION – BLOCK NERVE ENDINGS
- 25. WOUND INFILTRATION – BLOCK NERVE ENDINGS Bianconi.
- 26. VAS during Passive Mobilization after Spine Surgery Bianconi. Anesth Analg 2004;98:166
- 27. Diclofenac (mg, im) & Tramadol (mg, iv) Rescue after Spine Surgery Bianconi. Anesth Analg 2004;98:166
- 28. Maximum Pain Scores after Elective Shoulder Surgery
- 29. REGIONAL ANALGESIA initiated during surgery DECREASES OPIOID
- 30. LIMIT SPINAL CORD WIND-UP NMDA antagonists Magnesium Ketamine NSAIDS Local anesthetics iv
- 31. Ketamine: Pre-incision vs. Pre-emergence Fu. Anesth
- 32. Ketamine: Pre-incision vs. Pre-emergence Effect on Morphine (mg) Administered Fu. Anesth Analg 1997; 84:1086
- 33. Intraoperative MgSO4 Reduces Fentanyl Requirements During and
- 34. Effect of MgSO4 on Fentanyl Administration (μg/kg/min) Konig. Anesth Analg 1998;87:206
- 35. MgSO4 30 mg/kg + Ketamine 0.15 mg/kg
- 36. Liu. Anesth Analg 2001;92:1173 Super-additive Interactions between Ketamine and Mg2+ at NMDA Receptors
- 37. NMDA ANTAGONISTS - MAGNESIUM O’Flaherty, et al.
- 38. NEUROMUSCULAR BLOCKADE & Mg2+ Fuchs-Buder. Br J
- 39. NMDA ANTAGONISTS - METHADONE Byas-Smith, et al.
- 40. PREOPERATIVE ADMINISTRATION OF ORAL NSAIDS DECREASES POSTOPERATIVE
- 41. Preoperative Rofecoxib Oral Suspension as an Analgesic
- 42. Buvendendran. JAMA 2003;290:2411 Anesthesia for TKR Epidural
- 43. Buvendendran. JAMA 2003;290:2411 Rofecoxib group (vs placebo)
- 44. IV LIDOCAINE - 1 Groudine. Anesth Analg
- 45. IV LIDOCAINE - 2 Groudine. Anesth Analg
- 46. Lidocaine (intraop) + Ketorolac (postop) Groudine. Anesth Analg 1998; 86:235
- 47. IV LIDOCAINE - 3 Koppert. Anesthesiology 2000;93:A855
- 48. Epidural Analgesia after Partial Colectomy Liu. Anesthesiology
- 49. β-ADRENERGIC RECEPTOR ANTAGONISTS REDUCE POSTOPERATIVE OPIOID REQUIREMENTS
- 50. β-BLOCKERS REDUCE MORPHINE ADMINISTRATION Zaugg. Anesthesiology
- 51. Atenolol Reduces Fentanyl (μg/kg/h) Intraop & Morphine (mg) in PACU Zaugg. Anesthesiology 1999; 91:1674
- 52. Esmolol Infusion Intraop Reduces # of Patients
- 53. Esmolol Reduces Anesthetic Requirements, Need for Postop Analgesia, & LOS White. Anesth Analg 2003;97:1633
- 54. DOES MUSIC AFFECT ANESTHESIA OR POSTOPERATIVE ANALGESIA?
- 55. DOES MUSIC AFFECT ANESTHESIA OR POSTOPERATIVE ANALGESIA?
- 56. SUMMARY Considerable research activity addressing Basic -
- 57. WHAT DO I DO DIFFFERENTLY?
- 59. WOUND INFILTRATION VS. SYSTEMIC LOCAL ANESTHETICS EMLA
- 60. α-ADRENERGIC RECEPTOR AGONISTS REDUCE POSTOPERATIVE OPIOID REQUIREMENTS
- 61. Effect of Dexmedetomidine on Total PACU Morphine (mg) Administration Arain. Anesth Analg 2004;98:153
OVERVIEW Problems with opioids Hypothesis: if I improve analgesia with non-opioids, I can give less opioid, reduce opioid side-effects, improve patient satisfaction, and shorten length of stay. Pain physiology review Intraoperative
Слайд 2OVERVIEW
Problems with opioids
Hypothesis: if I improve analgesia with non-opioids, I can
give less opioid, reduce opioid side-effects, improve patient satisfaction, and shorten length of stay.
Pain physiology review
Intraoperative techniques
How can I modify a general anesthetic to reduce post-operative opioid requirements?
Pain physiology review
Intraoperative techniques
How can I modify a general anesthetic to reduce post-operative opioid requirements?
Слайд 3INTRAOPERATIVE TECHNIQUES
Prevent opioid hyperalgesia
Wound infiltration or regional anesthesia
Limit spinal cord wind-up
NMDA
antagonists, NSAIDs, methadone
Administer intravenous lidocaine
Administer β-adrenergic receptor antagonists
Play music
Administer intravenous lidocaine
Administer β-adrenergic receptor antagonists
Play music
Слайд 4PROBLEMS WITH OPIOIDS
Pharmacogenetic
Organ-specific side effects
Physiologic effects
Hyperalgesia, tolerance, addiction
Inadequate pain relief
Adverse physiologic
responses
Postoperative chronic pain states
Postoperative chronic pain states
Слайд 5PHARMACOGENETIC ISSUES WITH OPIOIDS
Cytochrome P450 enzyme CYP2D6
Normal (extensive metabolizers) convert:
Codeine (inactive)
-> morphine (active)
Hydrocodone (inactive) -> hydromorphone
At age 5 yrs. – only 25% of adult level
Poor metabolizers (genetic variants)
7-10% Caucasians, African-Americans
Codeine, hydrocodone (Vicodin) ineffective
Hydrocodone (inactive) -> hydromorphone
At age 5 yrs. – only 25% of adult level
Poor metabolizers (genetic variants)
7-10% Caucasians, African-Americans
Codeine, hydrocodone (Vicodin) ineffective
Слайд 6ORGAN-SPECIFIC SIDE EFFECTS WITH OPIOIDS - 1
GI
Stomach: decreased emptying, nausea, vomiting
Gallbladder:
biliary spasm
Small intestine: minimal effect
Colon: ileus, constipation (Mostafa. Br J Anaesth 2003; 91:815), fecal impaction
Small intestine: minimal effect
Colon: ileus, constipation (Mostafa. Br J Anaesth 2003; 91:815), fecal impaction
Слайд 7ORGAN-SPECIFIC SIDE EFFECTS WITH OPIOIDS - 2
Respiratory
Hypoventilation, decreased ventilatory response to
hypoxia & hypercarbia, respiratory arrest, (cough suppression)
Слайд 8ORGAN-SPECIFIC SIDE EFFECTS WITH OPIOIDS - 3
GU – urinary retention
CNS –
dysphoria, hallucinations, coma
Cardiac - bradycardia
Other
Pruritus, chest wall rigidity, immune suppression
Cardiac - bradycardia
Other
Pruritus, chest wall rigidity, immune suppression
Слайд 9REVERSING OPIOID SIDE EFFECTS - 1
Symptomatic therapy
Nausea, vomiting: 5-HT3 antagonists
Ileus: lidocaine,
Constipation: laxatives
Urinary retention: Foley catheter
Respiratory depression: antagonists, agonist/antagonist, doxapram
Pruritus: antihistamines
Urinary retention: Foley catheter
Respiratory depression: antagonists, agonist/antagonist, doxapram
Pruritus: antihistamines
Слайд 10REVERSING OPIOID SIDE EFFECTS - 2
Systemic antagonists – reverse analgesia
Peripheral antagonists
(in development)
Do not cross BBB
Improved GI, less pruritus
Methylnaltrexone, Alvimopan
Bates et al, Anesth Analg 2004;98:116
Dose reduction - this presentation
Do not cross BBB
Improved GI, less pruritus
Methylnaltrexone, Alvimopan
Bates et al, Anesth Analg 2004;98:116
Dose reduction - this presentation
Слайд 11UNDESIRABLE PHYSIOLOGIC EFFECTS OF OPIOIDS
Hyperalgesia
NMDA receptor
Tolerance
NMDA receptor
Addiction
Слайд 12PATIENT PERCEPTION of PAIN after OUTPATIENT SURGERY
Apfelbaum. A-1
At home after surgery
82%
- moderate to extreme pain
21% - analgesic side effects
21% - analgesic side effects
Слайд 13EXCESSIVE PAIN after AMBULATORY SURGERY
Chung F. Anesth Analg 1999; 89:
1352-9
Excessive pain
9.5%
22% longer stay in recovery
Excessive pain
9.5%
22% longer stay in recovery
Слайд 14POSTOPERATIVE CHRONIC PAIN STATES - 1
Perkins, Kehlet. Chronic pain as an
outcome of surgery. Anesthesiology 2000; 93:1123-33
Amputation: phantom limb pain 30-81%, stump pain 5-57%
Postthoracotomy pain syndrome 22-67%
Chronic pain after groin surgery 11.5% (0-37%)
Amputation: phantom limb pain 30-81%, stump pain 5-57%
Postthoracotomy pain syndrome 22-67%
Chronic pain after groin surgery 11.5% (0-37%)
Слайд 15POSTOPERATIVE CHRONIC PAIN STATES - 2
Perkins, Kehlet. Chronic pain as an
outcome of surgery. Anesthesiology 2000; 93:1123-33
Postmastectomy pain syndrome
Breast/chest pain 11-57%, phantom breast pain 13-24%, arm/shoulder pain 12-51%
Postcholecystectomy syndrome
Open 7-48%, laparoscopic 3-54%
Postmastectomy pain syndrome
Breast/chest pain 11-57%, phantom breast pain 13-24%, arm/shoulder pain 12-51%
Postcholecystectomy syndrome
Open 7-48%, laparoscopic 3-54%
Слайд 16PAIN PHYSIOLOGY REVIEW
Potential sites of intervention
Peripheral nerve ending
Peripheral nerve transmission
Dorsal
horn
Spinal cord
Brain
Spinal cord
Brain
Слайд 17PERIPHERAL NERVE ENDINGS
Pain receptor (nociceptor) stimulation
Incision, traction, cutting, pressure
Nociceptor sensitization
Inflammatory mediators
Primary
hyperalgesia
Area of surgery or injury (umbra)
Secondary hyperalgesia
Area surrounding injury (penumbra)
Area of surgery or injury (umbra)
Secondary hyperalgesia
Area surrounding injury (penumbra)
Слайд 18PERIPHERAL NERVE TRANSMISSION
Normal
A-δ fibers (sharp) + c-fibers (dull)
70-90% of peripheral nerve;
reserve:total = ?%
Peripheral sensitization
A-δ fibers + c-fibers
Normal + reserve traffic
A-α fibers (spasm) + A-β fibers (touch)
New traffic – terminate at different levels of dorsal horn than A-δ fibers & c-fibers
Peripheral sensitization
A-δ fibers + c-fibers
Normal + reserve traffic
A-α fibers (spasm) + A-β fibers (touch)
New traffic – terminate at different levels of dorsal horn than A-δ fibers & c-fibers
Слайд 19DORSAL HORN
Termination of nociceptor input
Lamina I – A-δ fibers
Lamina II (substantia
gelatinosa) – c-fibers
Deeper laminae – A-β fibers
Synapses
Ascending tracts
Descending tracts
Within dorsal horn at entry level
Dorsal horns above and below entry level
Deeper laminae – A-β fibers
Synapses
Ascending tracts
Descending tracts
Within dorsal horn at entry level
Dorsal horns above and below entry level
Слайд 20SPINAL CORD
Ascending tracts
Supraspinal reflexes – surgical stress response
Descending tracts
Opioids, α2-agonists
Spinal cord
“wind-up”
Central sensitization
NMDA receptors (post-synaptic cell membrane)
NR1 & NR2 subunits
c-fos induction -> fos protein production (cell nucleus)
Central sensitization
NMDA receptors (post-synaptic cell membrane)
NR1 & NR2 subunits
c-fos induction -> fos protein production (cell nucleus)
Слайд 21OPIOID HYPERALGESIA
Vinik. Anesth Analg 1998;86:1307
Rapid Development of Tolerance to Analgesia during
Remifentanil Infusion in Humans
Guignard. Anesthesiology 2000;93:409
Acute Opioid Tolerance: Intraoperative Remifentanil Increases Postoperative Pain and Morphine Requirements
Remember the days of “industrial dose” fentanyl for “stress-free” cardiac anesthesia – Did we create hyperalgesia?
Guignard. Anesthesiology 2000;93:409
Acute Opioid Tolerance: Intraoperative Remifentanil Increases Postoperative Pain and Morphine Requirements
Remember the days of “industrial dose” fentanyl for “stress-free” cardiac anesthesia – Did we create hyperalgesia?
Слайд 22PREVENT OPIOID HYPERALGESIA
Luginbuhl. Anesth Analg 2003;96:726
Modulation of Remifentanil-induced Analgesia, Hyperalgesia, and
Tolerance by Small-Dose Ketamine in Humans
Koppert. Anesthesiology 2003;99:152
Differential modulation of Remifentanil-induced Analgesia and Postinfusion Hyperalgesia by S-Ketamine and Clonidine in Humans
Koppert. Anesthesiology 2003;99:152
Differential modulation of Remifentanil-induced Analgesia and Postinfusion Hyperalgesia by S-Ketamine and Clonidine in Humans
Слайд 25WOUND INFILTRATION – BLOCK NERVE ENDINGS
Bianconi. Anesth Analg 2004; 98:166
Pharmacokinetics &
Efficacy of Ropivacaine Continuous Wound Instillation after Spine Fusion Surgery (n = 38)
Morphine group: baseline infusion + ketorolac
Ropivacaine group: wound infiltration 0.5% + continuous infusion 0.2% 5 ml/h via subq multihole 16-gauge catheter
Morphine group: baseline infusion + ketorolac
Ropivacaine group: wound infiltration 0.5% + continuous infusion 0.2% 5 ml/h via subq multihole 16-gauge catheter
Слайд 27Diclofenac (mg, im) & Tramadol (mg, iv) Rescue after Spine Surgery Bianconi.
Anesth Analg 2004;98:166
Слайд 28Maximum Pain Scores after Elective Shoulder Surgery Wurm. ANESTH ANALG 2003;97:1620
Pre- vs Postop Interscalene Block
Слайд 29REGIONAL ANALGESIA initiated during surgery DECREASES OPIOID DEMAND after inpatient surgery
Wang.
A-135
Capdevila. Anesthesiology 1999; 91: 8-15
TKR, epidural vs femoral nerve block vs PCA
Borgeat. Anesthesiology 1999; 92: 102-8
Shoulder, Patient controlled iv vs interscalene
Stevens. Anesthesiology 2000; 93: 115-21
THR, lumbar plexus block
Capdevila. Anesthesiology 1999; 91: 8-15
TKR, epidural vs femoral nerve block vs PCA
Borgeat. Anesthesiology 1999; 92: 102-8
Shoulder, Patient controlled iv vs interscalene
Stevens. Anesthesiology 2000; 93: 115-21
THR, lumbar plexus block
Слайд 31Ketamine: Pre-incision vs. Pre-emergence
Fu. Anesth Analg 1997; 84:1086
Ketamine administration
Pre-incision group
0.5
mg/kg bolus before incision + 10 ug/kg/min infusion until abdominal closure = 164 +/- 88 mg over 141 +/- 75 min
Pre-emergence group
none until abdominal closure, then 0.5 mg/kg bolus = 41 +/- 9 mg
Pre-emergence group
none until abdominal closure, then 0.5 mg/kg bolus = 41 +/- 9 mg
Слайд 32Ketamine: Pre-incision vs. Pre-emergence Effect on Morphine (mg) Administered Fu. Anesth Analg
1997; 84:1086
Слайд 33Intraoperative MgSO4 Reduces Fentanyl Requirements During and After Knee Arthroscopy
Konig. Anesth
Analg 1998; 87:206
MgSO4 administration
Magnesium group
50 mg/kg pre-incision +7 mg/kg/h
No magnesium group
Saline - same volume as in Mg group
MgSO4 administration
Magnesium group
50 mg/kg pre-incision +7 mg/kg/h
No magnesium group
Saline - same volume as in Mg group
Слайд 35MgSO4 30 mg/kg + Ketamine 0.15 mg/kg Gynecologic Surgery Lo. Anesthesiology 1998;
89:A1163
Morphine (mg/kg/1st 2 hrs postop)
Слайд 36Liu. Anesth Analg 2001;92:1173
Super-additive Interactions between
Ketamine and Mg2+ at NMDA
Receptors
Слайд 37NMDA ANTAGONISTS - MAGNESIUM
O’Flaherty, et al. A-1265
Pain after tonsillectomy, 40 patients
3-12 yrs
Monitored fentanyl dose (mcg/kg) in PACU
Mg 0.20 vs 0.91, P=0.009
Ketamine 0.43 vs 0.91, P=0.666
Combination - no synergism
Monitored fentanyl dose (mcg/kg) in PACU
Mg 0.20 vs 0.91, P=0.009
Ketamine 0.43 vs 0.91, P=0.666
Combination - no synergism
Слайд 38NEUROMUSCULAR BLOCKADE & Mg2+
Fuchs-Buder. Br J Anaesth 1995; 74:405
Mg2+ 40 mg/kg
Reduces
vecuronium ED50 25%
Shortens onset time 50%
Increases recovery time 100%
Fawcett. B J Anaesth 2003; 91:435
Mg2+ 2 gms in PACU (for dysrhythmia) 30 min after reversal of cisatracurium produced recurarization and need to reintubate.
Shortens onset time 50%
Increases recovery time 100%
Fawcett. B J Anaesth 2003; 91:435
Mg2+ 2 gms in PACU (for dysrhythmia) 30 min after reversal of cisatracurium produced recurarization and need to reintubate.
Слайд 39NMDA ANTAGONISTS - METHADONE
Byas-Smith, et al. Methadone produces greater reduction than
fentanyl in post-operative morphine requirements, pain intensity for patients undergoing laparotomy. A- 848
Слайд 40PREOPERATIVE ADMINISTRATION OF ORAL NSAIDS DECREASES POSTOPERATIVE ANALGESIC DEMANDS
Sinatra. Anesth Analg
2004; 98:135
Preoperative Rofecoxib Oral Suspension as an Analgesic Adjunct after Lower Abdominal Surgery
Buvendendran. JAMA 2003; 290:2411
Effects of Peroperative Administration of Selective Cyclooxygenase Inhibitor on Pain Management after Knee Replacement
Preoperative Rofecoxib Oral Suspension as an Analgesic Adjunct after Lower Abdominal Surgery
Buvendendran. JAMA 2003; 290:2411
Effects of Peroperative Administration of Selective Cyclooxygenase Inhibitor on Pain Management after Knee Replacement
Слайд 41Preoperative Rofecoxib Oral Suspension as an Analgesic after Lower Abdominal Surgery Sinatra.
Anesth Analg 2004; 98:135
Postoperative Morphine (mg)
Слайд 42Buvendendran. JAMA 2003;290:2411
Anesthesia for TKR
Epidural bupivacaine/fentanyl + propofol
“Traditional analgesia” (VAS
4)
Basal epidural + PCEA bupivacaine/fentanyl x 36-42 h
Hydrocodone 5 mg p.o. q 4-6 h thereafter
Rofecoxib
50 mg 24 h and 6 h preop, daily postop x 5 d
25 mg daily PODs 6-14
Basal epidural + PCEA bupivacaine/fentanyl x 36-42 h
Hydrocodone 5 mg p.o. q 4-6 h thereafter
Rofecoxib
50 mg 24 h and 6 h preop, daily postop x 5 d
25 mg daily PODs 6-14
Слайд 43Buvendendran. JAMA 2003;290:2411
Rofecoxib group (vs placebo)
Less opioid asked for – PCEA
and oral
Fewer opioid side effects
Nausea, vomiting, antiemetic use,
Lower VAS pain scores
Less sleep disturbance postop nights 1-3
Greater range of motion
At discharge and at 1 month
Greater patient satisfaction
Fewer opioid side effects
Nausea, vomiting, antiemetic use,
Lower VAS pain scores
Less sleep disturbance postop nights 1-3
Greater range of motion
At discharge and at 1 month
Greater patient satisfaction
Слайд 44IV LIDOCAINE - 1
Groudine. Anesth Analg 1998; 86:235-9
Radical retropubic prostatectomy, 64-yr-olds
Isoflurane-N2O-opioid
anesthesia
Lidocaine: none vs bolus (1.5 mg/kg) + infusion (3 mg/kg) throughout surgery & PACU
Ketorolac: 15 mg iv q 6 h starting in PACU
Morphine for “breakthrough” pain
Lidocaine: none vs bolus (1.5 mg/kg) + infusion (3 mg/kg) throughout surgery & PACU
Ketorolac: 15 mg iv q 6 h starting in PACU
Morphine for “breakthrough” pain
Слайд 45IV LIDOCAINE - 2
Groudine. Anesth Analg 1998; 86:235-9
Postoperative advantages
Lower VAS pain
scores
Less morphine
Faster return of bowel function
Shorter length of stay
Less morphine
Faster return of bowel function
Shorter length of stay
Слайд 47IV LIDOCAINE - 3
Koppert. Anesthesiology 2000;93:A855
Abdominal surgery
Lidocaine: none vs 1.5 mg/kg/hr
surgery/PACU
Total morphine (P < 0.05)
146 mg (none) vs 103 mg (lidocaine)
Nausea: less in lidocaine group
1st BM: no difference
Total morphine (P < 0.05)
146 mg (none) vs 103 mg (lidocaine)
Nausea: less in lidocaine group
1st BM: no difference
Слайд 48Epidural Analgesia after Partial Colectomy Liu. Anesthesiology 1995; 83:757 What if
[iv-lidocaine ± ketorolac + PCA-morphine] group?
Слайд 49β-ADRENERGIC RECEPTOR ANTAGONISTS REDUCE POSTOPERATIVE OPIOID REQUIREMENTS
Zaugg. Anesthesiology 1999; 91:1674
White. Anesth
Analg 2003; 97:1633
Слайд 50β-BLOCKERS REDUCE MORPHINE ADMINISTRATION
Zaugg. Anesthesiology 1999;91:1674
75-yr-olds, major abdominal surgery
Fentanyl-isoflurane anesthesia
Atenolol
administration (iv)
Group 1: none
Group 2: 10 mg preop + 10 mg PACU if HR > 55 bpm, SBP > 100 mmHg; none intraop
Group 3: 5 mg increments q 5 min for HR > 80 bpm, intraop only
limited fentanyl 2 μg/kg/h, isoflurane 0.4%
Group 1: none
Group 2: 10 mg preop + 10 mg PACU if HR > 55 bpm, SBP > 100 mmHg; none intraop
Group 3: 5 mg increments q 5 min for HR > 80 bpm, intraop only
limited fentanyl 2 μg/kg/h, isoflurane 0.4%
Слайд 51Atenolol Reduces Fentanyl (μg/kg/h) Intraop & Morphine (mg) in PACU Zaugg. Anesthesiology
1999; 91:1674
Слайд 52Esmolol Infusion Intraop Reduces # of Patients Requiring Analgesia White. Anesth
Analg 2003;97:1633
Gyn laparoscopy
Induction: midazolam 2 mg, fentanyl 1.5 μg/kg, propofol 2 mg/kg
Maintenance: desflurane-N2O (67%), vecuronium
Esmolol
None vs 50 mg + 5 μg/kg/min (92 ± 97 mg)
Слайд 53Esmolol Reduces Anesthetic Requirements, Need for Postop Analgesia, & LOS White. Anesth
Analg 2003;97:1633
Слайд 54DOES MUSIC AFFECT ANESTHESIA OR POSTOPERATIVE ANALGESIA?
Fentanyl (HR, BP), isoflurane (BIS
50)
Yes
Hemispheric synchronization, Δ 15 dec
Bariatric surgery, ⅓ less fentanyl intraop
Lewis. Anesth Analg 2004; 98:533-6
Yes
Hemispheric synchronization, Δ 15 dec
Bariatric surgery, ⅓ less fentanyl intraop
Lewis. Anesth Analg 2004; 98:533-6
Слайд 55DOES MUSIC AFFECT ANESTHESIA OR POSTOPERATIVE ANALGESIA?
No (patient-selected CD or Hemi-Sync)
Lumbar
laminectomy (Hemi-Sync)
Lewis. Anesth Analg 2004; 98:533-6
TAH-BSO (catechols, cortisol, ACTH)
Migneault. Anesth Analg 2004; 98:527-32
Lewis. Anesth Analg 2004; 98:533-6
TAH-BSO (catechols, cortisol, ACTH)
Migneault. Anesth Analg 2004; 98:527-32
Слайд 56SUMMARY
Considerable research activity addressing
Basic - new pain mechanisms
Translational - new drugs
based on these mechanisms
Clinical – new applications for newer & older drugs
Keeping up with current literature can change your practice!
Small doses make big differences
Clinical – new applications for newer & older drugs
Keeping up with current literature can change your practice!
Small doses make big differences
Слайд 57WHAT DO I DO DIFFFERENTLY?
If general anesthesia and not
regional or combined regional-general, I use:
Lopressor, labetalol aggressively
Ketamine – 10 mg pre-incision, 5-10 mg q1h
MgSO4 – 2 gm pre-incision, 0.5 gm q1h
Lidocaine – 100 mg load, 2 mg/min/OR
Less inhaled agent (BIS 50-60), less fentanyl, more morphine intraop
[COX-2 preoperatively]
Lopressor, labetalol aggressively
Ketamine – 10 mg pre-incision, 5-10 mg q1h
MgSO4 – 2 gm pre-incision, 0.5 gm q1h
Lidocaine – 100 mg load, 2 mg/min/OR
Less inhaled agent (BIS 50-60), less fentanyl, more morphine intraop
[COX-2 preoperatively]
Слайд 59WOUND INFILTRATION VS. SYSTEMIC LOCAL ANESTHETICS
EMLA CREAM -> DECREASED POSTOPERATIVE PAIN
Fassoulaki,
et al. EMLA reduces acute and chronic pain after breast surgery for cancer. Reg Anesth Pain Med 2000; 25: 350-5
Hollmann & Durieux. Prolonged actions of short-acting drugs: local anesthetics and chronic pain. Reg Anesth Pain Med 2000; 25: 337-9 [editorial]
Hollmann & Durieux. Prolonged actions of short-acting drugs: local anesthetics and chronic pain. Reg Anesth Pain Med 2000; 25: 337-9 [editorial]
Слайд 60α-ADRENERGIC RECEPTOR AGONISTS REDUCE POSTOPERATIVE OPIOID REQUIREMENTS
Locus ceruleus (sedation)
Dorsal horn (analgesia)
Arain.
Anesth Analg 2004; 98:153 – 30 min before end of surgery:
Dexmedetomidine: 1 μg/kg over 10 min + 0.4 μg/kg/h for 4 h OR
Morphine: 0.08 mg/kg
Dexmedetomidine: 1 μg/kg over 10 min + 0.4 μg/kg/h for 4 h OR
Morphine: 0.08 mg/kg
Слайд 61Effect of Dexmedetomidine on Total PACU Morphine (mg) Administration Arain. Anesth Analg
2004;98:153
