Pain relief after major oncologic surgery

Ksenija Mahkovic Hergouth Onkološki inštitut

GIT carcinomas Urologic,gynec.carcin.

Surgical procedures for

Retroperitoneal sark.

Sarkomas of thoracic/ abdominal wall with reconstruction Liver metastases Peritonectomies, cyto reductive surgery

Postoperative pain is due to



Surgical wound

(laparatomy – somatic pain; organ resections – visceral, sympatic pain) 

Analgesia during operation

consumption (opioid, LA 

Genetic determination of analgesic requirements

(gene polymorphism for opioid receptors) Havashida M, Pharmacogenomics 2008

Good pain relief after surgery is important part of quick and successfull recovery

It diminishes perioperative stress response to surgery

Pain relief after major oncologic surgery

1.

2.

Continuous/PCEA epidural analgesia – based on long acting local anesthetics Continuous/PCA intravenous analgesia – based on opioids 3.

Continuous drip of local anesthetics by the catheter in the surgical wound ?

All ways effective when proper used and with PCA technick Mann C et all, Anesthesiology 2000

Epidural analgesia – golden standard, insertion of epidural catether (EK) in the Th6–Th12) thoracic region (most of the abdominal wall and organs are inervated from



Physiologic effects of epidural analgesia

Blocade of aferent pain impulses  Blokade of aferent sypmatic impulses from intestine   of pain and  sympatic nerves activity in GIT  ↓ stress and inflammatory response to surgery   of postoperative ileus, shortens time to passing stools  Improves mobilisation after surgery Clemante A,Carli F. Minerva Anesthesiol 2008

Stress response I Hormonal and inflammat.response and recovery after radical cystectomy 1. group.:general anesthesia + piritramid i.v. postoperatively 2. group.: general + toracic epidural anesth. + piritramid i.v. postoperatively 3. group.: general + toracic epidural anesth. + epidur. analgesia postoperatively Results

↑

Cortisol and epinephrin: no difference among groups group 3 ↓ less inflammatory response (↓CRP, ↑albumini) group 3 ↓ less fatigue group 3 ↓ less postoperative pain group 3 ↑ better enteral feeding and passing stools sooner Brodner G et al. Multimodal perioperative management- combining thoracic epidural analgesia, forced mobilisation and oralnutrition-reduces hormonal and metabolic stress after major urologic surgery.AnesthAnalg 2001;92:1594-1600.

Stress response II

 study of 45 patients on hormonal and inflammatory stress responce to major abdominal surgery

1st group: epidural analgesia during surgery 2nd group: i.v. opioid analgesia during surgery Results Epidural group

: lower plasma epinephrine and cortisol higher lymphocyte number and T-helper cells no difference in IL 12 and clinical course Ahlers O et al. Intraoperative thoracic epidural anesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-7.

Advantages of epidural analgesia to systemic analgesia

• • • • • • Better analgesia (still and moving) than with systemic opioids (1,2,3) Less adverse events than with opioids – ↓ (2,3,4) nausea,vomiting, sedation Less paralytic ileus, less respiratory complications (5) But no difference in mortality compared to systemic opioid analgesia (3) Low incidence of motor block with thoracic epidurals compared to lumbal epidurals(2) Importance of the LA dose compared to volume or concentration (6) 1.Nishimori M et al. Cochrane Data Base Rev 2006 2.Flisberg P et al..Acta Anaesthesiol Scand 2003;47:457-65 3.Rudin A et al. J Cardiothorac Vasc Anesth 2005;19:350-7 4.Saeki H et al. Surgery Today 2009.

5..Popping DM et al .Arch Surg 2008 6..Dernedde M et al. Anaesth Intensive Care 2008

34 patients Random group of our patients after abdominal surgery in year 2006 with epidural analgesia 2 ASA  0,7 EK working In 31 patients 2 VAS  1,6 mg of piritramid in 48 h ( rescue.analg.

) 3  4 Dg.: 6 colon carcinoma,7 carcinoma of sygmoid colon, 9 rectum carcinoma, 5 stomac carcinoma, 7 retroperitoneal sarcoma

Postoperative pain relief by epidural analgesia

(we practice) 48h after surgery: continuous epidural infusion of local anesthetic (0,25% levobupivacain) 3–6 ml/h +PCA epidural.boluses 3-5 ml, LO 30 – 60 min. Sometimes combined with low dose opioid epiduraly or in i.v. infusion (< 30%) Metamizol 2,5g/12 h i.v.

Piritramid 3 – 5mg i.v. when VAS>4 3.-5. day: 10 ml boluses of 0,25% levobupivacain /6–8h into EK ±opioids p.os (oksicodon) after 5th day removal of epidural catheter.

from 5th day on: analgesic drugs p.o. (oksicodon, tramadol, NSAID, paracetamol)

Complications with epidural catheters

     Punction of dura (incidence 0,3 – 1,2%) Transitory neropathy (0,01 – 0,02%) Punction of epidural vein (3 – 12%), epidural hemmatoma very rare (1:150 000) Infection: local on insertion site 4%, epidural absscess: 0,05 – 0,1% (perioperative epidural catheters) Migration of the catheter into spinal space (0,18%)

Postoperative pain relief by systemic opioid analgesia

(we practice) Systemic opioid analgesia – when epidural analgesia is containdicated, technically not possible or refused by the patient. P ump needed.

 Piritramid 30-60mg/24 h in continuous i.v. infusion + PCA boluses   Sufentanil 50–100 μg/24h in continuous i.v. infusion + PCA boluses Morphine 30-60mg/24 h in continuous i.v. infusion + PCA boluses s.c./i.v.

I.v.analgesia up to 3 days+metamizol/neodolpasse After 2-3-days analgetic drugs in tablets by mouth (oxicodon, tramadol, paracetamol, NSAID) Monitoring pain (VAS) and side effects

Monitoring of the patient

 Day of surg.: pulse oximetry, blood pressure, VAS. Broader monitoring according to patient’s state.

 Next days: blood pressure /1-2 h, pulse oximetry, VAS. 50 – 100 μg/24 h. Broader monitoring according to patient’s state.

 Patient can be moved to the ward when cont.epidural infusion is stopped and regular epidural boluses given. Time of epidural catheter removal should be planned.

Bolnica 3.dan po op ca recti (LAR,TME) 54 let, ASA 1

94 bolnik Dg: Ca cekuma,eksulceriran. Op: desna hemikolektomija

3. dan po operaciji

Hvala za pozornost!

Vloga sester in tehnikov

    poznati morajo delovanje EK kot tudi kontinuirano i.v. analgezijo Redno morajo spremljati pooperativno bolečino z merjenjem bolečine po VAS Redno meriti bolnikove vitalne znake. Pomembna je tudi tudi odzivnost na bolnikovo bolečino ali neželjene učinke in ukrepanje v okviru možnosti in navodil.

Multimodalno perioperativno okrevanje

  Predoperativno informiranje in priprava bolnika na op

↓

kirurškega stresa (krg. tehnika, anestezija)  Optimalna pooperativna epidural. analgezija z LA (

torakalni EK

)  Hitra mobilizacija  Zgodnje enteralno hranjenje

Pooperativni problemi po operacijah v trebuhu

 Bolečina  Pooperativni ileus    Okužbe kirurške rane & druge okužbe  intraabdomin.pritisk

Motnje v delovanju organov