regional anaesthesia & pain - ucl...regional analgesia • peripheral nerve block – mainly...
TRANSCRIPT
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