Consultant Anaesthetist College Tutor QEHB What is Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Types of Pain ID: 1036089
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1. Acute Pain ManagementShiv ChavanConsultant AnaesthetistCollege TutorQEHB
2. What is Pain?An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
3. Types of PainAcutePain due to clear causeUsually goes away after the healing processUsually moderate to severeChronicPersistent pain even after tissue healingUsually dull, aching painDifficult to manage
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5. Why should we manage acute pain?Pain causes physical and emotional sufferingDelays wound healingLeads to other complicationsCan become chronicMore hospital stay, loss work etc
6. Acute Pain ManagementWHO Analgesic ladderReverse WHO Analgesic ladder
7. Acute Pain ManagementEnteralOralSublingualParenteralIntravenousIntramuscularSubcutaneous
8. Enteral RouteAdvantagesSimpleNo need for IV accessTolerated by mostDisadvantagesSlow onsetBioavailabilityAlmost useless in severe painPt may be NBMSome pt cant swallowIntolerence
9. ParenteralIV route is most effective and popular routeIM and SC can be used but slow to workCan be titrated to the effectQuick onsetBut need IV access, nursing expert and monitoring
10. IntravenousIntermittent bolusPatient Controlled AnalgesiaContinuous Infusion
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12. Patient Controlled AnalgesiaMost popularNeeds bolus to start withSafety features Better patient satisfaction
13. Adjuvants in acute pain managementAnti emeticsHydrationOxygen
14. Non Pharmacological interventionsImmobilisationProper dressingsPsychological interventions
15. Regional AnaesthesiaLocal InfiltrationNerve blocksNeuraxial blocksEpiduralSpinal (opioids)
16. Regional Anaesthesia for Core Surgical Trainees
17. Why do you need to know?Most of your patients would have had RA or will have one…..You might be called to see pt who has had a block/spinalYou might have to do something to give pain relief before surgeryPrescribe infusions/treat complications in emergency
18. What do you need to know?Common blocksSome side effects and complicationsLocal anaesthetic drugs and toxicitySpecific concerns with trauma patients
19. Regional anesthesia - UsesProvide anesthesia for a surgical procedure Provide analgesia post-operatively or during labor and deliveryDiagnosis or therapy for patients with chronic pain syndromes
20. Regional anesthesia - typesTopicalLocal/FieldIntravenous block (“Bier” block)Peripheral (named) nerve, e.g. radial n.Plexus - brachial, lumbarCentral neuraxial - epidural, spinal
21. AdvantagesRegional anaesthesia avoids GA in high risk patientsMay avoid GA in unstarved pts who can’t waitEarly ambulation – day caseUseful for post op analgesia
22. FacilitiesSkilled assistantResus facilitiesMonitoringAsepsisNerve stimulator / paraesthesiaNeedlesB-bevel (non cutting, 45 degree)InsulatedTube syringe-needle (aspirate!)
23. Common Peripheral Nerve BlocksUpper limb:InterscaleneSupraclavicularInfraclavicularAxillaryIndividual nerve blocksWrist blockRing blocks
24. Interscalene Block
25. Interscalene Block
26. Interscalene Block
27. Complication of Interscalene BlockHorner’s syndromePhrenic nerve palsyCervical spinal/epiduralIntra-arterial injectionPneumothoraxNerve damage
28. Supraclavicular block
29. Supraclavicular Block
30. Infraclavicular Block
31. Infraclavicular Block
32. Infraclavicular Block
33. Complications of Supra/Infraclavicular blockPneumothoraxIntravascular injectionsDamage to surrounding structures
34. Axillary Block
35. Axillary Block
36. Elbow BlockNot popular as no advantage over wrist block but much easier using USThree injectionsMedian medial to brachial arteryUlnar in ulnar groove (between olecranon and medial epicondyle)Radial lateral to biceps tendon
37. Forearm blocks
38. Wrist BlockPreferred to elbow for small hand surgeryEasy but not commonly practiced at this centre Hand procedures/post op3 injections
39. Wrist Block – MedianFlexor carpi radialisPalmaris longus2cm proximal to skin crease1cm deep3-5 ml1 ml to skin for palmar cutaneous branch
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42. Wrist Block – UlnarFlexor carpi ulnarisMedial to arteryPalmar or ulnar approachUlnar approach allows cutaneous branch blockade
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45. Wrist Block – RadialField block in area of anatomical snuff box
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47. Wrist Block – MedianFlexor carpi radialisPalmaris longus2cm proximal to skin crease1cm deep3-5 ml1 ml to skin for palmar cutaneous branch
48. Digital Nerve Block4 nervesBlock from dorsal side1-2 ml deep0.5 ml superficialMain complication vascular insufficiency – gangreneNO ADRENALINE
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50. Intravenous Regional Anaesthesia (Bier’s block)Reliable, easy, usually safeUsually done for short proceduresNeed some experience Double tourniquetLocal anaesthetics agents0.5-1% Lignocaine0.5-1% Prilocaine- Rarely some additives
51. Lower limb blocksLumbar PlexusFemoral/ 3 in 1 SciaticAnkle
52. Lumbar PlexusNerve stim/US guidededHip proceduresSingle shot/CatheterLA toxicity
53. FemoralThigh/Knee surgeryNerve stim/US guide3-in-1Pre op #NOF
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55. SciaticTransgluteal approch
56. SciaticKnee/Foot surgerySeveral approchesCurvilinear probe
57. Distal Sciatic Nerve BlockPopliteal Nerve blockFoot/ankle surgery
58. Ankle Block
59. Central Neuraxial BlocksSpinalEpiduralCombined spinal epidural
60. Physiological effectsCVSDrop in SVR leading to drop in BPBradycardiaRespMinimal effectHigh spinal- reduced MVGIIncreased peristalsisRenalIncreased RBF
61. What are local anesthetics?Drugs which produce reversible inhibition of excitation and conduction in peripheral nerve fibres and nerve endings, and thus produce loss of sensation in circumscribed area of the body.
62. ClassificationEstersCocaineProcaineChlorprocaineAmethocaineTetracaineAmidesLignocaineBupivacaineLevobupivacaineRopivacaineMepivacainePrilocaine
63. Mechanism of ActionThey act by blockade of sodium channels so that:1- The threshold for excitation increase2- Impulse conduction slow3- The rate of rise of the action potential declines, and4- The ability to generate an action potential is abolished or canceled
64. AgentpKaLipid SolubilityPotencyProtein binding %OnsetDurationProcaine8.91111SlowShortLidocaine7.7150265FastModPrilocaine7.750255FastModBupivacaine8.11000895ModLongRopivacaine8.1400694ModLong
65. Safe DoseAgentDoseDose( with adrenaline)Lignocaine 3mg/Kg 7mg/kgBupivacaine2mg/Kg 2.5mg/kgPrilocaine 6mg/kg 9mg/kgLevobupivacaine2.5mg/kg3mg/kgRopivacaine3mg/kg4mg/kg
66. Local Anesthetics - ToxicityTissue toxicity - RareCan occur if administered in high enough concentrations (greater than those used clinically)Usually related to preservatives added to solutionSystemic toxicity - RareRelated to blood level of drug secondary to absorption from site of injection.Range from lightheadedness, tinnitus to seizures and CNS/cardiovascular collapse
67. Safety Issues Related to Local AnestheticsDrugDoseSite of administrationCondition of the patient
68. CNS ToxicityTends to occur first (relative to CVS toxicity)See excitatory signs and symptoms firstFollowed by depressant signsCircumoral and tongue numbnessLightheadedness and tinnitusVisual disturbanceMuscle twitchingConvulsionsComaRespiratory arrestCVS depression
69. CVS ToxicityAlteration in the excitatory mechanism slower depolarization decreased HR prolonged PR interval widened QRSArrythmias bradycardia ectopic beats ventricular fibrillationDecreased cardiac output on the basis of HR contractility
70. Treatment of ToxicityIdentify the problem signs and symptoms temporal relationship IV injection 40-60 min post for peak plasma levelsCNS treatment with benzodiazepines
71. Signs and Symptoms of ToxicityRange of signs and symptomsCNS:Lightheadedness, faintPeri oral numbnessConfusion, drowsinessLOC, convulsionsCVS: Bradycardia, hypotensionCardiac arrhythmias, cardiac arrest
72. TreatmentStop injectingCall for helpSecure Airway, 100% oxygenLarge bore accessTreat ConvulsionsClose monitoring of cardiovascular status
73. TreatmentTreat cardiovascular symptomsIf in cardiac arrest, start CPR (ALS algorithm)Intralipid emulsion:1.5ml/kg over 1 minFollowed by 15ml/kg/hrTwo additional bolus doses if refractoryDouble the infusion rateMax dose: 12mg/kg
74. TreatmentContinued ITU careBloods for drug levelPaper work
75. Trauma and RAAcute polytraumaShockCompartment syndrome
76. Compartment syndromePNB and Compartment syndromeDoes it really mask the compartment syndrome?Most case reports from Surgeons say it does, but if you look closely every patient was in severe pain!!!!