Colin J.L. McCartneyColin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of A...
Objectives (25 mins)Objectives (25 mins)
 Understand incidence of CPSP (5 mins)Understand incidence of CPSP (5 mins)
 Wh...
SummarySummary
 CPSP common and varies by type of surgeryCPSP common and varies by type of surgery
 Preoperative pain an...
Incidence ofIncidence of
Chronic Post-Surgical PainChronic Post-Surgical Pain
 Pain after surgery of primary concern toPa...
A&A 2003
 300 patients300 patients
 2/3 had moderate-severe pain after2/3 had moderate-severe pain after
surgerysurgery
 No chan...
Or does it?
 5130 patients attending chronic pain5130 patients attending chronic pain
clinicsclinics
 Surgery contributed to pain in...
 Prevalence of persistent postsurgical painPrevalence of persistent postsurgical pain
 12982 participants/3111 undergone...
Poulakka PA et al EJA 2010
Differentiating CPSPDifferentiating CPSP
 Systematic review. 281 studies assessedSystematic review. 281 studies assessed
investigating PSPS in 11 surgical typesin...
Risk Factors for CPSP?Risk Factors for CPSP?
 Preoperative: Pain, Repeat surgery,Preoperative: Pain, Repeat surgery,
Psyc...
What can we do about theWhat can we do about the
problem?problem?
 Regional anaesthesia techniquesRegional anaesthesia te...
Regional anesthesia techniquesRegional anesthesia techniques
 23 RCTs in total23 RCTs in total
 Pooled 3 studies for epidural afterPooled 3 studies for epidural after
thoracotomy an...
Andreae MH et al BJA 2013
Perioperative pharmacotherapyPerioperative pharmacotherapy
 KetamineKetamine
 LidocaineLidocaine
 GabapentinoidsGabapen...
KetamineKetamine
2013 Cochrane Collaboration
 No long term benefit for:No long term benefit for:
– GabapentinGabapentin
– PregabalinPregabalin
– NSAIDSNSAIDS
– Cortic...
Modified Surgical TechniquesModified Surgical Techniques
Future PossibilitiesFuture Possibilities
 Impact of psychological factorsImpact of psychological factors
 Pharmacogenomi...
Psychological FactorsPsychological Factors
 Preoperative painPreoperative pain
 Pain catastrophizingPain catastrophizing
 Mental healthMental health
 Pain at oth...
Pain 2013
Predictive Factors Post-Predictive Factors Post-
MastectomyMastectomy
Schreiber et al Pain 2013
Pain GeneticsPain Genetics
PharmacogenomicsPharmacogenomics
Genetics of PainGenetics of Pain
 3 variants (haplotypes) of gene encoding3 variants (haplotypes) of gene encoding
COMT p...
 CPSP is likely 50% influenced by geneticCPSP is likely 50% influenced by genetic
determinantsdeterminants
 Identifying ...
Novel neuroactive agentsNovel neuroactive agents
 Not analgesic per seNot analgesic per se
 Prevent mechanism of transit...
SummarySummary
 CPSP common and varies by type of surgeryCPSP common and varies by type of surgery
 Preoperative pain an...
Good Acute Pain Control MajorGood Acute Pain Control Major
Concern for PatientsConcern for Patients
Apfelbaum et al A&A 20...
Acute pain controlAcute pain control
 Use regional anaesthesia where possibleUse regional anaesthesia where possible
 Us...
Preventing Acute to Chronic Pain after Surgery
Preventing Acute to Chronic Pain after Surgery
Preventing Acute to Chronic Pain after Surgery
Preventing Acute to Chronic Pain after Surgery
Preventing Acute to Chronic Pain after Surgery
Preventing Acute to Chronic Pain after Surgery
Preventing Acute to Chronic Pain after Surgery
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Preventing Acute to Chronic Pain after Surgery

Update on associated factors and possible preventive strategies for chronic pain after surgery. As prevented at AAGBI January 2015.
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Preventing Acute to Chronic Pain after Surgery

  • 1. Colin J.L. McCartneyColin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPC Professor and Chair of AnaesthesiaProfessor and Chair of Anaesthesia University of OttawaUniversity of Ottawa Head of AnaesthesiaHead of Anaesthesia The Ottawa HospitalThe Ottawa Hospital Scientist,Scientist, Ottawa Hospital Research InstituteOttawa Hospital Research Institute Chronic Pain after Surgery:Chronic Pain after Surgery: Does it exist and can weDoes it exist and can we prevent it?prevent it?
  • 2. Objectives (25 mins)Objectives (25 mins)  Understand incidence of CPSP (5 mins)Understand incidence of CPSP (5 mins)  Who are the populations at risk? (5 mins)Who are the populations at risk? (5 mins)  What new approaches exist for preventingWhat new approaches exist for preventing CPSP? (10 mins)CPSP? (10 mins)  What does the future hold? (5 mins)What does the future hold? (5 mins)
  • 3. SummarySummary  CPSP common and varies by type of surgeryCPSP common and varies by type of surgery  Preoperative pain and psychological factorsPreoperative pain and psychological factors major predictorsmajor predictors  Prevention possible with high qualityPrevention possible with high quality perioperative pain relief including LA techniquesperioperative pain relief including LA techniques and NMDA antagonists and surgical approachand NMDA antagonists and surgical approach  Future management possibilities include novelFuture management possibilities include novel therapeutic, psychological andtherapeutic, psychological and pharmacogenomic approachespharmacogenomic approaches
  • 4. Incidence ofIncidence of Chronic Post-Surgical PainChronic Post-Surgical Pain  Pain after surgery of primary concern toPain after surgery of primary concern to patients (Apfelbaum et al 1999)patients (Apfelbaum et al 1999)  Acute postoperative pain remainsAcute postoperative pain remains undertreatedundertreated  Incidence of severe acute pain a problemIncidence of severe acute pain a problem  Severe acute pain associated with CPSPSevere acute pain associated with CPSP  Definition: pain >2 months after surgeryDefinition: pain >2 months after surgery
  • 5. A&A 2003
  • 6.  300 patients300 patients  2/3 had moderate-severe pain after2/3 had moderate-severe pain after surgerysurgery  No change from 10 years earlierNo change from 10 years earlier Gan TJ et al CMRO 2014
  • 7. Or does it?
  • 8.  5130 patients attending chronic pain5130 patients attending chronic pain clinicsclinics  Surgery contributed to pain in 22.5%Surgery contributed to pain in 22.5%  Research needed into: aetiology andResearch needed into: aetiology and procedures contributing to highest risk ofprocedures contributing to highest risk of CPSP.CPSP.  Preventive strategiesPreventive strategies Pain 1998
  • 9.  Prevalence of persistent postsurgical painPrevalence of persistent postsurgical pain  12982 participants/3111 undergone surgery12982 participants/3111 undergone surgery within 3 yearswithin 3 years  Persistent pain in 40.4%. Mod-Severe 18.3%Persistent pain in 40.4%. Mod-Severe 18.3%
  • 10. Poulakka PA et al EJA 2010
  • 11. Differentiating CPSPDifferentiating CPSP
  • 12.  Systematic review. 281 studies assessedSystematic review. 281 studies assessed investigating PSPS in 11 surgical typesinvestigating PSPS in 11 surgical types  Prevalence of NeuP determined using NeuPPrevalence of NeuP determined using NeuP grading systemgrading system  Prevalence of NeuP high after thoracic andPrevalence of NeuP high after thoracic and breast surgery (66/68%). 31% after groin herniabreast surgery (66/68%). 31% after groin hernia repair and 6% after THA and TKArepair and 6% after THA and TKA  Prevalence of PneuP varies by type of surgeryPrevalence of PneuP varies by type of surgery and probability of nerve injuryand probability of nerve injury
  • 13. Risk Factors for CPSP?Risk Factors for CPSP?  Preoperative: Pain, Repeat surgery,Preoperative: Pain, Repeat surgery, Psychological factors, Female gender andPsychological factors, Female gender and younger age, Genetic predispositionyounger age, Genetic predisposition  Intraoperative: Surgical approach andIntraoperative: Surgical approach and risks of nerve injuryrisks of nerve injury  Postoperative: Acute Pain, Radiation Rx,Postoperative: Acute Pain, Radiation Rx, Neurotoxic chemotherapy, Anxiety andNeurotoxic chemotherapy, Anxiety and Depression, NeuroticismDepression, Neuroticism McIntyre et al 2010
  • 14. What can we do about theWhat can we do about the problem?problem?  Regional anaesthesia techniquesRegional anaesthesia techniques  Systemic drug interventionsSystemic drug interventions  Modified surgical techniquesModified surgical techniques  Focus on postoperative pain controlFocus on postoperative pain control
  • 15. Regional anesthesia techniquesRegional anesthesia techniques
  • 16.  23 RCTs in total23 RCTs in total  Pooled 3 studies for epidural afterPooled 3 studies for epidural after thoracotomy and 2 for PVB after breastthoracotomy and 2 for PVB after breast surgerysurgery  Unable to pool data from other studies dueUnable to pool data from other studies due to marked heterogeneityto marked heterogeneity
  • 17. Andreae MH et al BJA 2013
  • 18. Perioperative pharmacotherapyPerioperative pharmacotherapy  KetamineKetamine  LidocaineLidocaine  GabapentinoidsGabapentinoids  NSAIDSNSAIDS
  • 19. KetamineKetamine
  • 20. 2013 Cochrane Collaboration
  • 21.  No long term benefit for:No long term benefit for: – GabapentinGabapentin – PregabalinPregabalin – NSAIDSNSAIDS – CorticosteroidsCorticosteroids – MexilitineMexilitine 2013 Cochrane Collaboration
  • 22. Modified Surgical TechniquesModified Surgical Techniques
  • 23. Future PossibilitiesFuture Possibilities  Impact of psychological factorsImpact of psychological factors  Pharmacogenomics and personalizedPharmacogenomics and personalized medicinemedicine  Novel ‘analgesic’ agentsNovel ‘analgesic’ agents
  • 24. Psychological FactorsPsychological Factors
  • 25.  Preoperative painPreoperative pain  Pain catastrophizingPain catastrophizing  Mental healthMental health  Pain at other sitesPain at other sites
  • 26. Pain 2013
  • 27. Predictive Factors Post-Predictive Factors Post- MastectomyMastectomy Schreiber et al Pain 2013
  • 28. Pain GeneticsPain Genetics
  • 29. PharmacogenomicsPharmacogenomics
  • 30. Genetics of PainGenetics of Pain  3 variants (haplotypes) of gene encoding3 variants (haplotypes) of gene encoding COMT predicting low, moderate and highCOMT predicting low, moderate and high sensitivity to painsensitivity to pain  Encompass 96% of humansEncompass 96% of humans  Low COMT levels predict high painLow COMT levels predict high pain sensitivity and risk of developing TMDsensitivity and risk of developing TMD  Inhibition of COMT in rat model increasesInhibition of COMT in rat model increases pain sensitivitypain sensitivity Diatchenko L et al 2005
  • 31.  CPSP is likely 50% influenced by geneticCPSP is likely 50% influenced by genetic determinantsdeterminants  Identifying genetic basis of CPSP couldIdentifying genetic basis of CPSP could lead to significant improvement inlead to significant improvement in treatmenttreatment  Prediction of CPSP, PharmacogenomicsPrediction of CPSP, Pharmacogenomics  Improved treatmentsImproved treatments CJA: published ahead of print
  • 32. Novel neuroactive agentsNovel neuroactive agents  Not analgesic per seNot analgesic per se  Prevent mechanism of transition to chronicPrevent mechanism of transition to chronic painpain  rhBDNF, neuroprotective agents (e.g.rhBDNF, neuroprotective agents (e.g. acetyl l-carnitine) and anti-oxidantsacetyl l-carnitine) and anti-oxidants  Early promising resultsEarly promising results Bordet T et al Neurotherapeutics 2009
  • 33. SummarySummary  CPSP common and varies by type of surgeryCPSP common and varies by type of surgery  Preoperative pain and psychological factorsPreoperative pain and psychological factors major predictorsmajor predictors  Prevention possible with high qualityPrevention possible with high quality perioperative pain relief including LA techniquesperioperative pain relief including LA techniques and NMDA antagonists and surgical approachand NMDA antagonists and surgical approach  Future management possibilities include novelFuture management possibilities include novel therapeutic, psychological andtherapeutic, psychological and pharmacogenomic approachespharmacogenomic approaches
  • 34. Good Acute Pain Control MajorGood Acute Pain Control Major Concern for PatientsConcern for Patients Apfelbaum et al A&A 2003
  • 35. Acute pain controlAcute pain control  Use regional anaesthesia where possibleUse regional anaesthesia where possible  Use NSAIDS, paracetamol in multimodalUse NSAIDS, paracetamol in multimodal regimenregimen  For higher risk cases use ketamine and/orFor higher risk cases use ketamine and/or lidocaine infusion during surgerylidocaine infusion during surgery  Gabapentin/Pregabalin useful for acuteGabapentin/Pregabalin useful for acute pain control and reduction of opioidpain control and reduction of opioid consumptionconsumption

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