post-op pain control-د.سمير الجبعيتي

post-op pain control
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http://www.4shared.com/get/79983203/51e0fe8c/post_op_pain_control.html

مادة الشيت:

In the 90’s a study was done and they reached to a result that post –op pain control was inadequate for the following reasons:

1-misbeliefs they used to think that analgesics will lead to:
-addiction (morphine…)
-overdose of narcotics which leads to cardiac & respiratory arrest.

2-psychological causes: the patient thinks that post-op pain is normal and part of the operation, also his dignity will prevent him from admitting that he is in pain and he denies it, or the nurse is too busy or shouts at him when he asks for analgesia and he won’t ask for it again.

-there is addiction and over dose but not to the extent they used to think, they thought that taking analgesia for 1 week will lead to addiction but some burn patients take pethidine for 2 months and they don’t become addicted
“Post op analgesia doesn’t lead to addiction”
-to give analgesia without complications and avoid over dose and addiction it should be given in a controlled way

Why should we give adequate analgesia post-op?
1-humain causes; doctors should control pain and stop the suffering of patients.
2-physical causes: inadequate post-op pain control will increase mortality and morbidity
-affect of pain on the bodyincrease sympathetic stimulation:
1) Increase HR, BP, and oxygen demand
Note: if patient has border line coronary circulation and decreased cardiac reserve when there is increased oxygen demand this will lead to ischemia.
2) Decrease GIT motilityparalytic ileus

-if a patient has pain in the chest he will tend not to move it so he can’t take a deep breath which will lead to atelechtasis
Also he can’t cough due to pain so he’s unable to expectorate and secretions will accumulate and this predisposes to pneumonia
-the patient is also unable to move and in bed so he’s at increased risk of having DVT and PE
-pain also increases surgical stress and metabolic demand which predisposes to negative nitrogen balance.

In the last 20 years there have been new discoveries that decreased the need for analgesia, like
1-laparoscopic surgery, before all surgeries were open but now a lot of surgeries are laparoscopic and also endoscopic (surgery for bleeding in the stomach for example) thisdecreased the size of the incision and post-op pain
2-many diseases that used to be treated surgically are now treated by medications .for example peptic ulcer disease used to be treated by vagotomy but no it’s treated by medications.

Analgesia can be given: orally, S.C, I.M, I.V but mostly it’s given:
Oralminor surgery
I.V or I.M major surgery
-I.M the absorption is not predictable so it’s given I.V most of the time

Frequency of analgesia:
-regular (the doctor guarantees that pain is controlled)
-PRN (please repeat when necessary)
e.g:Q4hrs PRN:
this means that the doses are given at least 4 hrs apart and it doesn’t mean it’s given every 4 hrs so if the patient takes it at 8 the nurse checks him at 12 and if he needs analgesia she gives him but she can’t give him at 10 .
disadvantage :the patient doesn’t ask for analgesia for the reasons mentioned previously ,and if he asks for it the nurse gives him after an hour so he will learn not ask for it again
e.g:Q4hrs
This means it’s given every 4 hrs.
Disadvantage: the nurse will give him even if he doesn’t need it like when he’s asleep and not in pain because this is what the order says.

PCApatient controlled analgesia
It’s a pump that gives the patient a baseline dose of analgesia all the time ,if he’s in pain he presses a button that will give him an increased dose, but he doesn’t have absolute control there’s a safety interval that the doctor sets.
It was found that when the patient has control over the analgesia he tends to take lesser amount, even lesser than patients that take analgesia regularly or PRN on contrary to what is thought.


Note: analgesics are not expensive they are cheap so financial causes aren’t the reason for inadequate post-op analgesia.


Here are some notes about pictures that the doctor showed:
*lymphoedema: 1) congenitalmostly in young age
2) Acquired lymphatic obstruction after an operation (mastectomy for example)

*neurofibromatosis plexiform type, we treat it because:
1) It causes significant cosmetic and functional problem
2) It might undergo malignant transformation
If the removal caused a big defect but it’s in an area with redundant tissue we close it but direct closure.

*cut wound: 1) incised (sharp object): if there’s no tissue loss and its less than 6 hrs we close it directly.
2) Lacerated (blunt object, screw driver, human bite) we don’t close it directly it’s considered contaminated. We cut it to make it like an incised wound

-incised wounds of more than 6 hrs duration or more than 24 hrs in the face are considered contaminated.

*crushing injuries are liable to have compartment syndrome due to swelling of the muscles and also gangrene in muscle and skin and damage to nerves , we should remove all the necrotic tissue and open the muscle Plaines so there won’t be an anaerobic infection(gas gangrene) or compartment syndrome.
* if there’s injury to a finger and loss of tissue but the bone is still there the management is flap not graft.

*ulcers in the lower limb: arterialchronic ischemia, atheroscrelosis…
Venouschronic venous insufficiency
Neuropathicperipheral neuropathy, D.M., spina bifida (young patients).

The end.