Refining anaesthesia techniques in day surgery
PAIN RELIEF AT HOME
G.E Rudkin
Specialist Anaesthetic Services, Adelaide,SA
Postoperative pain is the most commonly reported complication of ambulatory surgery. Chung has shown that for orthopaedic patients over 10% still have severe pain in the first 24 hours post surgery. The ability to provide adequate pain management after ambulatory surgery has become a major limiting factor in determining the types of procedures that can be performed in this setting. Severe postoperative pain is associated with prolonged length of stay and a higher rate of unanticipated admissions.
Successful pain relief at home will depend upon careful preoperative patient preparation where issues are discussed such as previous experiences and expectations of pain, a pain management plan, emphasising potential side effects of analgesics so as to enable patients to feel confident that their pain be controlled. Regional Anaesthesia (RA) provides excellent and prolonged postoperative analgesia that decreases opioid requirements, improves mobility, facilitates patient participation in physiotherapy and return to normal activities. These characteristics result in a faster recovery and improvements in perioperative outcomes. Patients may suffer intense pain following resolution of a peripheral nerve block although it maximises pain relief in the first 12-24 hours. The combination of analgesic regimes in a multimodal approach with RA as a centrepiece can facilitate improved outcome.
Opioids and nonsteroidal anti-inflammatory drugs (NSAID’S) are important components of a day surgery analgesic regime in treating moderate to severe postoperative pain. Analgesic drug combinations with differing mechanisms of action may provide additive or even synergistic effects in improving pain control and facilitating the recovery process. Pavlin showed that intravenous ketorolac administered at the time of wound closure was associated with less severe pain, diminished fentanyl requirements in recovery, a shorter recovery duration and less likelihood of postoperative nausea and vomiting. Reuben reported that patients had less severe pain if oral cyclooxygenase 2 (COX 2) inhibitor was administered before knee arthroscopy. In a recent survey 33-51% patients reported that instructions about pain control was inadequate or non-existent. McGrath also identified that improvement in analgesic instructions may help in better pain management.
Recent published work on continuous local anaesthetic(LA) infusions demonstrate that. catheters can be placed either perineurally, intra articular or as wound infusions. Perineural catheters are commonly placed for interscalene, infraclavicular, femoral and popliteal blocks. Significant advantages are the sustained postoperative analgesia, opioid sparing, less sleep disturbances and improved rehabilitation. Presently researchers are helping define the balance of basal infusion rates versus patient controlled bolus doses in continuous infusions using ropivacaine 0.2%. This balance is likely to be different for continuous catheters in different locations. Intra-articular infusions particularly subacromial, are becoming popular, particularly with the plethora of elastomeric home infusion pumps currently available. Incisional LA is an attractive technique because of its simplicity, safety and low cost. Møiniche in a systematic review of incisional LA for pain relief after abdominal operations showed that analgesic effects were evident in some (herniotomy) but not all surgical procedures. Savoie found that 48 hours of LA wound perfusion following subacromial decompression led to decreased pain scores for 5 days.
The successful transition of catheters from hospital to the home requires further research, improved teaching, appropriate patient selection with attention to discharge and patient follow up. Awareness of catheter risks such as infection, nerve injury, catheter migration and knotting, intravascular catheter placement and local anaesthetic toxicity is vital. The availability of a 24 hour medical officer to answer pertinent questions regarding catheter infusions is necessary. Ilfield reported that 30% patients with catheters made unscheduled phone calls despite been given adequate written and verbal instructions. Patients have also been noted to have significant anxiety removing their catheter at home.
Time of Presentation
Saturday 13 May 2006 - 1530-1700
