Multimodal pain management for opiate-dependent patients

presenting for spinal fusion

Gert-Jan Eerdekens 4e Master Geneeskunde Coassistent Anesthesiologie

Promotor: Dr. V. De Sloovere

Inhoud

•  Huidige therapie •  Waarom alternatieven? •  Welke alternatieven? •  Protocol UZ Leuven

Huidige therapie •  Per-operatief:

–  Inhalatie-anesthesie of TIVA Propofol TCI indien neuromonitoring

–  Ketamine-infuus –  Zo nodig clonidine

•  Bij hoge analgesienood perop

•  Postoperatief: –  Paracetamol 1g IV per 6u –  PCIA cf PAZA-protocol

•  GEEN NSAIDs –  owv fusiechirurgie, op vraag van chirurgen

Waarom alternatieven?

1.  Minder opioïden minder nevenwerkingen

2.  Omzeilen van gewenning en tolerantie bij opioïd-dependente patiënten

3.  Goede analgesie minder ontwikkeling chronische pijn

Welke alternatieven? •  Systemische middelen

–  Intraveneus of lokaal –  Preëmptief –  Multimodaal

•  Intrathecaal

•  Epidurale katheter –  Perop plaatsing door chirurg

•  Vroeger ook gedaan hier •  Verlaten door chirurg owv infectierisico

–  PCEA

  hier: geen epidurale/intrathecale alternatieven •  cf lokale gewoonte

Systemische therapie •  α2-agonisten:

–  Clonidine –  Dexmedetomidine

•  Gabapentinoïden: –  Pregabaline –  Gabapentine

•  Propacetamol •  Ketamine •  NSAIDs:

–  Ketorolac •  Lidocaïne •  Locale wondinfiltratie •  …

Multimodale Therapie

Clonidine •  Geen studies single drug •  "Clonidine- a potent analgesic adjuvant" Tryba et al, Curr Op Anaestheisol 2002

Versterkt effect andere analgetica (LA, ketamine, NSAID, opioïden)

•  "Effect of Clonidine premedication on blood loss in spine surgery"

Taghipour Anvari, Anesthesiology and Pain 2012

Dexmedetomidine •  Hogere specificiteit / affiniteit tov clonidine

•  Dosisreductie = minder NE

•  Enkel indicatie voor sedatie op ITE in België

Dexmedetomidine

•  “Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study”

Hwang et al. BMC Anesthesiol. 2015;15:21–8

Gabapentinoïden

Bewezen analgetisch effect bij andere heelkunde, alsook neuropathische pijnen en andere complexe pijnproblemen

Gabapentine

•  “Analgesic effects of gabapentin after spinal surgery” Turan et al. Anesthesiology. 2004;100(4):935–8

  Pre-op 1200 mg:

Ketamine

•  “Comparison of Small Dose Ketamine and Dexmedetomidine Infusion for Postoperative Analgesia in Spine Surgery - A Prospective Randomized Double-blind Placebo Controlled Study” Garg et al. J Neurosurg Anesthesiol. 2016;28(1):27-31

•  Minder nood aan rescue morfine:

Ketamine •  Voordelen:

–  Pijnstilling –  Verminderde tolerantie opioïden

•  Nadelen: –  Dysforie –  Sedatie –  Hallucinaties –  Salivatie, nausea en diplopie

Respecteer max dagdosis: 2,4mg/kg/24h (APT-boek)

Ketorolac® Pro: •  Goede analgesie

Contra:

•  Vermoeden van non-union

Controversieel!

Ketorolac® •  Bij beperkt post-op gebruik vermoedelijk

onschadelijk

•  Blijft groot punt van discussie tussen orthopedie en anesthesie

Lokale wondinfiltratie

0,5% Ropivacaïne (alle spierlagen) + 0,2% continue infusie (fascia-subcutaan) Significant betere post-op analgesie dan opioïden + Ketorolac®

•  “The Pharmacokinetics and Efficacy of Ropivacaine Continuous Wound Instillation After Spine Fusion Surgery”

Bianconi et al. Pain Med 2004(13):166-72

In rust Bij bewegen

Lokale wondinfiltratie •  Toekomst…

 Langdurige vrijzetting  Bewezen effect bij mammectomie, colectomie, hemorrhoïdectomie en

totale knie artroplastie

Tong YC ai I, Kaye AD avid, Urman RD. Liposomal bupivacaine and clinical outcomes. Best Pract Res Clin Anaesthesiol. Elsevier Ltd; 2014;28(1):15–27

Multimodale therapie Door gebalanceerde analgesie in vorm van protocol met opvolging pijnscores

→ – Minder nood aan opioïden – Betere analgesie

•  Minder ontwikkeling chronische pijn (of FBSS)

Multimodale therapie

  MMD leidt tot:  Minder opioïden  Minder NE

“A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery”

Mathiesen O et al. Eur Spine J 2013;22:2089-96

VOORSTEL PROTOCOL UZ LEUVEN

Protocol UZ Leuven Preoperatief Peroperatief Postoperatief

Pregabaline (Lyrica®) •  1200mg •  1-2h preop

Paracetamol •  15mg/kg, dagdosis 4g

Ketamine

Ropivacaïne 0.5% infiltratie (40ml)

evt Clonidine (Catapressan®) •  75 mcg (+75mcg zn)

PCA: morfine continue en bolus

PCA enkel bolus + transdermale pleister

Afbouwschema

Protocol UZ Leuven •  Mogelijkheden bij aanhoudende pijn postop:

– Ketaminedrip – Clonidine – Pregabaline

Take Home Messages

•  Pijn is wat de patient zegt dat het is en zolang de patient het zegt.

•  Voorkomen is beter dan genezen: start op tijd multimodaal

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