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FROM PREEMTIVE TO PREVENTIVE ANALGESIA - Muhammad. Ramli Ahmad
The document discusses the evolution and significance of preemptive and preventive analgesia in postoperative pain management, highlighting their role in reducing acute and chronic pain through various pharmacological approaches. It covers the effectiveness of different analgesic strategies and emphasizes the need for comprehensive pain management throughout the perioperative period. Additionally, it reviews clinical studies and outcomes related to the application of these analgesic techniques in surgical settings.
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FROM PREEMTIVE TO PREVENTIVE ANALGESIA - Muhammad. Ramli Ahmad
- 1. CURRICULUM VITAE Name :dr.M. Ramli Ahmad, Sp.An-KAP,KMN Address : Jl. A.P.Pettarani Blok GA 7/9 Job : Dosen FK UNHAS Education : - FK UNHAS - Anestesiologi FK UNAIR Organization : - IDI - Ketua PERDATIN SUL-SEL
- 2. FROM PREEMTIVE TOPREVENTIVE ANALGESIA Muhammad. Ramli Ahmad Department of Anesthesiology Faculty of Medicine Hasanuddin University Makassar
- 3. 0% 20% 40% 60% Severe Pain ModeratePain 31% 47% To breath, cough and move easier INTRODUCTION Surgery with Pain Control Better pathophysiology & pharmacology at the end 1990-s butMost patients still worried about post operative pain Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003
- 4. Introduction Optimal Postoperative PainManagement Progress in medical fields WHO (2005) Pain : 5th vital sign Postoperative Pain Management
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- 6. Preemptive Analgesia Before incisionSurgery Post operative Begin in early of 1920’s by Crile & Lower Incision (Noxious signal) Preemptive Analgesia Note : Pain modulation by CNS takes a place before perception Central nervous system (CNS) protection until post operative period
- 7. Preemptive Analgesia Pre -Incision Surgery Post operative Incision (Noxious Signal) • Prevent acute pain • Prevent chronic pain as a result of untreated acute pain Preemptive Analgesia Combination of Local- Regional blockade & General Anesthesia Pain stimuli : Central Sensitization & “Wind- Up” • Prevent central sensitization • hyperalgesia
- 8. PREEMPTIVE ANALGESIA Preemptive therapy(administration of drugs at pre-incision) was consider : Prevent central sensitization hyperalgesia incidence severity of postoperative pain but Since the end of 1980-s, hundreds study (with various quality) failed to proved effectively of pain management at pra-incision compared to post-incision
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- 10. New insight Kissin I,Preemptive Analgesia at the Crossroad,Anesth Analg 2005,100:754-756
- 11. Preemptive Analgesia Preemptive analgesiaproblem is no more about timing (pre or post), but what is more important issues are: 1. Duration of PreemptiveAnalgesia , must include not only tissue injury phase but also phase of inflammatory process 2. Completeness of nociceptive blockade during both phases above Kissin I, Preemptive Analgesia at the Crossroad,Anesth Analg 2005,100:754-756
- 12. Preventive Analgesia Pre -Incision Surgery Post operative Incision (Noxious signal ) Preventive Analgesia Duration of action from the agent is longer than preemptive target Preventive Analgesia or Duration of action from the agent covering entire perioperative period Broader definition of preemptive Preventive Analgesia
- 13. Preventive Analgesia Pre- IncisionSurgery Post operative Incision (Noxious Signal) Analgesic effect must covers entire perioperative period, whenever the drug was administered MultimodalAnalgesia
- 14. Target of PreventiveAnalgesia Perioperative period Preoperative Intraoperative Postoperative Peripheral & central sensitization
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- 16. Preventive Analgesia Preventive analgesiais prevention Prevent before central sensitization occur Analgesic given prior to the surgery A preventive approach that aims to block transmission of the primary afferent injury barrage before, during, and after surgery
- 17. Targets of apreventive Analgesia Perioperative period Preoperative (days before surgery and just minutes before skin incision) Intraoperative (after incision to those initiated just prior to the end of surgery) Postoperative (after the end of surgery and may extend for days thereafter
- 18. Preemptive to PreventiveAnalgesia Earlier Definition: Preemptive Analgesia has been defined as: 1. Antinociceptive treatment starting before surgery 2. Antinociceptive treatment that prevents central sensitization New Definition: 3. Preventing centra sensitization induced byTISSUE INJURY and INFLAMANTORY INJURY (extending the period beyond the initial postoperative period) Preemptive means “ preventive” but this not simply just “before incison”
- 19. CENTRAL SENSI- TIZATION P A IN Initial Noxious Stimulus Changes in Dorsal Horn (e.g. surgical incision) Preemptive Analgesia PREVENTIVE ANALGESIA AS IMPROVEMENT OF PREEMPTIVE ANALGESIA Preventive AnalgesiaTo CENTRAL SENSI- TIZATION P A I N Another Noxious Stimulus (intraoperative manipulation) Postoperative Inflammation Pain Management Also applied intra- & postoperative Cousins MJ. Physiology and Psychology of acute pain. In Acute Pain Management: Scientific Evidence. Second Edition. Australian and Newzealand Collage of Anesthetists. Australia 2005. 1-17 Moiniche SM, Kehlet H, Dahl JB. A Qualitative and Quantitative Systemic Review of Preemptive Analgesia for Postoperative Pain Relief. Anesthesiology 2002; 96:725-41 Kissin I. Preemptive Analgesia at the Crossroad. Anesth Analg 2005; 100:754-6 Pain Management Before Initial Stimulus
- 20. TARGET POSTOPERATIVEHYPERALGESIA PERIODS : PRE (Pre emptive analgesia, pre emptive anti hyperalgesia) INTRA POSTOPERATIVE (general as well regional anesthesia) DRUG MECHANISMS : PRIMARY SENSITIZATION (PERIPHERY) AINS Local anesthetics SECONDARY SENSITIZATION (CENTRAL) NMDA receptors Kétamine, Dextromorphan … Voltage gated calcium channels (anti hyperalgesic drugs) Gabapentine, gabapentinoids, Nefopam… a2 adrenegic drugs descending inhibiting pathways) Clonidine PHARMALOGICAL CONTROL OF POSTOPERATIVE HYPERALGESIA
- 21. CONTROL OF HYPERALGESIA PrimarySecondary BULBO-SPINAL DESCENDING INHIBITORY CONTROLS MORPHINE a2 ADRENERGICS (Clonidine) N.S.A.I.D s “Inflammatory soup” Histamin Serotonin Bradykinin Prostaglandins ....................... Susbtance (SP) Neuropeptides CGRP Excitatory A.A. ....................…… • NMDA Receptors • Voltage gated calcium channels Péripheral NMDA RECEPTOR Kétamine Dextromorphan Central LOCAL ANAESTHETICS Protein kinases Protooncogen - C Fos - C Jun Second messengerr + + + WIND.UP Axon Reflex 5HT N.E. Synapse PRE POST + VOLTAGEGATED CALCIUM CHANNELS . Nefopam . Gabapentine
- 23. Clinical Applications ofPreemptive Analgesia Pro-Contra Pre - Incision Post - Incision Preemptive Analgesia Post incisional Analgesia • NSAIDs • EpiduralAnalgesics • LocalAnesthetic Infiltration • Opioid • NMDA antagonist RCTSs Review, Moiniche dkk., • Pain intensity • Onset rescue analgesic • Total analgesic requirement
- 24. PREEMPTIVE ANALGESIA Moiniche etal Ong et al Controversial 80 RCT Evaluated preemptive analgesia of NSAID, epidural, wound infiltration, opiate, NMDA antagonist No difference in effectifity between preemptive analgesia and post-incision analgesia 66 RCT Evaluated preemptive analgesia of NSAID, epidural, wound infiltration, opiate, NMDA antagonist Epidural analgesia preemptive: Pain intensity in 24-48 hours post-operative, onset of first rescue analgesia, & total supplement analgesic Local infiltration, NSAID, opiate, & NMDA antagonist preemptive: total supplement analgesic ,onset of first rescue analgesia & failed to improved pain intensity
- 25. CLINICAL APPLICATIONS OFPREEMPTIVE ANALGESIA NON STEROIDANTI INFLAMMATIONS DRUGS (NSAID) Pra-Incision Post-incision duration of analgesia Opiate consumption in 24 hours Incidental pain score Ruben et al No benefict effect Moniche et al Analgesic consumption Onset of First analgesic administration Not improved pain score Ong et al
- 26. CLINICAL APPLICATIONS OFPREEMPTIVE ANALGESIA NMDA RECEPTORANTAGONISTS Pra-Incision Post-incision Positive effect of preemptive analgesic, uncertain dose response McCartney et al Analgesic effect not consistent Analgesic consumption (67%) pain score (58%) Ong et al Activation of NMDA receptor has important role in central sensitization On focus in preventive & preemptive analgesia
- 27. CLINICAL APPLICATIONS OFPREEMPTIVE ANALGESIA LOCAL ANESTHETICS Pra-Incision Post-incision No epidural regiment that improve postoperative pain control, Wound Infiltration, peripheral nerve block, and intraperitoneal infiltration regiment had no benefit effect Moniche et al Wound Infiltration regiments decreased analgesic drugs consumption & extend duration of analgesia, but no effect on pain score Ong et al Epidural regiment : Improve pain intensity Long duration of action Ong et al
- 28. Had more advantagesthan Katz & McCartney Its imporatant to give multimodal analgesic therapy at all perioperative periode CLINICAL APPLICATIONS OF PREVENTIVE ANALGESIA Central Sensitization & Neuroplasticity of Nocisepsy Input Pra-Incision Intraoperative Intraoperative More extent than preemptive analgesia, involved all perioperative pain control regiment
- 29. From Preemptive toPreventive analgesia
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- 31. A QUALITATIVE SYSTEMATICREVIEW OF THE ROLE OF N-METHYL-D- ASPARTATE ANTAGONISTS IN PREVENTIVE ANALGESIA Mc CARTNEY C.J.L., SINHA A., KATZ J. Anesth Anal 2004;98:1385-400 META ANALYSIS USINGA MEDLINE (1966 - 2003) AND EMBASE (1985-2003) SEARCH FORTY ARTICLES MEETINGTHE INCLUSION CRITERIA OUTCOMES : Primary reduction of pain, analgesic cunsumption Secondary : time for first analgesic request, adverse effects PREVENTIVE EFFECTS OF : Dextromorphan (12 articles) = 67 % Ketamine (24 articles) = 58 % Magnesium ( 4 articles) = none
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- 35. Korean J Anesthesia2005:48:S 21-5
- 36. British Journal ofAnaesthesia 100 (2): 256–62 (2008)
- 37. Reg Anesth PainMed 2008;33:44-51.
- 38. Coll. Antropol. 31(2007) 4: 1071–1075 Original scientific paper
- 39. Summary of studiesof preemptive and preventive analgesia according to target agent administered Agents No. of studies Preemptive effects(%) Preventive effects(%) Opposite effects(%) Total No. effects(%)Positive Negative Positive Negative Local anesthetics 65 8(10.7) 16(21.3) 27(36.0) 18(24.0) 6(8.0) 75(100) Opioids 25 7(25.0) 5(17.9) 10(35.7) 3(10.7) 3(10.7) 28(100) NSAIDs 25 3(11.5) 12(46.2) 1(3.8) 8(30.8) 2(7.7) 26(100) NMDA anatgonists 31 5(13.2) 6(15.8) 19(50.0) 7(18.4) 1(2.6) 38(100) Clonidine 2 0(0.0) 0(0.0) 2(100.0) 0(0.0) 0(0.0) 2(100.0) Local anesthetics and opioids 21 4(17.4) 5(21.7) 7(30.4) 6(26.1) 1(4.3) 23(100) Multimodal 6 2(25.0) 0(0.0) 2(25.0) 3(37.5) 1(12.5) 8(100) Total 175 29(14.5) 44(22.0) 68(34.0) 45(22.5) 14(7.0) 200(100)
- 40. • Katz J,Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99.
- 42. • Katz J,Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99. Katz J, Kavanagh BP, Sandler AN et al. Preemptive analgesia. Clinical evidence of neuroplasticity contributing to postoperative pain.Anesthesiology. 1992; 77: 439–46.
- 43. • Katz J,Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99.
- 44. • Katz J,Clarke H. Preventive analgesia and beyond: current status, evidence, and future directions. In: Macintyre PE, Walker SM, Rowbotham DJ, eds. Clinical pain management: acute pain. 2nd ed. London: Hodder & Staughton, 2008: 154- 99.
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Editor's Notes
- #20 Cousins MJ. Physiology and Psychology of acute pain. In Acute Pain Management: Scientific Evidence. Second Edition. Australian and Newzealand Collage of Anesthetists. Australia 2005. 1-17 Moiniche SM, Kehlet H, Dahl JB. A Qualitative and Quantitative Systemic Review of Preemptive Analgesia for Postoperative Pain Relief. Anesthesiology 2002; 96:725-41 Kissin I. Preemptive Analgesia at the Crossroad. Anesth Analg 2005; 100:754-6
- #37 Preventive lebih efektif
- #38 efektif
- #39 Antagonis alpha 2 antagonis
- #47 GA + Infiltrasi .
- #49 Analgesia preventif: Definisi yg lebih luas dari analgesia preemptif Formula analgetik perioperatif yg mampu mengendalikan sensitisasi yang dipicu oleh nyeri Bukan waktu pemberian yg utama, namun durasi dan efektifitas yang lebih penting untuk menurunkan nyeri pasca bedah. Analgesia preventif yg adekuat harus mencakup teknik pendekatan multimodal dan dengan masa tatalaksana yg cukup