Functional Postoperative Recovery Breast Surgery. Eric Hodgson Inkosi Albert Luthuli Hosp & Nelson R Mandela School of Medicine Durban, KZN
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1 Functional Postoperative Recovery Breast Surgery Eric Hodgson Inkosi Albert Luthuli Hosp & Nelson R Mandela School of Medicine Durban, KZN
2 Declaration Advisory boards Abbvie, Fresenius Kabi, Sanofi- Aventis, MSD, Mundipharma Speaker Honoraria Aspen-GSK, Abbvie, Adcock- Ingram, Baxter, Roche, Janssen- Cilag, Mundipharma Accomodation costs paid by Mundipharma No influence on Content
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4 PreoperativeConsultation Human interaction Consults leading to law suits - Duration of consult: 15min vs. 18min - Attitude of HCW: Rushed vs. Concerned Careful choice of words Comfort vs. Pain Scratch vs. Sting Try to choose the most positive Reinforce with body language Establish Physical contact
5 Consultation Positive consultation Explanation in understandable terms Emphasise what CAN be done Self-care Emphasise YOUR Belief
6 Pre-operative assessment Pain History - Pain prior to surgery = worse postop pain At surgical site: At distal site Breast Hernia Intensity & Duration worse Arm pain after axillary dissection - Complementary & Alternative Medicine Acupuncture Mindfulness Problems
7 Pre-operative assessment Pain History - Aromatase inhibitors Highly Effective Disabling arthralgia - Acupuncture Well-accepted 225 patients Equivocal Little harm / Potential Benefit esp. with Clinician Belief
8 Pre-operative assessment Mindfulness - Presence in the moment No rumination on the past Avoid catastrophising about the future Catastrophising: - Can be applied acutely Better for longer Magnification Helplessness Can be measured
9 Pre-operative assessment Problems with CAM - May delay appropriate therapy Esp. in SA - Vulnerable patients Depression Loss of control Need to cope - Signs of harm from CAM Expense Exclusivity
10 Enhanced Recovery After Surgery ERAS - Pioneered by Kehlet in Denmark Colorectal surgery - General Principles Preoperative Counselling Minimise fasting Feed within 4 hours Premedication Prevent PONV Normothermia Postop support - Specific Principle Local anaesthetic blocks - Paravertebral / PECS 1&2 / Wound catheter
11 Enhanced Recovery After Surgery ERAS
![to 2 hours [0600] Feed within 4 hours - Fluids: offer but don t](/docs-images/94/121089739/images/12-2.jpg "compel - Premedication Anxiolytic (Lorazepam / Midazolam) if")
12 Enhanced Recovery After Surgery ERAS - Perioperative feeding Minimise fasting - Solid food up to 6 hours [2200] - Fluids up to 2 hours [0600] Feed within 4 hours - Fluids: offer but don t compel - Premedication Anxiolytic (Lorazepam / Midazolam) if requested
13 Enhanced Recovery After Surgery ERAS - Maintain normothermia Minimise postop cooling Intraoperative warming - Underbody Forced air - Prevent PONV Assess Risk esp. motion sickness Local anaesthetic blocks Anaesthesia (Propofol vs. Volatile) Pharmacologic esp. dexamethasone Opioid minimisation
14 Opioid Minimisation - Opioid analgesia facilitates Fight or Flight: Acute pain inhibition Healing and recovery: Hyperalgesia - Exogenous opioids Vital component of pain relief Unreasonably denied in many countries NOT the only option for managing severe pain May worsen / exacerbate pain / social functioning - Risk of Hyperalgesia Dependence / Addiction Different processing of endogenous / exogenous opioids Synthetic opioids receptors
15 Opioid Addiction - Pain alters Opioid responses Opioid reward/ euphoria Tolerance in pain studies Dependence/ Withdrawal - Discharge pain prescription May not require opioids Opioid prescription 10 days max BEWARE request for repeat prescription
16 - Thoracic epidural Risk vs.benefit - Paravertebral block Single shot Catheter superior Regional Blocks?Contralateral symmetrisation
17 Regional Blocks - Ultrasound is a game-changer - PECS 1 & 2 blocks Single shot Catheter not feasible BUT long-lasting Contralateral symmetrisation Bilateral blocks
18 Failed Blocks - Opioid free anaesthesia still possible - Applied successfully in Pretoria Multimodal using Paracetamol NSAID (Coxib preferred) Ketamine Dexmedetomidine Lignocaine Magnesium Continuous infusion PCA pump Elastomeric infusion pump
19 - CPSP Incidence Surgical Risk Up to 80% Severe in 10% ADL / Work Health Costs - Surgical Technique Open Surgery - Identify & Preserve Nerves - Partial injury worse - Neuropathic pain Incidence / Severity / Duration
20 Life stress - SA Baseline stress - Work stress Life-changing diagnoses Personal cost - Monitor yourself Therapy is a GOOD thing - Look after your colleagues
21 Questions? Presentation & references at:
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