Suvremena učinkovita analgezija podrazumijeva:
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1 STRUČNI I MEDICINSKI ASPEKTI BOLI Prof. dr. sc.višnja Majerić Kogler
2 Akutna bol Akutna bol je normalan, predvidljiv fiziološki odgovor na štetni kemijski, termički ili mehanički stimulus vezan s kirurškim zahvatom, traumom ili akutnom bolešću Akutna bol je bol vezana za novonastalu ozljedu tkiva koja traje manje od mjesec dana, no može trajati i dulje od 6 mjeseci; akutna bol može brzo evoluirati u kroničnu Neuronska ekspresija novih gena osnova neuronske senzitizacije i remodeliranja događa se već unutar 20 minuta nakon ozljede
3 Akutna bol To je početna faza snažne, trajne nocicepcijske kaskade koja u vrlo kratkom vremenskom razdoblju zbog razvoja centralne i periferne senzitizacije može prerasti u kroničnu bol.
4 Suvremena učinkovita analgezija podrazumijeva: Kontinuiranu analgeziju Analgeziju titriranu prema intenzitetu boli Uravnoteženu kombiniranu primjenu lijekova i tehnika Minimalni učinak na mobilizaciju bolesnika Minimalni broj komplikacija
5 Dokazano korisni učinci liječenja akutne boli. Pain 2008;136: ranije otpuštanje bolesnika iz jedinica intenzivnog liječenja kraće ukupno trajanje liječenja manje ozbiljnih komplikacija koje značajno produžuju vrijeme liječenja, učinkovitije korištenje radnog vremena zdravstvenog osoblja učinkovitije i racionalnije korištenje skupe bolničke opreme manje dana fizičke nesposobnosti za rad postignuto veće zadovoljstvo bolesnika smanjena učestalost razvoja kronične boli te znatno smanjeni troškovi liječenja
6 Uzroci loše liječene akutne boli definirani od Specijalne interesne grupe za liječenje akutne boli (SIGAP) IASPa kliničari su nedovoljno educirani o potrebi liječenja akutne boli, te o posljedicama neliječenja više od 50% svih bolnica u Evropi nemaju pisane vodiče ili protokole za zbrinjavanje boli u više od 50% bolnica bol se lijeći samo na zahtjev bolesnika postoji tendencija da se ne uvažava intenzitet bola, koji navodi bolesnik u većini bolnica, procijena intenziteta boli se ne provodi ne postoji opći konsensus struke o optimalnom izboru analgetske medikacije i tehnike za pojedina klinička stanja ne postoji interdisciplinarna suradnja kliničara u liječenju boli te odgovornost za loše liječenje
7 Poslijeoperacijska bol Oko 50% bolesnika iskusi umjerenu do tešku bol nakon kirurškog zahvata Razlozi učestalog slabog liječenja boli: - nedostatak znanja - strah od respiratorne depresije - strah od razvijanja ovisnosti
8 Vjerojatni uzroci neučinkovitoga liječenja akutne boli Nedovoljno poznavanje farmakokinetike i farmakodinamike lijekova multimodalne interakcije individualne potrebe i razlike među bolesnicima preopćeniti režimi propisivanja lijekova
9 Obim problema Popping DM i suradnici u istraživanju učinkovitosti i sigurnosti postoperativnog liječenja boli provedenoj u kliničkim bolnicama u razdoblju od 1998g 2006g navode da 30% do čak 80% bolesnika trpi umjerenu do snažnu poslijeoperacijsku bol. U istraživanju Flechera D i suradnika provedenog u Francuskoj u 76 kirurških centara navode učestalost umjereno jake do jake poslijeoperacijske boli od 40% Br J Anaesth.2008; 101(6): Pain 2008; 137(2):
10 A patient-based national survey on postoperative pain management in France reveals significant achievements and persitent challenges. Fletcher D et al. Pain 2008; 137: Nacionalna studija provedena u 76 kirurških centara 1900 bolesnika uključeno vrednovanje prije i postoperacijske boli, način liječenja, nuspojave podaci 24h nakon operacijskog zahvata U 18,2% bolesnika podaci o boli upisani na listu u JILu U 93,7% bolesnika na kirurškom odjelu podaci upisivani u 4h intervalima, ali je terapija dana u samo 32,7% bolesnika
11 Fiziološki odgovor na ozljedu i stres: - Poremećaj plućne funkcije - Poremećaj kardiovaskularne funkcije - Poremećaj gastrointestinalne funkcije - Poremećaj urinarne funkcije - Poremećaj mišićnog metabolizma i funkcije - Neuroendokrine i metaboličke promjene
12 PATOFIZIOLOGIJA katabolizma lučenje stresnih hormona opterećenje kardiovaskularnog sustava poremećaj plućne funkcije hiperkoagulabilno stanje imunosupresija paralitički ileus PONV
13 Negativni učinci nedostatno liječene akutne boli Posljednjih desetak godina snažna nocicepcijska somatska i visceralna akutna bol smatra se najznačajnijim čimbenikom razvoja endokrinih i neurohumoralnih poremećaja u neposrednom poslijeoperacijskom ili postraumatskom razdoblju te u nizu ostalih kliničkih stanja praćenih snažnom akutnom boli. Kehlet H 2002,2003, 2005 Dahl P 2002
14 Današnji status struke potvrđuje da je neliječena akutna bol tijekom perioperacijskog razdoblja najsnažniji okidač stresnog odgovora koji pokreće vitalno ugrožavajuće kaskade metaboličkog i upalnog odgovora.
15 Brojne su kliničke studije pokazale da produženi i pojačan simpatički, neurohumoralni te imunosni odgovor neliječenog akutnog bola u dnevnoj kliničkoj praksi, dovodi do: odloženog usporenog cijeljenja operacijske rane insuficijencije kirurških anastomoza povećane učestalosti plućnih komplikacija tromboemboličkih incidenata povećane učestalosti razvoja kardiovaskularnih komplikacija posebno koronarnih incidenata 3. Kehlet H. Effects of postoperative pain relief on outcome. 2005; An updated review: Refresher course syllabus. IASP Press. Seatle
16 Značenje liječenja akutne postoperacijske boli Liječenje boli dio multimodalnog koncepta perioperacijske rehabilitacije (liječenje boli, prijeoperacijske instrukcije, minimalizacija stresa, rana mobilizacija, rana enteralna prehrana) Prevencija kronifikacije boli (simpatička distrofija, fantomske boli) Profilaksa tromboembolije (lakša mobilizacija) Profilaksa pneumonije (lakše iskašljavanje) Niži tonus simpatikusa Kehlet H 2005,2007, Brevik H 2008, Visser EJ 2007
17 Neuroanatomy of pain processing Tracey I. Imaging pain. Br J Anaesth 2008; 101: 32-9.
18 Incizijska akutna bol je: Nocicepcijska Inflamatorna Neuropatska Periferna i centralna senzitizacija dovode do Pojave primarne i sekundarne hiperalgezije Kronifikacije boli Zahn Pk et al.mechanisms of pain caused by incision BrennanTJ et al. Mechanisam of incisional pain Pogatzki Zahn EB et al. Postoperative pain. Clinical implications of basic research.2007
19 Principal of Peripheral Sensitisation The afferent C-fibres react to the stimulus by peripherally releasing neuropeptides (Substance P, Calcitonin Gene-Related Peptide Substance P + CGRP + NKA und Neurokinin A) = neurogenic inflammation Release of inflammatory mediators from the damaged tissue. Prostaglandin Bradykinin Histamin H + -Ionen
20 Spinal sensitization process Ca 2+ Ca- Channel ATP CAMP NMDA K- Channel Mg 2+ ATP CAMP K+ C-fos Ca 2+ Store Cell Nucleus
21 Patofiziološke napomene Nove eksperimentalne i kliničke studije sigurno su utvrdile da su snažna nocicepcija i neuronska hipersenzitivnost nakon kirurške incizije uzrokovane i podržavane aferentnim impulsima podraženih preosjetljivih nociceptora tijekom perioperacijskog razdoblja, a ne samo za nastanka ozljede. U liječenju poslijeoperacijske bitni su stoga vrijeme primjene, ali i učinkovitost i trajanje analgetskih i antihiperalgezijskih procedura liječenja
22 The role of an acute pain service Acute pain services /APS/ reduce acute post- operative pain and may therefore reduce CPSP, although this «link» has not been studied directly. An APS may facilitate identification and surveillance of «at risk» patients and optimise the use of preventive analgesia techniques such as epidurals or intravenous ketamine infusions. Rawal N. Pain 2008.
23 Ideally, a «multidisciplinary APS» should provide patient education, addres psycho-social social «risk factors», particularly peri-operative anxiety and facilitate effective physical therapy and «functional rehabilitation» of the surgical site and the patient as a whole during the early post- operative period. By reducing the incidence of CPSP, an APS deliver benefits extending well beyond its «traditional brief» of providing acute post-operative operative analgesia.
24 PREVENTIVNA ANALGEZIJA Preventivna analgezija: sprečava i zaustavlja bolni podražaj na putu prema centralnom nervnom sistemu, umanjuje bolni doživljaj umanjuje ukupnu ekscitabilnost centralnog nervnog sistema sprečava razvoj centralne senzitizacije sprečava pojavu hiperalgezije i alodinije.
25 PREVENTIVNA ANALGEZIJA Učinkovita,trajna analgezija koja kontrolira i prevenira nastanak centralne senzitacije u postoperacijskom razdoblju Primjena učinkovitih lijekova prije incizije može blokirati stresni odgovor na kiruršku ozljedu preemptivna analgezija Multimodalne tehnike Primjena koanalgetike
26 The incidence of chronic pain after surgical procedures Type of surgery Incidence % Knee arthroplasty Brest augmentation Vasectomy 0-37 Radical prostatectomy 35 Gynecological laparotom. 32 Hip arthroplasty 28
27 The incidence of chronic neuropatic pain after surgical procedures Type of surgery Incidence % Amputation > 85 Thoracotomy > 46 Mastectomy > 65 Inguinal hernia repair > 80 Current Opinion in Anaesthesiology Octobre 2011; 24:
28 The incidence of severe chronic neuropatic pain after surgical Trauma 15% Surgery 4-10% procedures 40% kliničkih studija vrednuje dinamičku postoperacijsku bol 37% bolesnika 6 dan nakon operacije trpi snažnu bol uzlazna krivulja Chapman CR et al. JPain2011;12:
29 Rizični čimbenici za KPBS Australian and New Zealand College of Anaesthesists and Faculty of Pain Medicine; 2010 Preoperacijski: Bol umjerena do snažna traje > 1 mjesec Ponavljana kirurgija Psihološka vulnerabilnost Preoperacijska napetost Ženski spol Mlađi bolesnici Genska predispozicija
30 Rizični čimbenici za KPBS Intraoperacijski čimbenici Kirurški pristup rizik oštećenja živca Anesteziološka tehnika
31 Rizični čimbenici za KPBS Poslijeoperacijski čimbenici Bol umjerena do snažna Radiacijska terapija Neurotoksična kemoterapija Depresija Psihološka vulnerabilnost Neurotičnost - nepetost
32 KOANALGEZIJSKI LIJEKOVI Anksiolitici Antikonvulzivi Antidepresivi Ketamin Blokatori NMDA receptora Kapsaicin
33 Procedure- based preventive analgesia techniques Visser E J. Acute Pain 2006.
34 Procedure-based techniques Procedure preventive Preventive analgesia analgesia technique Li mb amputation(plp): Epidural analgesia (I); i.v. ketamine infusion (III); i.v. calcitonin (after the onset of PLP post op) (IV)
35 Thoracotomy: Epidural analgesia (II); i.v. ketamine infusion (II) Laparotomy: Epidural analgesia (II); i.v. ketamine infusion (II)
36 Brest surgery: Venlafaxine (II); topical EMLA cream (II); i.v. ketamine bolus (II); multimodal analgesia with LA nerve blocks+emla+gabapentin (II); i.v. Methylprednisolone bolus (II); i.v. parecoxib bolus (II)
37 Iliac crest bone graft harvest: Morphyne wound infiltration (II); celecoxib (II); ropivacaine wound infusion(ii)
38 Limb surgery CRPS prevention: IVRB with clonidine and lignocaine(ii) (II); axillary brachial plexus block with clonidine and lignocaine (III); stellate ganglion block (III); Vitamin C (III); multimodal analgesia (III); calcitonin(iii)
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