How to manage severe postoperative pain? Pr Patricia Lavand homme Anesthesiology Dpt & Acute Pain Service Brussels, Belgium

How to manage severe postoperative pain? Pr Patricia Lavand homme Anesthesiology Dpt & Acute Pain Service Brussels, Belgium

No conflict of interest to declare.

Does severe acute postoperative pain still occur today? Anesthesiology 2013

ACTUAL PICTURE OF POSTOPERATIVE PAIN Preoperative Pain Severe acute postoperative pain CPSP Moderate / severe ~ 35-60% ~ 30% 11.8% / 2.2% Same incidence is reported in ambulatory patients

Percentage of time spent in severe pain A 10% increase in time spent in severe pain at day 1 was associated with a 30% increase of CPSP incidence at 12 months

Pain results from pain amplification and psychological distress

Nociception & Hyperalgesia Omoigui S. Med Hypotheses 2007

J Pain 2011 Pain is a dynamic process

MESSAGE n 1 30% patients with severe postoperative pain (VAS >6/10) during the first 24h Modification of postoperative analgesic treatment in only 12% of the patients Pain 2008

MESSAGE n 2 Orthopaedic surgeries European patients: less pain, less emotional discomfort, less pain interference with activities J Pain Palliat Pharmaco 2013 US patients EU patients Perioperative opioids 98,3% 70,2% RA technique 41% 16%

MESSAGE n 3 «Pain specific» postoperative management Correct diagnosis Adaptation of postoperative treatment

Figure 2. 10 9 No PPSP PPSP NeuP PPSP Mobilization Pain score (NRS 0-10) 8 7 6 5 4 3 2 1 * * * * * * Neuropathic component of acute POP pain? 0 day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 CPSP at 3 months: 58% with 10.7% NeuP (Lavand homme et al, Clin Orthop Relat Res 2013)

NeuP component (DN4 applied in 593 patients) in 5.6% (95%CI 3.6-8.3) patients at day 0 and 12.9% (95%CI 9.7-16.7) at day 2 DN4 positive post-surgery is a significant risk factor for CPSP NeuP (OR 4.22)

Pain 2001 Pain 2014

2013 Successful inflammatory reaction is capital for body homeostasis and for postoperative recovery (excessive or insufficient inflammatory reaction is deleterious) KET acts as a REGULATOR of inflammatory reaction - Modulation of pro-inflammatory cytokines production ( IL-6) - Decrease of hyperalgesia and prevention of OIH

Can J Anesth 2011 23 RCTs included in final analysis Postoperative opioid use associated with improved postoperative pain control (78% studies) Greatest efficacy for thoracic, upper abdominal and major orthopedic surgeries The highest the pain, the better the efficacy of ketamine

Pain 2016 19 RCTs included with KET added to morphine pain by 32% and morphine consumption by 28% at 24 h PONV by 44%, no difference in the risk of respiratory depression and hallucination No dose-responsiveness could be established

PCA ratio Morphine:KET = 1.5 : 5 Use for 96 hours 40% morphine sparing effect ( max 87 mg KET/ 24h) Better rehabilitation scores No more side effects Kollender et al, Eur J Cancer 2008

Clonidine, 2-adrenergic agonist Analgesic effect: spinal > epidural >>> IV Antihyperalgesic effect: spinal = epidural (NO intravenous effect) 21

POSToperative systemic clonidine (IV, PO) Anxiolytic effect (75 100-150 µg, 2 3 x/ day) similar to that of BZD, > placebo will reduce the use of PCA / PCEA will reduce pain scores J Pain 2009 22

Methylprednisolone 125 mg Similar pain relief than ketorolac 30 mg (immediately until > 24h after administration) Higher (and sustained) opioid sparing effect by comparison with ketorolac 30 mg (Romundstad et al, AAS 2004)

Anesthesiology 2014 MESSAGE n 4 Prevention is better than cure Predictive factors of severe postoperative pain to target high risk patients Female gender, younger age, preoperative pain intensity

J Pain 2011 Chronic pain slower rate of postoperative pain resolution Chronic pain patients who use OPIOIDS not only - Have a slower rate of postoperative pain resolution BUT - Have higher postoperative pain scores across the entire postoperative pain resolution trajectory

Opioids amplify pain transmission Acute OIH and acute tolerance are often a challenge Early recognition and treatment of symptoms and behavioral changes that might indicate withdrawal Minimize stress

- groups of patients: who regularly used opioids and successfully weaned ( 50% MED/day) vs patients who did not use opioids vs patients who did not wean from opioids *low MED < 30 mg/d; high MED > 60 mg/d (Kidner et al. JBJS Am 2009)

Conclusion