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Thibault Riant Post operative pain Uyumluluk Modu

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Thibault Riant Post operative pain Uyumluluk Modu Powered By Docstoc
					thibault.riant@wanadoo.fr




                          Th. Riant
 19th International Pelvic Pain Society annual Scientific Meeting
                           Istanbul 2011
Definition: Chronic pain after
surgery
  ž Pain developed after surgical procedure
  ž Pain is of at least 2 months duration
  ž Others causes for the pain should have
    excluded (continuing malignancy, chronic
    infection..)
  ž Pain is not continuing from a pre existing
    problem (It must be explored )
                               Macrae Davies IASP 1999
    IMPORTANCE of the problem
                                                             Crombie Pain 1998
                                                             AKKAYA Agri 2009
ž   Second cause of chronical pain
ž   Phantom pain:                                                Macrae BrJ Anesth 2001
                                                                 Khelet lancet 2006
    •   Phantom breast pain : 10 to 36% (3 Weeks/ 6 years)
    •   12 % à 6 ans

ž   Herniorraphy
                                          Aasvang Br J Anaesth 2005
    •   2,2 % will not work again

•   Scar Pain                                            Kroner K Clin J pain 1992)
    •   22,7 % at one year, 30,9% at 6 years

ž    Post Mastectomy pain syndrome                           Mac donald. Br J Cancer
    •    40 à 52% à deux ans                                 2005, Smith Pain 1999
Pain or Pains?

ž   Nociceptive, inflammatory pain
    irrelevant (cf definition) but can explain acute post surgical pain
ž   Neuropathic pain
    — Sensory loss
    — Positive phénomena (spontaneous pain, hyperpathia,..)
    — Hypersensitization, neuronal plasticity
Hypersensitization?

ž   Nociceptive pain intense mechanical, chemical,
    or thermal noxious stimuli:

ž   Opioids induced hyperalgesia

ž   individual vulnerability of the patient
                                   Kehlet Lancet 2006




           thalamus

         hypothalamus


Limbic
system
                      Brain stem




                   DRG




                        nerve
SYSTEM:                 DYNAMIC and COMPLEX
                                                                          Surgery
                          patient


                                                    Activation
    Phénotypic
  Transformation                                    autosensitization,
                            Peripheral              fast, reversible, %
 Pain is the desease,                                noxious stimuli
                            Spinal
   less reversible
                            Brain

                               Modulation
                               Hypersensitization
                                   Subacute,
                                 reversible, +/-
                                  autonomous
Variables
ž   Surgical factors
    — Operated zone
    — Surgical techniques and procedures
    — Acute post surgery pain , anesthesia
ž   Patient : Individual vulnerability
    —   The pathology it self (cancer..),
    —   Pre existing pain
    —   Life’s story
    —   ATCD
Surgery’s zone
      Surgical Factors

ž Laparoscopie vs open approach
ž Low (vs high) volume surgical unit
ž Duration of surgery++ (>3h)
ž Nerve damage (Absence of specific dissection)
                           Patient: Risk
                                factors
ž Age and sex
ž Genetic susceptibility
                                       W. A. Macrae
ž Psychosocial factors                 Br J Anaesth 2008
    — PTSD, fear of surgery, anxiety   Khelet
                                       Lancet 2006
ž Acute post surgery pain +++
ž Chemo/radiotherapy
ž Pre operative pain, fibromyalgia, IBS,
  Painful bladder, migraine, use of
  narcotics
ž Anterior surgeries
              Diffuse Noxious Inhibitory
                        Control (DNIC)
ž   For acute post surgery pain
                       Weissman-Fogel I J Pain. 2009

ž   For chronic post surgical pain

                            Yarnitsky D Pain. 2008
                                                 Treatment
                                                Prevention:
To Diversify Is to Satisfy Rowlingson 2006
ž   From preemptive analgesia to the treament of
    hyperalgesia
    — Multimodal treatment
    — before, during and after surgery
    — Less analgesic than antihyperalgesic
ž   From a unique and normative treatment of the
    pathology to a strategy personalized to the patient


                Pogatzki-Zahn EM Curr Opin Anaesthesiol. 2006 / 2009
                Macrae 2008 BJA 2008
                Simonet Pain 2005
           Acute post surgical Pain
                                  I

ž Organisation+++
ž to identify and to understand the pains
ž Drugs:
  ž Narcotics
  ž Paracétamol
    ž NSAIDs
    ž Néfopam
ž    epidural analgesia, local wound
    infiltrations….
                       Antihyperalgésics

ž   Kétamine                           Suzuki Curr Opin Anaesthesiol. 2009

    — Intraoperative
ž   Gabapentinoïdes

                       Ho Pain 2006
                       Tiippana anaesth analg 2007
                                New approach
                                        Simonet 2010
ž Nitrous oxyde
ž Diet without polyamin          Richebé anesth 2007

                                   ;Simonet 2007 …   chez le rat!!
ž   Reasoned use of opiates

ž   Psychologic Préparation
    — Hypnosis
    — Focusing on realistic aims for the surgery?
ž   Time , moment of surgery, day surgery
            Chronic Pain treatment

ž Not Specific
ž To Identify and to authenticate it
ž Focusing the patient on realistic aims
ž Transdisciplinary approach with the surgeon
ž Place of the pain unit
fear                                       Duration
Anxiety
                                                                                            PTSD
                                            « open » surgery
PTSD                                       Nerve lesion
surgeries              Pain
                                                            Operative
                                           Inflammatory
Bad hope
                                           High surgery unit
ATCD

                                                            Period
                                           anesthesia
                                                                                        Functional

                                                       Pre operative period       Acute
                                                                    analgésics          disability


             Psychosocial
               Aspects
                                                            pain
                                                                                  Post
                                                   S
                                                   U
                                                                                  operative
                                                   R
                                                   G
                                                                                  period
                                                   E
                                                                 Psychosocial      Chronic
                  Biologic
                  Aspects                          R               Aspects     From Katz 2009
                                                                                   Post
                                                   Y                                           Surgery
                                                                                               PAIN

                                                                    Fear,
        Age                                                         catastrophism
        Sexe                                                        Anxiety
        genetic                                                     PTSD




                               Preventive multimodal analgesia

                                                                                    ANALGESICS
   ANTIHYPERALGESICS
                                                                                    Local and nerve blocks anesthésia
   Kétamine
                                      « psychologic » preparation                   Opiacé, PCA
   N2O
                                      Soutien social                                clonidine
   Pregabaline, gabapentline
                                      Refocusing
Conclusions

 — To ANTICIPATE pain, to DETECT the risk situations
   ○ In relation with Patients
   ○ In relation with surgery
 — Adapted regimen:
   ○ surgical
   ○ Anaesthesic,
   ○ Preventive
 — to identify and to authenticate pain: before, during and later
 — to Agree to speak about it, to favor a place of listening
                        thibault.riant@wanadoo.fr

A new paradigm??
Holistic and pragmatic

From the treatment (surgical) of the pathology


     …. to an individualised therapeutic
                strategy for the patient


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                   Thank you for your attention
                   Merci de votre attention

				
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posted:11/30/2011
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