Multimodal pain management for opiate-dependent patients presenting for spinal fusion

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1 Multimodal pain management for opiate-dependent patients presenting for spinal fusion Gert-Jan Eerdekens 4 e Master Geneeskunde Coassistent Anesthesiologie Promotor: Dr. V. De Sloovere

2 Inhoud Huidige therapie Waarom alternatieven? Welke alternatieven? Protocol UZ Leuven

3 Huidige therapie Per-operatief: Inhalatie-anesthesie of TIVA Propofol TCI indien neuromonitoring Ketamine-infuus Zo nodig clonidine Bij hoge analgesienood perop Postoperatief: Paracetamol 1g IV per 6u PCIA cf PAZA-protocol GEEN NSAIDs owv fusiechirurgie, op vraag van chirurgen

4 Waarom alternatieven? 1. Minder opioïden minder nevenwerkingen 2. Omzeilen van gewenning en tolerantie bij opioïddependente patiënten 3. Goede analgesie minder ontwikkeling chronische pijn

5 Welke alternatieven? Systemische middelen Intraveneus of lokaal Preëmptief Multimodaal Intrathecaal Epidurale katheter Perop plaatsing door chirurg Vroeger ook gedaan hier Verlaten door chirurg owv infectierisico PCEA hier: geen epidurale/intrathecale alternatieven cf lokale gewoonte

6 Systemische therapie α2-agonisten: Clonidine Dexmedetomidine Gabapentinoïden: Pregabaline Gabapentine Propacetamol Ketamine NSAIDs: Ketorolac Lidocaïne Locale wondinfiltratie Multimodale Therapie

7 Clonidine Geen studies single drug "Clonidine- a potent analgesic adjuvant" Tryba et al, Curr Op Anaestheisol 2002 Versterkt effect andere analgetica (LA, ketamine, NSAID, opioïden) "Effect of Clonidine premedication on blood loss in spine surgery" Taghipour Anvari, Anesthesiology and Pain 2012

8 Dexmedetomidine Hogere specificiteit / affiniteit tov clonidine Dosisreductie = minder NE Enkel indicatie voor sedatie op ITE in België

9 Dexmedetomidine Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study Hwang et al. BMC Anesthesiol. 2015;15:21 8

10 Gabapentinoïden Bewezen analgetisch effect bij andere heelkunde, alsook neuropathische pijnen en andere complexe pijnproblemen

11 Gabapentine Analgesic effects of gabapentin after spinal surgery Turan et al. Anesthesiology. 2004;100(4):935 8 Pre-op 1200 mg:

12 Ketamine Comparison of Small Dose Ketamine and Dexmedetomidine Infusion for Postoperative Analgesia in Spine Surgery - A Prospective Randomized Double-blind Placebo Controlled Study Garg et al. J Neurosurg Anesthesiol. 2016;28(1):27-31 Minder nood aan rescue morfine:

13 Ketamine Voordelen: Pijnstilling Verminderde tolerantie opioïden Nadelen: Dysforie Sedatie Hallucinaties Salivatie, nausea en diplopie Respecteer max dagdosis: 2,4mg/kg/24h (APT-boek)

14 Ketorolac Pro: Goede analgesie Contra: Vermoeden van non-union Controversieel!

15 Ketorolac Bij beperkt post-op gebruik vermoedelijk onschadelijk Blijft groot punt van discussie tussen orthopedie en anesthesie

16 Lokale wondinfiltratie The Pharmacokinetics and Efficacy of Ropivacaine Continuous Wound Instillation After Spine Fusion Surgery Bianconi et al. Pain Med 2004(13): ,5% Ropivacaïne (alle spierlagen) + 0,2% continue infusie (fascia-subcutaan) Significant betere post-op analgesie dan opioïden + Ketorolac In rust Bij bewegen

17 Lokale wondinfiltratie Toekomst Langdurige vrijzetting Bewezen effect bij mammectomie, colectomie, hemorrhoïdectomie en totale knie artroplastie Tong YC ai I, Kaye AD avid, Urman RD. Liposomal bupivacaine and clinical outcomes. Best Pract Res Clin Anaesthesiol. Elsevier Ltd; 2014;28(1):15 27

18 Multimodale therapie Door gebalanceerde analgesie in vorm van protocol met opvolging pijnscores Minder nood aan opioïden Betere analgesie Minder ontwikkeling chronische pijn (of FBSS)

19 Multimodale therapie A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery Mathiesen O et al. Eur Spine J 2013;22: MMD leidt tot: Minder opioïden Minder NE

20 VOORSTEL PROTOCOL UZ LEUVEN

21 Protocol UZ Leuven Preoperatief Peroperatief Postoperatief Pregabaline (Lyrica ) 1200mg 1-2h preop Paracetamol 15mg/kg, dagdosis 4g Ketamine Ropivacaïne 0.5% infiltratie (40ml) evt Clonidine (Catapressan ) 75 mcg (+75mcg zn) PCA: morfine continue en bolus PCA enkel bolus + transdermale pleister Afbouwschema

22 Protocol UZ Leuven Mogelijkheden bij aanhoudende pijn postop: Ketaminedrip Clonidine Pregabaline

23 Take Home Messages Pijn is wat de patient zegt dat het is en zolang de patient het zegt. Voorkomen is beter dan genezen: start op tijd multimodaal

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