University Hospitals Ghent Chronificeren van acute postoperatieve pijn een onderschat probleem? Patrick Wouters Anesthesie & Perioperatieve Geneeskunde Ugent UZ Gent
Terminologie! Chronification! When acute pain does not regress despite healing / disappearance of the initial nociceptive stimulus (European terminology)! Maldynia = Maladaptive pain! In the absence of noxious stimuli Eudynia = nociceptive pain! Does not promote healing and repair (American Academy of Pain Medicine, American Council on Science and Public Health Pain Medicine 2010;11:1635-53) 2
Chronic Postsurgical Pain (CPSP) Persistent (PPSP)! Pain at the site of surgery at least 2(3) months after surgery - when other causes have been excluded -! Is a direct consequence of acute postoperative pain! Reported incidence: 10 50 % of all surgical patients! Severe & debilitating in 0.5-1.5 % of all surgical patients,! Limiting activities, sleep disturbances in 30 %! Incidence in children is 15 % 3 Curr Opin Anesthesiol 2012; 25:584 588
Wetenschappelijke Aandacht voor CPSP 4
Incidentie volgens type chirurgie Incidentie CPSP Ernstig - Invaliderend Amputatie 30-50 % 5-10 % Borstchirurgie 20 30 % 5-10 % Thoracotomie 30 40 % 10 % Inguinale Hernia 10 % 2 4 % Hartchirurgie (CABG) 30 50 % 5-10 % Keizersnede 10 % 4 %! Chronic Pain after anesthesia-related nerve injury : 15 % of claims - Patient Positioning - Locoregional anesthesia - Ulnar nerve 28 %, Brachial plexus 20% Anesthesiology. 1999 Apr;90(4):1062-9 5
Oorzaken aanhoudende postoperatieve pijn ü Inflammatie ü Residueel chirurgisch probleem of complicatie ü Neuropathische pijn Lancet 2006; 367: 1618 25 6
NEUROPATHISCHE PIJN! Pijn in een neuro-anatomisch afgelijnde zone corresponderend met perifeer of centraal innervatiegebied! Vermelding van ziekte of laesie van het zenuwstelsel temporeel gekoppeld aan ontwikkeling van pijn! Partieel of volledig gevoelsverlies in de pijnlijke zone! Al dan niet samen met spontane pijn, dysaesthesie, hypersensitiviteit zoals allodynie, hyperalgesie! Bevestiging van ziekte/laesie door specifieke test: chirurgische wonde, beeldvorming, biopsie, neurofysio 7
PAIN 154 (2013) 95 1028
News Physiol. Sci. 6; 268-73 9
Pathofysiologie van chronificatie 10
Sensitisatie Perifeer Centraal 11
Disinhibitie Science of Pain 2009 : Basbaum, Bushnell eds Bulbospinale afdalende pijnmodulerende banen - noradrenerge - serotonerge - inhibitie + facilitatie 12
Excitabiliteit spontane PM Sprouting 13
Behandeling excit inhib! Gabapentine, pregabalin! Alpha2-delta Voltage Gated Ca ++ channels! Reduces substance P and glutamate! NMDA receptor antagonists (ketamine)! Tricyclic Antidepressants (amitriptyline)! Dual serotonin and NE reuptake inhibitors BUT: * < 50 % effective * side effects! Experimenteel! Minocycline - spinal microglia and DH neurons! BDNF 14
Preventie! Beperk Weefselschade!! Laparoscopie - Thoracoscopie! Zenuwsparende incisie! Pre- emptive Analgesia?! RCT niet overtuigend! Adequate Perioperatieve Pijnstilling! Multimodale Analgesie! LRA: Afferent zenuw block! Alpha2 agonisten Opioid sparing techniques?! Veelbelovend : ketamine, gabapentin 15
Locoregionale Anesthesie Cochrane Database of Systematic Reviews 2012 16
Nieuwe tendensen! Opiate free anesthesia! Rationale : Hoge dosis opiaten wakkeren inflammatie aan (?)! Verminderd gebruik van NSAIDs! Rationale : Interferentie met weefselheling (?)! Cardiovasculaire neveneffecten (?)! Bij chronisch gebruik in hoge doses! Geen evidentie in perioperatieve fase! Pijn geassocieerd met cardiovasculaire schade 17
Roadblocks to progress! Poor Study Design! Heterogeneous populations (no risk stratification)! Inadequate measurements definitions various criteria! Lack of attention to the problem! Preconceptions & Neglect! Complexity! Macrae : It is hard for any doctor to accept that the treatments they offer may cause morbidity, especially if they feel that they may be to blame! Surgeons are less exposed to patients who developed chronic postsurgical pain than physicians in other specialties! Surgeon does not feel responsible 18
Risico predictie - predispositie! - Type of surgery! - Level of Acute Postoperative pain! - Pre-operative pain & pain- response! - Genotype! - Anxiety level! - Catastrophizing score! - Psychological Inflexibility in Pain Score Anesthesiology 2010: 113; 1260 Avoid & Control vs Accept & Commit strategies 19
Anesthesiology 2013; 118:934-44! Severe pain after surgery remains a major problem, occurring in 20 40% of patients!!!! 50,523 patients 105 hospitals - compared pain scores among 179 surgical groups! Pain scores were often high and, generally speaking, were worst in minor procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy! Many relatively small operations are associated with considerable pain, perhaps because these patients are given less analgesia than needed 20
Anesthesiology 2013; 118:934-44 21
Pijn anno 2014: Kansen en Uitdagingen?! Aandacht voor het probleem CPSP! Preventie! Optimaliseren van postoperatieve acute pijn therapie! Continuïteit perioperatief = multidisciplinair dagchirurgie!! Intra-operatieve aanpak! > Locoregionale technieken! Multimodale analgesie! < Opiaat gebaseerd?! Onderzoek! Klin: Risicogroepen (patient/type chirurgie)! Exp: Pathofysiologie è translationeel! Bio-Psycho-Sociale aanpak 22
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