Postoperative Pain Management for Craniotomy Patients 전남대학교의과대학 마취통증의학과학교실 윤명하
Pain: Disease or Dis-ease? Byproduct of some disease Pain is a disease in its own right
Postoperative pain - patient anesthesiologist surgeon 의관심과인식의변화 Postoperative pain in neurosurgical patients - patients (???) anesthesiologist & surgeon 은무시하는경향 It was not until 1996 when De Benedettis et al. undertook a pilot study to assess postoperative pain in neurosurgery.
Innervation of the scalp Pathogenesis of pain after craniotomy the trigeminal n., three principal division & their br. the upper three cervical n. the cervical sympathetic trunk minor br. from the vagus & the hypoglossal some twigs from the facial & glossopharyngeal n. being thought to arise from pericranial m. & soft tissue, but not from the brain tissue itself
Adverse effects of postoperative pain 1) Physiologic responses - pulmonary, CV, GI, urinary dysfunction - impairment of muscle metabolism & function - neuroendocrine & metabolic changes (stress response) : hypertension & tachycardia ICP 의상승, hemorrhage or rebleeding : shunt & hypoxemia cerebral hypoxia 의 risk 증가
: hypothalamic stimulation catecholamine & catabolic hormone 의증가 anabolic hormone 의감소 hyperglycemia, retention of sodium & water 2) Psychologic responses - fear and anxiety - anger, resentment, adversarial relationship with doctors and nurses delirium & acute psychosis
Intensity of postoperative pain 영향인자 site, nature, and duration of surgery type & extent of the incision and other surgical trauma physiologic & psychologic makeup of the patients physiologic, psychologic & pharmacologic preparation presence of complications related to the surgery anesthetic management before, during and after surgery quality of postoperative care preoperative treatment to eliminate painful stimuli prior to surgery
Postoperative Pain in Neurosurgery : A Pilot Study in Brain Surgery De Beneditts, Neurosurgery, 1996. Purpose: to assess the incidence, magnitude, characteristics, and duration of pain after main brain surgery Methods : 37 명의 elective brain surgery 를받는 neurosurgical patient : pain intensity (VAS) 1, 6, 12, 24, 36, 48, and more hours after operation light:1-3, moderate:3-7, severe:7-10
Results 1) incidence, magnitude and evolution of postoperative pain 60% of patients: complained pain : moderate and severe pain - 40.9% and 22.7 % at 12 hours *quality of pain: pulsating & pounding, tensive, stabbing, steady & continuous, heavy, burning
2) surgical route and postoperative pain : surgical route 에따른차이는없었다. 3) anesthetic agent, postop neurological status, complication : no significant influence on incidence & magnitude of postoperative pain 4) topography of postoperative pain : 16 (72.7%) superficial 3 (13.6%) deep 3 (13.6%) both : 15 (68.2%) absolute congruence with the site of operation 4 (18.2%) partial 2 ( 9.1%) partial and/or absolute analogy with previous pain history
Conclusions : postoperative pain after brain surgery is an important,although neglected, clinical problem, that deserves greater attention by surgical teams, to provide better and more appropriate treatment
Pain after craniotomy. A time for reappraisal? N. Quiney, British Journal of Neurosurgery, 1996. Purpose: to investigate the severity of pain and the effectiveness of codeine phosphate as an analgesic Methods : 52 명의 elective craniotomy 를받는 patient : 5-point pain scoring system No pain (1) Mild pain (2) Moderate pain (3) Severe pain (4) Excruciating pain (5)
Results 1. pain scores for a period of at least 2 hr excruciating(5) severe(4) moderate(3) mild(2) no(1) 10(18%) 19(37%) 15(29%) 2(4%) 6(12%) 2. there was no significant relationship between the site of the operation and the severity of the pain 3. no significant difference between the site of the operation and the use of codeine phosphate
Conclusions : contrary to standard assumptions, severe or moderate pain in the first 24 hr after craniotomy is common and is poorly treated with codeine phosphate alone.
Craniotomy Procedures Are Associated with Less Analgesic Requirements than Other Surgical Procedures. Dunbar, Anesthesia & Analgesia, 1999. Purpose: to test the hypothesis that patients undergoing brain surgery have significantly less postoperative pain than patients undergoing other surgical procedures Methods : 1995 년수술환자의 postanesthesia care unit 의 record : 3 group - Group E (open fixation of mandible or maxilla) Group I (clipping of aneurysms or excision of tumors) Group L (lumbar laminectomy)
morphine use and pain reports by patients in PACU with GCS of 14 or 15 (P < 0.001)
Conclusions : most patients report minimal pain after intracranial surgery.
Pain management for neurosurgical patient 1) weak opioid: codeine phosphate (IM or SC) 1995 년영국의 neuroanesthesia 회원을대상으로한조사에서 97% 가 IM codeine 을 neurosurgery 후에 analgesia 를위해사용 50% 이상에서 inadequate analgesia 그럼에도불구하고단지 3% 만다른 opioids 를사용 (respiratory depression 과 sedation 에대한공포때문 ) (Stoneham MD; Post-operative analgesia for craniotomy patients : current attitude among neuroanesthetists, Eur J Anaesthesiol 1995: 12; 571-5.) * 그때부터여러저자들에의해서 craniotomy 후에 acute pain 의치료의재검토가주장되어왔고, pain relief 를위해다른방법들의혼합사용이권장되어왔다.
A double blind comparison of codeine and morphine for postoperative analgesia following intracranial surgery - Stoneham MA, et al. Anesthesia 1995 vol 51 1176-8 Method : morphine 10 mg or codeine 60 mg을무작위로준비 : 환자가 analgesia를요구할때투여 : 약물투여직전과 20, 40, 60, 120분후에다음사항을측정 ; pain score (0 = no pain, 1 = mild pain, 2 = moderatie pain, 3 = severe pain) ; sedation score (6 point Ramsay score) ; heart rate, arterial blood pressure ; PaCO2, PaO2
Results 1. both drug provided pain relief 2. resting pain: morphine had significantly greater analgesic effect than codeine at 120 min after the injection (P=0.01) 3. head raising pain: morphine was significantly better than codeine at 60 min (P=0.01) and 120 min (P=0.005) 4. neither drug caused significant alterations from baseline values of sedation score, respiratory rate, PaCO2, PaO2, pupil reactivity, heart rate and arterial blood pressure.
2) potent opioids - 지금까지많이사용되지않음 : postoperative pain - mild sedation, respiratory depression, PaCO2 & ICP increase neurologic exam ( pupillary sign ) - PCA with morphine, oxycodone : safe and effective (Goldsack C: Anaesthesia 1996: 51; 1029-32. Stoneham MD: Anaesthesia 1997: 52; 604-5. Tanskanen P: Acta Anaesthesiol Scand 1999: 43; 42-5.) - remifentanil : short half - life (9-10 min) short context - sensitive half time (3-4 min) small volume of distribution rapid up and down titration
3) NSAIDs - 주로환자의요구에의해간헐적으로사용 - risk factor of postoperative bleeding ( inhibition of platelet aggregation) : 특히 heavy alcohol intake malignancy outside the CNS administration of anticoagulants prolonged PT or PTT platelet count < 150,000
4) scalp infiltration with local anesthetics : scalp infiltration with 0.25% bupivacaine before skin incision and at skin closure -- decreasing pain in postoperative period ( Bloomfield: Anesth & Analg 1998: 87; 579-82.) 5) scalp nerve block : scalp nerve block after skin closure and before awakening 0.75% ropivacaine vs saline group : moderate to severe pain ( VAS >3 ) - 70% of patients in the saline group 20% of patients in the ropivacaine group (Anh N: Anesth & Analg 2001: 93; 1272-6.)
Post-craniotomy analgesia: current practices in British neurosurgical centers a survey of post-craniotomy analgesic practices - G.C. Roberts EJA 2005; 22: 328-332 : 2003년영국의중환자실의 senior nurse를대상으로설문조사 ( 이전의 study에서 neuroanaesthetists의 poor response 때문에 )
Post-craniotomy analgesia questionnaire
Results : 33 centers 에설문을보내 23 centers 의설문을분석 1. principal analgesic used post-craniotomy ; 78% - codeine phosphate 13% - morphine, 9% - dihydrocodeine 2. route major (codeine): combination of either oral or IM route minor (morphine): IV, SC PCA 3. 52% routinely prescribed analgesia regularly 48% as required. 4. majority of units (82%) used supplementary analgesia for its synergic effect; paracetamol (all of units), diclofenac
5. assessment of pain ; 57% 43% not undertake pain assessment 6. assessment tool: verbal categorical scale (85%), VAS (15%) 7. 92% of units ; pain assessments by ward nurse 8. 13% of units used face recognition pain assessment for dysphasia or aphasia pts. none of the units used verified pain assessment tool for the cognitively impaired.
Conclusions : codeine phosphate continues to be the mainstay of post-craniotomy analgesia, however, it is proposed that patient controlled analgesia with morphine is an efficacious and safe alternative.
Summary & Future Research 뇌수술후통증 : should treat ideal analgesics:? 향후국내 well-designed clinical, epidemiological study: 필요함뇌수술후통증에대한관심과다양한각도에서의접근이필요
감사합니다