Multimodal practices to reduce pain after lap ...

Multimodal practices to reduce pain after lap ...

Multimodal practices to reduce pain after LC : How can we do better? & personal experience Chung-Ang Univ. Yoo Shin Choi Laparoscopic Cholecystectomy (LC) World widely common & simple op. Outpatient setting Laparoscopic Cholecystectomy (LC) World widely common & simple op. Outpatient setting

But, early pain after LC: still problem 3 main Components of Pain after LC Parietal pain Incisional trauma at port site Visceral pain Pneumoperitoneum (local & systemic changes) Postcholecystectomy wound within liver Shoulder tip pain (by diaphragmatic stretching)

Tearing of blood vessels Traumatic traction of the nerves Release of inflammatory mediators Phrenic nerve neuropraxia 3 main Components of Pain after LC Parietal pain Incisional trauma at port site Visceral pain Pneumoperitoneum (local & systemic changes) Postcholecystectomy wound within liver

Shoulder tip pain (by diaphragmatic stretching) Tearing of blood vessels Traumatic traction of the nerves Release of inflammatory mediators Phrenic nerve neuropraxia Anesth Analg. 1995 Aug;81(2):37984 Br J Surg. 2000 Mar;87(3):273-84 Various methods/studies for reducing pain

Medications Prophylactic or perioperative use of NSAIDs/COX-2 inhibitors/dexmedetomidine Other medication (tramadol/gabapentin/pregabalin) Procedures Low pressure pneumoperitoneum Local anesthesia Local wound anesthetic infiltration Instillation of intraperitoneal local anesthetics Multimodal analgesic treatment Medication Dextro-methorphan (IM) & ketorolac (IV)

C- control DM - dextro-methorphan K - ketorolac DM+K - dextro-methorphan +ketorolac Best pain relief: DM+K group Clin J Pain. 2006 Nov;22(9):799-804 Medication COX-2 inhibitor Lower Pain intensity score Better satisfaction in global evaluation Anesth Analg. 2004 Feb;98(2):33642

Medication Dexmedetomidine Dose dependent analgesic effect Indian J Anaesth. 2014 Nov-Dec; 58(6): 726 731 Medication Gabapentin/Tramadol Lower mean VAS score Lower mean fentanyl consumption

Can J Aaesth. 2004 Apr;51(4):35863 Medication Pregabalin Lower mean VAS score Lower pethidine consumption Can J Aaesth. 2004 Apr;51(4):35863 Procedure Low-pressure pneumoperitoneum 13 mmHg CO2

9 mmHg CO2 Lower pain intensity score Decreased shoulder-tip pain Br J Surg. 2000 Sep;87(9):1161-5 Procedure Single incision Lower VAS score Significant lower pain (Post op.

6hrs) Chin Med J. 2015 Dec;128(24):3310-6 Procedure Single incision Lower VAS score ? Significant lower pain (Post op. 6hrs) Chin Med J. 2015 Dec;128(24):3310-6

Procedure Local anesthesia (LA) Procedure Local anesthesia (LA) Type of LA Ropivacaine Lidocaine Levobupivacaine Type of injection Intraperitoneal Peritrocal Intravenous

Various methods Concentration Total contents Total volume Timing & site of instillation Different results Personal experience of LA

2 trial for pain relief after LC Personal experience of LA 2 trial for pain relief after LC prospective, randomized, double-blind controlle d Trial 1 (May 2008 ~ May 2009) Ropivacaine: Peritrocal vs. Intraperitoneal Trial 2

(May 2011 ~ May 2012) Lidocaine: Intraperitoneal vs. intravenous Trial 1 Peritrocal (PT) & Intraperitoneal (IP) inject ion Ropivacaine Minimal side effect Longer duration Considered to offer advantage in postop. pain J Surg Res. 2012 Jun 15;175(2):2518 Peritrocal (PT) for parietal pain

before insertion of the trocar 16 mL (ropivacaine-2 mg/mL) 6 mL for the umbilical port 6 mL for the epigastric port 4 mL for RUQ working port J Surg Res. 2012 Jun 15;175(2):2518 Intraperitoneal (IP) for visceral pain immediately after pneumoperitoneum 100 mL of ropivacaine solution (2 mg/kg) J Surg Res. 2012 Jun 15;175(2):2518 Treatment

Group A (n = 20) Group B (n = 20) Group C (n = 20) Group D (n = 20) Peritrocal

Saline Saline Ropivacaine Ropivacaine Intraperitoneal Saline Ropivacaine Saline

Ropivacaine J Surg Res. 2012 Jun 15;175(2):2518 Treatment Group A (n = 20) Group B (n = 20) Group C (n = 20)

Group D (n = 20) Peritrocal Saline Saline Ropivacaine Ropivacaine Intraperitoneal

Saline Ropivacaine Saline Ropivacaine Assessment of pain after treatment . Total postoperative pain severity (TPPS) by VAS I. Frequency pushed the button (FPB) of PCA

II. Total fentanyl consumption (TFC) of PCA Continuous + Additional J Surg Res. 2012 Jun 15;175(2):2518 Total postoperative pain severity (TPPS) in control group J Surg Res. 2012 Jun 15;175(2):2518 Total postoperative pain severity (TPPS) in control group Parietal P. > shoulder tip P. J Surg Res. 2012 Jun 15;175(2):2518

Total postoperative pain severity (TPPS) in control group Parietal P. > shoulder tip P. Visceral P. > parietal P. J Surg Res. 2012 Jun 15;175(2):2518 Total postoperative pain severity (TPPS) Visceral pain Parietal pain IP & IP+PT< C PT & IP+PT < C

PT Peritrocal injection IP Intraperitoneal injection C Control Shoulder tip pain

IP & IP+PT < C J Surg Res. 2012 Jun 15;175(2):2518 Total fentanyl consumption (TFC) Frequency push the button (FPB) J Surg Res. 2012 Jun 15;175(2):2518 Total fentanyl consumption (TFC)

Frequency push the button (FPB) Highest in C Lowest in IP+PT PT Peritrocal injection IP Intraperitoneal injection C

Control J Surg Res. 2012 Jun 15;175(2):2518 Total fentanyl consumption (TFC) IP PT PT Peritrocal injection IP

Intraperitoneal injection C Control Frequency push the button (FPB)

Total fentanyl consumption (TFC) PT Peritrocal injection IP Intraperitoneal injection C Control

IP PT IP+PT PT Frequency push the button (FPB)

Lidocaine Neural response by Blocking nerve conduction suppressing central sensitizat ion Inhibiting spinal visceromotor neurons Reducing inflammation to postoperative pain J Int Med Res 2014 Apr;42(2):30719 Intraperitoneal (IP) 100 mL of lidocaine solution (3.5 mg/kg)

Intravenous (IV) Bolus 1.5 mg/kg continuous IV of 2 mg/kg/h of lidocain e during operation J Int Med Res 2014 Apr;42(2):30719 Treatment Group C (n = 24) Group IP (n = 22) Group IV (n = 26)

IV Saline Saline lidocaine IP Saline lidocaine Saline

Assessment of pain after treatment Total postoperative pain severity (TPPS) by VAS . Frequency pushed the button (FPB) of PCA I. Total fentanyl consumption (TFC) of PCA Continuous + Additional J Int Med Res 2014 Apr;42(2):30719 Total postoperative pain severity (TPPS) IP < C IV < C

IV Intravenous injection IP Intraperitoneal injection C Control J Int Med Res 2014 Apr;42(2):30719

Total postoperative pain severity (TPPS) IP < IV IP < C IV < C IV Intravenous injection IP Intraperitoneal injection

C Control J Int Med Res 2014 Apr;42(2):30719 Total fentanyl consumption (TFC) Frequency push the button (FPB) IV & IP < C IV

Intravenous injection IP Intraperitoneal injection C Control J Int Med Res 2014 Apr;42(2):30719 Total fentanyl consumption

(TFC) No difference between IV & IP IV Intravenous injection IP Intraperitoneal injection C

Control Frequency push the button (FPB) IP < IV J Int Med Res 2014 Apr;42(2):30719 Summary 3 main components of pain after LC Visceral, parietal, shoulder tip pain How to reduce pain after LC Medications Procedures

Multimodal practices: maybe helpful for soothing pain after

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