Professional Documents
Culture Documents
OTHER REFERENCES:
ROBERT W. HURLEY
CHRISTOPHER L. WU
JAMIE D. MURPHY
Neurotrophin?
Dimeric growth factors that regulate development and
maintenance of central and peripheral nervous systems
Members of this protein family include
Nerve growth factor (NGF)
Neurotrophin-3 (NT-3)
Brain-derived neurotrophic factor (BDNF)
Neurotrophin-4/5 (NT-4/5)
Encyclopedia of Pain. G.F. Gebhart
, Robert F. Schmidt . Springer; 2nd ed. 2013 edition
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Noxious stimulus :
Is one that is painful and potentially
damaging to normal tissues. Stimuli that are
painful can be thermal, mechanical or
chemical
Nociceptor
Encyclopedia of Pain. G.F. Gebhart , Robert F. Schmidt . Springer; 2nd ed. 2013 edition
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Since the nature and intensity of noxious stimuli will vary for different
tissues, the responsive characteristics of nociceptors will differ from one
tissue to another
1-Effective Stimuli
NOCICEPTORS CLASSIFICATIONS
2-Conduction Velocity
3-Molecular Features
Encyclopedia of Pain.
G.F. Gebhart , Robert F. Schmidt
. Springer; 2nd ed. 2013 edition
4- Tissue of Origin
5-Central Projection
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Sensitization
Peripheral Sensitization
Inflammatory mediators such as prostaglandin
enhance the sensitivity of nociceptors, a process
described as peripheral sensitization
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran
painGroup.
fellowshipCRC
anesthesiologist
Acute pain management , Taylor
& Rezvani
Francis
press 2015
& acupuncturist
CPSP
(miller)
Pain Types
Nociceptive pain
Somatic
Visceral
Pain
Neuropathic
pain
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Nociceptive pain
Most common type of pain seen in the acute clinical setting
Somatic
usually well
Visceral
is often poorly
a wide area
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Neuropathic pain
Hx of Injury of peripheral or central nervous system
Pain confined to the innervation area correlating with
this damage, but poorly localized
Pain is burning, shooting, or stabbing pain
Pain may be spontaneous or paroxysmal, with no clear
triggers
Pain that appears to be responding poorly to opioids
Pain that appears to respond well to antineuropathic
agents
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Neuropathic pain
Phantom phenomenon
Increased sympathetic activity
Allodynia: The sensation of pain in response to a stimulus that does
not normally cause pain (e.g., light touch)
Hyperalgesia: An increased (i.e., exaggerated) response to a stimulus
that is normally painful
Dysesthesias: Unpleasant abnormal sensations
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Acute Effects
Increased levels of
Blood
glucose
Free fatty
acids
Ketone
bodies
Lactate
COAGULATION
Natural Anticoagulants
Procoagulants
Fibrinolysis
Platelet reactivity
Plasma viscosity
Deep venous
thrombosis
Vascular graft
failure
Myocardial ischemia
Sympathetic activation
Myocardial oxygen consumption
Myocardial oxygen supply
Paralytic ileus
Chronic Effects
Chronic postsurgical pain [CPSP] is a largely
unrecognized problem that may occur in 10% to 65% of
postoperative patients (depending on the type of
surgery)
2% to 10% of these patients experiencing severe CPSP
Poorly controlled acute postoperative pain may be an
important predictive factor
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
FACTORS for
PPP
Preoperative
Intraoperative
Postoperative
PREOPERATIVE FACTORS
for PPP
Postoperative pain : science and clinical practice/Smith, Lar IASP Press .2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Postoperative pain : science and clinical practice/Smith, Lar IASP Press .2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Other factors
Pretreatment with opioids ?
Female gender
Acute pain management , Taylor & Francis Group. CRC press 2015
INTRAOPERATIVE FACTORS
Postoperative pain : science and clinical practice/Smith, Lar IASP Press .2015
Chan MT, Wan AC, Gin T, et al. Chronic postsurgical pain after nitrous oxide anesthesia. Pain
2011; 152(11): 251420.
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
POSTOPERATIVE FACTORS
Other factors
Psychological:
Depression
Psychological vulnerability
Neuroticism
Anxiety
Radiotherapy to the area of surgery
Chemotherapy
Acute pain management , Taylor & Francis Group. CRC press 2015
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
CASE
Preventive Analgesia
Preemptive analgesia :
An antinociceptive intervention that starts before surgical
incision and is more effective in relieving acute
postoperative pain than the same treatment starting
after surgery
Regional Anesthesia and Pain Medicine & Volume 36, Number 1, JanuaryFebruary 2011 P 4
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Preventive analgesia:
Is aimed to block the development of sustained pain. This
broader definition includes any regimen given at any
time during the perioperative period that will be able to
control pain-induced sensitization
Regional Anesthesia and Pain Medicine & Volume 36, Number 1, JanuaryFebruary 2011 P 4
Dr Mehran Rezvani pain fellowship anesthesiologist
& acupuncturist
Preventive Analgesia
This definition broadly includes any regimen
given at any time during the perioperative
period that is able to control pain-induced
sensitization
MULTIMODAL APPROACH TO
PERIOPERATIVE RECOVERY
Early mobilization
Early enteral nutrition
Attenuation of the perioperative stress response
Multimodal analgesia
(up to 36 hours
after the procedure) reduces postoperative pain and
improves bowel function after digestive surgery
Todate, a single study has found a preventive effect at 3
months after breast cancer surgery in terms of PPSP
incidence (11.8% versus 47.4%)
Grigoras A, Lee P, Sattar F, Shorten G. Perioperative intravenous lidocaine decreases the
incidence of persistent pain after breast surgery. Clin J Pain 2013; 28(7): 56772.
TREATMENT METHODS
Side Effects
Cardiovascular: hypotension,
bradycardia, or tachycardia
Respiratory status: respiratory rate,
level of sedation
Nausea and vomiting, pruritus, urinary
retention
Neurologic examination
Assessment of motor block or function
and sensory level
Evidence of epidural hematoma
Routine Monitoring
Instructions Provided