Wound Analgesia � The Ignored Modality

Wound Analgesia – The Ignored ModalityJoseph Eldor, MDcsen_international@csen.com : 

Wound Analgesia – The Ignored ModalityJoseph Eldor, MDcsen_international@csen.com

The Wounded ManA wood cut - early trauma-medicine. first appearing inJohannes de Ketham’s Fasciculus Medicinae, 1492. : 

The Wounded ManA wood cut - early trauma-medicine. first appearing inJohannes de Ketham’s Fasciculus Medicinae, 1492.

Portia Wounding Her Thigh1664 : 

Portia Wounding Her Thigh1664

Andrea Lynch shows off her shark bite wound : 

Andrea Lynch shows off her shark bite wound

Advanced Wound Management Market by Product Segment : 

Advanced Wound Management Market by Product Segment

Worldwide Advanced Wound Management Market, by Segment, 2008 & 2017 : 

Worldwide Advanced Wound Management Market, by Segment, 2008 & 2017

Treatment of wound with lance : 

Treatment of wound with lance

Achilles bandaging the wounded Patroclus. From a Greek vase painting. : 

Achilles bandaging the wounded Patroclus. From a Greek vase painting.

Elastic Wound Adhesive Plaster : 

Elastic Wound Adhesive Plaster

Slide 11: 

Effective postoperative analgesia is important from the patient’s perspective and can also improve clinical outcomes. Recent surveys report only modest success in providing suitable analgesia, as 30% to 86% of surgical patients report moderate to severe pain after a surgical procedure.

Slide 12: 

Postoperative pain mostly results from sensitization of afferent fibers at injury sites driving central sensitization. Recently, peripheral processes have gained attention as mechanisms of hyperalgesia, and prostaglandins are among highly sensitizing agents.

Slide 13: 

Beyond the sensitization of damaged tissue, surgical incision also induces central neuronal sensitization and probably the development of residual pain after surgery.

Slide 14: 

The concept of preemptive analgesia to reduce the magnitude and duration of postoperative pain was paved in 1983 by Woolf, who showed evidence for a central component of postinjury pain hypersensitivity in experimental studies.

Slide 15: 

Intermittent or continuous intrapleural bupivacaine infused through the chest tube reliably reduces postoperative pain and 24-hour opioid usage in thoracoscopy patients.

Slide 16: 

The use of large doses of opioid analgesics to treat pain after cardiac surgery can prolong the time to tracheal extubation and interfere with recovery of bowel and bladder function in the postoperative period. White et al. investigated the efficacy of a continuous infusion of bupivacaine 0.25% or 0.5%, at the median sternotomy site, for 48 h after cardiac surgery in reducing the opioid analgesic requirement and improving the recovery process.

Slide 17: 

A continuous infusion of bupivacaine 0.5% at 4 ml/h is effective for decreasing pain and the need for opioid analgesic medication as well as for improving patient satisfaction with their pain management after cardiac surgery. Patients in the bupivacaine-0.5% group were able to ambulate earlier, leading to a reduced length of hospital stay.

Slide 18: 

The use of continuous local anesthetic infusion at the iliac crest may help in alleviating graft-related pain beyond the perioperative phase.

Slide 19: 

Wound infiltration with tramadol may be a good choice for postoperative analgesia in children having inguinal herniotomy.

Slide 20: 

Wound infiltration with levobupivacaine after induction of general anesthesia and before the end of the surgery in children both provide postoperative pain relief following hernia repair, and decrease the stress response to postoperative pain.

Slide 21: 

Topical application of EMLA (5%) provides postoperative analgesia comparable to infiltration with 1% lidocaine after inguinal hernia repair in children.

Slide 22: 

All wounds have the potential to cause pain, and the nature of the pain varies with the type of wound. Many factors may exacerbate wound pain, including infection, trauma at dressing changes and poor technique when applying compression therapy. Failure to assess wound pain or inadequate pain assessment can cause the patient further anguish and extended suffering.

Slide 23: 

Since the introduction of cocaine in 1884, local anesthetics have been used as a mainstay of pain management. However, numerous studies over the past several decades have elucidated the supplemental role of local anesthetics as antimicrobial agents. In addition to their anesthetic properties, medications such as bupivacaine and lidocaine have been shown to exhibit bacteriostatic, bactericidal, fungistatic, and fungicidal properties against a wide spectrum of microorganisms.

Slide 24: 

Limited studies attribute the mechanism of action of antimicrobial activity of local anesthetics to a disruption of microbial cell membrane permeability, leading to leakage of cellular components and subsequent cell lysis. Local anesthetics not only serve as agents for pain control, but possess antimicrobial activity as well. In such a capacity, local anesthetics can be considered as an adjunct to traditional antimicrobial use in the clinical or laboratory setting.

Slide 25: 

The bactericidal activity of 0.5% bupivacaine with preservatives is stronger at body temperature than at room temperature; the bactericidal activity may be due, to a large extent, to bupivacaine rather than to the preservatives; and S. aureus is more resistant to the bactericidal activity of bupivacaine than are S. epidermidis and E. coli.

Slide 26: 

The low concentrations of local anaesthetic usually used in epidural infusions have minimal antibacterial activity. While the clinical implications of this in vitro study are not known, consideration should be given to increasing the concentration of bupivacaine in an epidural infusion or to administering a daily bolus of 0.25% bupivacaine to reduce the risk of epidural bacterial growth.

Slide 27: 

Bupivacaine at a concentration of 2.5 mg/ml inhibited the growth of the sensitive S. epidermidis strain, S. pyogenes, and S. pneumoniae, and all of the others except P. aeruginosa at a concentration of 5 mg/ml. Morphine 0.2 and 2 mg/ml (0.02 and 0.2%) did not inhibit any of the strains.

Slide 28: 

There is no increase in the risk of postoperative infection with the use of continuous local-anesthetic infusion pain pumps used after aesthetic and reconstructive abdominal procedures.

Slide 29: 

Pain has a protective function in nature, warning of damage, and promoting careful treatment of the affected area. However, trauma pain can be destructive too: by heightening the cellular stress response, the autonomic, somatic and endocrine reflexes are diminished, resulting in protein breakdown, platelet aggregation, nausea, ileus and a suppressed immune system.

Slide 30: 

Postoperative pain is effectively relieved by continuous infusion of local anesthetic into the surgical wound after abdominal hysterectomy. This technique provides good analgesia with less morphine consumption and scarce adverse effects. Patient satisfaction and the sense of receiving quality pain management are high.

Slide 31: 

In patients undergoing laparoscopic cholecystectomy, the intraperitoneal administration of morphine plus bupivacaine 0.25% reduced the analgesic requirements during the first 6 postoperative hours compared with the control group. However, the combination of intraperitoneal bupivacaine 0.25% and i.v. morphine was more effective for treatment of pain after laparoscopic cholecystectomy.

Slide 32: 

Continuous extrapleural infusion of bupivacaine over five days after thoracotomy is associated with a steady increase in total serum bupivacaine concentration and no elevation in free serum bupivacaine concentration.

Slide 33: 

An understanding of the implications of unrelieved pain is not new, and Nimmo and Duthie in 1987 highlighted the four major adverse effects of severe pain following surgery:

Slide 34: 

1. Decreased respiratory movement especially after upper laparotomy or thoractomy. A decreased functional lung capacity, difficulty in breathing deeply and in coughing all contribute to hypoxia after operation.

Slide 35: 

2. Decreased mobility because of pain on movement. Early mobilisation is more difficult and the risk of deep venous thrombosis is increased.

Slide 36: 

3. Increased sympathetic activity leads to a release of catecholamines which has adverse effects such as hypertension followed by myocardial ischaemia and decreased blood flow to some tissues.

Slide 37: 

4. Hormonal and metabolic activity resulting from surgery and made worse by pain increases protein breakdown and mobilisation of free fatty acids.

Slide 38: 

Preoperative subcutaneous infiltration of bupivacaine significantly reduced the postoperative consumption of intravenous morphine.

Slide 40: 

References: 1. Joseph Eldor. POSTOPERATIVE WOUND ANALGESIA: A RENEWED MODALITY? http://www.nysora.com/jnysora/jnysora_volume_13/3173-postoperative_wound_analgesia_eldor.html 2. Joseph Eldor. The Antibacterial and Antifungal Effects of Bupivacaine Wound Analgesia http://www.nysora.com/jnysora/jnysora_volume_14/3198-The-Antibacterial-and-Antifungal-Effects-Bupivacaine-Wound-Analgesia.html 3. Joseph Eldor. Wound Analgesia in Trauma Patients. http://www.csen.com/trauma.pdf

Slide 41: 

Thank you.