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ASRA Acute to Chronic Pain 2015 McCartney
1. Colin J.L. McCartneyColin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of AnaesthesiaProfessor and Chair of Anaesthesia
University of OttawaUniversity of Ottawa
Head of AnaesthesiaHead of Anaesthesia
The Ottawa HospitalThe Ottawa Hospital
Scientist,Scientist,
Ottawa Hospital Research InstituteOttawa Hospital Research Institute
Regional Anesthesia CanRegional Anesthesia Can
Decrease the Incidence ofDecrease the Incidence of
Chronic Pain after SurgeryChronic Pain after Surgery
3. Objectives (20 mins)Objectives (20 mins)
Understand incidence of CPSPUnderstand incidence of CPSP
Who are the populations at risk?Who are the populations at risk?
What new approaches exist including RAWhat new approaches exist including RA
techniques for preventing CPSP?techniques for preventing CPSP?
What does the future hold?What does the future hold?
4. SummarySummary
CPSP common and varies by type of surgeryCPSP common and varies by type of surgery
Preoperative pain and psychological factorsPreoperative pain and psychological factors
major predictorsmajor predictors
Prevention possible with high qualityPrevention possible with high quality
perioperative pain relief including LA techniquesperioperative pain relief including LA techniques
and NMDA antagonists and surgical approachand NMDA antagonists and surgical approach
Future management possibilities include novelFuture management possibilities include novel
therapeutic, psychological andtherapeutic, psychological and
pharmacogenomic approachespharmacogenomic approaches
5. Incidence ofIncidence of
Chronic Post-Surgical PainChronic Post-Surgical Pain
Pain after surgery of primary concern toPain after surgery of primary concern to
patients (Apfelbaum et al 1999)patients (Apfelbaum et al 1999)
Acute postoperative pain remainsAcute postoperative pain remains
undertreatedundertreated
Incidence of severe acute pain a problemIncidence of severe acute pain a problem
Severe acute pain associated with CPSPSevere acute pain associated with CPSP
Definition: pain >2 months after surgeryDefinition: pain >2 months after surgery
8. 300 patients300 patients
2/3 had moderate-severe pain after2/3 had moderate-severe pain after
surgerysurgery
No change from 10 years earlierNo change from 10 years earlier
Gan TJ et al CMRO 2014
10. Objectives (20 mins)Objectives (20 mins)
Understand incidence of CPSPUnderstand incidence of CPSP
Who are the populations at risk?Who are the populations at risk?
What new approaches exist including RAWhat new approaches exist including RA
techniques for preventing CPSP?techniques for preventing CPSP?
What does the future hold?What does the future hold?
11.
12. 5130 patients attending chronic pain5130 patients attending chronic pain
clinicsclinics
Surgery contributed to pain in 22.5%Surgery contributed to pain in 22.5%
Research needed into: aetiology andResearch needed into: aetiology and
procedures contributing to highest risk ofprocedures contributing to highest risk of
CPSPCPSP
Preventive strategiesPreventive strategies
Pain 1998
13. Prevalence of persistent postsurgical painPrevalence of persistent postsurgical pain
12982 participants/3111 undergone surgery12982 participants/3111 undergone surgery
within 3 yearswithin 3 years
Persistent pain in 40.4%. Mod-Severe 18.3%Persistent pain in 40.4%. Mod-Severe 18.3%
17. Systematic review. 281 studies assessedSystematic review. 281 studies assessed
investigating PSPS in 11 surgical typesinvestigating PSPS in 11 surgical types
Prevalence of NeuP determined using NeuPPrevalence of NeuP determined using NeuP
grading systemgrading system
Prevalence of NeuP high after thoracic andPrevalence of NeuP high after thoracic and
breast surgery (66/68%). 31% after groin herniabreast surgery (66/68%). 31% after groin hernia
repair and 6% after THA and TKArepair and 6% after THA and TKA
Prevalence of PneuP varies by type of surgeryPrevalence of PneuP varies by type of surgery
and probability of nerve injuryand probability of nerve injury
18. Risk Factors for CPSP?Risk Factors for CPSP?
Preoperative: Pain, Repeat surgery,Preoperative: Pain, Repeat surgery,
Psychological factors, Female gender andPsychological factors, Female gender and
younger age, Genetic predispositionyounger age, Genetic predisposition
Intraoperative: Surgical approach andIntraoperative: Surgical approach and
risks of nerve injuryrisks of nerve injury
Postoperative: Acute Pain, Radiation Rx,Postoperative: Acute Pain, Radiation Rx,
Neurotoxic chemotherapy, Anxiety andNeurotoxic chemotherapy, Anxiety and
Depression, NeuroticismDepression, Neuroticism
McIntyre et al 2010
19. Objectives (20 mins)Objectives (20 mins)
Understand incidence of CPSPUnderstand incidence of CPSP
Who are the populations at risk?Who are the populations at risk?
What new approaches exist including RAWhat new approaches exist including RA
techniques for preventing CPSP?techniques for preventing CPSP?
What does the future hold?What does the future hold?
20. What can we do about theWhat can we do about the
problem?problem?
Regional anaesthesia techniquesRegional anaesthesia techniques
Systemic drug interventionsSystemic drug interventions
Modified surgical techniquesModified surgical techniques
Focus on postoperative pain controlFocus on postoperative pain control
22. 23 RCTs in total23 RCTs in total
Pooled 3 studies for epidural afterPooled 3 studies for epidural after
thoracotomy and 2 for PVB after breastthoracotomy and 2 for PVB after breast
surgerysurgery
Unable to pool data from other studies dueUnable to pool data from other studies due
to marked heterogeneityto marked heterogeneity
30. No long term benefit for:No long term benefit for:
– GabapentinGabapentin
– PregabalinPregabalin
– NSAIDSNSAIDS
– CorticosteroidsCorticosteroids
– MexilitineMexilitine
2013 Cochrane Collaboration
34. Objectives (20 mins)Objectives (20 mins)
Understand incidence of CPSPUnderstand incidence of CPSP
Who are the populations at risk?Who are the populations at risk?
What new approaches exist including RAWhat new approaches exist including RA
techniques for preventing CPSP?techniques for preventing CPSP?
What does the future hold?What does the future hold?
35. Future PossibilitiesFuture Possibilities
Impact of psychological factorsImpact of psychological factors
Pharmacogenomics and personalizedPharmacogenomics and personalized
medicinemedicine
Novel ‘analgesic’ agentsNovel ‘analgesic’ agents
37. Preoperative painPreoperative pain
Pain catastrophizingPain catastrophizing
Mental healthMental health
Pain at other sitesPain at other sites
43. Genetics of PainGenetics of Pain
3 variants (haplotypes) of gene encoding3 variants (haplotypes) of gene encoding
COMT predicting low, moderate and highCOMT predicting low, moderate and high
sensitivity to painsensitivity to pain
Encompass 96% of humansEncompass 96% of humans
Low COMT levels predict high painLow COMT levels predict high pain
sensitivity and risk of developing TMDsensitivity and risk of developing TMD
Inhibition of COMT in rat model increasesInhibition of COMT in rat model increases
pain sensitivitypain sensitivity
Diatchenko L et al 2005
44. CPSP is likely 50% influenced by geneticCPSP is likely 50% influenced by genetic
determinantsdeterminants
Identifying genetic basis of CPSP couldIdentifying genetic basis of CPSP could
lead to significant improvement inlead to significant improvement in
treatmenttreatment
Prediction of CPSP, PharmacogenomicsPrediction of CPSP, Pharmacogenomics
Improved treatmentsImproved treatments
CJA: published ahead of print
45. Novel neuroactive agentsNovel neuroactive agents
Not analgesic per seNot analgesic per se
Prevent mechanism of transition to chronicPrevent mechanism of transition to chronic
painpain
rhBDNF, neuroprotective agents (e.g.rhBDNF, neuroprotective agents (e.g.
acetyl l-carnitine) and anti-oxidantsacetyl l-carnitine) and anti-oxidants
Early promising resultsEarly promising results
Bordet T et al Neurotherapeutics 2009
46. SummarySummary
CPSP common and varies by type of surgeryCPSP common and varies by type of surgery
Preoperative pain and psychological factorsPreoperative pain and psychological factors
major predictorsmajor predictors
Prevention possible with high qualityPrevention possible with high quality
perioperative pain relief including LA techniquesperioperative pain relief including LA techniques
and NMDA antagonists and surgical approachand NMDA antagonists and surgical approach
Future management possibilities include novelFuture management possibilities include novel
therapeutic, psychological andtherapeutic, psychological and
pharmacogenomic approachespharmacogenomic approaches
47. Good Acute Pain Control MajorGood Acute Pain Control Major
Concern for PatientsConcern for Patients
Apfelbaum et al A&A 2003
48. Acute pain controlAcute pain control
Use regional anaesthesia where possibleUse regional anaesthesia where possible
Use NSAIDS, paracetamol in multimodalUse NSAIDS, paracetamol in multimodal
regimenregimen
For higher risk cases use ketamine and/orFor higher risk cases use ketamine and/or
lidocaine infusion during surgerylidocaine infusion during surgery
Gabapentin/Pregabalin useful for acuteGabapentin/Pregabalin useful for acute
pain control and reduction of opioidpain control and reduction of opioid
consumptionconsumption
49. Objectives (20 mins)Objectives (20 mins)
Understand incidence of CPSPUnderstand incidence of CPSP
Who are the populations at risk?Who are the populations at risk?
What new approaches exist includingWhat new approaches exist including
regional techniques for preventing CPSP?regional techniques for preventing CPSP?
What does the future hold?What does the future hold?
Editor's Notes
Good morning. My name is Colin McCartney and I am an anesthetist and consultant in chronic pain management from Toronto Western Hospital.