ACUTE PAIN SERVICE COMPLICATIONS

POSSIBLE COMPLICATIONS
 Related to drugs used
Opioids NSAIDS Local anaesthetics

 Related to techniques used

Intravenous drug administration Epidural

POSSIBLE COMPLICATIONS
Minor complications
       Nausea and vomiting Headache Giddiness Urinary retention Ileus Pruritus Backache

POSSIBLE COMPLICATIONS
Major complications
     Respiratory depression Systemic toxicity from local anaesthetic Epidural haematoma Epidural abscess High epidural block

COMPLICATIONS RELATED TO DRUGS

OPIOIDS
      Respiratory depression Oversedation Nausea and vomiting Urinary retention Ileus Pruritus

COMPLICATIONS RELATED TO DRUGS

NSAIDS
    GIT bleeding Coagulopathy Acute renal failure Allergic reactions

Local Anaesthetics
 Hypotension  Motor block  Systemic toxicity

COMPLICATIONS RELATED TO TECHNIQUES

Due to epidural
     Epidural abscess Epidural haematoma Backache Headache (accidental dura puncture) Catheter migration and knotting

COMPLICATIONS RELATED TO TECHNIQUES

PCA  Due to drugs used
opioid side effects

 Due to IV line
thrombophlebitis accumulation of opioid in IV line (need to use anti-reflux valve)

RESPIRATORY DEPRESSION
 Most dangerous effect of opioid overdose  May occur with opioids via all routes ie IV, IM, SC, epidural, spinal  DELAYED respiratory depression due to epidural opioid (esp. morphine)  Incidence 0.3 7 %

RESPIRATORY DEPRESSION
Pre-disposing conditions
 Extremes of age (neonate, elderly)  Concomitant use of other CNS depressant drugs  Morbidly obese  Patient sensitivity to opioid  Poor pulmonary function

RESPIRATORY DEPRESSION
WARNING SIGNS
    Patient not arousable when called Respiration shallow and slow Pinpoint pupils Cyanosis (late sign)

RESPIRATORY DEPRESSION
MANAGEMENT
     Call for help Stop PCA or epidural Give oxygen Ask patient to breathe Give IV/IM naloxone 0.1mg stat and repeat at 2-3min interval until 0.4mg

NAUSEA AND VOMITING

 Postoperative nausea and vomiting (PONV)  High incidence (20-30%)  More common in: female patients paediatric patients obese patients history of motion sickness history of previous PONV

NAUSEA AND VOMITING

Problems of PONV  Very uncomfortable for patients  Complicate surgical outcome
wound dehiscence dislocation of lens implant eye surgery

 Metabolic imbalance  Oesophageal tear  Increased nursing labor and cost

NAUSEA AND VOMITING

Causes: Effects of general anaesthetics
 Perioperative opioids  Inhalational agents  Induction agents

Related to surgery
   

Gynaecological procedures Laparoscopic surgey Bowel surgery ENT

NAUSEA AND VOMITING

Prophylaxis and treatment
 Avoid excessive movements esp. during transportation  Avoid emetic triggering agent  For APS patients on opioids reduce bolus dose administer opioid slowly stop background infusion give anti-emetic

NAUSEA AND VOMITING

ANTI-EMETIC AGENTS  Metoclopropamide (maxolon)
10mg in adult (0.15mg/kg)

 Droperidol
0.25mg in adult (50mcg/kg)

 Ondansetron
4mg in adult

NB: maxolon can be given by ward nurses

droperidol and ondansetron given by APS doctors

HYPOTENSION
 Numerous causes, often not related to APS  Must rule out surgical problems esp. immediate postoperative period bleeding, hypovolaemia  Management run in fluids (eg Hartmans) 200-500mls call ward/APS doctors stop PCA or epidural

REDUCED GIT MOTILITY

     Common problem after abdominal surgery May not be due to APS Consider surgical related causes May be due to inadequate pain relief Management delay oral intake insert nasogastric tube laxatives

URINARY RETENTION
 Incidence difficult to determine (40% APS patients have indwelling urinary catheter)  Maybe due to opioid or local anaesthetic  Rule out acute renal failure  Management reassure, coax catheterise

PRURITUS
    Incidence 2% More with morphine than pethidine Esp common with epidural or spinal morphine Management: reassurance calamine lotion change to pethidine or other technique caution with anti-histamine eg piriton