Abdominal Aortic Aneurysm Quality improvement Programme

1. Abdominal Aortic Aneurysm Quality improvement Programme Post-operative Pain Care Pathway Dr Ali Abbas Consultant Anaesthetist Sherwood Forest Hospitals

2. Post operative pain care • Aim: • Effective pain control • Who was involved: • Anaesthetists • Intensivists • Vascular surgeons • Acute pain team

3. Post operative pain care • Thoracic epidural analgesia • Epidural analgesia is safe and provides effective postoperative pain relief • It decreases the incidence of pulmonary and cardiovascular complications • it provides a very high level of patient satisfaction and a very low level of perceived postoperative pain. • It attenuate detrimental physiological responses

4. Post operative pain care • Thoracic epidural analgesia • Adhere to the aseptic technique. Use sterile gloves, gown, mask and drapes. Prepare patient’s skin with chlorhexidine 0.5% in 70% alcohol. • Allow the antiseptic to dry. • Insert the epidural catheter at the level of the incisional dermatome (T8-T9 or T9-T10).

5. Post operative pain care • Thoracic epidural analgesia • Use a premixed solution of Levobupivacaine 0.125% with Fentanyl 4 mcgs/ml in a 500ml. • Alternatively if opioid is to be removed from the epidural infusion a Levobupivacaine 0.25% or 0.125% infusion may be obtained from pharmacy.

6. Post operative pain care • Thoracic epidural analgesia • Infusion rate (mls/hr) depends on: • Position of the catheter • Number of segments to be blocked • Age and height of the patient • Consider starting with 1ml per segment to be blocked and increase as necessary. • Continuous epidural infusion is combined with patient-controlled epidural analgesia (PCEA) of the same mixture.

7. Post operative pain care • Thoracic epidural analgesia • Monitor and assess pain using the Verbal Rating Score VRS-4 • Involve the acute pain team • Utilise epidural catheter for 48-72 hours • Enhanced recovery programme • Chest physiotherapy • Incentive spirometry

8. Post operative pain care • Thoracic epidural analgesia • If the epidural is not effective, try to optimise it • Scale down the epidural 24 hours post-operatively and assess the pain regularly.  • Use NSAIDs and paracetamol with the epidural concomitently as multi-modal analgesia.

9. Post operative pain care • Transversus abdominis plane (TAP) bolck • The needle insertion is at the level of the apex of lumbar triangle of Petit • The facial plane contains nerves from T7 – L1 • reducing post-operative pain and morphine consumption for up to 48 hours • Have a role in abdominal procedures • Offer no analgesia for viscera

10. TAP block • TAP block – US guided • 20 mls levobupivacaine 0.25% each side

11. Indications of TAP block • Surface abdominal procedure • Part of multi-modal analgesia. • Rescue analgesia. • Epidural is not feasible.

12. Contraindications of TAP block • Patient refusal • Anticoagulation treatment • Haemorrhagic diasthesis • Abdominal wall hernia (lumbar hernia through the Triangle of Petit)

13. PCA morphine • PCA morphine. • Can be used if the epidural and TAP block fail or as step down from epidural.

14. Oral analgesics • Oral morphine • Tramadol • NSAIDs • Paraceramol

15. Changes in clinical protocol • Emphasis on effective epidural • TAP block with PCA morphine as alternative • Active involvement of the pain team • Enhanced recovery programme • Chest physiotherapy

16. Difficulties and challenges • Lack of awareness/education among the staff • Limited number of patients for open repair • Limited resources