analgesie du(patient(obese( · · 2011-06-20analgesie(du(patient(obese(francis bonnet hôpital...

ANALGESIE DU PATIENT OBESE

Francis Bonnet

Hôpital Tenon

APHP - UPMC

AMIEN JUIN 2011

ANALGESIE DU PATIENT OBESE •  La douleur périopératoire ou obstétricale

est elle différente chez l’obèse? •  Faut il adapter les traitements antalgiques

chez l’obèse? – Opioides – Analgésie locorégionale

•  Comment parvenir à assurer une bonne analgésie pour le travail obstétrical

•  Quel protocole analgésique pour la chirurgie bariatrique?

Shibutani, K. et al. Pharmacokinetic mass of fentanyl for postoperative analgesia in lean and obese patients Br. J. Anaesth. 2005 95:377-383;

FAUT IL ADAPTER LES TRAITEMENTS ANTALGIQUES CHEZ L’OBESE ?

Non-linear relationship between postoperative analgesic dosing requirements for fentanyl and total body weight (TBW)

Patients : 37 BMI<30 vs 33 BMI>30 Fentanyl infusion rate titrated To achieve analgesia. Plasma c° measured at steady state

TBW vs PK mass 52 - 52 70   - 65 100   - 83 140   - 99 180   - 107 200 - 109

Shibutani K et al. Pharmacokinetic mass of fentanyl for postoperative analgesia in lean and obese patients; Br J

Anaesth 2005;95:377-83

Group L Group O P-value (70kg) (116 kg) Mean (SD) Mean(SD)

Average fentanyl dose over 213 (51) 275 (58) <0.001 surgical period (µg h–1) Cpm-end-surgery (ng ml–1) 1.67 (0.50) 1.51 (0.57) NS Response to verbal command before extubation (%) 89 97 NS No pain after extubation (%) 86 75 NS Nausea during the early 30 26 NS Postoperative period (%)

Derrode, N. et al. Br. J. Anaesth. 2003 91:842-849 LE REMIFENTANIL EST IL LA SOLUTION ?

Influence of peroperative opioid on postoperative pain after major abdominal surgery: Sufentanil TCI versus Remifentanil TCI. A randomised controlled trial

.

Derrode, N. et al. Br. J. Anaesth. 2003 91:842-849


Derrode, N. et al. Br. J. Anaesth. 2003 91:842-849


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Cumulative morphine consumption (mg) starting from the stopping of desflurane until 18 h afterwards in Group R and Group S.

Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid

obesity De Baerdemaeker LEC et al. Br. J. Anaesth. 2007;99:404-11


De Baerdemaeker LEC et al. Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid obesity Br. J. Anaesth. 2007;99:404-11

FVC, FEV1, PEF, and mean expiratory flow 25-75% (MEF) expressed as a percentage of the preoperative value in Group R and Group S.

Data are means (SD)

Shireen A et al. Postoperative Hypoxemia in Morbidly Obese Patients With and Without Obstructive Sleep Apnea Undergoing Laparoscopic Bariatric Surgery. Anesth & Analg 2008;107:138-143

Chio YK et al. Efficacy and safety of patient-controlled analgesia for morbidly obese patients following gastric bypass surgery.Obese Surg 2000;10:154-9

•  25 morbidly obese patients received PCA with morphine sulfate following RYGBP.

•  PCA settings –  morphine, 20 mcg/kg of ideal body weight, –  10-min lock out interval –  80 % of a calculated amount for a 4-hour limit.

•  Average morphine use – 44.2+/-28.7 mg DOS;

– 49.1+/-27.4 mg POD #1;

– 36.6+/-22.8 mg POD#2 (p < 0.01). •  24 patients satisfied with pain control on POD#1.

Batistich S et al. Analgesic requirements in morbidly obese patients. Anaesthesia 2004;59:505 •  40 morbidly obese patients scheduled for open

gastric bypass surgery (BMI 53;41-75) •  60-80 ml bupivacaine 0.25% infiltrated into the

rectus sheath and subcutaneously.

DOS POD1 POD2 Morphine

consumption (mg)

23[13-31] 32[22-55] 10[3-27]

Patient controlled iv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. Roshanak Charghi, Can J Anaesth 2003;50:672

Pain VAS scores at rest Time PCA group Epidural group Morphine Bupi/fentanyl P Day of surgery Pm 1 (1–2.5) 2 (1–2) 2 (1–2) 1 (1–2) 0.64 Postoperative day 1 Am 1 (0–2) 1 (0–2) 1 (0–2) 0 (0–2) 0.47 Pm 1 (0–2) 1 (0–2) 1 (0–2) 1 (0–2) 0.51 Postoperative day 2 Am 1 (0–1) 1 (0–1) 1 (0–1) 1 (0–2) 0.45 Pm 1 (0–2) 0 (0–1) 0 (0–1) 0 (0–1) 0.29 Values are median (range)

Etude retrospective – 86 patients (40 vs 46)

ANALGESIE ET OBESITE

•  La stratégie analgésique doit privilégier l’épargne morphinique

– En utilisant des analgésiques non opiacés – En utilisant les blocs et infiltrations –  (dont la réalisation n’est pas toujours facile)

Analgesic Effects of a Single Preoperative Dose of Pregabalin (150 mg) after Laparoscopic Sleeve Gastrectomy

Cabrera Schulmeyer MC, de la Maza J, Ovalle C, Farias C, Vives I. Obese Surg 2010

Percentage reduction in 24-hour morphine consumption with transversus abdominis plane block compared with control group (*P<0.05).

TAP block for postoperative analgesia

P. L. PETERSEN, O. MATHIESEN, H. TORUP and J. B. DAHL. Acta Anaesthesiologica Scandinavica 2010

ULTRASOUND GUIDED TAP BLOCK

ANALGESIE PERIDURALE & OBESITE MORBIDE

OBESITE ET ACCOUCHEMENT

•  Douleur plus importante pdt le travail obstétrical – Dystocie; augmentation du pds fœtal

•  Taux de césarienne plus élevé – Weiss JL Am J Obstet Gynecol

2004;190:1091 47% vs 21% – Hood DD Anesthesiology 1993;79:1210 >

50%

Hood DD& Dewan DM. Anesthestic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993;79:1210


•  Difficultés de réalisation de l’analgésie péridurale –  Absence de repères –  Incidence plus élevée de brèches vasculaires –  Incidence plus élevée de brèche de la dure mère –  Taux d’échec supérieur (42% Hood DD

Anesthesiology 1993) Réduction de la dose d’anesthésique local (diminution

du vol du LCR & diminution de l’espace péridural)

REPERAGE ANATOMIQUE PAR ECHOGRAPHIE

.

Arzola, C. et al. Anesth Analg 2007;104:1188-1192

Quality of Anatomical Landmarks by Palpation and Structure Visualization by Ultrasound

69 parturients;BMI:29.7 +/- 4.8;

Transverse approach at the tip of the spinous process identifies the midline of the spine

Transverse approach at a lumbar interspace shows the

typical « flying bat » sign.

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Ultrasound imaging in the transverse approach shows the vertebral body, dural sac, ligamentum flavum, and dura mater

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Figure 3. Ultrasound imaging shows measurements with the built-in caliper

SONOANATOMY OF PREGNANT WOMEN AT TERM

Borges BCR Reg Anesth pain Med 2009;34:581

Interspace level

Atypical LF images n=100

Inconclusives images n=100

atypical LF / conclusive images %

L1 – L2 2 1 2.0

L2 –L3 1 0 1.0

L3 – L4 3 4 3.1

L4 – L5 18 9 19.8

L5 – L6 19 34 28.8

DISTANCE FROM SKIN-EPIDURAL SPACE IN TRANSVERSE SCAN

Interspace level SS-ES cm DSW cm

L1-L2 4.55 +/-0.64 1.03+/-0.19

L2-L3 4.98+/-0.66 0.91+/-0.16

L3-L4 5.37+/-0.70 0.82+/-0.18

L4-L5 5.71+/-0.78 0.65+/-0.19

L5-S1 5.91+/-1.04 0.56+/-0.28

Borges BCR Reg Anesth Pain Med 2009;34:581-‐5

Longitudinal approach identifies the sacrum and the lumbar interspaces.

Longitudinal paramedian approach with the typical saw sign.


Grau, T. et al. Br. J. Anaesth. 2001 86:798-804;

VISIBILITE ECHOGRAPHIQUE DE LA DURE MERE ET DE L’ESPACE PERIDURAL

EN FIN DE GROSSESSE


•  Réduction de la dose d’anesthésique local (diminution du vol du LCR & diminution de l’espace péridural)

•  Difficultés de réalisation de l’analgésie péridurale –  Absence de repères –  Incidence plus élevée de brèches vasculaires –  Incidence plus élevée de brèche de la dure mère –  Taux d’échec supérieur (42% Hood DD Anesthesiology

1993)

A L1-L2 intervertebral foramen at baseline (BL) and during abdominal compression (AC). Dural area decreased from 2.71 to 2.56 cm2 with compression. B Section through the L3 vertebral body before (BL) and during (AC) abdominal compression. Dural area at this level decreased from 2.72 cm2 to 2.49 cm2 with compression. There is displacement of the anterior dural sac posteriorily by the expanded veins during abdominal compression. C Section through the L5-S1 intervertebral foramen before (BL) and during (AC) abdominal compression.

Panni, M. K. et al. Br. J. Anaesth. 2006 96:106-110

up-down sequences of the two groups of parturients--obese and normal with 95% CI shown

Obese parturients have lower epidural and local anaesthetic requirements for analgesia in labour.

ANALGESIE DE LA PARTURIENTE OBESE

•  Tout faire pour mettre en place un cathéter péridural efficace – Echographie – Répéter les tentatives –  Insérer le cathéter sur une distance > 4 cm

•  Eviter l’anesthésie générale et le risque d’intubation (morbidité x 20)

ANALGESIE DU PATIENT OBESE

PROTOCOLE ANALGESIQUE POUR LA CHIRURGIE DE L’OBESITE

A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer

Nelson et al. New Engl J Med 2004;350:2050-9

cœlioscopie laparotomie

n = 428 n = 435

conversion (%) 21 -

durée opératoire (min) 150 [35-450] 95 [27-435] *

complications (%) 20 21 intraop 2 4 postop 19 19

opiacés (j) 3 [2-4] 4 [3-5] *

durée hospitalisation (j) 5 [4-6] 6 [5-7] *

Mediane [IC95%] * = p<0,05

Randomized clinical trial comparing Epidural Anaesthesia and Patient-Controlled Analgesia after laparoscopic segmental colectomy Senagore et al. Br J Surg 2003; 90: 1195-1199

APD thoracique T8-T10 Bupiva 1 mg/ml + fentanyl 20 µg/ml - 4 à 6 ml/h pendant 18h

NVPO rétention urinaire

hypotension dépression respiratoire

prurit douleur (VAS)

6h 18h 24h 36h

6 1 1 0 3

2,2 ± 0,4 2,2 ± 0,3 1,9 ± 0,4 1,7 ± 0,3

6 0 0 0 1

6,6 ± 0,5 * 4,0 ± 0,4 * 3,3 ± 0,2 2,1 ± 0,3

PCA APD

durée hospitalisation (j) 2,4 (0,2) 2,3 (0,3)

Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate

postoperative period

P Ekstein et al. Annals of Surgery 2006

Antalgiques de secours 0-4 h : 3/31 2/36 5-9 h : 5/31 5/36 10-24 h : 5/31 19/36 * p<0.05

145 patients (cholécystectomies – résections grêle – néphrectomies)

VAS Instillations Placebo

Busley 99 Chundrigar 93 Dath 99 Elfberg 00 Joris 95 Labaille 02 Lee 01 Mraovic 97 Pasqualucci 94 Pasqualucci 96 Rademaker 94 Raetzell 95 Szem 96 Weber 97 Zmora 00

17 28 50 33 20 11 20 40 14 28 15 12 26 50 26

4 (0,0) 1,99 (0,0) 2,9 (2,2) 3 (0) 1,89 (0) 1,8 (0) 5 (0) 2,2 (1,25) 2,12 (1,5) 3 (0) 2 (0) 1 (0) 3,4 (0,6) 2 (0) 4,93 (0)

Studies N m (ds) N m (ds) WMD Weight (%)

TOTAL (CI 95 %) 506 508 100 -1,44(-1,69,-1,18)

favour instillation favour placebo 0 -5 -10 5 10

5 28 10 0 1 1 5 6 3 1 10 0 5 10 5

P = 0,001

Instillation with LA for lape chole surgery (data PROSPECT )

16 30 47 32 20 12 25 40 11 27 15 12 29 50 25

3,6 (0,0) 4 (0,0) 4,5 (2,3) 3 (0) 2,83 (0) 3,96 (0) 5 (0) 4,3 (2,44) 3,3 (1,9) 3,5 (0) 4 (0) 2 (0) 4,7 (0,5) 7 (0) 5,8 (0)

Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized controlled trial.

Sherwinter DA et al. Obes Surg. 2008;18:1581-6.

Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized controlled trial.

Gastric banding, continuous infusion with bupivacaine 0.375%

Sherwinter DA et al. Obes Surg. 2008;18:1581-6.

Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized controlled trial. Sherwinter DA et al. Obes Surg.

2008;18:1581-6.

15

15

Lidocaïne iv et réhabilitation en chirurgie abdominale E Marret et al. Br J Sug 2008

EVA à 24h

Durée iléus digestif

Durée hospitalisation

Study

Treatment

Control

WMD (random) N

Mean (SD)

N

Mean (SD)

95% CI Cassuto

10 4.00(3.00) 10 20.00(14.00) Groudine

20 4.67(3.94) 20 13.25(7.65) Herroeder

31 30.00(17.00) 29 32.00(18.00) Kaba

20 11.50(16.40) 20 21.30(25.10) Kuo

20 25.00(5.00) 20 29.00(3.00) Wu

25 26.00(3.75) 25 27.00(11.25) Total (95% CI)

126 124 Test for heterogeneity: Chi² = 13.73, df = 5 (P = 0.02), I² = 63.6%

Test for overall effect: Z = 3.14 (P = 0.002) -100

-50

0

50

100 Favours treatment

Favours control

Study Treatment Control WMD (random) N Mean (SD) N Mean (SD) 95% CI

Groudine 20 4.00(0.70) 20 5.10(2.20) Herroeder 31 7.00(1.00) 29 8.00(2.00) Kaba 20 2.45(0.51) 20 3.75(1.77) Koppert 20 12.80(4.20) 20 14.20(3.10) Kuo 20 6.90(0.80) 20 7.10(0.80)

Total (95% CI) 111 109 Test for heterogeneity: Chi² = 7.51, df = 4 (P = 0.11), I² = 46.7% Test for overall effect: Z = 3.08 (P = 0.002)

-10 -5 0 5 10 Favours treatment Favours control

Study Lidocaine Control WMD (random) N Mean (SD) N Mean (SD) 95% CI

Groudine 20 28.50(13.40) 20 42.10(16.00) Herroeder 31 66.60(26.40) 29 82.10(33.80) Kaba 20 18.00(9.10) 20 31.30(11.50) Koppert 20 79.00(13.34) 20 85.00(20.76) Kuo 20 60.20(5.80) 20 71.70(4.70) Rimback 15 37.60(2.40) 15 42.40(4.80) Wu2 25 22.10(1.60) 25 22.90(1.80)

Total (95% CI) 151 149 Test for heterogeneity: Chi² = 63.71, df = 6 (P < 0.00001), I² = 90.6% Test for overall effect: Z = 3.35 (P = 0.0008)

-100 -50 0 50 100 Favours Lidocaine Favours control

PROPOSITION DE PROTOCOLE ANALGESIQUE POUR LA CHIRURGIE BARIATRIQUE

•  PREOPERATOIRE –  Information –  Anxiolyse

•  PEROPERATOIRE –  Instillation péritonéale –  Infiltration des incisions

•  POSTOPERATOIRE –  AINS –  Analgésiques non opiacés –  PCA morphine en secours

0

10

20

30

40

50

0 - 24 h 24 - 48 h 48 - 72 h

heures postopératoires

mg

MIT PCA

*

*

consommation morphine iv repos

toux

0

2

4

6

8

10

12

14

16

18

20

22

24

26

PCA MIT

PCA MIT

PCA MIT

PCA MIT

PCA MIT

PCA MIT

patients

EVS = 2EVS = 1EVS = 0

D2 D3 D4 D5D1H12

*

0246

81012141618

20222426

PCA

MIT

PCA

MIT

PCA

MIT

PCA

MIT

PCA

MIT

PCA

MIT

patients

EVS = 3EVS = 2EVS = 1EVS = 0

D2 D3 D4 D5D1H12* *

A randomized comparison between intrathecal morphine and intravenous PCA morphine for postoperative analgesia and recovery course after major colorectal surgery in elderly patients Beaussier et al. 2006. Reg Anesth Pain Med

patients > 71 ans, ASA 1 et 2 (n = 56)

chirurgie colorectale lourde - morphine intrathécale (MIT) 300 µg vs PCA seule

/!/!

0

20

40

60

0,5 1 0 4 12 20

/!

2

/!

/!/!

Mor

phin

e (m

g)

Temps post-extubation (h)

Desflurane

Rémifentanil

M ± IC 95 %

P < 0,05 versus desflurane

Consommation de morphine en PCA après anesthésie par rémifentanil versus desflurane

Guignard et al. Anesthesiology 2000;93:409-17.


Grau, T. et al. Br. J. Anaesth. 2001 86:798-804;

analgesie du(patient(obese( · · 2011-06-20analgesie(du(patient(obese(francis bonnet hôpital...

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