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Management of postoperative pain after vascular surgery


Endovascular surgery with its minimally invasive techniques is carried out for an increasing number of vascular conditions. Management of postoperative pain in vascular patients will be determined by a variety of issues, amongst them that cardiac and coronary comorbidity is common in this population of patients and they are often treated by anticoagulants.

The chapter is subdivided into management of pain after carotid surgery, peripheral vascular reconstruction and abdominal vascular reconstruction German, section 4.4.1, p 40.

There is limited procedure-specific evidence about management of patients after vascular surgery.

Evidence-based treatment recommendations specific to the condition

Carotid surgery

Preoperative

There is insufficient evidence from randomised trials comparing carotid endarterectomy performed under local and general anaesthesia. Non-randomised studies suggest potential benefits with the use of local anaesthetic. German, section 4.4.2.2., page 41

Postoperative

Systemic COX2-inhibitors, conventional NSAIDs and paracetamol are generally adequate; opioids can be used if pain is not sufficiently controlled. German, section 4.4.2.2., page 42

Peripheral revascularisation types of surgery

Preoperative

For peripheral bypass surgeries, peripheral regional or epidural analgesia (for surgery in the lower extremity) may be combined with general anaesthesia. German, section 4.4.3.1, p 42.

In contrast, epidural analgesia is not recommended because it does not improve respiratory or cardiovascular morbidity French, section 10.4, p 408.

Postoperative

Continuewith peripheral regional or epidural analgesia. If not possible, provide opioids by IV-PCA. German, section 4.4.3.3., p 42.

  • Provide systemic analgesics, when peripheral regional or epidural analgesia is stopped. German, section 4.4.3.3., p 42.
  • Whenever possible, patients should be given multimodal pain management therapy.
  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.

Abdominal vascular reconstruction(e.g. repair of abdominal aortic aneurysm)

Preoperative

Pain therapy will not mask symptoms or compromise diagnosis of abdominal pain of vascular origin and so should be initiated even before definitive diagnosis is made. German, section 4.4.4.2, p 43.

General anaesthesia should be supplemented by thoracic epidural analgesia. German, section 4.4.4.3., p 44.

Postoperative

  • Continue epidural analgesia.
  • After cessation of epidural analgesia OR in patients without an epidural:
    • Strong opioids for severe pain orweakopioids for moderate to mild pain and COX-2-selective inhibitors or conventional NSAIDs.
    • Opioids can be administered by IV-PCA. German, section 4.4.4.3, p 44.
  • Whenever possible, patients should be given multimodal pain management therapy.
    • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
    • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.

Summary

Regional techniques, peripheral or epidural analgeisa are useful inmanagement of postoperative pain after vascular surgery. If not available or contraindicated, opioids can be administered by IV-PCA with systemic, multimodal treatment.

Supplementary reading

  1. Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012 May;37(3):310-7
  2. Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD000126.