DR FATMA AL DAMMAS. The management of pain is a multidisciplinary team effort involving physicians,...

DR FATMA AL DAMMAS

DR FATMA AL DAMMAS

The management of pain is a multidisciplinary team effort involving physicians, psychologists, nurses, and

physical therapists.

Copyright © 2003 American Society of Anesthesiologists. All rights reserved

Anesthesiologists are physicians and are experts in the diagnosis and

treatment of acute and chronic pain disorders.

Copyright © 2003 American Society of Anesthesiologists. All rights reserved

Causes of Post-Operative PainCauses of Post-Operative Pain

• incisional skin and subcutaneous tissue• deep cutting, coagulation, trauma • positional bed sore, nerve compression & traction• IV site needle trauma, extravasation, venous irritation• tubes drains, nasogastric tube, ETT• respiratory from ETT, coughing, deep breathing• rehab physiotherapy, movement, ambulation• surgical complication of surgery• others cast, dressing too tight, urinary retention

CAUSES OF VARIATION IN ANALGESIC CAUSES OF VARIATION IN ANALGESIC REQUIREMENTSREQUIREMENTS

• Site and type of surgery• Age, gender • Psychological factors • Pharmacokinetic variability• Pharmacodynamic variability

Site and type of surgery

• general upper abdominal surgery produces greater pain than lower abdominal surgery

• operation on the richly innervated digits associated with severe pain.

• The type of pain differ with different types of surgery.

Age, gender and body weight• analgesic requirements of males and females are

identical for similar types of surgery.

• There is a reduction in analgesic requirements with

advancing age.

Psychological factors

• The patient’s personality affects pain perception and response to analgesic drugs.

• Patients with a less anxiety exhibit less postoperative pain and require smaller doses of opioid than patients who rate highly on anxiety scales.

TREATMENT OF PAINTREATMENT OF PAINGOALS OF THERAPYGOALS OF THERAPY

• Decrease the frequency and / or severity Decrease the frequency and / or severity of the painof the pain

• General sense of feeling betterGeneral sense of feeling better• Increased level of activityIncreased level of activity• Return to workReturn to work• Decreased health care utilizationDecreased health care utilization• Elimination or reduction in medication Elimination or reduction in medication

usageusage

Copyright © 2003 American Society of Anesthesiologists. All rights reserved

PainPain

• Pain is subjective and difficult to quantify

PAINPAIN

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.( International association of study of pain)

CLASSIFICATION OF PAINCLASSIFICATION OF PAIN

S U P E R F IC IA L D E E P

S O M A TIC

TR U E V IS C E R A L TR U E P A R IE TA L R E F E R E D V IS C E R A L R E F E R E D P A R IE TA L

V IS C E R A L

A C U TE

D E A F F E R E N TA TIO NP A IN

S Y M P A TH E TIC A L L YM E D IA TE D P A IN

C H R O N IC

P A IN

TYPES OF PAINTYPES OF PAINAccording to durationAccording to duration

Acute

Chronic

TYPES OF PAINTYPES OF PAINAccording to PathophysiologyAccording to Pathophysiology

• Nociceptive;

Due to activation, sensitization of peripheral nociceptors.

• Neuropathic:

Due to injury or acquired abnormalities of peripheral OR central nervous system.

TYPES OF PAINTYPES OF PAINAccording to EtiologyAccording to Etiology

• Post operative

OR • cancer pain

TYPES OF PAINTYPES OF PAINAccording to Type of the organ affectedAccording to Type of the organ affected

–Toothache

–Earache

–Headache

–Low backache

PAINPAIN PATHWAYPATHWAY

12 3

4

1.Transduction-changing of the noxious stimuli in sensory nerve ending to impulse.

2.Transmission-movement of impulse from site of transduction.

3.Perception –recognizing, defining and responding.

4.Modulation-involves activation of the descending pathway that exert inhibitory effect on pain transmission.

ACUTE PAINACUTE PAIN

• Caused by noxious stimulation due to injury, a disease process or abnormal function of muscle or viscera

• It is nearly always nociceptive• Nociceptive pain serves to detect, localize

and limit the tissue damage.

TYPES OF ACUTE PAINTYPES OF ACUTE PAIN

• Somatic OR

• Visceral

SOMATIC PAINSOMATIC PAIN

• SuperficialOR

• Deep

SUPERFICIAL SOMATIC PAINSUPERFICIAL SOMATIC PAIN

• Nociceptive input from skin, sub-cutaneous tissue and mucous membranes

• Well localized and described as sharp, pricking, burning and throbbing

DEEP SOMATIC PAINDEEP SOMATIC PAIN

• Arise from Muscles, Tendons and Bones• Dull, aching quality and is less well

localized• Intensity and Duration of stimulus affects

the degree of localization

VISCERAL PAINVISCERAL PAIN

• Due to disease process, abnormal function of internal organ or its covering e.g Parietal pleura, Pericardium or Peritoneum

SUBTYPES OF SUBTYPES OF VISCERAL PAINVISCERAL PAIN

– True localized visceral pain

– Localized parietal pain– Referred Visceral pain– Referred parietal pain

TRUE VISCERAL PAINTRUE VISCERAL PAIN

• Dull, diffuse and in midline• Frequently associated with abnormal sympathetic

activity causing nausea, vomiting, sweating and changes in heart rate and blood pressure.

PARIETAL PAINPARIETAL PAIN

• Sharp, often described as stabbing sensation either localized to the area around the organ or referred to a distant site.

PATTERNS OF REFERRED PAINPATTERNS OF REFERRED PAIN

Lungs T2 – T6

Heart T1 –T4

Aorta T1 –L2

Esophagus T3 – T8

Pancreas & Spleen T5 –T10

Stomach, liver and gall bladder T6 –T9

Adrenals T6 – L1

Small intestine T6 – T9

Colon T10 – L1

Ureters T10 – T12

Uterus T11 – T12

Bladder and prostate S2 – S4

Urethra & Rectum S2 – S4

Kidneys, Ovaries & Testis T10 – L1

SYSTEMIC RESPONCES TO ACUTE SYSTEMIC RESPONCES TO ACUTE PAINPAIN

Efferent limb of the pain pathway is

• Sympathetic nervous system • Endocrine system.

Cardiovascular effectsCardiovascular effects

        Tachycardia

        Hypertension

        Increased systemic vascular resistance

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

• Increased oxygen demand and consumption• Increased minute volume• Splinting and decreased chest excursion • Atelactasis, increased shunting, hypoxemia• Reduced vital capacity, retention of secretions

and chest infection

GASTROINTESTINAL AND URINARY EFFECTSGASTROINTESTINAL AND URINARY EFFECTS

• Increased sympathetic tone• Decreased motility, ileus and urinary retention• Hypersecretion of stomach• Increased chance of aspiration• Abdominal distension leads to decreased chest

expansion

ENDOCRINE EFFECTSENDOCRINE EFFECTS

• Increase secretion of Catecholamine, Cartisol and Glucagon

• Decreased secretion of Insulin and testosterone

HEMATOLOGICAL EFFECTSHEMATOLOGICAL EFFECTS

1. Increased platelet adhesiveness

2. Reduced fibrinolysis and hypercoagulatability

IMMUNE EFFECTSIMMUNE EFFECTS

Leukocytosis

Lymphopenia

Depression of reticuloendothetial system

GENERAL SENSE OF WELL-BEINGGENERAL SENSE OF WELL-BEING

• Anxiety

• Sleep disturbances

• Depression

There are many different techniques,non-pharmacological &pharmacological , both regional and non-regional to provide post op analgesia.

Nonpharmacologic Approaches toNonpharmacologic Approaches toRelieve Pain and Prevent SufferingRelieve Pain and Prevent Suffering

hydrotherapy

intradermal water blocks

movement and

Positioning

touch and massage

acupuncture

transcutaneous electrical nerve stimulation (TENS

aromatherapy

heat and cold

music and audioanalgesia.

J Midwifery Womens Health 49(6):489-504, 2004. © 2004 Elsevier Science, Inc.

PHARMACOLEGICAL PHARMACOLEGICAL

WHO Ladder

An essential principle in using medications to manage pain is to individualize the regimen

to the patient

WHO analgesic guidelinesWHO analgesic guidelines

• Oral medications whenever possible

• Dose “by the clock” – but always have “as

needed”medications for breakthrough pain

• Titrate the dose

• Use appropriate dosing intervals

• Be aware of relative potencies

• Treat side effects

Pharmacological approachPharmacological approach

• Acetamenophen • NSAIDs• Tramal• Opioids• Adjuvents therapy

– Anticonvulsantants – Antideperssants – NMDA antagonists– Muscle relaxants– Clonidine – Corticosteroids– Local Anesthetics– Sedatives

AcetaminophenAcetaminophen

• The most widely used analgesic• Non acidic and a phenol derivative • Readily crosses the BBB.• Its action mainly in the CNS, where prostaglandin

inhibition produces analgesia and antipyresis.• Its peripheral and anti-inflammatory effects are weak.

AcetaminophenAcetaminophen

• Doses of 10 to 15 mg/kg every 4 hours up to a daily maximum of 100 mg/kg

• For the treatment of mild to moderate pain.

Perfalgan

Making paracetamol (hydrophobic) soluble

Use of hydrophilic ingredients (mannitol and disodium phosphate)

Ensuring its stability in solution

- By controlling hydrolysis

Use of a pH buffer (disodium phosphate and sodium hydroxide)

- By preventing oxidation

Addition of cysteine hydrochloride

Oxygen-free manufacturing process

Perfalgan 1g indications

Short-term treatment of moderate pain, especially following surgery

Short-term treatment of fever

Alone or in combination

In adults or children over 33kg

1. Take the cap off

2. Link the bottle to a drip with an air intake

3. Hook the bottle with the built-in calliper

How to handle Perfalgan

First administration in the operating theatre

Frequency of administration:15-minute infusion every 4 to 6 hours

Dosages

- Adolescents and adults weighing more than 50kg: 1 g / 4 times a day

- Children weighing more than 33kg, adolescents and adults weighing less than 50kg:

15 mg/kg (4 times a day )

How to infuse Perfalgan

NSAIDsNSAIDs

NSAIDsNSAIDs• The NSAIDs are weak organic acids (PKa3 to 5.5)• Act mainly in the periphery• Bind extensively to plasma albumin (95% to 99%

bound)• Do not readily cross the BBB• Extensively metabolized by the liver• Have low renal clearance «10% .

NSAIDsNSAIDs

NSAIDs are powerful inhibitors of prostaglandin synthesis through their effect on cyclooxygenase (COX)

The adverse effects of NSAIDs in surgical patients The adverse effects of NSAIDs in surgical patients

• gastrointestinal hemorrhage • renal dysfunction or failure• hematoma formation• asthma in susceptible individuals• anaphylaxis • decreased healing of gastrointestinal

anastomoses

TramalTramal®® (Tramadol) (Tramadol)

is a

with

for

centrally acting analgesic

opioid and non-opioid activity

moderate to severe pain associated with acute and chronic conditions

Dual mode of action of TramadolDual mode of action of Tramadol

Two complementary mechanisms of action:

Opioid action:weak µ-receptor agonist

Monoaminergic action:weak, indirect 2-receptor agonist

TramalTramal®® presentations (I) presentations (I)

Prolonged-release tablets 100 mg, 150 mg, 200 mg

Drops Soluble tabletsCapsules

Ampoules

Suppositories

Adverse events (AEs)Adverse events (AEs)

• Most common reported AEs: headache, nausea, vomiting, dizziness and somnolence

Moore RA, McQuay HJ. Pain 1997

Opioids

TERMINOLOGY TERMINOLOGY

• Opiates are drugs derived from opium,

• Opioid applies to substances with morphine-like activity• Endorphin is endogenous opioid peptides.

CLASSIFICATION OF OPIOIDSCLASSIFICATION OF OPIOIDS

• There are alternative classifications

Agonist A drug that, when bound to the receptor, stimu lates the receptor to the maximum level; by defi nition the intrinsic, .activity of a full agomstis unity.

Morphine

Antagonist A drug that, when bound to the receptor, fails completely to produce any stimulation of that receptor; by definition, the intrinsic activity of a pure antagonist is zero.

Naloxone

Partial agonist A drug that, when bound to the receptor, stimu lates the receptor to a level below the maxi mum level; by defini tion the intrinsic, . activity of a partIal ago nist lies between zero and unity.

Buprenorphine (partial mu agonist)

Mixed agonist antagonist

A drug that acts simulta neously on different subtypes, with the potential for agonist action on one or more subtypes and antago nist action on one

or more subtypes

Nalbuphine (partial mu agonist, kappa agonist, delta antagonist)

Transdermal therapeutic systems

Advantages– constant blood levels– long duration of effect– avoidance of the gastrointestinal tract (no first-pass

effect)– high patient compliance

Disadvantages– risk of dermal irritation

MORPHINEMORPHINE

• Oldest ,safe .• Water soluble , works longer.• No upper limit to dose.• Metabolized by liver and extra hepatic site ,excreted by

kidney.• Metabolite M6G very potent. • Causes respiratory depression, nausea, vomiting,pruritus

and urinary retention

DemerolDemerol

• Most commonly used opioid• 10mg is equal to 1mg of morphine• fat soluble therefore short duration of action.• Metabolite nor meperidine is a potent CNS stimulant.• Side effects same as other opioids.

Therapeutic approaches in side effects of opioid therapy

Therapeutic approachesTherapeutic approaches

HaloperidolOpioid rotation-Ca. 1%Hallucina-tions

AntihistaminesOpioid rotation-Ca. 2%Pruritus

Application close to the spinal cord

Opioid rotationCa. 20%Sedation

Opioid rotationAnti-emeticsCa. 30%Nausea/ vomiting

Change the mode of administration

Laxatives- Ca. 95%Constipation

Second stepFirst stepToleranceIncidenceSide-effect

Co AnalgesicsCo Analgesics

Classification

– Anticonvulsantants – Antideperssants – Muscle relaxants– Clonidine – Corticosteroids– Local Anesthetics– Sedatives

Methods of Acute Postoperaive Pain Methods of Acute Postoperaive Pain ReliefRelief

Methods of Acute Postoperaive Pain ReliefMethods of Acute Postoperaive Pain Relief

• Intramuscular

• Intravenous - Intermittent Bolus

• Intravenous-Continuous Infusion

• Patient Control Analgesia (PCA)

• Epidural analgesia

• Peripheral Blocks

POSTOPERATIVE PAIN MANAGEMENT

POSTOPERATIVE PAIN MANAGEMENTPOSTOPERATIVE PAIN MANAGEMENT

• Pain management continues to be a challenge to anaesthetist .

• PCA ; epidural and nerve block are advance in analgesia that may assist this challenge.

• Post op Pain management can be evaluated in terms of its ability to meet 2 main goals:

To relieve postoperative pain. To relieve patient of inhibition of respiratory

movement without sedation.

IMPORTANCE OF POSTOPERATIVE IMPORTANCE OF POSTOPERATIVE ANALGESIAANALGESIA

• Pain relief is desirable not only for humane and moral reasons,but also because

pain relief improves the patients physiological and psychological status

• 3. Number?: What is the severity of the pain?

0 1 2 3 4 5 6 7 8 9 10

Visual analog scale -

Numerical intensity scale -

Descriptive intensity scale -

No pain Mild painModerate

painSevere

painWorst possible

pain

No painPain as bad as it could possibly be

Pain Assessment: the 6 N’sPain Assessment: the 6 N’s

11 of 16

Pain Intensity Rating ScalesPain Intensity Rating Scales

• Pain Faces Scale

00

No No hurthurt

22

Hurts Hurts just a just a

little bitlittle bit

44

Hurts a Hurts a little bit little bit moremore

66

Hurts Hurts even even moremore

88

Hurts a Hurts a whole whole

lotlot

1010

Hurts as Hurts as much as much as you can you can imagineimagine

• Brief Pain Inventory

Shade areas of worst painShade areas of worst pain

Put an X on area that hurts mostPut an X on area that hurts most

(Cleeland, 1991; Wong et al, 2001)

Pre-emptive analgesiaPre-emptive analgesia

The administration of analgesic agents prior to an injury in order to prevent development of central nervous system hyperexcitability or

sensitization

PATIENT CONTROLLED ANALGESIAPATIENT CONTROLLED ANALGESIA

• PCA is based on the belief that patients are the best judges of their pain.

• They should be allowed an active role in controlling their pain.

PCAPCA

• PCA are modified infusion pumps that allow patient to self administer a small dose of opioid when pain is present , thus allowing patients to titrate their level of analgesia against the amount of pain they are experiencing.

PCAPCA

• PCA is well tolerated.• Offer flexibility in dose size and dose interval in individual

patients.• Therapeutic serum level can be reached relatively quickly

because the drug is administered into the vascular system directly.

PCAPCA

• Patient can secure an early therapeutic serum level with repeated doses titrated to individual pain needs.

• A steady state plasma level occurs because the elimination of the drug from the plasma is balanced by the

patients self administered drug injection.

Relationship of mode of delivery of analgesia to serum Relationship of mode of delivery of analgesia to serum analgesic levelanalgesic level

• IM and IV PCA

PCAPCA

• PCA allows patient control over their pain and therefore gives greater satisfaction.

• PCA also eliminates the lag time between pain sensation and administration of analgesia.

PAIN CYCLE

I.M PRN ANALGESIA

PATIENT FEELS PAIN

Nurse Screen

Meds PreparedI.M Given

Calls Nurse

Drug Absorbed

Sedation

PAIN CYCLE

I.M PRN ANALGESIA

PATIENT FEELS PAIN

Nurse screen

Meds preparedI.M Given

Calls Nurse

absorbed

Sedation

BENEFITSBENEFITS

• Decreased nursing time• Increased patient satisfaction.• Used in a variety of medical and post-op surgical

conditions.• Decreased narcotic usage.• Decreased level of sedation.• Earlier ambulation.

BENEFITSBENEFITS

• Decreased overall pain scores reported by patients.• Increased compliance to post op care.• Less anxiety.• More autonomy regarding pain control.• Improved rest and sleep pattern

PCA FEATURES.PCA FEATURES.

• Drug concentration.• Drug reservoir volume.• Demand dose-amount patient will receive each time patient self

administer.• Delay(lockout)-period of time no drug is available to the demand

button.• Basal-continuous infusion of drug/hour,is optional.

DRUG CONCENTRATIONSDRUG CONCENTRATIONS

• Morphine =1mg/1ml. (0.1 -0.2 mg/kg).

• Tramadol =10mg/1ml. (1-2 mg/kg ).

• Fentanyl = 10 mcg/1ml. (10 mcg/kg).

• Demerol = 10mg/1ml. (1-2 mg/kg).

Epidural AnalgesiaEpidural Analgesia

INSERTION OF EPIDURAL CATHETERINSERTION OF EPIDURAL CATHETER

• The site is dependent upon the area of pain• Fixing the catheter

Incision LevelThoracic T4-T6

Upper abdo T6-T8

Lower abdo T8-T10

Pelvic T8-T10

Lower extremity L1-L4

MEDICATION COMMONLY USEDMEDICATION COMMONLY USED

• OPIOIDS-Fentanyl +Morphine

(affect the pain transmission at the

opioid receptors)

• L.A.-Bupivacaine(marcaine)

(inhibits the pain impulse

transmission in the nerves with

which it comes in contact)

Epidural AnalgesiaEpidural Analgesia

• Mode of administration– intermittent opioid bolus– PCA opioid– continuous infusion - LA+opioid

• Advantages– most effective analgesia– systemic effect of opioid minimal– pre-empty analgesia– reduce incidence of thromboembolism

Epidural Analgesia - Side EffectsEpidural Analgesia - Side Effects

• From the technique– dural puncture– epidural haematoma– epidural abscess– nerve root trauma

• From LA– hypotension– paraesthesia– motor weakness

• From opioid– delay resp depress– urinary retention– pruritus

Caudal AnaesthesiaCaudal Anaesthesia

Brachial Plexus BlockBrachial Plexus Block

IVRA (BIER’S BLOCK)IVRA (BIER’S BLOCK)