Acute Pain Management

Parisa Partownavid, MDAssistant Clinical Professor

David Geffen School of Medicine at UCLADepartment of Anesthesia

Definition of Pain

An Unpleasant Sensory and An Unpleasant Sensory and Emotional Experience Associated Emotional Experience Associated

with Actual or Potential Tissue with Actual or Potential Tissue Damage, or Described in Terms of Damage, or Described in Terms of

Such Damage. Such Damage.

Acute Pain

Pain in Perioperative SettingPain in Perioperative Setting Pain in Patients with Severe or Pain in Patients with Severe or

Concurrent Medical Illnesses Concurrent Medical Illnesses (Pancreatitis)(Pancreatitis)

Acute Pain Related to Cancer or Acute Pain Related to Cancer or Cancer TreatmentCancer Treatment

Labor PainLabor Pain

Acute Perioperative Pain

Pain that is Present in a Pain that is Present in a Surgical Patient Because of Surgical Patient Because of

Preexisting Disease, the Preexisting Disease, the Surgical Procedure, or a Surgical Procedure, or a

Combination of BothCombination of Both

Importance of Pain Management Adequate Pain ControlAdequate Pain Control Reduce the Risk of Adverse OutcomesReduce the Risk of Adverse Outcomes Maintain the Patient’s Functional Maintain the Patient’s Functional

Ability, as well as Psychological Well-Ability, as well as Psychological Well-beingbeing

Enhance the Quality of LifeEnhance the Quality of Life Shortened Hospital Stay and Reduced Shortened Hospital Stay and Reduced

CostCost

Adverse Outcomes Associated with Management of Acute Pain Respiratory DepressionRespiratory Depression Circulatory DepressionCirculatory Depression Sedation Sedation Nausea and VomitingNausea and Vomiting PruritusPruritus Urinary RetentionUrinary Retention Impairment of Bowel FunctionImpairment of Bowel Function

Adverse Outcome of Undertreatment of Acute Pain

Thromboembolic or Pulmonary Thromboembolic or Pulmonary ComplicationsComplications

Needless SufferingNeedless Suffering Development of Chronic PainDevelopment of Chronic Pain

The Incidence of Moderate to The Incidence of Moderate to Severe Pain with Cardiac, Severe Pain with Cardiac,

Abdominal, and Orthopedic Abdominal, and Orthopedic Inpatient Procedures has been Inpatient Procedures has been

Reported as High as 25%-Reported as High as 25%-50%, and Incidence of 50%, and Incidence of

Moderate Pain after Moderate Pain after Ambulatory Procedures is Ambulatory Procedures is

25% or Higher. 25% or Higher.

Goal

Pain Management Interventions Pain Management Interventions Should be Offered Around the Should be Offered Around the ClockClock

Pain Management is to Provide Pain Management is to Provide Continuous Pain ReliefContinuous Pain Relief

Patient Should be Assessed for Patient Should be Assessed for Adequacy of Pain ControlAdequacy of Pain Control

Preoperative Evaluation of the Patient

Type of SurgeryType of Surgery Expected Severity of Postoperative Expected Severity of Postoperative

PainPain Underlying Medical Condition Underlying Medical Condition

(Respiratory or Cardiac Disease)(Respiratory or Cardiac Disease)

Preoperative Preparation of the Patient Adjustment or Continuation of Adjustment or Continuation of

Medications (Sudden Cessation Medications (Sudden Cessation may Provoke a Withdrawal may Provoke a Withdrawal Syndrome)Syndrome)

Treatment to Reduce Preexisting Treatment to Reduce Preexisting Pain and AnxietyPain and Anxiety

Patient and Family EducationPatient and Family Education

Pain Assessment Tools

Pain Assessment Tools

In Adults: Self Report Measurement In Adults: Self Report Measurement Scales, such as Numerical ScalesScales, such as Numerical Scales

Pain Assessment Tools

In Pediatric Patients:In Pediatric Patients: Physiologic and Behavioral Physiologic and Behavioral

Indicators of Pain ( Infants, Indicators of Pain ( Infants, Toddlers, Nonverbal or Critically Toddlers, Nonverbal or Critically Ill Children)Ill Children)

Face Scale (Age 3-10 yrs)Face Scale (Age 3-10 yrs) Visual Analogue Scales (Age 10-Visual Analogue Scales (Age 10-

18)18)

Management of Acute Pain

Pharmacologic Pharmacologic InterventionalInterventional

Pharmacologic Management Alter Nerve Conduction (Local Alter Nerve Conduction (Local

Anesthetics)Anesthetics) Modify Transmission in the Dorsal Modify Transmission in the Dorsal

Horn (Opioids, Antidepressants) Horn (Opioids, Antidepressants)

Routes of Administration POPO PRPR IV IV IMIM TransdermalTransdermal TransmucosalTransmucosal EpiduralEpidural IntrathecalIntrathecal

Opioid Analgesics

Bind to Opioid Receptors: Bind to Opioid Receptors: Mu, Delta and KappaMu, Delta and Kappa

Morphine, Hydromorphone, Morphine, Hydromorphone, Meperidine, Fentanyl, Codeine, Meperidine, Fentanyl, Codeine, Methadone, Oxycodone, Hydrocodone, Methadone, Oxycodone, Hydrocodone, TramodolTramodol

Opioids may be Combined with NSAIDs Opioids may be Combined with NSAIDs to Enhance the Opioid Analgesic Effectto Enhance the Opioid Analgesic Effect

Opioid Analgesics

Equianalgesic Conversion Charts Equianalgesic Conversion Charts are used when Converting form one are used when Converting form one Opioid to Another, or Converting Opioid to Another, or Converting from Parenteral to Oral Formfrom Parenteral to Oral Form

Respiratory Monitors may be Used Respiratory Monitors may be Used Depending on the Patients Age, Co-Depending on the Patients Age, Co-existing Medical Problems, or Route existing Medical Problems, or Route of Opioid Administered of Opioid Administered

Opioid Analgesics

Conversions: MorphineConversions: Morphine

OralOral Parenteral Epidural Parenteral Epidural Intrathecal Intrathecal

300300 100100 10 10 11

Opioids

DrugDrug PO PO mgmg

IV IV mgmg

Starting Starting Oral Dose Oral Dose mgmg

CommentsComments

MorphineMorphine 3030 1010 15-3015-30 MS Contin, Release 8-12 MS Contin, Release 8-12 hrshrs

MSIR for BTPMSIR for BTP

Hydro-Hydro-morphonmorphonee

7.57.5 1.51.5 4-8 4-8 Duration Slightly Shorter Duration Slightly Shorter than Morphine than Morphine

MeperidinMeperidinee

303000

7575 Duration Slightly Shorter Duration Slightly Shorter than Morphine than Morphine

Normeperidine Causes Normeperidine Causes CNS ToxicityCNS Toxicity

MethadoMethadonene

2020 1010 5-10 Qd5-10 Qd Long Half-Life, 24-36 hrsLong Half-Life, 24-36 hrs

Accumulates on Days 2-3Accumulates on Days 2-3

FentanylFentanyl 0.02-0.02-0.050.05

Fentanyl Patch, 12 hrs Fentanyl Patch, 12 hrs Delay Onset and OffsetDelay Onset and Offset

Opioids

DrugDrug PO mgPO mg CommentsComments PrecautioPrecautionsns

CodeineCodeine 30-6030-60 Combined With Combined With Nonnarcotic AnalgesicsNonnarcotic Analgesics

Maximal Dose Maximal Dose for for Acetaminophen Acetaminophen 4gm/d4gm/d

OxycodonOxycodonee

5-105-10 PercocetPercocet

PercodanPercodan

Oxycodone 10-30mg Q Oxycodone 10-30mg Q 4h4h

Oxycontin 10mg Q 12hOxycontin 10mg Q 12h

Acetaminophen Acetaminophen or Aspirin or Aspirin toxicitytoxicity

Hydro-Hydro-codonecodone

5-105-10 Vicodin or LortabVicodin or Lortab Acetaminophen Acetaminophen ToxicityToxicity

TramodolTramodol 50-100 50-100 Q4-6hrQ4-6hr

Central Acting, Affinity Central Acting, Affinity for Mu Receptorsfor Mu Receptors

Maximal Dose Maximal Dose 400 mg/d400 mg/d

Patient Controlled Analgesia Small Doses of Analgesic Drug (Usually Small Doses of Analgesic Drug (Usually

Opioids), are Administered (IV) by PatientOpioids), are Administered (IV) by Patient Allows Basal Infusion and Demand Allows Basal Infusion and Demand

BolusesBoluses Over Dosage is Avoided Over Dosage is Avoided

by Limiting the Amount by Limiting the Amount

and Number of Boluses and Number of Boluses

in a Set Period of Timein a Set Period of Time

Dose Regimens for PCA

DrugDrug Bolus Dose Bolus Dose (mg)(mg)

Lock-Out Lock-Out (Minutes)(Minutes)

MorphineMorphine 0.5-20.5-2 5-155-15

HydromorphonHydromorphonee

0.1-0.20.1-0.2 5-105-10

FentanylFentanyl 0.01-0.020.01-0.02 5-105-10

Non-Opioid Analgesics

AcetaminophenAcetaminophen NSAIDs (Aspirin, Ibuprofen, NSAIDs (Aspirin, Ibuprofen,

Ketorolac, Ketorolac,

COX-2 Inhibitors)COX-2 Inhibitors) Lidocaine Patch (Lidoderm)Lidocaine Patch (Lidoderm)

NSAIDs

Relieve of Mild to Moderate PainRelieve of Mild to Moderate Pain Complication: Complication:

GI DiscomfortGI Discomfort GI Bleeding (Inhibition of COX-1)GI Bleeding (Inhibition of COX-1) NephrotoxicityNephrotoxicity Inhibition of Platelet Aggregation Inhibition of Platelet Aggregation OsteogenesisOsteogenesis

Ketorolac

Potent AnalgesicPotent Analgesic Parenteral (IV or IM)Parenteral (IV or IM) 15-30 mg Q 6hr15-30 mg Q 6hr Patients Older than 16 yrsPatients Older than 16 yrs Should not Exceed 5 daysShould not Exceed 5 days

Cox-2 Inhibitors

DrugDrug DoseDose

Celecoxib (Celebrex)Celecoxib (Celebrex) 100-200mg PO Bid100-200mg PO Bid

Rofecoxib (Vioxx)Rofecoxib (Vioxx)

Valdecoxib (Bextra)Valdecoxib (Bextra) 10-20mg PO Qd10-20mg PO Qd

ParecoxibParecoxib 20-40mg IM20-40mg IM

20-100mg IV20-100mg IV

Lidoderm

Lidoderm

5% Lidocaine Patch5% Lidocaine Patch Indicates for Pain Relief in Post-Indicates for Pain Relief in Post-

herpetic Neuralgiaherpetic Neuralgia Each Patch Contains 700 mg of Each Patch Contains 700 mg of

LidocaineLidocaine Should be Applied to Intact SkinShould be Applied to Intact Skin About 3% is AbsorbedAbout 3% is Absorbed 1-3 Patches Once a Day for 12 hrs1-3 Patches Once a Day for 12 hrs

Interventional Management

Epidural Analgesia (Continuous Epidural Analgesia (Continuous Lumbar or Thoracic Epidural Lumbar or Thoracic Epidural Catheter Placement, PCEA)Catheter Placement, PCEA)

Spinal AnalgesiaSpinal Analgesia Peripheral Nerve Block ( Single Peripheral Nerve Block ( Single

Shot or Continuous)Shot or Continuous)

Anatomy of Epidural Space

Surrounds the Dural Surrounds the Dural

SacSac Anteriorly: Post. Anteriorly: Post.

Long. LigamentLong. Ligament Posteriorly: Posteriorly:

Ligamentum FlavumLigamentum Flavum Laterally: Pedicles and Laterally: Pedicles and

Intervertebral ForaminaIntervertebral Foramina

Anatomy of Epidural Space

AP Dimension of the Epidural AP Dimension of the Epidural Space is Largest in the Lumbar Space is Largest in the Lumbar Region, 5-6 mm Region, 5-6 mm

In Thoracic Region the AP In Thoracic Region the AP Dimension Decreases but the Dimension Decreases but the Space is More Continuous Space is More Continuous

                    

          MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE

Epidural Anesthesia

Anesthestizes the Emerging Nerve Anesthestizes the Emerging Nerve Roots of the Spinal CordRoots of the Spinal Cord

Epidural Injection of Anesthetic Epidural Injection of Anesthetic Produces a Regional Dermatomal Produces a Regional Dermatomal “band” of Anesthesia Spreading “band” of Anesthesia Spreading Cephalad and Caudad from the Site of Cephalad and Caudad from the Site of InjectionInjection

Level of Anesthesia Depends on :Level of Anesthesia Depends on : Volume of the DrugVolume of the Drug Level of InjectionLevel of Injection

Epidural Anesthesia

Lumbar Epidural: Lower Extrimity, Lumbar Epidural: Lower Extrimity, Pelvic, and Lower Abdominal Pelvic, and Lower Abdominal ProceduresProcedures

Thoracic Epidural: Upper Abdomen Thoracic Epidural: Upper Abdomen and Thoracic Proceduresand Thoracic Procedures

Caudal Injection: More Commonly Caudal Injection: More Commonly Used for Pediatric Patients Used for Pediatric Patients (Genitourinary and Lower (Genitourinary and Lower Abdominal Procedures)Abdominal Procedures)

Advantages Superior Pain ReliefSuperior Pain Relief Less Systemic Side EffectsLess Systemic Side Effects Lower Incidence of DVT and Pulmonary EmboliLower Incidence of DVT and Pulmonary Emboli Decrease Blood Loss Intraoperatively during Decrease Blood Loss Intraoperatively during

Orthopedic, Urologic, Gynecologic and Obstetric Orthopedic, Urologic, Gynecologic and Obstetric ProceduresProcedures

More Rapid Recovery of Bowel FunctionMore Rapid Recovery of Bowel Function Earlier AmbulationEarlier Ambulation Better PFTBetter PFT Suppression of Neuroendocrine Stress ResponseSuppression of Neuroendocrine Stress Response Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative

Outcome. Anesthesiol Clin North America 01-JUN-2000; 18(2): 407-28Outcome. Anesthesiol Clin North America 01-JUN-2000; 18(2): 407-28

Contraindications

AbsoluteAbsolute Patient RefusalPatient Refusal CoagulopathyCoagulopathy Increased ICPIncreased ICP Skin InfectionSkin Infection

RelativeRelative Uncooperative Uncooperative

Patient Patient Pre-existing Pre-existing

Neurologic Neurologic DisorderDisorder

Anatomical Anatomical AbnormalitiesAbnormalities

Factors Affecting Epidural Dosage

Patient Factors: Age , Height, Patient Factors: Age , Height, Weight, PregnancyWeight, Pregnancy

Site of InjectionSite of Injection

Drugs Used for Epidural Anesthesia

Local AnestheticsLocal Anesthetics OpioidsOpioids

Local Anesthetics in Epidural Space

Lidocaine: 1-2% , 45-90 min.Lidocaine: 1-2% , 45-90 min. Bupivacaine: 0.25-0.5% , 90-120 Bupivacaine: 0.25-0.5% , 90-120

min. min.

Opioids in Epidural SpaceDrugDrug DosageDosage Onset Onset

(min)(min)Duration Duration (hrs)(hrs)

MorphineMorphine 2-3 mg2-3 mg 30-9030-90 6-246-24

HydromoHydromor-phoner-phone

0.4-0.8 mg0.4-0.8 mg 20-3020-30 6-186-18

FentanylFentanyl 50-100 50-100 mcgmcg

5-155-15 2-42-4

Hydrophilic Opioids Morphine, Hydromorphone Slow Onset, Long Duration, High CSF Solubility AdvantagesAdvantages Prolonged Single Prolonged Single

Dose AnalgesiaDose Analgesia Thoracic Analgesia Thoracic Analgesia

with Lumbar with Lumbar AdministrationAdministration

Minimal Dose Minimal Dose Compared with IV Compared with IV AdministrationAdministration

DisadvantagesDisadvantages Delayed Onset of Delayed Onset of

AnalgesiaAnalgesia Unpredictable Unpredictable

DurationDuration Delayed Respiratory Delayed Respiratory

DepressionDepression

Lipophilic Opioids FentanylRapid Onset, Short Duration, Low CSF Solubility

AdvantagesAdvantages Rapid AnalgesiaRapid Analgesia Ideal for Continuous Ideal for Continuous

Infusion or PCEAInfusion or PCEA

DisadvantagesDisadvantages Systemic AbsorptionSystemic Absorption Brief Single Dose Brief Single Dose

AnalgesiaAnalgesia Limited Thoracic Limited Thoracic

Analgesia with Analgesia with Lumbar Lumbar AdministrationAdministration

PCEA

Technique that Allows Basal Infusion and Technique that Allows Basal Infusion and Demand Boluses into the Epidural SpaceDemand Boluses into the Epidural Space

Solutions Used:Solutions Used:

Local Anesthetics: 0.05-0.125%Local Anesthetics: 0.05-0.125% Bupivacaine Bupivacaine

Opioids: Morphine 50 mcg/mlOpioids: Morphine 50 mcg/ml

Hydromorphone 10 mcg/mlHydromorphone 10 mcg/ml

Fentanyl 2-5 mcg/mlFentanyl 2-5 mcg/ml

Complications of Epidural Analgesia

Failure of Block (Patchy or Unilateral Failure of Block (Patchy or Unilateral Block)Block)

Injury to NerveInjury to Nerve InfectionInfection Epidural Hematoma or AbscessEpidural Hematoma or Abscess Dural Puncture (Total Spinal or PDPH)Dural Puncture (Total Spinal or PDPH)

Complications of Epidural Analgesia

Side Effect of Drugs in Epidural SpaceSide Effect of Drugs in Epidural Space

- Hypotension Secondary to Sympathetic - Hypotension Secondary to Sympathetic BlockadeBlockade

- Intravascular Injection (Local Anesthetic - Intravascular Injection (Local Anesthetic Toxicity) Toxicity)

- Respiratory Depression- Respiratory Depression

- Sedation- Sedation

- Bladder Distention- Bladder Distention

- - Difficulty in AmbulationDifficulty in Ambulation

Spinal Anesthesia

Spinal Anesthesia is Induced by Spinal Anesthesia is Induced by Injecting Small Amount of Local Injecting Small Amount of Local Anesthetic (Bupivicaine) in the CSFAnesthetic (Bupivicaine) in the CSF

Results in Rapid Onset of BlockResults in Rapid Onset of Block More Rapid Onset and Requiring More Rapid Onset and Requiring

less Medicine Compared to less Medicine Compared to Epidural AnalgesiaEpidural Analgesia

Spinal Anesthesia

CSE, Used in LaborCSE, Used in Labor Preservative Free Morphine Preservative Free Morphine

(Duramorph) Provides Pain Relief (Duramorph) Provides Pain Relief for Abdominal, Pelvic, or Lower for Abdominal, Pelvic, or Lower Extrimity SurgeriesExtrimity Surgeries

Complications Similar to Epidural Complications Similar to Epidural Technique Except for Higher Risk Technique Except for Higher Risk of PDPHof PDPH

Peripheral Nerve Block

Anesthetizing the Nerve that is Anesthetizing the Nerve that is Innervating Surgical or Painful AreaInnervating Surgical or Painful Area

Single Shot or Continuous Infusion Single Shot or Continuous Infusion through Catheterthrough Catheter

Upper Extrimity: Brachial Plexus, Upper Extrimity: Brachial Plexus, Median, Ulnar or Radial NerveMedian, Ulnar or Radial Nerve

Peripheral Nerve Block

Lower Extrimity: Sciatic, Femoral, Lower Extrimity: Sciatic, Femoral, Posterior Tibial, Sural, Saphenous, Posterior Tibial, Sural, Saphenous, Deep and Superficial Peroneal Deep and Superficial Peroneal Nerve Nerve

Intercostal Nerve Block Intercostal Nerve Block Surgical Wound Infiltration of Local Surgical Wound Infiltration of Local

AnestheticAnesthetic

Acute Pain Management for Pediatric Patients

Consider Physiologic and Anatomic Consider Physiologic and Anatomic DifferencesDifferences

Pain Assessment and Pain Assessment and CommunicationCommunication

Pain and Anxiety Associated with Pain and Anxiety Associated with Minor Procedures or Unfamiliar Minor Procedures or Unfamiliar SituationsSituations

Caudal Block

Single Injection or Continuous Infusion Single Injection or Continuous Infusion through a Catheterthrough a Catheter

Excellent Intraoperative and Excellent Intraoperative and Postoperative Pain ControlPostoperative Pain Control

Easier to Perform in ChildrenEasier to Perform in Children Analgesia that Last About 12 hrs if Analgesia that Last About 12 hrs if

Bupivacaine UsedBupivacaine Used Performed Following Induction of Performed Following Induction of

General AnesthesiaGeneral Anesthesia

Indications for Caudal Block Surgeries in Sacral Segments, Surgeries in Sacral Segments,

(Circumcision and other Urologic (Circumcision and other Urologic Surgeries, Rectal Dilation)Surgeries, Rectal Dilation)

Combined with Light General Combined with Light General Anesthesia Provides Adequate Anesthesia Provides Adequate Intraoperative AnalgesiaIntraoperative Analgesia

Complications of Caudal Block InfectionInfection Dural Puncture and Spinal Dural Puncture and Spinal

AnesthesiaAnesthesia Intravascular Injection of Local Intravascular Injection of Local

AnestheticsAnesthetics

Acute Pain Management in Elderly Patient Population Older than 65 yrs Patient Population Older than 65 yrs

of Age is Growingof Age is Growing Age Related Physiologic Changes Age Related Physiologic Changes

(Decreased Muscle Strength): (Decreased Muscle Strength): Decreased CoughDecreased Cough

Decreased Mental Status Decreased Mental Status (Dementia): Decreased Narcotic (Dementia): Decreased Narcotic DoseDose

Acute Pain Management in

Elderly

Age Related Anatomic Changes: Age Related Anatomic Changes: Difficulty in Placing Epidural Difficulty in Placing Epidural CatheterCatheter

Multiple Drug Therapy: Withdrawal Multiple Drug Therapy: Withdrawal or Interaction with Other Drugsor Interaction with Other Drugs