Pain lecture for icu club meeting

RAVINDAR BETHIAL RASS GENERAL HOSPITAL

PAIN MANAGEMENT

PAIN MANAGEMENT

• What is pain ?

• What causes pain ? • How to classify and measure the pain ?• How to treat the pain ?

PAIN MANAGEMENT

• What are the systemic effects of pain ?

• What is the cause of this pain ? • How can this pain be classified ?• How to address and treat this pain ?

Howthe treatment of pain

Is so important ?

• What is pain ?

• What causes pain ? • How to classify and measure the pain ?• How to treat the pain ?

• What are the systemic effects of pain ?

• What is the cause of this pain ? • How can this pain be classified ?• How to address and treat this pain ?

PAIN

Pain is an unpleasant

sensory and emotional experience

associated with actual or potential tissue damage

or described in terms of such

damage

The International Association for the Study of Pain

PAIN

associated with

tissue damage actual or potential

PAIN an unpleasant experience

emotionalsensory

described in terms of such

damage

Pain is an unpleasant

sensory and emotional experience

associated with actual or potential tissue damage

or described in terms of such

damage


actual or potential

PAINPain is

an unpleasant sensory and emotional

experience associated with

actual or potential tissue damage or

described in terms of such damage


PAINPain is

an unpleasant sensory and emotional

experience associated with

actual or potential tissue damage or

described in terms of such damage


isU S E E

UNPLEASANTSENSORY &EMOTIONALEXPERIENCE

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Anatomy and physiology

STIMULUS


RECEPTIONSTIMULUS


RECEPTION

TRANSMISSI

ON

STIMULUS


RECEPTION

TRANSMISSI

ON

INTERPRETATION

STIMULUS


PHYSICAL

PHYSICAL

EMOTIONAL

EMOTIONAL

PHYSICAL RATIONAL

PHYSICAL

EMOTIONAL

IMPORTANT• Pain can manifest without physical

component

• This type of pain too deserves the same attention, evaluation and treatment

PHYSICAL RATIONAL

• GATE CONTROL THEORY

TYPES OF PAIN

TYPES OF PAIN

ACUTE PAIN

• Usually related an identifiable event or condition• resolves in days/weeks• usually nociceptive

• Needs anxiolytics

CHRONIC PAIN

http://en.wikipedia.org/wiki/File:Clock_in_Kings_Cross.jpg

TYPES OF PAIN

ACUTE PAIN CHRONIC PAIN



• May/may not be related an identifiable event or condition• Persists for an indefinite period• usually multifactorial

• Needs antidepressants


TYPES OF PAIN







TYPES OF PAIN







NEUROPATHIC PAIN

TYPES OF PAIN

NOCICEPTIVE PAIN

SOMATIC VISCERAL

TYPES OF PAIN

NOCICEPTIVE PAIN

SOMATIC VISCERAL

TYPES OF PAIN

NOCICEPTIVE PAIN

• Involves skin, soft tissues, muscle, bone etc• stimulation of somatic nerves

• Sharp , aching, throbbing• Easily localized

SOMATIC VISCERAL

TYPES OF PAIN

NOCICEPTIVE PAIN



• Involves viscera-heart, lung, GIT, GUT• stimulation of autonomic nerves

• Gripping, vague aching• Difficult to localize and often referred

SOMATIC VISCERAL

TYPES OF PAIN

NOCICEPTIVE PAIN




• Gripping, vague aching• Difficult to localize, often referred

SOMATIC VISCERAL

TYPES OF PAIN

NOCICEPTIVE PAIN




• Gripping, vague aching• Difficult to localize, often referred

NEUROPATHIC PAIN

TYPES OF PAIN

• Burning, Shooting• Tingling, Numbing• Electrical shock like

Intensity exceeding the observable injury

NEUROPATHIC PAIN

TYPES OF PAIN

Cancer in vicinity of nerves

• Compression• Traction• Infiltration• Ischemia

NEUROPATHIC PAIN

TYPES OF PAIN

Cancer infiltration of nerves

Post herpeticneuralgia


NEUROPATHIC PAIN

TYPES OF PAIN

Cancer infiltration of nerves


Post herpeticneuralgia

Phantom limb

NEUROPATHIC PAIN

TYPES OF PAIN • Opioids + Analgesics

• Antidepressants• Anticonvulsants• Anti arrhythmics

• Nerve blocks, • Neurolysis, resections

NEUROPATHIC PAIN




PAIN ASSESSMENT - RGH• Frequency• Intensity• Location• Exclusive Quality• Since when ?

NEUROPATHIC PAIN




PAIN ASSESSMENT - RGH• Frequency• Intensity• Location• Exclusive Quality• Since when ?

MEASURING THE PAIN INTENSITYPAIN CAN NOT BE SEEN

BUT CAN BE SHOWN


BUT CAN BE SHOWN


BUT CAN BE SHOWN

• Hospital reception areas• Nursing stations

VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE

5/10

3/10

9/10


5/10

3/10

9/10

HOW OFTEN ?• On admission• On change of every shift• After every procedure• After analgesic medication


5/10

3/10

9/10

HOW MUCH TIME AFTER ANALGESIC ?• 15 min after iv• 30 minutes after IM/SC• 60 minutes after oral • according to manufacturer’s recommendations


5/10

3/10

9/10

HOW OFTEN ?• ON ADMISSION• ON CHANGE OF EVERY SHIFT• AT EVERY PROCEDURE• AFTER MEDICATION


5/10

3/10

9/10

Signs of inadequate pain relief• Continuing pain > 4/10• Inability to concentrate• Inability to perform the activities of daily living• Tachycardia/HTN• Tachypnea /inadequate respiration


5/10

3/10

9/10

Signs of analgesic overdosing• Decreased LOC unresponsiveness• Bradycardia• Decreased rate of respiration• Shallow respiration• Pinpoint pupils

RELIEF OF PAIN

What first ?TO DIAGNOSE THE CONDITION

VS TREATMENT OF PAIN

SYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN• Neuro-endocrine stress

response

• Respiratory restriction in abdomino-thoracic surgeries

• Moderate to severe pain, regardless of the site, can affect every organ function and may adversely affect th post operative morbidity and mortality

SYSTEMIC EFFECTS OF PAIN


response



CHRONIC PAIN• CARDIO-VASCULAR

• Tachycardia, HTN• Myocardial irritability• Increased SVR• O2 demand/supply

imbalance MI• RESPIRATORY

• Oxygen demand• CO2 production• Atelectasis due to

prolonged bed rest• GIT & URINARY SYSTEM

• Ileus• Urinary retention



response



CHRONIC PAIN• ENDOCRINE

• Catecholamines • Neg N2 balance• Carbohydrate intolerance

• Renin-angiotensin, aldosterone• Sodium & water retention

• HEMATOLOGICAL• Platelet adhesiveness• Reduced0fibrinolysis hypercoagulability

• IMMUNE SYSTEM• Lymphopenia depressed

RE systeminfection


RELIEF OF PAIN

ACETAMINOPHEN AND NSAIDS

CEILING EFFECTHEPATO AND RENAL TOXICITY

RELIEF OF PAIN

OPIOIDS• ACT ON IOPIATE RECEPTORS

• FEARS AND MYTHS ABOUT DEPENDANCE AND ADDITION

• HEPATIC – RENAL CLEARANCE

• ORAL• PARENTERAL• SKIN PATCHES

RELIEF OF PAIN HOW OFTEN ?

• Duration of action• Formulation

• What is PRN ?• What is break though pain ?





PCA



RELIEF OF PAIN

ADJUVANTS• Anxiolytics• Antidepressants• Anticonvulsants• Anti-arrhythmics

Adjuvants for local anesthetic interventions

• Narcotics• Clonidine

RELIEF OF PAIN

PHYSICAL THERAPY

RELIEF OF PAIN

PHYSICAL THERAPY

RELIEF OF PAIN

PHYSICAL THERAPY

RELIEF OF PAIN

ACUPUNCTURE

RELIEF OF PAIN

INTERVENTIONAL PROCEDURES

RELIEF OF PAIN


RELIEF OF PAIN


RELIEF OF PAIN


RELIEF OF PAIN


RELIEF OF PAIN


RELIEF OF PAIN


RELIEF OF PAIN

• All related medical specialists

• Nurses• Social workers• Pharmacists• Religious affairs• Physiotherapists• Occupational

therapists• Child life specialists

PAIN TEAM

WHO PAIN RELIEF LADDER

1

2

3

MILD

MODERATE

SEVERE


1

2

3

MILD

MODERATE

SEVERE


NON-OPIOD + ADJUVANT

1

2

3

MILD

MODERATE

SEVERE



OPIOD

1

2

3

MILD

MODERATE

SEVERE




OPIOD


OPIOD

1

2

3

MILD

MODERATE

SEVERE




OPIOD


OPIOD

1

2

3

MILD

MODERATE

SEVERE


FREEDOM FROM CANCER PAIN



OPIOD


OPIOD

1

2

3

MILD

MODERATE

SEVERE


FREEDOM FROM CANCER PAIN

PAIN IS VERY OFTEN POORLY TREATED

PAIN IS VERY OFTEN POORLY TREATED

BARRIERS• Lack of knowledge and

commitment• Myths about addiction • Other barriers• Patient related• System related• Profession related

TAKE HOME MESSAGE

• Pain is one of the vital signs

• Pain by itself needs to be addressed

• Pain is a team approach

• Commit yourself for giving pain relief

day to day

THANK YOU

Health & Medicine

Pain lecture for icu club meeting