Pain!!!!!
Dr. Mridul M. Panditrao      CONSULTANTDEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE            RAND MEMORIAL HOSPITAL  ...
Pain            A universal problem!   For eternity, it has plagued mankind Till 18th century there was nothing!          ...
AGE OF DARKNESS   NO ANALGESIA  NO ANAESTHESIANO DEFINED SURGERY“AGONY GALORE!!!”
BARBARIC PRACTICESWOODEN BOWL & WOODEN HAMMER”    PARTIAL STRANGULATION “WHISKY BOTTLE: ½ YOU & ½ ME”     MAGIC & WITCH-CR...
METHODS OF PAIN RELIEF
“ DAWN OF ANALGESIA ”FREDERICH SERTURNER:1806                MORPHINE“LAUGHING GAS ” PARTIES & HORACE WELLS : Dec. 10, 1...
SWEET OIL OF VITRIOL    (“WHIFF OF ETHER”)          16TH OCTOBER 1846    William Thomas Greene MORTONUSHERING IN OF “ ERA ...
“GOOD OUT OF BAD”  LEAF CHEWING NATIVES OF ANDIES   (PERU & BOLIVIA): “NUMBNESS OF               MOUTH”           COCAINE ...
“MORPHINE & COMPANY”• NEWER OPIOIDS: FENTANYL….• “NEURO-LEPT ANAESTHESIA”• ENDOGENOUS OPIOIDS:      ENDORPHINES, ENCEPHALI...
INTRODUCTIONFor All The Happiness  Mankind can gain.  Is not in pleasureBut in rest from “pain”               JOHN DRYDEN
INTRODUCTION (Contd.)                MAGNITUDE Of PROBLEM      Millions of Post-op pts : 48-53% unrelieved      Moderate...
INTRODUCTION (Contd.)Nociception: Transduction                Transmission                     Modulation                 ...
INTRODUCTION (Contd.)“Reynolds Theory of ‘Supra-Spinal DescendingControl in Modulation in Dorsal Horn’ ”: 1969“Woolf C.J -...
INTRODUCTION (Contd.)                   DefinitionThe International Association for the Study of Pain  “Unpleasant sensory...
CLASSIFICATION OF PAIN• Origin• Pathology• Onset & Duration
Classification of Pain by Origin   Somato-sensory Pain   Deep Visceral Pain   Referred Pain   Psychogenic Pain
Classification of Pain by Pathology Nociceptive pain Neuropathic Pain
Classification of Pain by Onset & Duration1. Acute- a) Surgical-         (i) Pre-operative                              (i...
Classification of Pain by Onset & Duration2. Chronic-   a) Oncogenic              b) Non-oncogenic                  (i) Or...
Terms Used In Pain Management•   Hyperesthesia•   Hyperpathia•   Hypesthesia•   Neuralgia•   Paresthesia•   Radiculopathy
Terms Used In Pain Management•   Allodynia•   Analgesia•   Anesthesia•   Anesthesia dolorosa•   Dysesthesia•   Hypalgesia•...
Psychological and behavioural response to acute pain fear general sense of unpleasantness or uneaseAnxietyNegative emo...
Psychological response to chronic pain Intermittent pain produces a physiologic response similar to acute pain. Persistent...
Psychological response to chronic pain• often is associated with a sense of  hopelessness and helplessness• abnormal tempe...
Immunological effects of Pain• Decrease natural killer cell counts• Effects on other lymphocytes not yet defined.
NociceptionTransduction       Transmission              Modulation                    Perception
Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hydera...
Nociception• “Gate Control Theory of Melzac & Wall” : 1965
Nociception“Reynolds Theory of „Supra-SpinalDescending Control in Modulation inDorsal Horn‟ ”: 1969“Woolf C.J - Supra spin...
Peripheral and Central Pathways for               Pain       Ascending Tracts            Descending Tracts                ...
Pain-Sensing System in the Malfunction in Chronic Pain   Pain                              Acute pain:  Sensing           ...
Pain Pathway:s & Multimodal Analgesia                                                          Opioids                    ...
Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2...
THE ANAESTHESIOLOGIST          NOT JUST IN THE OPERATING ROOM• Operating room           • “CPCR” team     hospital        ...
The management of pain is a    multidisciplinary team effort              involvingphysicians, psychologists, nurses, and ...
ANAESTHESIA    FOR “PAIN MANAGEMENT”:       ACUTE : OPERATIVEPHARMACOTHERAPY & SPECIAL PROCEDURESREGIONAL & LOCAL BLOCKSNE...
Pharmacological        Depending upon site of ActionCNS: GAAs, N2O, OpioidsPeripherally :-------- NSAIDS                ...
Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hydera...
Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2...
Adjuvants to Neuraxial Blockade: Why needed?              Problems of LAAS• If duration of action to be prolonged?• Motor ...
ALTERNATIVES TO LAAs:            Problems:•   Side effects of Opioids•   Difficulty in procuring•   Minimal muscle relaxat...
LAAs & ADJUVANTSCOMBINATION!!!!
Advantages of Adjuvants•   Improvement of quality of block•   Onset of analgesic effect of LAAs is enhanced•   Duration of...
Routes of Administration• In sub-arachnoid space when only SA  is given• In epidural space through epidural  catheter when...
Various drugs used as Adjuvants• Opioids agonists: Morphine, Fentanyl etc.  Agonist /antagonist:  Butorphanol, Buprenorphi...
SUB-ARACHNOID BLOCK
Combined Spinal Epidural             (CSE)in the Same Intervertebral Space        Using Combipack
Combined Spinal &Epidural (CSE) in twodifferent Intervertebral         Spaces
CONTINUOUSSUPRA-CLAVICULAR BRACHIAL-PLEXUS     BLOCK
CHRONIC PAIN             Prevalence of chronic pain•   - 35% in the society•   - 40% in females, 31% in males•   - 25% ≤ 1...
CHRONIC PAIN             Prevalence of chronic pain•   - 35% in the society•   - 40% in females, 31% in males•   - 25% ≤ 1...
Prevalence and Impact             of Chronic Pain on Society • Chronic pain is one of the most common conditions for   whi...
Undertreatment of Chronic Pain>40% to 50% of patients in routine practice settings fail to achieve adequate pain reliefI...
The story of chronic painWHY?-Such a high incidence-Increasing incidence by aging- Higher in females
The story of chronic painThe answer: a CUMULATIVE STATE of      CENTRAL SENSITIZATION             over time
ACUTE                 SOMATIC                nociceptive                                     ACUTENEUROGENIC   Ideal cockt...
Somatic Nociceptive                               pain                         (Trauma & Surgery)NEUROPATHIC PAIN         ...
INTRACTABLECHRONIC PAINUNRESPONSIVETO ANALGESICS
CHRONIC PAIN is     a provoked irreversible     progressive or stable     dysfunctional or neurodegenerative disease   ...
Role of the AnesthesiologistDefine the patients at riskDevelopment of preventive strategiesEarly and prompt diagnosis a...
Role of the Anaesthesiologist            Define the patients at risk• Unrelieved acute pain• Anxiety• Depression• Prolonge...
Role of the Anaesthesiologist         Develop preventive strategies• Neuraxial or regional nerve blocks• Multimodal pain t...
Role of the Anaesthesiologist Start early diagnosis and treatment when pain persists• 50% reduction of chronic pain in CVA...
Role of the Anaesthesiologist          Inform the patients / medical community• Negative consequences of unrelieved pain• ...
Chronic Pain : Oncogenic• “Pain is what the patient says hurts!”• “Accept the pain as what the patient says it is and  not...
Chronic Pain : Oncogenic          Treatment Modalities:1. Treatment of Disease (cancer) itself2. Analgesics and Adjuvants ...
If pain occurs, there should be prompt oral administration of drugs in the following order:  nonopioids (aspirin and parac...
Modified WHO Analgesic Ladder                            Quality of Life                                Invasive treatment...
Chronic Pain : Oncogenic            Treatment Modalities:7. Neuro-stimulation-Lysis-Surgical/Anaesthesia/: tri-    cyclics...
PAIN CLINIC                   Definition The Care provided to the patients for the relief ofAcute or Chronic pain of oncog...
PAIN CLINIC                (CONTD.)                       TEAM Physicians : Anaesthesiologists              Oncologists m...
CONCLUSION                     PAIN• Is all encompassing, everlasting & complex• Quest for MANAGEMENT is unending• Journey...
..... For that availsValour or strength though matchless, quelled with painWhich all subdues and makes remiss the handsof ...
NociceptionTransduction       Transmission              Modulation                    Perception
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist
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Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist

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Prof.Mridul panditrao tries to explain the various finer aspects of Pain,topic very close to his heart, historical aspects, classification, management especially by and from Anaesthesiologist's perspective

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Prof. mridul m. panditrao's pain pathophysiology, management & role of anaesthesiologist

  1. 1. Pain!!!!!
  2. 2. Dr. Mridul M. Panditrao CONSULTANTDEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE RAND MEMORIAL HOSPITAL FREEPORT, GRAND BAHAMA THE COMMONWEALTH OF BAHAMAS
  3. 3. Pain A universal problem! For eternity, it has plagued mankind Till 18th century there was nothing! Remedies likeOpium, Alcohol, Mandragora, soporific sponges and Magical potions were tried, but the dark ages of “Pain and suffering” continued
  4. 4. AGE OF DARKNESS NO ANALGESIA NO ANAESTHESIANO DEFINED SURGERY“AGONY GALORE!!!”
  5. 5. BARBARIC PRACTICESWOODEN BOWL & WOODEN HAMMER” PARTIAL STRANGULATION “WHISKY BOTTLE: ½ YOU & ½ ME” MAGIC & WITCH-CRAFT MANDRAGORA / HASHISH / HERBS „ DECREE OF CHURCH‟
  6. 6. METHODS OF PAIN RELIEF
  7. 7. “ DAWN OF ANALGESIA ”FREDERICH SERTURNER:1806 MORPHINE“LAUGHING GAS ” PARTIES & HORACE WELLS : Dec. 10, 1844, N2O IN DENTISTRYDEBACLE OF N2O DEMONSTRATION & SETBACKGQC COLTON : RE-INTRODUCES N2O AS A CARRIER GAS
  8. 8. SWEET OIL OF VITRIOL (“WHIFF OF ETHER”) 16TH OCTOBER 1846 William Thomas Greene MORTONUSHERING IN OF “ ERA OF ANAESTHESIA” “INVENTOR AND REVEALER OF ANESTHETIC INHALATION BEFORE WHOM IN ALL TIME, SURGERY WAS AGONYBY WHOM PAIN IN SURGERY WAS AVERTED AND ANNULLED SINCE WHOM SCIENCE HAS CONTROL OF PAIN” WORLD ANAESTHESIA DAY
  9. 9. “GOOD OUT OF BAD” LEAF CHEWING NATIVES OF ANDIES (PERU & BOLIVIA): “NUMBNESS OF MOUTH” COCAINE ADVENT OF LOCAL ANALGESICSREGIONAL: SPINAL, EPIDURAL, FIELD “POST-OPERATIVE ANALGESIA”
  10. 10. “MORPHINE & COMPANY”• NEWER OPIOIDS: FENTANYL….• “NEURO-LEPT ANAESTHESIA”• ENDOGENOUS OPIOIDS: ENDORPHINES, ENCEPHALINS• OPIOID RECEPTORS: μ, κ, ζ, δ, ε• “CUSTOM OPIOIDS” : REMIFENTANIL
  11. 11. INTRODUCTIONFor All The Happiness Mankind can gain. Is not in pleasureBut in rest from “pain” JOHN DRYDEN
  12. 12. INTRODUCTION (Contd.) MAGNITUDE Of PROBLEM Millions of Post-op pts : 48-53% unrelieved Moderate pain in hospitalized pts: ~ 40% Child- bearing age group females : 35-43% Ch. Non-oncogenic pain; Ch. Arthritis : 25-30% Cancer Patients suffering from pain: 80%+Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2007 : 180
  13. 13. INTRODUCTION (Contd.)Nociception: Transduction Transmission Modulation Perception“Gate Control Theory of Melzac & Wall” : 1965
  14. 14. INTRODUCTION (Contd.)“Reynolds Theory of ‘Supra-Spinal DescendingControl in Modulation in Dorsal Horn’ ”: 1969“Woolf C.J - Supra spinal inhibition ofnociception” : 1989
  15. 15. INTRODUCTION (Contd.) DefinitionThe International Association for the Study of Pain “Unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in term of such damage.”
  16. 16. CLASSIFICATION OF PAIN• Origin• Pathology• Onset & Duration
  17. 17. Classification of Pain by Origin Somato-sensory Pain Deep Visceral Pain Referred Pain Psychogenic Pain
  18. 18. Classification of Pain by Pathology Nociceptive pain Neuropathic Pain
  19. 19. Classification of Pain by Onset & Duration1. Acute- a) Surgical- (i) Pre-operative (ii) Intra-operative (iii) Post-operative b) Non-surgical- (i) Traumatic (ii) Organic- Physiological Pathological (iii) Psychosomatic
  20. 20. Classification of Pain by Onset & Duration2. Chronic- a) Oncogenic b) Non-oncogenic (i) Organic (ii) Neuropathic
  21. 21. Terms Used In Pain Management• Hyperesthesia• Hyperpathia• Hypesthesia• Neuralgia• Paresthesia• Radiculopathy
  22. 22. Terms Used In Pain Management• Allodynia• Analgesia• Anesthesia• Anesthesia dolorosa• Dysesthesia• Hypalgesia• Hyperalgesia
  23. 23. Psychological and behavioural response to acute pain fear general sense of unpleasantness or uneaseAnxietyNegative emotions: depressionSleep deprivationExistential suffering: may lead to patients seeking actively end of life.
  24. 24. Psychological response to chronic pain Intermittent pain produces a physiologic response similar to acute pain. Persistent pain allows for adaptation (functions of the body are normal but the pain is not relieved)Chronic pain produces significant behavioural and psychological changesThe main changes are:- depression- an attempt to keep pain - related behaviour to a minimum- sleeping disorders- preoccupation with the pain- tendency to deny pain
  25. 25. Psychological response to chronic pain• often is associated with a sense of hopelessness and helplessness• abnormal temperature regulation, tactile dysfunction Alteration in sensory function  dysfunctions of the general or special senses  chronic pain
  26. 26. Immunological effects of Pain• Decrease natural killer cell counts• Effects on other lymphocytes not yet defined.
  27. 27. NociceptionTransduction Transmission Modulation Perception
  28. 28. Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hyderabad, 1stedition. 2007 : 180
  29. 29. Nociception• “Gate Control Theory of Melzac & Wall” : 1965
  30. 30. Nociception“Reynolds Theory of „Supra-SpinalDescending Control in Modulation inDorsal Horn‟ ”: 1969“Woolf C.J - Supra spinal inhibition ofnociception” : 1989
  31. 31. Peripheral and Central Pathways for Pain Ascending Tracts Descending Tracts Cortex Thalamus Midbrain Pons Medulla Spinal Cord (Brookoff, 2000)
  32. 32. Pain-Sensing System in the Malfunction in Chronic Pain Pain Acute pain: Sensing Pain-sensing signals are initiated in response to aIn chronic pain, stimuluspain signals are • They elicit a pain-generated without relieving responsephysiologicsignificance Chronic pain: Pain signals are generated for no reason and may be intensified • Pain-relieving mechanisms may be defective or deactivated (Illustration: Seward Hung, 2000)
  33. 33. Pain Pathway:s & Multimodal Analgesia Opioids Pain 2 -agonists Centrally acting analgesics COX-2 selective inhibitors Traditional NSAIDs Ascending input Descending modulation Local anesthetics & blocks Dorsal Opioids ,2-agonists horn NMDA antagonists Interventional modalities Dorsal root ganglion Spinothalamic tract Local anesthetics Peripheral Peripheral nociceptors nerve Local anesthetics COX-2 selective inhibitors Trauma Traditional NSAIDsFrom: Gottschalk et al. Am Fam Physician. 2001;63:1979-1984.
  34. 34. Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2007 : 845
  35. 35. THE ANAESTHESIOLOGIST NOT JUST IN THE OPERATING ROOM• Operating room • “CPCR” team hospital • Respiratory therapy physician office • Administration• Labor & delivery suite operating room hospital• Other procedural areas Medical College• Intensive care unit • Education• PACU health professionals• Pain management public acute • Research chronic / cancer
  36. 36. The management of pain is a multidisciplinary team effort involvingphysicians, psychologists, nurses, and physical therapists.Anesthesiologists are ‘physicians and experts’ in the diagnosis andtreatment of acute and chronic pain disorders. American Society of Anesthesiologists. 2003
  37. 37. ANAESTHESIA FOR “PAIN MANAGEMENT”: ACUTE : OPERATIVEPHARMACOTHERAPY & SPECIAL PROCEDURESREGIONAL & LOCAL BLOCKSNEURAXIAL PROCEDURES
  38. 38. Pharmacological Depending upon site of ActionCNS: GAAs, N2O, OpioidsPeripherally :-------- NSAIDS LAAsNeuraxially : -------- ADJUVANTS
  39. 39. Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hyderabad, 1st edition. 2007 : 180
  40. 40. Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2007 : 845
  41. 41. Adjuvants to Neuraxial Blockade: Why needed? Problems of LAAS• If duration of action to be prolonged?• Motor blockade causing interference with the mobility of the patient• Sympathetic blockade leading to bradycardia and hypotension.• So alternatives to LAAs were tried
  42. 42. ALTERNATIVES TO LAAs: Problems:• Side effects of Opioids• Difficulty in procuring• Minimal muscle relaxation• Other agents viz. Clonidine, Neostigmine, Ketamine, Midazolam and their side effects
  43. 43. LAAs & ADJUVANTSCOMBINATION!!!!
  44. 44. Advantages of Adjuvants• Improvement of quality of block• Onset of analgesic effect of LAAs is enhanced• Duration of action of LAAs is prolonged• Dose requirement of each drug is reduced• Lower incidence of side effects
  45. 45. Routes of Administration• In sub-arachnoid space when only SA is given• In epidural space through epidural catheter when Combined Spinal Epidural (CSE) Analgesia is given
  46. 46. Various drugs used as Adjuvants• Opioids agonists: Morphine, Fentanyl etc. Agonist /antagonist: Butorphanol, Buprenorphine• Clonidine• Neostigmine• Ketamine• Midazolam• Tramadol
  47. 47. SUB-ARACHNOID BLOCK
  48. 48. Combined Spinal Epidural (CSE)in the Same Intervertebral Space Using Combipack
  49. 49. Combined Spinal &Epidural (CSE) in twodifferent Intervertebral Spaces
  50. 50. CONTINUOUSSUPRA-CLAVICULAR BRACHIAL-PLEXUS BLOCK
  51. 51. CHRONIC PAIN Prevalence of chronic pain• - 35% in the society• - 40% in females, 31% in males• - 25% ≤ 18 years, 55% ≥ 65 years• 20% of the chronic pain population = postsurgical chronic pain 23rd International Winter Symposium in Leuven, Dr. Jan Maeyaert, 11-12 january 2008
  52. 52. CHRONIC PAIN Prevalence of chronic pain• - 35% in the society• - 40% in females, 31% in males• - 25% ≤ 18 years, 55% ≥ 65 years• 20% of the chronic pain population = postsurgical chronic pain 23rd International Winter Symposium in Leuven, Dr. Jan Maeyaert, 11-12 january 2008
  53. 53. Prevalence and Impact of Chronic Pain on Society • Chronic pain is one of the most common conditions for which people seek medical treatment • 35% of Americans suffer from chronic pain • >50 million Americans are partially or totally disabled by chronic pain • 50 million workdays are lost per year • $100 billion is the estimated annual cost in lost productivity, medical costs, and lost income(American Pain Society, 2001; Gitlin, 1999; Glajchen 2001; Loesser et al, 2001)
  54. 54. Undertreatment of Chronic Pain>40% to 50% of patients in routine practice settings fail to achieve adequate pain reliefIn a recent study of 805 chronic pain sufferers, >50% had to change physicians to achieve relief because the physician: was unwilling to treat pain aggressively did not take the patient’s pain seriously had inadequate knowledge about pain treatment(American Pain Society, 2001; Glajchen, 2001; Lister, 1996; Portenoy, 1996)
  55. 55. The story of chronic painWHY?-Such a high incidence-Increasing incidence by aging- Higher in females
  56. 56. The story of chronic painThe answer: a CUMULATIVE STATE of CENTRAL SENSITIZATION over time
  57. 57. ACUTE SOMATIC nociceptive ACUTENEUROGENIC Ideal cocktail for VISCERAL DAMAGE SENSITIZATION nociception Psychogenic factors (stress, anxiety)
  58. 58. Somatic Nociceptive pain (Trauma & Surgery)NEUROPATHIC PAIN VISCERAL CENTRAL(nerve dysfunction, NOCICEPTIVE PAIN nerve injury) SENSITIZATION (renal/biliary colic, dysmenorhea) PSYCHOGENIC PAIN (anxiety, depresseion, prolonged stress)
  59. 59. INTRACTABLECHRONIC PAINUNRESPONSIVETO ANALGESICS
  60. 60. CHRONIC PAIN is a provoked irreversible progressive or stable dysfunctional or neurodegenerative disease of the CNS• Whatever is the initial pain mechanism• All types of unrelieved pain end as CENTRAL NEUROPATHIC PAIN
  61. 61. Role of the AnesthesiologistDefine the patients at riskDevelopment of preventive strategiesEarly and prompt diagnosis and treatmentInformation of the public and medical community 23rd International Winter Symposium in Leuven, Dr. Jan Maeyaert, 11-12 Januari 2008
  62. 62. Role of the Anaesthesiologist Define the patients at risk• Unrelieved acute pain• Anxiety• Depression• Prolonged stress• Nerve damage CNS/PNS• Recurrent surgery• Female sex/genetic predisposition
  63. 63. Role of the Anaesthesiologist Develop preventive strategies• Neuraxial or regional nerve blocks• Multimodal pain treatment protocols• Early use of antidepressants and anti-epileptics in patients with nerve damage• Use of COX-II inhibitors• Opiate sparing strategies
  64. 64. Role of the Anaesthesiologist Start early diagnosis and treatment when pain persists• 50% reduction of chronic pain in CVA and postherpetic neuralgia pain patients by starting amitryptiline in the acute phase• 8 fold decrease of chronic low back pain by starting multimodal therapy in the acute phase• Patients with acute neuropathic pain after surgery do better when amitryptiline and gabapentin are started early after surgery
  65. 65. Role of the Anaesthesiologist Inform the patients / medical community• Negative consequences of unrelieved pain• Possibilities to manage the pain• Inform the surgeons - to use minimal invasive techniques - To take care of neurogenic structures - Repeat surgery for chronic pain is not an option - Surgery in a patient with a chronic pain condition is less successful - To infiltrate the site of incision with long acting local anesthetics
  66. 66. Chronic Pain : Oncogenic• “Pain is what the patient says hurts!”• “Accept the pain as what the patient says it is and not what you think it should be”• “ Your pain is your’s and is real!”• “Addiction/Dependance has lost it’s significance in these patients”
  67. 67. Chronic Pain : Oncogenic Treatment Modalities:1. Treatment of Disease (cancer) itself2. Analgesics and Adjuvants (WHO ladder)3. Custom Opioids4. Computerized drug Delivery : ‘pumps’.. PCA, CCIP(Computerized controlled infusion pumps’5. Non-Invasive drug Delivery Devices (NIDDS): TTS- fentanyl, EMLA, TMDS, intra-nasal, Pulm6. Implantable Neuraxial Delivery Devices (INDDS):
  68. 68. If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additionaldrugs – “adjuvants” – should be used. To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on demand” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90%effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are
  69. 69. Modified WHO Analgesic Ladder Quality of Life Invasive treatments Proposed 4th Step Opioid Delivery Pain persisting or increasing Step 3 Opioid for moderate to severe pain Nonopioid Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain Nonopioid Adjuvant Pain persisting or increasing Step 1 Nonopioid Adjuvant PainDeer, et al., 1999
  70. 70. Chronic Pain : Oncogenic Treatment Modalities:7. Neuro-stimulation-Lysis-Surgical/Anaesthesia/: tri- cyclics, anti-convulsants, TENS, Ketamine8. Psycho Therapy & Counselling9. Physio and Occupational Therapy10. Miscellaneous: N/V, infections, Patho- fractures, constipation..... CONCEPT OF PAIN CLINIC
  71. 71. PAIN CLINIC Definition The Care provided to the patients for the relief ofAcute or Chronic pain of oncogenic as well as non-oncogenic origin on comprehensive, interdisciplinary and multi-dimensional basis by a teamof experts with broad base of knowledge, and skillsunder one roof is called “multi-disciplinaryapproach to management of Pain” and such anestablishment is called as pain Clinic.
  72. 72. PAIN CLINIC (CONTD.) TEAM Physicians : Anaesthesiologists Oncologists medical surgical radiation Psychologist/Behavioural Therapist Physio/Occupational Therapist Nursing staff Social Worker
  73. 73. CONCLUSION PAIN• Is all encompassing, everlasting & complex• Quest for MANAGEMENT is unending• Journey from non- existent /barbarism to PCAs, CCIPs, TTSs, NIIDs or INDDs• From Opium, Hashish, alcohol, Mandragora & herbs to Remifentanil, ropivacane.Must go on & on & on.........never-ending search.
  74. 74. ..... For that availsValour or strength though matchless, quelled with painWhich all subdues and makes remiss the handsof mightiest? Sense of pleasure we may wellSpare out of life perhaps, and not repineBut live content – which is calmest life ;But pain is the perfect misery, the worstOf evils and excessive over turnsAll patience. John Milton - Paradise Lost Book VI
  75. 75. NociceptionTransduction Transmission Modulation Perception
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