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......

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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  • 1. Pain!!!!!
  • 2. Dr. Mridul M. Panditrao CONSULTANTDEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE RAND MEMORIAL HOSPITAL FREEPORT, GRAND BAHAMA THE COMMONWEALTH OF BAHAMAS
  • 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. AGE OF DARKNESS NO ANALGESIA NO ANAESTHESIANO DEFINED SURGERY“AGONY GALORE!!!”
  • 5. BARBARIC PRACTICESWOODEN BOWL & WOODEN HAMMER” PARTIAL STRANGULATION “WHISKY BOTTLE: ½ YOU & ½ ME” MAGIC & WITCH-CRAFT MANDRAGORA / HASHISH / HERBS „ DECREE OF CHURCH‟
  • 6. METHODS OF PAIN RELIEF
  • 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. 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. “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. “MORPHINE & COMPANY”• NEWER OPIOIDS: FENTANYL….• “NEURO-LEPT ANAESTHESIA”• ENDOGENOUS OPIOIDS: ENDORPHINES, ENCEPHALINS• OPIOID RECEPTORS: μ, κ, ζ, δ, ε• “CUSTOM OPIOIDS” : REMIFENTANIL
  • 11. INTRODUCTIONFor All The Happiness Mankind can gain. Is not in pleasureBut in rest from “pain” JOHN DRYDEN
  • 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. INTRODUCTION (Contd.)Nociception: Transduction Transmission Modulation Perception“Gate Control Theory of Melzac & Wall” : 1965
  • 14. INTRODUCTION (Contd.)“Reynolds Theory of ‘Supra-Spinal DescendingControl in Modulation in Dorsal Horn’ ”: 1969“Woolf C.J - Supra spinal inhibition ofnociception” : 1989
  • 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. CLASSIFICATION OF PAIN• Origin• Pathology• Onset & Duration
  • 17. Classification of Pain by Origin Somato-sensory Pain Deep Visceral Pain Referred Pain Psychogenic Pain
  • 18. Classification of Pain by Pathology Nociceptive pain Neuropathic Pain
  • 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. Classification of Pain by Onset & Duration2. Chronic- a) Oncogenic b) Non-oncogenic (i) Organic (ii) Neuropathic
  • 21. Terms Used In Pain Management• Hyperesthesia• Hyperpathia• Hypesthesia• Neuralgia• Paresthesia• Radiculopathy
  • 22. Terms Used In Pain Management• Allodynia• Analgesia• Anesthesia• Anesthesia dolorosa• Dysesthesia• Hypalgesia• Hyperalgesia
  • 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. 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. 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. Immunological effects of Pain• Decrease natural killer cell counts• Effects on other lymphocytes not yet defined.
  • 27. NociceptionTransduction Transmission Modulation Perception
  • 28. Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hyderabad, 1stedition. 2007 : 180
  • 29. Nociception• “Gate Control Theory of Melzac & Wall” : 1965
  • 30. Nociception“Reynolds Theory of „Supra-SpinalDescending Control in Modulation inDorsal Horn‟ ”: 1969“Woolf C.J - Supra spinal inhibition ofnociception” : 1989
  • 31. Peripheral and Central Pathways for Pain Ascending Tracts Descending Tracts Cortex Thalamus Midbrain Pons Medulla Spinal Cord (Brookoff, 2000)
  • 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. 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. Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2007 : 845
  • 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. 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. ANAESTHESIA FOR “PAIN MANAGEMENT”: ACUTE : OPERATIVEPHARMACOTHERAPY & SPECIAL PROCEDURESREGIONAL & LOCAL BLOCKSNEURAXIAL PROCEDURES
  • 38. Pharmacological Depending upon site of ActionCNS: GAAs, N2O, OpioidsPeripherally :-------- NSAIDS LAAsNeuraxially : -------- ADJUVANTS
  • 39. Panditrao MM, Pain and it’s Physiological considerations, eds, Deshpande S et al. Principles of Anaesthesia, Paras, Hyderabad, 1st edition. 2007 : 180
  • 40. Panditrao MM, Pain and it’s Management, eds, Deshpande S et al. Principles of Anaesthesia,Paras, Hyderabad, 1st edition. 2007 : 845
  • 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. 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. LAAs & ADJUVANTSCOMBINATION!!!!
  • 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. 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. Various drugs used as Adjuvants• Opioids agonists: Morphine, Fentanyl etc. Agonist /antagonist: Butorphanol, Buprenorphine• Clonidine• Neostigmine• Ketamine• Midazolam• Tramadol
  • 47. SUB-ARACHNOID BLOCK
  • 48. Combined Spinal Epidural (CSE)in the Same Intervertebral Space Using Combipack
  • 49. Combined Spinal &Epidural (CSE) in twodifferent Intervertebral Spaces
  • 50. CONTINUOUSSUPRA-CLAVICULAR BRACHIAL-PLEXUS BLOCK
  • 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. 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. 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. 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. The story of chronic painWHY?-Such a high incidence-Increasing incidence by aging- Higher in females
  • 56. The story of chronic painThe answer: a CUMULATIVE STATE of CENTRAL SENSITIZATION over time
  • 57. ACUTE SOMATIC nociceptive ACUTENEUROGENIC Ideal cocktail for VISCERAL DAMAGE SENSITIZATION nociception Psychogenic factors (stress, anxiety)
  • 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. INTRACTABLECHRONIC PAINUNRESPONSIVETO ANALGESICS
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. PAIN CLINIC (CONTD.) TEAM Physicians : Anaesthesiologists Oncologists medical surgical radiation Psychologist/Behavioural Therapist Physio/Occupational Therapist Nursing staff Social Worker
  • 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. ..... 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. NociceptionTransduction Transmission Modulation Perception