Pain relief; A basic human right Pain is leading cause of ER visits and hospitalizations Pain is a common mode of presentation in patients with sickle cell disease (SCD) but there is considerable variability in the way SCD pain is managed
Pain relief; A basic human right Pain is common undertreated entity One of the factors contributing to poor pain management is conflicting perceptions between patients, their families and healthcare professionals about pain that is reported and analgesia that is required (Stinson & Naser, 2003).
Pain relief; A basic human rightThe most reliable indicator of the existence pain and its intensityis the patient’s description
Pain relief; A basic human right The aim of the wise is not to secure pleasure, but to avoid pain. Aristotle Pain is a worst lord of mankind than death itself.
Pain relief; A basic human right Tachycardia And elevated blood pressure Decreased Limb movement; increased risk of DVT Respiratory effects; shallow breathing , tachypnea, cough suppression. due to increased risk of pneumonia & atelectasis Decreased GI Motility Increased catabolic demands
Pain relief; A basic human right Psychological effects of Pain Negative emotions: anxiety, depression Sleep deprivation Existential suffering: may lead to patients seeking active end of life Immunologic Effects of pain Decrease natural killer cell counts Effects on other lymphocytes not yet defined
Pain relief; A basic human right 5TH Vital Sign Basic human Right; Human rights watch
Pain relief; A basic human right Effective control of pain Lack of awareness among public Minimal knowledge among health providers
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 The WHO Nonopioid Adjuvant Ladder Pain persisting or increasing Step 1 Nonopioid Adjuvant PainDeer, et al., 1999
Pain relief; A basic human right Pain relief; A basic human right
Pain relief; A basic human right Paediatric Scales
Pain relief; A basic human right Table: Severity of pain (Using a simple pain score) . 0 Mafee alam No Pain 1 Shoa alam Mild Pain 2 Nus nus alam Moderate pain 3 Kateer alam) Severe Pain
Acute Pain in Sickle Cell DiseaseSomatic pain – Deep structures – Focal or referredVisceral pain – Spleen, liver, lungs – Vague, poorly localized, referred, diffuse, dull-aching in character – Nausea, vomiting, sweating – Associated with muscle spasms, tenderness, hyperaesthesia
Comprehensive Regimen for the sickle cell disease pain Maintenance therapy with opioid analgesic Non opioid analgesic Rescue therapy for breakthrough pain Adjuvant therapy Anxiolytics/muscle relaxants Laxatives Non-pharmacologic therapy Incentive spirometry Hydration (1-1.5x maintenance) Physical: Heating pads, massage, TENS, acupuncture, physical therapy Behavioral: Relaxation, deep breathing, behavior modification, biofeedback •Psychological: cognitive therapies, distraction, social support, hypnotherapy
Pain relief; A basic human right WHO Pain Ladder
Meperidine Shorter duration of action (1-2 hours only ) Seizures on repeated administration Dermal and sub dermal fibrosis on I.M injectionPethidine Narrow therapeutic index Norpethidine > Antagonistic Seizures on repeated administration
Pain relief; A basic human rightS.No Severity of pain Regimen1 Mild Paracetomol 0.5g to 1g every 8H / Lornoxicam4-8 mg Every 12-24 H2 Moderate Paracetomol 0.5g to 1g every 8H / Lornoxicam4-8 mg Every 12-24 H + Tramadol50-100mgs Q 8H3 Severe Paracetomol 0.5g to 1g every 8H / Lornoxicam4-8 mg Every 12-24 H + Morphine 5-mgs Q 8 H
Pain relief; A basic human rightPRN Schedule IllogicalPain Cycle (Basal + Incident + Breakthrough PainStart (1Hr)} Asses} Reassess} AdjustTapering and not abrupt withdrawl
Pain relief; A basic human rightNSAIDS Bone Pain Opiod Sparing Ceiling EffectOpiods Potent analgesics Safety Profile
Pain relief; A basic human rightAddiction Nightmare for physician Curse for the patient
Pain relief; A basic human right When asked, 59% of the patients desired that oral non- opioid analgesics be prescribed while 31% were not bothered about what analgesic was given. Only 8% requested opioids. A total of 65% of the patients did not require hospital admission but were observed in the day-care unit and allowed home within 24 h. Only 17% required hospital admission for more than a week.
Pain relief; A basic human right Prevention of Pain Triggers of pain: viral illness, infection/sepsis, stress, extreme exercise, change in temperature, change in altitude Fluids (2 glasses of water q 2 hours) Avoiding extreme temperatures, activities (e.g. swimming in cold water) Regular moderate exercise Penicillin prophylaxis to prevent infection