Pain relief in sickle cell disese

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  • 1. Pain relief;A basic human right Yousf M. Tak Consultant of Anesthesia Security Forces Hospital Dammam KSA
  • 2. Regards from Kashmir; a paradise on earth
  • 3. 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
  • 4. 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).
  • 5. Pain relief; A basic human rightThe most reliable indicator of the existence pain and its intensityis the patient’s description
  • 6. 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.
  • 7. 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
  • 8. 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
  • 9. Pain relief; A basic human right 5TH Vital Sign Basic human Right; Human rights watch
  • 10. Pain relief; A basic human right Effective control of pain  Lack of awareness among public  Minimal knowledge among health providers
  • 11. Pain relief; A basic human rightPain Clinic
  • 12. 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
  • 13. Pain relief; A basic human right
  • 14. Pain relief; A basic human right
  • 15. Pain relief; A basic human right
  • 16. Pain relief; A basic human right Pain relief; A basic human right
  • 17. Pain relief; A basic human right Paediatric Scales
  • 18. 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
  • 19. Acute Pain in Sickle Cell DiseaseSomatic pain  – Deep structures  – Focal or referredVisceral pain  – Spleen, liver, lungs  – Vague, poorly localized, referred, diffuse, dull-aching in character  – Nausea, vomiting, sweating  – Associated with muscle spasms, tenderness, hyperaesthesia
  • 20. 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
  • 21. Pain relief; A basic human right WHO Pain Ladder
  • 22. 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
  • 23. Pain relief; A basic human right
  • 24. 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
  • 25. Pain relief; A basic human rightPRN Schedule IllogicalPain Cycle (Basal + Incident + Breakthrough PainStart (1Hr)} Asses} Reassess} AdjustTapering and not abrupt withdrawl
  • 26. Pain relief; A basic human rightNSAIDS  Bone Pain  Opiod Sparing  Ceiling EffectOpiods  Potent analgesics  Safety Profile
  • 27. Pain relief; A basic human rightAddiction Nightmare for physician Curse for the patient
  • 28. 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.
  • 29. 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
  • 30. STAYPAINFREE