pain management in surgical floor .

1. PAIN CONTROL IN
SURGICAL PATIENTS
BY DR. FARKHANDA QAISER
HOUSE SURGEON
EAST SURGICAL WARD
MAYO HOSPITAL, LAHORE

2. DISCLOSURE

3. DEFINITION OF PAIN
An unpleasant sensory and emotional
experience arising from actual or potential
tissue damage or described in terms of
such damage.
IASP Pain Definition (1994, 2008)

4. CLASSIFICATION OF PAIN
•Acute or Chronic
•Nociceptive or Neuropathic

5. ACUTE PAIN
•Pain in Perioperative Setting
•Pain in Patients with Severe or Concurrent
Medical Illnesses (Pancreatitis)
•Acute Pain Related to Cancer or Cancer
Treatment
•Labor Pain

6. ACUTE PERIOPERATIVE
PAIN
Pain that is Present in a Surgical Patient
Because of Preexisting Disease, the
Surgical Procedure, or a Combination of
Both

7. SOURCES OF
POSTOPERATIVE
PAIN
•Acute nociceptive pain from incision
•Musculoskeletal pain from abnormal body
positioning and immobility during and
after surgery
•Neuropathic pain from excessive
stretching or direct trauma to peripheral
nerves

9. MANAGEMENT OF ACUTE
PAIN
Pharmacologic
Interventional

10. PAIN MANAGEMENT IN A
SURGICAL PATIENT
Recommendations
•Level 1: Convincingly justifiable based on available
scientific information alone
•Level 2: Reasonably justifiable based on available
scientific evidence and strongly supported by
expert opinion
•Level 3: Supported by available data, but scientific

11. RECOMMENDATIONS
• Level 1
None
• Level 2
The efficacy of a patient’s pain medication regimen must be
constantly assessed and altered as needed to achieve the intended
effect
For enteral opioid therapy, a combination of a sustained-release
formulation for long-acting pain control and an immediate-release
formulation for breakthrough pain is preferred
For parenteral opioid therapy, morphine, fentanyl or
hydromorphone should be utilized in titrated doses as indicated

12. Enteral pain medication therapy should be initiated as
soon as the patient is able to tolerate such medications
COX-2 inhibitors and non-selective NSAIDS should be
avoided in patients with or at high risk for thrombotic
cardiovascular events
• Level 3
NSAIDS and COX-2 inhibitors should not be used in
patients with renal dysfunction, hypovolemia or active
gastrointestinal hemorrhage
NSAIDS and COX-2 inhibitors should not be used in
patients with acute orthopedic fractures unless the benefit

14. WHO ANALGESIC
LADDER

15. ANALGESICS
•Nonopioid analgesics (aspirin, acetaminophen,
NSAIDS)
•Opioid analgesics (morphine, hydromorphone,
fentanyl, oxycodone, hydrocodone)
•Local anesthetics (lidocaine, bupivacaine)
•Analgesic adjuvants (tricyclic antidepressants,
antihistamines, benzodiazepines, steroids,
phenothiazines, anticonvulsants, clonidine)

16. ROUTES OF
ADMINISTRATION• PO
• PR
• IV
• IM
• Transdermal
• Transmucosal
• Epidural
• Intrathecal

17. NON-OPIOID
ANALGESICS
•Acetaminophen
•NSAIDs (Aspirin, Ibuprofen, Ketorolac,
COX-2 Inhibitors)
•Lidocaine Patch
• (Lidoderm)

18. ACETAMINOPHEN
•First-line treatment if no contraindication
•Mechanism: inhibits prostaglandin synthesis in CNS
→ analgesia, antipyretic
•Only available in PO form
•Typical dose: 650 to 1000 mg PO Q6H
•Max dose: 4 g / 24 hrs from all sources
•Warning: ↓ dose / avoid in those with liver damage

19. NSAIDS
• Relieve Mild to Moderate Pain
• Mechanism
• Block cyclooxygenase (COX) enzyme → ↓ prostaglandin synthesis
• COX-2 → Prostaglandins → pain, inflammation, fever
• COX-1 → Prostaglandins → gastric protection, hemostasis
• Warnings: ↓dose / avoid if
• GI ulceration
• Bleeding disorders / Coagulopathy
• Renal dysfunction
• High cardiac risk – COXII inhibitors
• Asthma
• Allergy

20. KETOROLAC
•Potent Analgesic
•Parenteral (IV or IM)
•15-30 mg Q6hr
•Patients Older than 16 yrs
•Should not Exceed 5 days

21. COX-2 INHIBITORS
Drug Dose
Celecoxib
(Celebrex)
100-200mg PO
Bid

23. OPIOIDS
Key Points:
• Centrally acting on opioid receptors
• No ceiling effect
• High dose/response variability in non-
opiate users
• Previous dependence creates a challenge
in acute on chronic pain management
cases
• Balancing safety and efficacy can be

24. OPIOIDS CLASSIFICATION
Weak Opioids: Codeine, Tramadol
Strong Opioids: Morphine, Pethidine,
Oxycodone
Adjuvant: Ketamine, Gabapentin, Pregabalin

25. OPIOIDS
CHARACTERISTICS
•Immediate release preparations:
Half-life: 2 - 4 hours
Duration of analgesic effect: 4-5
hrs
• Sustained release formulations:
Duration of analgesic effect: 8-

26. OPIOIDS - SIDE EFFECTS
•Nausea / Vomiting
•Sedation
•Respiratory Depression
•Pruritus
•Constipation -- need to write for this
immediately
•Urinary Retention
•Ileus
•Tolerance

27. MORPHINE
• Can cause hypotension in the hemodynamically unstable or
hypovolemic patient as a result of peripheral vasodilation
• Onset of action: 15 to 60 minutes
• Peak Effect: 30 minutes to 1 hr
• Half Life: 1.5 to 2 hr. It has a longer duration of action making
intermittent dosing efficacious.
• IV: 0.05 to 0.1 mg/kg
• Max: 15 mg/dose
• Side effects: Sedation, somnolence, respiratory distress or

28. HYDROMORPHONE
(DILAUDID)
•Better tolerated by elderly, better S/E profile
•Preferred over morphine for renal disease
patients
•Low cost, IV and PO forms available
•Hydromorphone has a similar duration of
effect as morphine, but is not associated with
histamine-mediated vasodilatation

29. Oxycodone
• Good S/E profile, but $$
• PO form only
• Percocet (oxycodone + acetaminophen)
Codeine
• 1/10th Potency of morphine
• Metabolized into morphine by body
• Ineffective in 10% of Caucasian patents
• Challenge with combination formulations

30. Meperidine (Demerol)
•Not very potent
•Decreases seizure threshold, dystonic
reactions
•Neurotoxic metabolite (normeperidine)
•Avoid in renal disease

31. FENTANYL
• Fentanyl is 80 to 100 times more potent than morphine
• Of the IV opioids, fentanyl has the most rapid onset and shortest
duration of effect
• Onset: 1 to 5 minutes
• Half Life: 1.5 to 6 hr
• IV: 0.5 to 3 mcg/kg/dose; may repeat after 30 to 60 minutes; max: 50
mcg/dose
• Use lower doses (0.5 to 1 mcg/kg/dose) when used in combination
with other agents, such as midazolam
• Side effects: Respiratory distress or depression, apnea, seizures,
shock, chest wall rigidity (most likely to occur with rapid infusion or
high doses)

32. MANAGEMENT OF SIDE
EFFECTS
Nausea / Vomiting
• Ondansetron
• Dimenhydrinate
• Metoclopramide
• Changing medication(s) / ↓ dose
Pruritus
• Diphenhydramine (Benadryl)
• Changing medication(s) / ↓ dose

34. BREAK THROUGH PAIN
•Provision for a supplementary, rapid-acting opioid
for “break through” pain in addition to the
scheduled sustained release formulations.
•In general, approximately two-thirds of the
patient’s estimated opioid dose should be
administered as a sustained-release formulation
with the remaining one-third prescribed as an
immediate-release formulation to be administered

35. LIDODERM
•5% Lidocaine Patch
•Indicated for Pain Relief in Post-herpetic Neuralgia
•Each Patch Contains 700 mg of Lidocaine
•Should be Applied to Intact Skin
•About 3% is Absorbed
•1-3 Patches Once a Day for 12 hrs

36. INTERVENTIONAL
MANAGEMENT
•Epidural Analgesia (Continuous Lumbar or
Thoracic Epidural Catheter Placement, PCEA)
•Spinal Analgesia
•Peripheral Nerve Block ( Single Shot or
Continuous)

37. ADVERSE OUTCOME OF
UNDERTREATMENT OF ACUTE
PAIN
•Thromboembolic or Pulmonary
Complications
•Needless Suffering
•Development of Chronic Pain

38. TOLERANCE
•Definition: A change in the dose-response
relationship induced by exposure to the drug and
manifest as a need for a higher dose to maintain an
effect
•“Tolerance” refers to the need for increasing doses
of an analgesic to maintain the original effect
•This is a common finding in virtually all patients on
chronic opioid analgesics. The first sign of
tolerance may be a decrease in the duration of

39. WITHDRAWAL
•“Withdrawal” refers to the development of anxiety,
tachycardia, sweating, and other autonomic
symptoms occurring with the abrupt
discontinuation of a drug.
•Such symptoms can be avoided by slowly tapering
the dose downward prior to discontinuing therapy
altogether.
•Symptoms may also be lessened by administration
of a transdermal clonidine patch delivering 0.1-

40. DEPENDENCE
•Definition: The development of a withdrawal
syndrome following dose reduction or
administration of an antagonist
•Often develops after only a few days of opioid
therapy
•Not a clinical problem if drug is tapered before
discontinuation
•Taper by no more than 50% of the dose/day

41. ADDICTION
• Compulsive use
•Loss of control
• Continued use despite harm to self and others
• Risk of iatrogenic addiction in patients with pain and no
prior history of substance abuse is extremely small
• “Pseudoaddiction”- behavior that resembles addiction,
but is driven by pain and disappear with adequate
analgesia

42. Thank You