Pain management

1. Saeid Safari, MD.
Pain Management
By
Dr.Roshan Kumar
Shah
Phase A Resident
Pediatric Surgery

2. What is the Pain?
“Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage.”

3. Types of Pain
1. Acute (<6 months)
– Somatic
– Visceral
2. Chronic (6 months <)
 Malignant (cancer)
 Nonmalignant
• Neuropathic (nerve injury)
• Inflammatory (musculoskeletal)
• Mixed or unspecified
• Psychogenic

4. Peripheral Nerve Fibers Involved in
Pain Perception
A-delta fibers–small, myelinated fibers that transmit sharp
pain
C-fibers–small unmyelinated nerve fibers that transmit dull or
aching pain.

5. Major Categories of Pain
1. Nociceptive pain
(stimuli from somatic and visceral structures)
2. Neuropathic pain
(stimuli abnormally processed by the nervous system)

10. Pain Assessment

11. Instruments
• Single-dimension
– Visual analog scale
– Verbal numerical scale
– Verbal rating scale
• Multidimensional
– Assesses the pain as well as the emotional and behavioral
effects of the pain.

14. Principles of Treatment
• Reduction of Pain:
– Behavioral, Meds, Blocks, Surgery, Complementary
– There is no magic bullet, no single cure
• Rehabilitation:
– Reconditioning & Prevention
• Coping:
– Management of Residual Pain

15. Pain
Step 1 ± Nonopioid
± Adjuvant
Pain persisting or increasing
Step 2 Opioid for mild to moderate pain
± Nonopioid ± Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
± Nonopioid ± Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
Modified WHO 3- Step Analgesic
Ladder
Proposed 4th Step
The WHO
Ladder
Deer, et al., 1999
8 -10
4 - 7
1 - 3
Pain
Severity

16. Treatment Modalities
Analgesic Agents
- Acetaminophen
- NSAIDS
- Opioids
Adjuvant
- Ketamine
- Local Anaesthetics
- Anti-convulsants
- Anti- depressants
- Benzodiazepines
- Clonidine
- Steroids

17. Copyright © 2003 American Society of Anesthesiologists. All rights reserved
Treatment of Pain
1. Non-pharmacologic
2. Pharmacological

18. Nonpharmacological Management

19. pharmacological Management
1. Paracetamol
2. NSAID
3. Opioids
4. PCA ( Patient controlled analgesia)
5. Tramadol
6. Local anesthesia
7. Preemptive anesthesia

20. Paracetamol
Mechanism of action:
•Inhibit cyclooxygenase enzyme
•Analgesia and antipyretic effect
Contraindication :
Liver disease
Glucose 6 phosphate dehydrogenase deficiency

21. NSAID
Mechanism of action:
•Inhibit cyclooxygenase enzyme
•Inhibit Secration of PG which produces pain
Side effects :
•Gastric ulceration
•Nephrotoxicity
•Impaired hemostasis
•Aspirin induced asthma

22. Opioids
Mechanism of action:
•Direct effect on opioid receptor
•Stimulation of brain stem pain inhibition fibers
Contraindication:
•Head Injury
•Respiratory Failure
Comonly used opioids
•Morphine
•Pethidine

23. PCA( Patient Controlled
analgesia)Mechanism of action:
•By pressing button, patient delivers the predetermined dose
•The timing unit prevents overdose
Contraindication:
•History of Drug abuse
•Sepsis
•Electrolyte abnormality
•End Stage renal/hepatic disease
•Sever COPD
•Sleep apnea
Parts Of device:
•Timing unit
•Pump
•Analgesic medication is connected to IV line

24. Patient Controlled Analgesia (PCA)

25. Tramadol
Mechanism of action:
•Weak agonist to some opioid receptors
•CNS effect via noraderenergic/serotonergic pathway
•So classified as both opioid and non opioid analgesic

26. Local anesthesia
Can be used in many ways :
1.Local wound infiltration
2.Injection close to a peripheral nerve
3.Brachial plexus/axillary block
4.Central neural blockage
• Epidural anesthesia
• Spinal anesthesia