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  1. 1. PAIN MANAGEMENT Dr .Thrishi Sagna DNB Pediatric Indraprastha Apollo Hospital New Delhi
  2. 2. WHAT IS PAIN? • In 1968 McCaffery defined pain as “whatever the experiencing person says it is, existing whenever he/she says it does” • In 1979 IASP defined pain as “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” • Pain from poena ---> Latin means punishment.
  3. 3. Physiology of Pain • • • • Nociceptors Stimulus Transmission Termination Modulation
  4. 4. Receptors  There are no specialised receptors  Pain receptors are called nociceptors  A sensory receptor that is capable of transducing and encoding noxious stimuli (actually or potentially tissue damaging stimuli)  Nociceptors are free nerve endings  Free nerve endings are distributed everywhere  both somatic and visceral tissues  except brain tissue and lung parenchyma
  5. 5. Nerve pathways carrying pain signals to the brain • Pain signals enter the spinal cord • First synapse is present in the dorsal horn of the spinal cord • Then the second order neuron travels through the lateral spinothalamic tracts
  7. 7. central connections • afferent fibre enters the spinal cord • synapses in laminae ii,iii – substantia gelatinosa substantia gelatinosa Neurotransmitter at the first synapse of the pain pathway is substance P • Acute pain : glutamate • Chronic pain: substance P • Pain inhibitory neurotransmitters: enkephalin, GABA
  8. 8. ascending pathway • crosses the midline • ascends up as the lateral spinothalamic tract Pain C fibre substantia gelatinosa lateral spinothalamic tract
  9. 9. thalamoc ortical tracts thalamus lateral spinothalamic tract C fibre
  10. 10. Pain perception • This occurs at different levels – thalamus is an important centre of pain perception • lesions of thalamus produces severe type of pain known as ‘thalamic pain’ – Sensory cortex is necessary for the localisation of pain – Other areas are also important • reticular formation, limbic areas, hypothalamus and other subcortical areas
  11. 11. PAIN PATHWAY
  12. 12. Pathophysiology of pain Pain sensations could arise due to – Inflammation of the nerves (neuritis) – Injury to the nerves and nerve endings with scar formation (disc prolapse) – Injury to the structures in the spinal cord, thalamus or cortical areas that process pain information (spinal trauma) – Abnormal activity in the nerve circuits that is perceived as pain (phantom limb pain) – Nerve invasion, for example by cancer (brachial plexopathy)
  13. 13. PHYSIOLOGICAL EFFECTS OF PAIN Pulmonary (Dec lung volume) Atelectasis Ventilation perfusion mismatch Arterial hypoxemia Hypercarbia pneumonia CVS(SNS Stim) HTN Tachycardia Myocardial Ischemia Cardiac Dysrhythmia Endocrine system Hyperglycemia Sodium & water retention Protein catabolism
  14. 14. PHYSIOLOGICAL EFFECTS OF PAIN Immune system Decreased immune function Coagulation system Increased platelet adhesiveness Decreased fibrinolysis Hypercoagulation DVT GI system Ileus Genitourinary system Urinary retention
  15. 15. ACUTE Vs CHRONIC 1. Nociceptive and has Biologic function 1. No biologic value 2. Acts as warning and indicates tissue injury 2. Detrimental effects 3. Recent onset & finite duration-weeks to days Illness or injury-months 3. Persists beyond acute 4. Remits when underlying pathotlogy resolves 4. Chronic pathological process & can recur
  17. 17. PAIN CATEGORY DEFINITION AND EXAMPLES CHARACTERISTICS Somatic Pain resulting from injury to or inflammation of tissues . Examples: burns, lacerations, fractures, infections, inflammatory conditions In skin and superficial structures: sharp; pulsatile; well-localized In deep somatic structures: dull; aching; pulsatile; not welllocalized Visceral Pain resulting from injury to or inflammation of viscera Examples: angina, hepatitic distention, bowel distention or hypermobility, pancreatitis Aching and cramping; nonpulsatile; poorly localized (e.g., appendiceal pain perceived around umbilicus) or referred to distant locations (e.g., angina perceived in shoulder) Neuropathic Pain resulting from injury to, inflammation of, or dysfunction of the peripheral or central nervous systems. Examples: complex regional pain syndrome (CRPS), Spontaneous; burning; lancinating or shooting ; pain may be perceived distal or proximal to site of injury, usually corresponding to innervation pathways (e.g., sciatica)
  20. 20. Premature Infant Pain Profile • Facial Actions – Brow bulge – Eye squeeze – Nasolabial furrow • Physiological Indicators – Heart rate – Oxygen saturation • Context – Gestational age – Behavioral state
  21. 21. PIPP Scale
  22. 22. CRIES Scale
  23. 23.
  24. 24. PAIN ASSESSMENT Visual Analog Scale (VAS) Likert Scale Faces Scales -Wong-Baker, Oucher, Bieri, McGrath scales Behavioral- FLACC, N-PASS, CHEOPS, OPS, FACS. Autonomic measures changes in heart rate, blood pressure, or measures of heart rate variability. Non specific. Hormonal-metabolic measures of Plasma or salivary sampling of “stress” hormones . Non specific.
  25. 25. FLACC scale
  27. 27. PHARMACOLOGICAL • Non-opioid: Acetaminophen ,Aspirin, NSAIDS • Opioid: Morphine, Fentanyl
  28. 28. MEDICATION DOSAGE SIDE EFECTS Acetaminophen 10-15 mg/kg PO q4h 20-30 mg/kg/PR q4h Aspirin 10-15 mg/kg PO q4h Anti-inflammatory; prolonged antiplatelet effects; may cause gastritis; associated with Reye's syndrome Ibuprofen 8-10 mg/kg PO q6h Anti-inflammatory; transient antiplatelet effects; may cause gastritis; extensive pediatric safety experience Naprosyn 5-7 mg/kg PO q8-12h Anti-inflammatory; transient antiplatelet effects; may cause gastritis; more prolonged duration than that of ibuprofen Ketorolac Loading dose 0.5 mg/kg, then 0.25-0.3 mg/kg IV q6h to a maximum of 5 days; maximum dose 30 mg loading with maximum dosing of 15 mg q6h Anti-inflammatory; reversible antiplatelet effects; may cause gastritis; useful for short-term situations in which oral dosing is not feasible n Little anti-inflammatory action; no antiplatelet or adverse gastric effects; can produce fulminant hepatic failure
  29. 29. • Morphine:0.05-0.1mg/kg i.v Q2-4h 0.010.03 mg/kg/hr • Fentanyl:0.5-1 mcg/kg q1-2h Side effects: Nausea and vomiting , Respiratory depression, Pruritis, constipation, urinary retention.
  30. 30. Mild – moderate pain: Acetaminophen , NSAIDS. Moderate- Severe pain not responding to analgesics : Opiods
  31. 31. NON PHARMACOLOGICAL • • • • • • • Relaxation techniques Distraction Hypnotherapy Biofeedback Iyengar yoga Massage Psycotherapy individual& family • • • • • Physical therapy Acupuncture TENS Music & Art therapy Dance, Aromatherapy
  32. 32. Non-pharmacological therapy • Relaxation techniques promote muscle relaxation and reduction of anxiety, which often accompanies and increases pain. Controlled breathing and progressive muscle relaxation are commonly used relaxation techniques • Distraction techniques- Focusing a child's attention away from something negative to something more positive such as music, toys or bubbles • Hypnosis helps a child focus on an imaginative experience that is comforting, safe, fun. • Biofeedback involves controlled breathing, relaxation, or hypnotic techniques with a mechanical device that provides visual or auditory feedback to the child when the desired action is approximated. • Iyengar yoga was developed to achieve balance in mind, body, and spirit. • Physical therapy can be especially useful for children with chronic, musculoskeletal pain and for those deconditioned from inactivity.
  33. 33. Non-pharmacological therapy • Transcutaneous nerve electrical stimulation (TENS) refers to sending small electric currents through the skin. It is a possible treatment for neuropathic pain (in combination with opioids) but is not always effective. It has few side-effects so is often trialed initially in patients with moderate pain. • Acupuncture involves the placement of needles at specific acupuncture points along a meridian, or energy field, after a diagnosis of excess or deficiency energy in that meridian as the primary cause of the pain is made by the acupuncturist • Music and art therapy. • Dance, movement, pet therapies, and aromatherapy
  34. 34. INVASIVE INTERVENTIONS • Neuraxial and peripheral nerve blocks provide intraoperative anesthesia, postoperative analgesia ,treatment of acute pain and contribute to the management of chronic pain • Regional anesthesia -It is an alternative to or augmentation of opioid-based pain control, thereby minimizing the opioid side effects. - It generally provides better quality pain stress responses; - It results in earlier ambulation in recovering surgical patients; -It helps prevent atelectasis in the setting of severe chest pain; -It usually results in earlier discharge from the hospital. • Nerve ablation & destruction.
  36. 36. Neonatal Pain Management Minimally invasive procedures: • Sucrose 0.5ml 24% sol p/o -2min before and just prior to procedure along with non pharmacological strategies. • Breast feeding. • Topical Analgesia : EMLA( lidocaine+Prilocaine) Invasive Procedures : Opioids Post Operative Analgesia: • • • • & sedatives Pain history & previous opioid use. Severity of procedure. Post op airway management. Post op desired level of sedation.
  37. 37. Prior h/o opioid exposure Major Sx Procedure Prolonged intubation anticipated All No LOW DOSE PROTOCOL 1.I.P phase Fentanyl/ Morphine -3doses 2. Cont. Phase Fentany/Morphine infusion Any Yes HIGH DOSE PROTOCOL 1.I.P Fentanyl/Morphine-3 dose 2. Cont. Phase Fentanyl/Morphine Adjunctive Therapy Acetaminophen for 72 hrs BDZ( Midaz bolus/ infusion) Weaning Protocol
  38. 38. Low dose protocol: Evaluate at 24hrs after sx and then every 12hrs. Pt extubated & pain well managed- cont . Infusions stopped & managed with non opioids. High dose protocol: Pt specific weaning plan should be developed.
  40. 40. Advanced diseases: Neurodegenerative disorders, AIDS , cancer –palliatve care for optimal QOL. Pharmacological & non pharmacological therapy. Recurrent Pain Syndromes: Neuropathic pain- Anti Depressants-TCA & SSRI, AED (Gabapentin, Pregabalin, Lamotrigine). Invasive interventions may be tried.
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