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pain mangement Lecture for 3rd year MBBS

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pain mangement Lecture for 3rd year MBBS

  1. 1. Pain control and postoperative analgesia DR.NADIR MEHMOOD Asst professor Department ofSurgery, RMC
  2. 2. Objectives • Define pain and its types. • Explain the physiology of pain • Explain pain as the “fifth vital sign” • Enumerate factors influencing pain • Enlist pain control strategies • Elaborate rules for pharmacotherapy • Introduce some pharmacological approaches to treating pain. • Algorithms for pain management • Describe nursing interventions for pain control • Enumerate complementary (non pharmacological therapies used to control pain)
  3. 3. “Pain is a Sensory and Emotional experience, associated with actual or potential tissue damage or described in terms of such damage” (IASP) Definition of pain?
  4. 4. Pain Types • NOCICEPTIVE PAIN – results from ongoing activation of mechanical, thermal, or chemical nociceptors – typically opioid-responsive – eg. pain related to mechanical instability • NEUROPATHIC PAIN – spontaneous or evoked pain that occurs in the absence of ongoing tissue damage,Dysfunction of the nervous system – Abnormality in the processing of sensations – Associated with medical conditions rather than tissue damage – typically opioid-resistant*** – eg. pain secondary to nerve root injury • Phantom Pain
  5. 5. Phantom Pain • Occurs after the loss of a body part from amputation • Patient “feels” pain in the amputated part for years after the amputation has occurred • May be controlled Accessed 11 February 2009 from http://www.pc.rhul.ac.uk/staff/J.Zanker/PS1061/L6/phantom.gif
  6. 6. Time-based classification of pain • Acute: short-term; usually due to nociception (tissue damage); resolves with healing. • In back pain, Acute = < 4 wks Sub-acute = 4-12 weeks Chronic = > 12 weeks • Chronic pain: pain lasting > 3-6 months • Persisting pain (NHMRC: acute pain guidelines)
  7. 7. “pain is whatever the experiencing person says it is, existing whenever he says it does.” (McCaffery & Pasero, 1989). “It is not the responsibility of clients to prove that they are in pain; it is the physician’s responsibility to believe them.” (Crisp & Taylor, 2005).
  8. 8. Factors Influencing Pain • Age • Gender • Culture • Meaning of pain • Attention • Anxiety • Fatigue • Previous experience • Coping style • Family and social support
  9. 9. Causes of Acute Pain  Post-operative  Burns  Trauma  Infective / Inflammatory conditions  Ischaemic pain  Visceral pain  Obstetric - Labor
  10. 10. Causes of Post-Operative Pain  Incisional skin and subcutaneous tissue  Deep cutting, coagulation, trauma  Positional nerve compression, traction & bed sore.  IV site needle trauma, extravasation, venous irritation  Tubes drains, nasogastric tube, ETT  Respiratory from ETT, coughing, deep breathing  Rehab physiotherapy, movement, ambulation  Surgical complication of surgery  Others cast, dressing too tight, urinary retention
  11. 11. Causes of Chronic Pain  Cancer pain  Cancer related  From cancer therapy  Cancer unrelated  Non-cancer  Nociceptive  Neuropathic  Idiopathic
  12. 12. Basics of Pain Management • 1st step: is the good pain assessment. • Pain medications must be taken:  when the pain is first perceived. • Doses of opioids are increased:  with the patient’s report of pain • Adjuvant medications are used for:  opioid non-responsive & neuropathic pain. • Non-pharmacologic approaches are always a part of  any pain management protocol.
  13. 13. The “Costs” of Uncontrolled Pain  Stress response  Hypothalamo-Pituitary-Adrenal axis:  Disturbed cytokine cascade.  Impairment of immune function.  Increased catabolism.  Negative nitrogen balance.  Pain Chronicity.  Cardiovascular  Respiratory  GIT  Neuro-psychiatric  Impairment of mobility, Gait disturbances.
  14. 14. Physiological effects of Pain • Increased catabolic demands: poor wound healing, weakness, muscle breakdown • Decreased limb movement: increased risk of DVT/PE • Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis • Increased sodium and water retention (renal) • Decreased gastrointestinal mobility • Tachycardia and elevated blood pressure
  15. 15. Psychological effects of Pain • Negative emotions: anxiety, depression • Sleep deprivation • Existential suffering: may lead to patients seeking active end of life.
  16. 16. Immunological effects of Pain • Decrease natural killer cell counts • Effects on other lymphocytes not yet defined.
  17. 17. The ‘fifth’ Vital Sign • Assessed in all patients • Patient/client right to appropriate assessment and management of pain
  18. 18. Acute Pain Management
  19. 19. Goal • To provide patients with a level of pain control that allows them to actively participate in recovery – This level will be individual to each patient • To minimize nausea and vomiting • To minimize other side effects of analgesics – Sedation – Ileus – Weakness – Hypotension
  20. 20. Why all this is vital?? • Pain is a miserable experience • Pain increases sympathetic output – Increases myocardial oxygen demand – Increases BP, HR • Pain limits mobility – Increases risk for DVT/PE – Increases risk for pneumonia, atelectasis secondary to splinting
  21. 21. Principles of Assessment • Assess and reassess • Use methods appropriate to cognitive status and context • Assess intensity, relief, mood, and side effects • Use verbal report whenever possible • Document in a visible place • Expect accountability • Include the family
  22. 22. Assessment • Location • Intensity • Onset • Duration • Radiation • Exacerbation • Alleviation
  23. 23. Good assessment = Successful management Pain Assessment N R S
  24. 24. Pain Assessment Tools • In Adults: Self Report Measurement Scales, such as Numerical Scales
  25. 25. Pain Assessment Tools • In Pediatric Patients: – Physiologic and Behavioral Indicators of Pain ( Infants, Toddlers, Nonverbal or Critically Ill Children) – Face Scale (Age 3-10 yrs) – Visual Analogue Scales (Age 10-18)
  26. 26. • Subjective: • Pain Scores: • Unidimentional  Acute pain • VRS, VAS & NRS. • Facial expression. • Multidimentional  Chronic pain • McGill & Pain Inventory. • Objective: – Behavioral: refusal to move, cough & deep breath – Physiological:  PR, RR, ABP, sweatiness & dilated pupils – Neuro-endocrinal: RBS, Stress hormones Pain Assessment
  27. 27. Numeric Rating Scale (NRS) Visual Analogue Scale (VAS) 0 10 Pain Scores
  28. 28. Wong-Baker “Faces Scale” Verbal scale No Pain Mild Moderate Severe Pain
  29. 29. –Pharmacotherapy – Anesthetic approaches – Implantable devices – Neurostimulation approaches – Alternative approaches – Surgical approaches – Rehabilitative approaches – Lifestyle changes – Psychological approaches Pain Control Strategies
  30. 30. Drug Strategies• Non Opioid Analgesics: – NSAA – NSAIDs • Non-selective COX inhibitors • Selective COX-2 inhibitors • Opioids – Weak Opioids. – Strong opioids. – Mixed agonist – antagonists • Adjuvants – Antidepressants – Anticonvulsants – Substance P inhibitors – NMDA (N-methyl-D-aspartate receptor) inhibitors – LA – Drugs for Headache – Drugs for Bone pain – Others .
  31. 31. • Alternative medicine: – Acupuncture – TENS – Cupping – Chiropractice • Physical Therapy – ice, heat, massage • Exercise • Psychological therapy – Cognitive-behavioral therapy – Relaxation techniques – Biofeedback – Hypnosis Non-Drug Strategies
  32. 32. Routes of Administration • PO • PR • IV • IM • Transdermal • Transmucosal • Epidural • Intrathecal
  33. 33. WHO step Ladder 1 mild 2 moderate 3 severe Morphine Hydromorphone Methadone Pethidine Fentanyl Oxycodone ± Adjuvants Codeine Hydrocodone Oxycodone Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAIDs ± Adjuvants
  34. 34. 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 Analgesic Ladder Proposed 4th Step The WHO Ladder Deer, et al., 1999
  35. 35. How do we do it? • Multimodal analgesia: Several analgesics with different mechanisms of action, each working at different sites in the nervous system
  36. 36. OPIOIDS Efficacy is limited by Side-Effects • The harder we “push” with single mode analgesia, the greater the degree of side-effects Analgesia Side-effects
  37. 37. Multimodal Analgesia • Lower doses of each drug can be used therefore minimizing side effects • With the multimodal analgesic approach there is additive or even synergistic analgesia, while the side-effects profiles are different and of small degree (Pasero & Stannard, 2012). Analgesia Side-effects
  38. 38. Systemic Analgesia • Opioids – Potent analgesics – Drug of choice for moderate to severe pain – Unfortunately, they are often the only drug ordered – Side effects:
  39. 39. Epidural Infusions • Used for major surgery ie. Oncologic surgery, thoracotomy • Ideally placed pre-operatively and used in combination with a GA for surgery and continued ~ 2 days • Usually patient is tolerating diet and ambulation to chair when epidural is D/C
  40. 40. • Advantages: – Patients can titrate their own analgesia – Improved: • Pain relief • Pulmonary function. – Decreased: • Total daily dose. • Over sedation. • Postoperative complications. Routes of Administrations - PCA
  41. 41. Miscellaneous Adjuvant Analgesics • Pamidronate (Aredia) • Zoledronic acid (Zometa) • Strontium-89 (Metastron) • Calcitonin (Calcimar) Not in cancer ? arthritis • Capsaicin (Zostrix) scheduled in neuropathic pain • Clonidine (Catapres) all forms • Cannabinoid (Marinol)
  42. 42. Analgesics for Neuropathic Pain • Tricyclic antidepressants – nortriptaline (1st choice) • Anticonvulsants – Gabapentin, Carbamazepine, Pregaba • Local anesthetics – Parenteral, oral, topical • Topical capsaicin • Opioids for selected patients
  43. 43. Multidisciplinary Pain Clinic Personnel • Physicians – Neurosurgeon – Orthopedic surgeon – Anesthesiologist – Neurologist – Physiatrist – Internal medicine – Psychiatrist – Addictionologist • Nurses • Psychologists • Physical Therapist • Occupational Therapist • Vocational counselor • Social worker • Dietician • Recreational staff • Administrative support staff
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