Pain lecture for icu club meeting

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This lecture shows how easy and important to know the definition of pain. It shows the components of pain , scales of pain and various modalities of pain management. This lecture is made for the staf of Al Rass General Hospital, Al Gassim, Saudi Arabia, and follows the hopspital policy and procedures of pain management

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Pain lecture for icu club meeting

  1. 1. PAIN MANAGEMENT
  2. 2. PAIN MANAGEMENT• What is pain ?• What causes pain ?• How to classify and measure the pain ?• How to treat the pain ?
  3. 3. PAIN MANAGEMENT• What are the systemic effects of pain ? How• What is the cause of this pain ? the treatment classified ?• How can this pain be of pain• How to address and treat ? pain ? Is so important this
  4. 4. PAIN• What is pain ?systemic effects of pain ? are the• What causes pain ? this pain ? is the cause of• How to classify and measure the pain ? can this pain be classified ?• How to treat theand treat this pain ? address pain ?
  5. 5. Pain is an unpleasant sensory and emotional experience associated with PAINactual or potential tissue damage or described in terms of such damage The International Association for the Study of Pain
  6. 6. Pain is an unpleasant sensory and emotional experience associated with PAINactual or potential tissue damage an unpleasant experience or described in terms of such damage sensory emotional The International Association for the Study of Pain associated with described in actual or potential terms of such tissue damage damage
  7. 7. Pain is an unpleasant sensory and emotional experience associated with PAINactual or potential tissue damage or described in terms of such damage The International Association for the Study of Pain
  8. 8. Pain is an unpleasant sensory and emotional experience associated with PAINactual or potential tissue damage is or U SEE described in terms of such UNPLEASANT damage SENSORY & The International EMOTIONAL Association for the EXPERIENCE Study of Pain
  9. 9. Anatomyand physiology
  10. 10. Anatomyand physiology STIMULUS
  11. 11. Anatomyand physiology STIMULUS RECEPTION
  12. 12. Anatomyand physiology T R A N S M I S S I O N STIMULUS RECEPTION
  13. 13. INTERPRETATION Anatomyand physiology T R A N S M I S S I O N STIMULUS RECEPTION
  14. 14. PHYSICAL
  15. 15. EMOTIONALPHYSICAL
  16. 16. EMOTIONALPHYSICAL RATIONAL
  17. 17. EMOTIONAL PHYSICALIMPORTANT RATIONAL• Pain can manifest without physical component• This type of pain too deserves the same attention, evaluation and treatment
  18. 18. TYPES OF PAIN
  19. 19. TYPES OF PAIN ACUTE PAIN CHRONIC PAIN• Usually related an identifiable event or condition• resolves in days/weeks• usually nociceptive• Needs anxiolytics
  20. 20. TYPES OF PAIN ACUTE PAIN CHRONIC PAIN• Usually related an identifiable • May/may not be related an event or condition identifiable event or condition• resolves in days/weeks • Persists for an indefinite period• usually nociceptive • usually multifactorial• Needs anxiolytics • Needs antidepressants
  21. 21. TYPES OF PAIN ACUTE PAIN CHRONIC PAIN• Usually related an identifiable • May/may not be related an event or condition identifiable event or condition• resolves in days/weeks • Persists for an indefinite period• usually nociceptive • usually multifactorial• Needs anxiolytics • Needs antidepressants
  22. 22. TYPES OF PAIN ACUTE PAIN CHRONIC PAIN• Usually related an identifiable • May/may not be related an event or condition identifiable event or condition• resolves in days/weeks • Persists for an indefinite period• usually nociceptive • usually multifactorial• Needs anxiolytics • Needs antidepressants
  23. 23. TYPES OF PAIN NEUROPATHIC PAIN NOCICEPTIVE PAIN
  24. 24. TYPES OF PAIN SOMATIC VISCERAL NOCICEPTIVE PAIN
  25. 25. TYPES OF PAIN• Involves skin, soft tissues, muscle, bone etc• stimulation of somatic nerves• Sharp , aching, throbbing• Easily localized SOMATIC VISCERAL NOCICEPTIVE PAIN
  26. 26. TYPES OF PAIN• Involves skin, soft tissues, muscle, bone etc • Involves viscera-heart, lung, GIT, GUT• stimulation of somatic nerves • stimulation of autonomic nerves• Sharp , aching, throbbing • Gripping, vague aching• Easily localized • Difficult to localize and often referred SOMATIC VISCERAL NOCICEPTIVE PAIN
  27. 27. TYPES OF PAIN• Involves skin, soft tissues, muscle, bone etc • Involves viscera-heart, lung, GIT, GUT• stimulation of somatic nerves • stimulation of autonomic nerves• Sharp , aching, throbbing • Gripping, vague aching• Easily localized • Difficult to localize, often referred SOMATIC VISCERAL NOCICEPTIVE PAIN
  28. 28. TYPES OF PAIN• Involves skin, soft tissues, muscle, bone etc • Involves viscera-heart, lung, GIT, GUT• stimulation of somatic nerves • stimulation of autonomic nerves• Sharp , aching, throbbing • Gripping, vague aching• Easily localized • Difficult to localize, often referred SOMATIC VISCERAL NOCICEPTIVE PAIN
  29. 29. TYPES OF PAIN• Burning, Shooting NEUROPATHIC• Tingling, Numbing PAIN• Electrical shock likeIntensity exceeding the observable injury
  30. 30. TYPES OF PAIN • Compression • Traction • Infiltration • Ischemia Cancer in vicinity of nerves NEUROPATHIC PAIN
  31. 31. TYPES OF PAIN • Compression • Traction • Infiltration • Ischemia Cancer infiltration of nerves NEUROPATHIC PAIN Post herpetic neuralgia
  32. 32. TYPES OF PAIN • Compression • Traction • Infiltration • Ischemia Cancer infiltration of nerves NEUROPATHIC PAIN Post herpetic neuralgia Phantom limb
  33. 33. TYPES OF • Opioids + Analgesics PAIN • Antidepressants • Anticonvulsants • Anti arrhythmics • Nerve blocks, • Neurolysis, resections NEUROPATHIC PAIN
  34. 34. TYPES OF • Opioids + Analgesics PAIN • Antidepressants • Anticonvulsants • Anti arrhythmics • Nerve blocks, • Neurolysis, resectionsPAIN ASSESSMENT - RGH• Frequency NEUROPATHIC• Intensity PAIN• Location• Exclusive Quality• Since when ?
  35. 35. TYPES OF • Opioids + Analgesics PAIN • Antidepressants • Anticonvulsants • Anti arrhythmics • Nerve blocks, • Neurolysis, resectionsPAIN ASSESSMENT - RGH• Frequency NEUROPATHIC• Intensity PAIN• Location• Exclusive Quality• Since when ?
  36. 36. MEASURING THE PAIN INTENSITY PAIN CAN NOT BE SEEN BUT CAN BE SHOWN
  37. 37. MEASURING THE PAIN INTENSITY PAIN CAN NOT BE SEEN BUT CAN BE SHOWN
  38. 38. MEASURING THE PAIN INTENSITY PAIN CAN NOT BE SEEN BUT CAN BE SHOWN
  39. 39. • Hospital reception areas• Nursing stations
  40. 40. VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE 5/10 3/10 9/10
  41. 41. VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE 5/10 3/10 9/10 HOW OFTEN ? • On admission • On change of every shift • After every procedure • After analgesic medication
  42. 42. VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE 5/10 3/10 9/10 HOW MUCH TIME AFTER ANALGESIC ? • 15 min after iv • 30 minutes after IM/SC • 60 minutes after oral • according to manufacturer’s recommendations
  43. 43. VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE 5/10 3/10 9/10 HOW OFTEN ? • ON ADMISSION • ON CHANGE OF EVERY SHIFT • AT EVERY PROCEDURE • AFTER MEDICATION
  44. 44. VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE 5/10 3/10 9/10 Signs of inadequate pain relief • Continuing pain > 4/10 • Inability to concentrate • Inability to perform the activities of daily living • Tachycardia/HTN • Tachypnea /inadequate respiration
  45. 45. VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE 5/10 3/10 9/10 Signs of analgesic overdosing • Decreased LOC unresponsiveness • Bradycardia • Decreased rate of respiration • Shallow respiration • Pinpoint pupils
  46. 46. RELIEF OF PAIN What first ?TO DIAGNOSE THE CONDITION VS TREATMENT OF PAIN
  47. 47. SYSTEMIC EFFECTS OF PAINSYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN• Neuro-endocrine stress response• Respiratory restriction in abdomino-thoracic surgeries• Moderate to severe pain, regardless of the site, can affect every organ function and may adversely affect th post operative morbidity and mortality
  48. 48. SYSTEMIC EFFECTS OF PAINSYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN CHRONIC PAIN• Neuro-endocrine stress • CARDIO-VASCULAR response • Tachycardia, HTN • Myocardial irritability• Respiratory restriction in • Increased SVR abdomino-thoracic • O2 demand/supply surgeries imbalance  MI • RESPIRATORY• Moderate to severe pain, • Oxygen demand regardless of the site, • CO2 production can affect every organ • Atelectasis due to function and may prolonged bed rest adversely affect th post • GIT & URINARY SYSTEM operative morbidity and • Ileus mortality • Urinary retention
  49. 49. SYSTEMIC EFFECTS OF PAINSYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN CHRONIC PAIN• Neuro-endocrine stress • ENDOCRINE response • Catecholamines • Neg N2 balance• Respiratory restriction in • Carbohydrate intolerance abdomino-thoracic • Renin-angiotensin, surgeries aldosterone • Sodium & water retention• Moderate to severe pain, • HEMATOLOGICAL regardless of the site, • Platelet adhesiveness can affect every organ • Reduced0fibrinolysis function and may hypercoagulability adversely affect th post • IMMUNE SYSTEM operative morbidity and • Lymphopenia depressed mortality RE systeminfection
  50. 50. RELIEF OF PAINACETAMINOPHENAND NSAIDSCEILING EFFECTHEPATO AND RENAL TOXICITY
  51. 51. RELIEF OF PAIN • ORAL • PARENTERALOPIOIDS • SKIN PATCHES• ACT ON IOPIATE RECEPTORS• FEARS AND MYTHS ABOUT DEPENDANCE AND ADDITION• HEPATIC – RENAL CLEARANCE
  52. 52. RELIEF OF HOW OFTEN ? PAIN • Duration of action • Formulation • What is PRN ? • What is break though pain ?
  53. 53. RELIEF OF HOW OFTEN ? PAIN • Duration of action • Formulation • What is PRN ? • What is break though pain ?
  54. 54. RELIEF OF HOW OFTEN ? PAIN • Duration of action • Formulation • What is PRN ? • What is break though pain ? PCA
  55. 55. RELIEF OF PAINADJUVANTS• Anxiolytics• Antidepressants• Anticonvulsants• Anti-arrhythmicsAdjuvants for local anesthetic interventions• Narcotics• Clonidine
  56. 56. RELIEF OF PAINPHYSICALTHERAPY
  57. 57. RELIEF OF PAINPHYSICALTHERAPY
  58. 58. RELIEF OF PAINPHYSICALTHERAPY
  59. 59. RELIEF OF PAINACUPUNCTURE
  60. 60. RELIEF OF PAININTERVENTIONALPROCEDURES
  61. 61. RELIEF OF PAININTERVENTIONALPROCEDURES
  62. 62. RELIEF OF PAININTERVENTIONALPROCEDURES
  63. 63. RELIEF OF PAININTERVENTIONALPROCEDURES
  64. 64. RELIEF OF PAININTERVENTIONALPROCEDURES
  65. 65. RELIEF OF PAININTERVENTIONALPROCEDURES
  66. 66. RELIEF OF PAININTERVENTIONALPROCEDURES
  67. 67. RELIEF OF PAIN PAIN TEAM • All related medical specialists • Nurses • Social workers • Pharmacists • Religious affairs • Physiotherapists • Occupational therapists • Child life specialists
  68. 68. WHO PAIN RELIEF LADDER 3 SEVERE 2MODERATE 1 MILD
  69. 69. WHO PAIN RELIEF LADDER 3 SEVERE 2MODERATE 1 MILD
  70. 70. WHO PAIN RELIEF LADDER 3 SEVERE 2MODERATE 1 NON-OPIOD + ADJUVANT MILD
  71. 71. WHO PAIN RELIEF LADDER 3 SEVERE OPIOD 2 NON-OPIODMODERATE + ADJUVANT 1 NON-OPIOD + ADJUVANT MILD
  72. 72. WHO PAIN RELIEF LADDER OPIOD 3 NON-OPIOD SEVERE + ADJUVANT OPIOD 2 NON-OPIODMODERATE + ADJUVANT 1 NON-OPIOD + ADJUVANT MILD
  73. 73. WHO PAIN RELIEF LADDER FREEDOM FROM CANCER PAIN OPIOD 3 NON-OPIOD SEVERE + ADJUVANT OPIOD 2 NON-OPIODMODERATE + ADJUVANT 1 NON-OPIOD + ADJUVANT MILD
  74. 74. WHO PAIN RELIEF LADDER FREEDOM FROM CANCER PAIN OPIOD 3 NON-OPIOD SEVERE + ADJUVANT OPIOD 2 NON-OPIODMODERATE + ADJUVANT 1 NON-OPIOD + ADJUVANT MILD
  75. 75. PAIN IS VERY OFTEN POORLY TREATED
  76. 76. PAIN IS VERY OFTEN BARRIERS POORLY TREATED • Lack of knowledge and commitment • Myths about addiction • Other barriers • Patient related • System related • Profession related
  77. 77. TAKE HOME MESSAGE• Pain is one of the vital signs• Pain by itself needs to be addressed• Pain is a team approach• Commit yourself for giving pain relief day to day
  78. 78. THANK YOU

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