Dr. Fatma Al-Dammas is an anesthesiology professor and director of the anesthesia and acute/chronic pain management programs. She specializes in managing pain, which requires a multidisciplinary team approach. The goals of pain treatment are to improve quality of life, facilitate recovery, reduce morbidity, and allow for early hospital discharge. Pain management involves both pharmacological and non-pharmacological approaches, including the WHO pain ladder and various methods of drug delivery like epidural analgesia. Epidural analgesia provides effective post-operative pain relief, improves pulmonary function, and enables earlier ambulation.
The presentation enhances the reader to get comprehensive view about Pain ( physiology of pain, assessment of pain and Management of pain). This will help you to management pain effectively.
The presentation enhances the reader to get comprehensive view about Pain ( physiology of pain, assessment of pain and Management of pain). This will help you to management pain effectively.
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Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
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Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
1. Dr .Fatma Al-Dammas
Assistant Professor
Anesthesia consultant
Anesthesia program director
Acute &chronic Pain management
2. The management of pain is a
multidisciplinary team effort involving
physicians, psychologists, nurses, and
physical therapists
3. GOAL OF PAIN TREATMENT
Improve quality of the pt .
Facilitate rapid recovery &return to full
function .
Reduce morbidity .
Allow early discharge from hospital .
6. PAIN
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage or described in terms of
such damage.
( International
association of study of pain
1979)
7. CLASSIFICATION OF PAIN
SUPERFICIAL DEEP
SOMATIC
TRUEVISCERAL TRUEPARIETAL REFEREDVISCERAL REFEREDPARIETAL
VISCERAL
ACUTE
DEAFFERENTATION
PAIN
SYMPATHETICALLY
MEDIATEDPAIN
CHRONIC
PAIN
8. CLASSIFICATION OF PAIN
SUPERFICIAL DEEP
SOMATIC
TRUEVISCERAL TRUEPARIETAL REFEREDVISCERAL REFEREDPARIETAL
VISCERAL
ACUTE
DEAFFERENTATION
PAIN
SYMPATHETICALLY
MEDIATEDPAIN
CHRONIC
PAIN
9. According to Pathophysiology
• Nociceptive;
Due to activation, sensitization of peripheral
nociceptors.
• Neuropathic:
Due to injury or acquired abnormalities of
peripheral OR central nervous system.
CLASSIFICATION OF PAIN
13. • Caused by noxious stimulation due to injury, a
disease process or abnormal function of muscle
or viscera
• It is nearly always nociceptive
• Nociceptive pain serves to detect, localize and
limit the tissue damage.
ACUTE PAIN
16. SUPERFICIAL SOMATIC PAIN
• Nociceptive input from skin, sub-cutaneous tissue
and mucous membranes
• Well localized and described as sharp, pricking,
burning and throbbing
17. DEEP SOMATIC PAIN
• Arise from Muscles, Tendons and Bones
• Dull, aching quality and is less well localized
• Intensity and Duration of stimulus affects the
degree of localization
18. VISCERAL PAIN
• Due to disease process, abnormal function of
internal organ or its covering, e.g. Parietal pleura,
Pericardium or Peritoneum.
19. SUBTYPES OF VISCERAL PAIN
– True localized visceral pain
– Localized parietal pain
– Referred Visceral pain
– Referred parietal pain
20. VISCERAL PAIN
• Dull, diffuse and in midline
• Frequently associated with abnormal sympathetic
activity causing nausea, vomiting, sweating and
changes in heart rate and blood pressure.
21. PARIETAL PAIN
• Sharp, often described as stabbing sensation
either localized to the area around the organ or
referred to a distant site.
31. GENERAL SENSE OF WELL-BEING
Anxiety
Sleep disturbances
Depression
32. POSITIVE ROLE OF PAIN
Acute pain plays a useful positive physiological role by
providing a warning of tissue damage .
33. Acute Pain management
Pain management continues to be a challenge to nurses.
PCA &epidural analgesia are advance in analgesia that
may assist nurse with this challenge
Pain management can be evaluated in terms of its ability
to meet 2 main goals:
– To relieve postoperative pain.
– To relieve patient of inhibition of respiratory movement
without sedation.
34.
35. CHRONIC PAIN
Chronic pain is defined as that which persists
beyond the usual course of an acute disease or after
a reasonable time for healing to occur
period varies between 6 or > months in most
definitions.
37. CHRONIC PAIN
Pt with chronic pain often have an absent
nuroendocrine stress response
Have prominent sleep and affective (mood)
disturbances.
38. Chronic pain Acute pain
Classification – division according to duration of time
Is caused by external or
internal injury or damage
Its intensity correlates
with the triggering
stimulus
It can be easily located
Has a distinct warning and
protective function
Lasts longer than expected
Is uncoupled from the
causative event
Becomes a disease in its own right
Its intensity no longer correlates
with a causal stimulus
Has lost its warning and
protective function
Is a special therapeutic challenge
Requires interdisciplinary
procedures
44. What is the severity of the pain?
0 1 2 3 4 5 6 7 8 9 10
Visual analog scale -
Numerical intensity scale -
Descriptive intensity scale -
No pain Mild pain
Moderate
pain
Severe
pain
Worst possible
pain
No pain
Pain as bad as it
could possibly be
Pain Assessment:
11 of 16
45. PAIN RATING SCALE
• The WONG BAKER FACES
SCALE.
• 0-No pain
• 10-Severe pain.
• User friendly.
• Easy to explain to patient.
• Compact to carry
46. • Wong Baker Faces Pain Rating Scale could be used as three scales
because it combines
• Facial expression.
• Numbers.
• Words.
• (Ask patient to point to the faces that matches their feeling.The
number used to record the score)
49. Children between 3-8 years
• Usually have a word for pain
• Can articulate more detail about the presence and
location of pain; less able to comment on quality or
intensity
• Examples:
– Color scales
– Faces scales
50. Children older than 8 years
• Use the standard visual analog scale
• Same used in adults
53. There are many different techniques,non-
pharmacological &pharmacological , both
regional and non-regional to provide post op
analgesia.
54. Nonpharmacologic Approaches to Relieve Pain and
Prevent Suffering
hydrotherapy
intradermal water blocks
movement & Positioning
touch and massage
acupuncture
(TENS)
aromatherapy
heat and cold
audioanalgesia.
58. WHO analgesic guidelines
• Oral medications whenever possible
• Dose “by the clock” – but always have “as
needed”medications for breakthrough pain
• Titrate the dose
• Use appropriate dosing intervals
• Be aware of relative potencies
• Treat side effects
63. Acute Pain
Postop pain is a type of “Acute Pain”
Recent onset,
Limited duration,
Has a causal relationship,
Variable pain intensity,
Variable response to analgesia
PCA
64. • PCA is based on the belief that patients are
the best judges of their pain.
• They should be allowed an active role in
controlling their pain.
• That pain relief should be secured as
quickly as possible.
Patient Controlled Analgesia
65. P C A
PCA are modified infusion
pumps that allow patient
to self administer a small
dose of opioid when pain
is present , thus allowing
patients to titrate their
level of analgesia against
the amount of pain they
are experiencing.
66. PATIENT SELECTION
• Patient should not be denied access to
this modality simply because of age.
• Screen for cognitive and physical ability
to manage their pain by using the PCA.
• Should have the understanding of pain
relief , using the demand button and
when to use the demand button.
67. PCA not offered to confused patient and those who
become confused should have PCA discontinued.
The same patient selection guidelines and
consideration for the use of PCA apply to
children.
Important to remind parents and caregivers not to
press the demand button .
PATIENT SELECTION
68. • PCA is well tolerated.
• Offer flexibility in dose size and dose interval in
individual patients.
• Therapeutic serum level can be reached relatively
quickly because the drug is administered into the
vascular system directly.
P C A
69. P C A
• Patient can secure an early therapeutic serum
level with loading doses titrated to individual
pain needs.
• A steady state plasma level occurs because the
elimination of the drug from the plasma is
balanced by the patients self administered drug
injection.
70. Relationship of mode of delivery of analgesia to serum
analgesic level
• IM and IV PCA
71. PCA
• PCA allows patient control over their pain and
therefore gives greater satisfaction.
• PCA also eliminates the lag time between pain
sensation and administration of analgesia.
72. PAIN CYCLE
I.M PRN ANALGESIA
Nurse Screen
Meds Prepared
I.M Given
Calls Nurse
Drug Absorbed
Sedation
PATIENT FEELS PAIN
74. PCA
• The pump documents the total number of mg of
drug delivered, the number of times the patient
requests a bolus and number of times
medication is delivered in response to demands.
• This information is helpful when assessing
whether the established PCA parameters are
appropriate to patient’s need.
75. • Decreased nursing time
• Increased patient satisfaction.
• Used in a variety of medical and post-op surgical
conditions.
• Decreased narcotic usage.
• Decreased level of sedation.
• Earlier ambulation.
BENEFITS
76. • Decreased overall pain scores reported by
patients.
• Increased compliance to post op care.
• Less anxiety.
• More autonomy regarding pain control.
• Improved rest and sleep pattern
BENEFITS
77.
78.
79. Benefits of Epidural Analgesia
Better pain control
Earlier ambulation
Improved Pulmonary Mechanics
Decreased incidence of DVT
Faster return of bowel function
82. SPINAL CORD
• Located and protected within vertebral column
• Extends from the foramen magnum to lower border 1st L1
(adult) S2 (kids)
• SC taper to a fibrous band - conus medullaris
• Nerve root continue beyond the conus- cauda equina
• Surrounded by the meninges,(dura,arachnoid &pia mater.)
83.
84.
85.
86. EPIDURAL SPACE
• Potential space
• Between the dura mater,luigamentum flavum
• Made up of vasculature, nerves, fat and lymphatic
• Extends from foramen magnum to the
sacrococcygeal ligament
87. INDICATIONS
The objective of epidural analgesia is to relieve pain.
Major surgery
Trauma (# ribs)
Palliative care (intractable pain)
Labour and Delivery
88. CONTRAINDICATIONS
• Patient refusal
• Known allergy to opioid or local anesthetic
• Infection/abscess near the proposed injection site
• Sepsis
• Coagulation disorder
• Hypotension / hypovolemia
• Spinal deformity/increased ICP
89.
90.
91. Patient assume a sitting or side-lying position
with the back arched toward the
physician.Help to spread the vertebrae apart
93. INSERTION OF EPIDURAL CATHETER
• Positioning of patient
• The site is dependent upon the area of pain
• Fixing the catheter
Incision Level
Thoracic T4-T6
Upper abdo T6-T8
Lower abdo T8-T10
Pelvic T8-T10
Lower extremity L1-L4
94.
95.
96.
97.
98.
99.
100.
101.
102. EPIDURAL CATHETERS
• Ideal Placement (adult) 10-12 cm at the skin
• Epidural catheters have markings that indicate their length.
= there is a mark at the tip of the catheter
= the 1st single mark up the catheter is 5cm
= double mark up the catheter is 10 cm
= triple mark on the catheter is 15 cm
= four mark together indicate 20cm
A change in depth of the catheter indicates migration either into or
out of the epidural space.
103. CATHETER MIGRATION
Catheter migration into a blood vessel in the epidural space or
subarachnoid space
rapid onset LOC
Decrease loss of sensory or motor loss (marcain)
Toxicity
Profound hypotension
104. CATHETER MIGRATION
Out of the epidural space
• ineffective analgesia
• no analgesia
• drugs deposited into soft tissue.
105. MEDICATION COMMONLY USED
• OPIOIDS-Fentanyl +Morphine
(affect the pain transmission at the opioid receptors)
• L.A.-Bupivacaine(marcaine)
(inhibits the pain impulse transmission in the nerves
with which it comes in contact)
106. METHODS OF ADMINISTRATION
BOLUS (FENTANYL, DURAMORPH)
CONTINUOUS INFUSION(MARCAINE+FENTANYL)
All drugs administered epidural should be preservative free.
All epidural opioids should be diluted with normal saline prior to
intermittent bolus administration.
107. Motor and Sensory Assessment
• Motor assessment
• Sensory assessment
109. Motor and Sensory Assessment
Sensory assessment:
Use ice in the tip of a glove
Start in upper neck and move down thorax bilaterally
assessing all potential dermatomes
Level of block is where intensity of cold changes or
the cold sensation is absent
assess the dermatomes below the pelvis
110.
111.
112.
113.
114.
115. Adverse Effects L.A
• Hypotension-
-assess intravascular volume status
-no trendelenberg positioning
• Teach patient to move slowly
from a lying position to sitting to
standing position.
Treatment
• fluids
116. Cont.
• Temporary lower-extremity motor
or sensory deficits.
Tx: lower the rate or
concentration.
• Urine retention
Tx: catheter
• Local anesthetic toxicity
(neurotoxicity)
Tx: stop infusion.
• Resp. insufficiency
Tx:stop infusion
- ABC(100% o2
call for help)
- Assess spread
and
height of block
- Alt.analgesia
117. OTHER COMPLICATIONS
• Headache (dural puncture)
Tx: symptomatic treatment
Autologous blood patch
• Infection
• nausea and vomiting.
• Intravenous placement of
catheter
• Subdural placement of catheter
• Haematoma
118. EPIDURAL ANALGESIA(GUIDELINES)
• Collect items
• Assess patient
• Inspect site
• Wash hands
• Aspiration test – Glucose test
• Administer
• Document
• Evaluate the outcome