This document discusses pain, including definitions of pain, types of pain, factors influencing pain, effects of pain, individual variations in pain response, and pain assessment tools. It also covers postoperative pain management principles like the WHO pain ladder, pharmacological and non-pharmacological interventions for pain control, preemptive analgesia using local anesthetics or other drugs before a painful stimulus to reduce later pain, and techniques like patient-controlled analgesia and epidural analgesia. The goal of pain management is to prevent pain from interfering with recovery through adequate assessment and treatment.

2. Sensory and emotional experience associated with actual
or potential tissue damage

3. According to Katz and Melzack, pain is a
personal and subjective experience that
can only be felt by the sufferer.
According to McCaffery pain is whatever
the experiencing person says it is and
exists whenever they say it does.

4. TYPES OF PAIN
 ACUTE PAIN
 CHRONIC PAIN
 CUTANEOUS PAIN
 DEEP SOMATIC PAIN
 VISCERAL PAIN
 REFERRED PAIN
 NEUROPATHIC PAIN
 PHANTOM PAIN

5. Effects of pain
Sympathetic responses
 Pallor
 Increased blood pressure
 Increased pulse
 Increased respiration
 Skeletal muscle tension
 Diaphoresis

6. Effects of pain
Parasympathetic responses
 Decreased blood pressure
 Decreased pulse
 Nausea & vomiting
 Weakness
 Pallor
 Loss of consciousness

11. Individual Variations in
response to Pain:-

12. Behavioral
characteristics
 Facial expressions- grimace, clenched teeth,
wrinkled forehead, crying
 Body movements -restlessness, immobilization,
muscle tension, protective movement of body
parts
 Social interaction- avoidance of conversation &
contacts

13. FACTORS INFLUENCING
PAIN
 PHYSIOLOGICAL
 SOCIAL
 SPIRITUAL
 PSYCHOLOGICAL
 CULTURAL

14. PAIN ASSESSMENT
 PAIN RATING
SCALES- NRS,
VAS,VAT,FACES
RATING SCALE,
 PAIN-0-METER
 McGill PAIN
QUESTIONNAIRE
 BODY MAP

28. Post operative pain
 Acute
 Nociceptors and Neuropathic pain
 Surgical pain

29. Why is control important
 Delays post op recovery
 Increases morbidity
 Delays return to normal function
 Restricts mobility -> thromboembolism
 Catecholamine release
 Pulmonary dysfunction

30. Assessment
 Pre op prediction
 Post op subjective assessment
 Post op objective assessment

31. Initial Pain Evaluation
 The initial evaluation of pain should include a
description of the pain using the PQRST
characteristics:
 P Palliative or provocative factors: ‘What makes it
less intense?’
 Q Quality: ‘What is it like?’
 R Radiation: ‘Does it spread anywhere else?’
 S Severity: ‘How severe is it?’
 T Temporal factors: ‘Is it there all the time, or does it
come and go?’

32.  To study the effects of both physical and non-physical influences on
patient well-being, an instrument
 must assess more dimensions than the intensity of pain or other
physical symptoms. Several validated
 questionnaires to assess various QoL dimensions are available,
including the Medical Outcomes Short-Form
 Health Survey Questionnaire 36 (SF-36), and the European
Organisation for Research and Treatment of Cancer
 Quality of Life Core Questionnaire (EORTC QLQ-C30) (26-30).
There are several rating scales available to assess pain. Rating pain
using a visual analogue scale (VAS, Figure
1) or collection of VAS scales (such as the brief pain inventory) is an
essential part of pain assessment. Its
ease of use and analysis has resulted in its widespread adoption. It is,
however, limited for the assessment of
chronic pain.

33. Pre op assessment
 Past medical and surgical history
 Current Rx (prescribed and illicit)
 Allergies
 Past pain history and treatments
 Patients expectations of pain
 Advice re pain Mx and modes of delivery
 How we measure pain and patients reporting

34. Subjective assessment
 Pain scales - single dimensional and multi
dimensional

39. Objective
 Look at the patient
 Physiological parameters
 Functional parameters

40. Outcomes assessment
 Response to therapy

43. ABCDE for pain assessment
&management
 Ask about pain regularly
 Believe the patient and family in their reports &what
relieves it
 Choose pain control options appropriate for the
patient
 Deliver interventions timely, logical &coordinated
fashion
 Empower patient and their families

44. JCAHO Standards for postoperative
pain management are:
 Recognize patients’ rights to appropriate
assessment and management of pain
 Screen for pain and assess the nature and
intensity of pain in all patients
 Record assessment results in a way that allows
regular reassessment and follow-up
 Determine and ensure that staff are competent
in assessing and managing pain.
 Address pain assessment and management
when orienting new clinical staff

45. Standards Contd..
 Establish policies and procedures that support
appropriate prescribing of pain medications
 Ensure that pain doesn’t interfere with a patient’s
participation in rehabilitation
 Educate patients and their families about effective
pain management

47. POSTOPERATIVE PAIN
MANAGEMENT

48. WHO Pain ladder

49. PRINCIPLES OF PHARMACEUTICAL
PAIN MANAGEMENT
 Provide medication in adequate doses.
 Utilize a preventive approach to pain relief. Use
round the clock dosing with rescue medication
available.
 Closely assess clients with particular diligence
with first doses or when medication dose or the
type is changed
 Combinations of analgesics may be more
effective than those given singularly.

50. PRINCIPLES CONTD.
 Understand and be prepared to treat side
effects of medications
 avoidance of non-life threatening side
effects (such as constipation, nausea,
pruritis) more important that providing pain
relief. These concomitant conditions are
easily treated.
 Additions of adjuvant medications enhance
pain relief.

51. Principles contd.
 Believe the patient’s report of pain.
 Maintain a therapeutic relationship that
facilitates mutual trust.
 Do not use placebos for pain.
 incorporate the goal of total pain relief into
the pain management regimen
 operate as a team to provide the most
effective pain relief outcomes

52. PRINCIPLES CONTD.
 Asking for pain medication reflects the need for
pain relief in 99.9% of people with pain and
doses does not reflect an addictive personality.
 Recognize that respiratory depression is a rare
occurrence, occurring most commonly among
clients who are over sedated. Respiratory
depression rarely occurs after the first few
doses of an opioid.

53. Principles contd.
 Only the patient and no one else can determine the
amount of pain experienced
 There are no objective indicators that can be
observed by another

54. Management contd..
Non-pharmacological
interventions
 Massage
 Diversion therapy
 Relaxation therapy
 TENS
 Heat & cold
applications
 Yoga

55. Pain management
Medications to control pain (Pharmacological)
 Anesthetic agents
 Analgesic agents
 NSAIDs

56. Anesthetic agents
Local Anesthetics-
 Lidocaine
 Bupivacaine
 Ketamine

57. Analgesics
Opioid Analgesics
 Fentanyl
 Morphine
 Codeine
 Demerol (Meperidine)
 Benzodiazepines

58. Commonly used drugs
 Inj.Morphine(50mg) & Inj.Lorazepam(16mg) in 37
ml of 5% dextrose@ 4-8ml/hr
 Inj.Medazolam2mg/hr
 If agitated -Halopperidol

59. Analgesics contd..
Non-Opioid Analgesics
 Paracetamol
 Aspirin
 NSAIDs- ketorolac
 Celecoxib
 Brufen

60. NSAIDs

61. NSAID

62. Patient receiving
Epidural Analgesia

63. Epidural Analgesia
syringe

64. Patient Controlled
Analgesia (PCA)

65. Practicalities
 Pre op assessment
 Prediction of pain
 Preempt with preventative Rx
 Assess post op subjectively and objectively
 Treat with appropriate Rx
 Assess response
 Modify Mx

68.  The concept of pre-emptive analgesia was
introduced in by Woolf who demonstrated through
experimental studies that post injury pain
hypersensitivity results via a central mechanism.

69.  Concept of pre-emptive anlgesia is introduced
because of the greater understanding of pain
mechanism.
 Analgesic is introduced before the painful
stimulus……. Prevents,
1. central sensitization and amplification of
postoperative pain.
2. covers both the operative and postoperative
period.

70.  Therapies that have been tested in pre-emptive
trials include NSAIDS, intravenous opioids,
peripheral local anaesthetics, caudal and epidural
analgesia, dextromethorphan and gabapentin .

71.  Tissue injuries cause an increase in the
excitability of dorsal neurons in the central
nervous system, which is a normal physiologic
response, and contribute to the postoperative
pain.
 Afferent noxious stimulus could be interrupted at
the periphery, afferent input in sensory axons, and
central neurons

72.  Local tissue infiltration has long been established
as a reliable pain relief technique. The main
advantages of this technique are its simplicity,
safety and low cost. The agent most widely used
for this purpose is 0.25% bupivacaine.

73.  It has been suggested that preoperative infiltration
of local anesthetics provides a greater reduction in
postoperative pain than perioperative or
postoperative infiltration.
 . The local infiltration of anesthetic blocks C-fiber
input to the dorsal horn and may thereby inhibit
central sensitization.

74. Local aneasthetics infiltration has also been used in
percutaneous nephrolithotomy (PCNL) to increase
the patients comfort and reduce the pain and
analgesic requirements postoperatively in a
variety of procedures like
herniorrhaphy,chlecystectomy and PCNL etc.