Anaestesia

1. WELCOME TO
THE
MORNING
SESSION

2. Topic of
Presentation:
“MANAGEMEN
T OF PAIN”

3. Introduction
DR-RIFATUZZAMAN &
DR-SAYEDA SULTANA BITHI
Intern Doctor
Surgery Department
TMMC & H

4. The word pain is derived from latin word peone &
greek word poine meaning penalty or punishment.
Pain is an unpleasant sensory and emotional
experience associated with actual and potential
tissue damage.
Medical
Definition of
“PAIN”

9. “TYPES
OF PAIN”

10. ACCORDING
TO DURATION
Acute pain- lasts only through the expected recovery
period whether it has a sudden or slow onset and
regardless of intensity.
Chronic pain- is prolonged, usually recurring o
persisting over 6 months or longer, and interferes with
functioning.
Mild to severe, constant or recurring without an
anticipated or predictable end and a duration of
greater than 6 months. (Ackley&Ladwig, 2006)

19. INTENSIT
Y
Classified using a standard 0(no pain) to 10 (worst
possible pain) scale.
Mild pain- rating of 1-3
Moderate pain- rating of 4-6
Severe pain- reaching 7-10 and is associated with
worst outcome.

20. ETIOLOGY
Physiological pain- experienced when an intact, properly
functioning nervous system sends signals that tissue are
damaged, requiring attention and proper care.
Somatic pain- originates in the skin, muscles, bones or
connective tissue with sharp sensation of a paper cut or
aching of sprained ankle.
Visceral pain- poorly located and may have cramping,
throbbing, pressing, or aching quality. Often associated
with feeling sick.

21. Neuropathic pain- experienced by people with
damaged or malfunctioning nerves. Peripheral
neuropathic pain- follows damage and/or
sensitization of peripheral nerves.

22. NOCICEPTIO
NNociceptive pain occurs when nociceptors in the body detect
noxious stimuli that have the potential to cause harm to the
body. Neuropathic pain is caused by damage to
the neurons that are involved in the pain signaling pathways
in the nervous system.

23. TRANSDUCTION
Transduction is the conversion of a noxious stimulus
(mechanical, chemical or thermal) into electrical
energy by a peripheral nociceptor (free afferent nerve
ending)

24. TRANSMISSION
Includes 3 segments.
First segment- pain impulse travels from the peripheral
nerve fibers to the spinal cord.
Second segment- transmission from the spinal cord
and ascension via spinothalamic tracts, to the brain
stem and thalamus.
Third segment- involves transmission of signals
between thalamus to the somatic sensory cortex
where pain perception occurs.

25. Pain control can take place during this second
process. Opoids (narcotic analgesics) block
the release of neurotransmitters, particularly
substance P, which stops the pain at the
spinal level. Capsaicin may also deplete
substance P that could inhibit the transmission
of pain signals.

26. MODULATION
Often descibed as “descending System”
Occurs when neurons in the thalamus and brain
stem send signals down to the dorsal horn of the
spinal cord.

27. PERCEPTION
Is when the client becomes conscious of
the pain.

29. NURSING MANAGEMENT
ASSESSING- pain history, location, pain intensity
with pain scale, pattern. Precipitating factors, alleviating
factors, associated symptoms, effect on daily activities,
coping resources, affective response.
DIAGNOSING- acute or chronic pain.

40. PHARMACOLOGIC
MANAGEMENT

41. Chronic Pain Management
Nociceptive pain:
It may result from musculoskeletal disorders or cancer
activating cutaneous nociceptors.

42. Neuropathic or neurogenic Pain:
It is classically of a ‘burning’, ‘shooting’ or ‘stabbing’
type & may be associated with allodynia,numbness & diminished
thermal sensation. It is poorly response to opoids. Monoaminergic,
tricyclic inhibitors & anticonvulsant drugs are the mainstay of
treatment.

43. Psychogenic Pain:
It is associated with depressive illness,
chronic pain & illness may exacerbate each other.

44. Chronic Pain control in Benign
Disease:
* Bring pain under control before amputation to avoid
phantom pain. * Local anesthetic &
steroid Injection around a nerve may reduce muscle spasm.
* Transcutaneous nerve stimulators (TNS) modify pain by
increasing endorphin production.
* Trigeminal neuralgia responds to decompression of the nerve.

45. Drugs In Chronic Non Malignant
Pain:

46. Pain Control in Malignant
Disease
* First step: Simple analgesics:
-aspirin
-paracetamol
-non steroidal anti inflammatory
drugs
-Tricyclic drugs or anticonvulsant drugs

47. *Second Step: Intermediate
Strength opoids:
-codeine
-tramadol or
dextropropoxyphene
*Third Step: Strong opoids:
-morphin (pethidine has now been withdrawn)

48. Infusion of subcutaneous,
intravenous, intrathecal or epidural
opiate Drugs:
as possible of developing infection with catastrophic effect.The
infusion of opiates is necessary if a patient is unable to take oral
drugs. Subcutaneous infusion of diamorphine is simple & effective
to administer. Epidural infusions of diamorphine with an external
pump can be used on mobile patients. Intrathecal infusions with
pumps programmed by external computer are used.

49. Neurolytic Techniques in Cancer
pain:
* Subcostal phenol injection for a rib
metastasis * Coeliac
plexus neurolytic block with alcohol for pain of
pancreatic,gastric or hepatic cancer
* Intrathecal neurolytic injection of hyperbaric phenol
*
Percutaneous anterolateral cordotomy divides the spino-
thalamic ascending pathway

50. Alternative strategies Include:
* The development of anti-pituitary hormone
drugs, such as tamoxifen & cyproterone, enables effective
pharmacological therapy for the pain of widespread metastasis
instead of pituitary ablation surgery *
Palliative radioptherapy can be most beneficial for the relief of
pain in metastatic disease
* Adjuvant drugs, such as corticosteroids to reduce cerebral
oedema or inflammation around a tumor, may be useful in
symptom control

53. NON-
PHARMACOLOGIC
MANAGEMENT

54. NON - PHARMACOLOGIC
Non-pharmacological pain management is the
management of pain without medications.
Methods of non-pharmacological pain include:

55. Bed Rest
The use of prolonged bed rest in the treatment of patients with neck and
low back pain and associated disorders is without any significant scientific
merit. Bed rest supports immobilization with its deleterious effects on
bone, connective tissue, muscle, and psychosocial well-being. For severe
radicular symptoms, limited bed rest of less than 48 hours may be
beneficial to allow for reduction of significant muscle spasm brought on
with upright activity. Patients should be instructed to avoid resting with the
head in a hyperflexed or extended position. The proactive approach
emphasizes activity modification as opposed to bed rest and
immobilization.

56. Manipulation and
MobilizationManipulative treatment is commonly used in the treatment of
patients with neck pain and associated disorders. Many
different types of manual treatment exist, including soft tissue
myofascial release, muscle energy/contract-relax, and high-
velocity low-amplitude manipulation. Soft tissue myofascial
release may include various techniques, including effleurage,
pétrissage, friction, and tapotement. It has been shown to
improve flexibility, decrease the perception of pain, and
decrease the levels of stress hormones.

57. TractionCervical traction is a therapeutic modality that can be administered with the patient in
the supine or seated position. Traction may reduce neck pain and works through a
number of mechanisms including passive stretching of myofascial elements, gapping of
facet joints, improving neural foraminal opening, and reducing cervical disc
herniation. It has been found to reduce radicular symptoms in individuals with
confirmed radiculopathy and localized neck pain in individuals with cervicogenic pain
and spondylosis. Cervical traction may be initiated during physical therapy with the
patient properly instructed in home use. It is not a stand-alone treatment modality and
should be done in conjunction with range-of-motion (ROM) exercises, appropriate
strengthening, and correction of postural issues.

58. Therapeutic
Modalities
Therapeutic modalities should be considered
an adjunct to an active treatment program in
the management of acute low back pain.
They should never be used as the sole
method of treatment.

59. Transcutaneous Electrical Nerve
Stimulation
Transcutaneous electrical nerve stimulation (TENS)
has been used to treat patients with various pain
conditions, including neck and low back pain. Success
may be dictated by many factors, including electrode
placement, chronicity of the problem, and previous
modes of treatment. TENS is generally used in chronic
pain conditions and not indicated in the initial
management of acute cervical or lumbar spine pain.
Overall, research is limited in regard to the isolated use
of TENS in the treatment of patients with acute cervical
and lumbar spine disorders, though it has been used in
combination with ROM exercises, spray and stretch,
and myofascial release.

60. Superficial Heat
Superficial heat can produce heating effects at a depth limited to
between 1 cm and 2 cm. Deeper tissues are generally not heated
owing to the thermal insulation of subcutaneous fat and the
increased cutaneous blood flow that dissipates heat. It has been
found to be helpful in diminishing pain and decreasing local
muscle spasm. Superficial heat, such as the hydrocollator pack,
should be used as an adjunct to facilitate an active exercise
program. It is most often used during the acute phases of
treatment when the reduction of pain and inflammation are the
primary goals.

61. Cryotherapy
Cryotherapy can be achieved through the use of ice,
ice packs, or continuously via adjustable cuffs
attached to cold water dispensers. Intramuscular
temperatures can be reduced by between 3 °C and
7 °C, which functions to reduce local metabolism,
inflammation, and pain.

62. Exercise
Correction of posture may be the simplest technique to relieve
symptoms in patients with nonspecific neck or low back pain,
though it is extremely difficult to change habits. The physician
should instruct patients to assume their worst postural “slump
position” with forward protrusion of the head, flexion of the neck,
rounding of the shoulders, and increased thoracic kyphosis and
reversed lumbar lordosis while sitting. Next, the physician should
instruct patients to correct these postural abnormalities through
retraction and extension of the head, retraction of the shoulders,
extension of the thoracic spine, and return of the lumbar lordosis.

63. Electrical Stimulation
High-voltage pulsed galvanic stimulation has been used in
acute neck pain to reduce muscle spasm and soft tissue
edema. It is commonly used despite the lack of hard
scientific evidence for its efficacy. Its effect on muscle spasm
and pain is thought to occur by its counterirritant effect on
nerve conduction and a reduction in muscle contractility. Use
of electrical stimulation should be limited to the initial stages
of treatment, such as the first week after injury, so that
patients may quickly progress to more active treatment that
includes restoration of ROM and strengthening. Electrical
stimulation often may be combined with ice or heat to
enhance its analgesic effects.