pain management in surgical patient

1. Presented by:
Dr. Md. Nazmus Sakib
Registrar, Surgery unit-I
MMCH.

2. Pain
“an unpleasant sensory and emotional
experience
associated with actual or potential tissue
damage or described in terms of such
damage”
International Association for the Study of Pain

3. Biopsychosocial Model of Pain
Overall functional status

4. PAIN - What is it ?
understood universally
Difficult to define.
Manifestation of pain is a product of :
Physical , psychological , social and
spiritual experiences of the person.
Often considered as the FIFTH VITAL SIGN.

5. Physiology of Pain
• Reception: nerve receptors in the skin and tissues respond
to stimuli resulting from actual or potential tissue damage.
Noxious (pain) stimuli may be thermal, mechanical,
chemical or electrical.
• Perception: is the point at which a person experiences pain.
(Research states that ideally, patients should be given pain medicine during the
PERCEPTION stage).
• Reaction: is the physiological and behavioral responses that
occur after pain is perceived.

6. Physiology of Pain
• Nociceptors
• Stimulus Transmission
• Termination
• Modulation

7. Physiology of Pain

11. Categories of Pain by Type
Somatic
Source: Skin, muscle, and connective tissue
Examples: Sprains, headaches, arthritis
Description: Localized, sharp/dull, worse with
movement or touch
Pain med: Most pain meds will help,
if severe, need a stronger medication

12. Categories of Pain by Type
Visceral
Source: Internal organs
Examples: Tumor growth, gastritis, chest pain
Description: Not localized, refers, constant and dull,
less affected with movement
Pain Med: Stronger pain medications

13. Categories of Pain by Type
Bone Pain
Source: Sensitive nerve fibers on the outer surface of bone
Examples: Cancer spread to bone, fracture
Description: Tends to be constant, worse with movement
Pain Med: Stronger pain meds, opiates with NSAIDS as adjunct

14. Categories of Pain by Type
Neuropathic
Source: Nerves
Examples: Diabetic neuropathy, phantom limb pain,
cancer spread to nerve plexis
Description: Burning, stabbing, pins and needles, shock-
like, shooting
Pain Meds: Opiates + tricyclic antidepressants or
other adjuvant

15. Pain Evaluation
• We must determine if overall goals and outcomes are
achieved.
• Flow sheet records and diaries are helpful in this
process, to evaluate the effectiveness of an analgesic.

16. Pain Assessment
• P recipitating/Alleviating Factors:
– What causes the pain? What aggravates it? Has medication or treatment
worked in the past?
• Q uality of Pain:
– Ask the patient to describe the pain using words like “sharp”, dull, stabbing,
burning”
• R adiation
– Does pain exist in one location or radiate to other areas?
• S everity
– Have patient use a descriptive, numeric or visual scale to rate the severity of
pain.
• T iming
– Is the pain constant or intermittent, when did it begin, and does it pulsate or
have a rhythm

17. 0-10 Pain Scale
No Pain.
O. Feeling perfectly normal.
Minor
Does not interfere with most activities. Able to adapt with medication or devices such as cushions.
1. Very Mild
Very light barely noticeable pain, like a mosquito bite.
2. Discomforting
Minor pain, like lightly pinching the skin.
3. Tolerable
Very noticeable pain, like an accidental cut. Still manageable.

18. 0-10 Pain Scale
Moderate
Interferes with many activities. Requires lifestyle changes but still independent.
Unable to adapt.
4. Distressing
Strong, deep pain, like an average toothache or stubbing your toe real hard.
5. Very Distressing
Strong, deep, piercing pain, such as a sprained ankle when you stand on it
wrong or mild back pain.
6. Intense
Strong, deep, piercing pain so strong it seems to partially dominate your senses,
causing you to think somewhat unclearly.

19. 0-10 Pain Scale
Severe
Unable to engage in normal activities. Feeling disabled and unable to function
independently.
7. Very Intense
Same as 6 except the pain completely dominates your senses, causing you to
think unclearly about half the time..
8. Utterly Horrible
Pain so intense you can no longer think clearly at all.
9. Excruciating, Unbearable
Pain so intense you cannot tolerate it.
10. Unimaginable, Unspeakable
Pain so intense you will go unconscious shortly.
(Most people have never experience this level of pain.)

20. Consequences of Untreated Pain
What happens if pain isn’t properly treated?
Retention of secretion, atelectasis & pneumonia
Pain causes tachycardia, hypertension, increase
catecholamine ultimately may cause myocardial ischemia
Increase catecholamine causes increase metabolism &
sodium & water retention
Less post operative mobilization so increase chance of DVT
Prolong hospital stay

21. Results of Untreated Pain
• Depression, anxiety, decreased socialization
• Sleep disturbance
• Increased healthcare use and costs

22. Goals of pain management
• To relieve suffering
– Increase functional capacity
– Improve quality of life

23. Juggling?
Balancing
BENEFITS HARMS

24. General principles of pain management
 Pain type and pain intensity should guide pain management
 The least invasive route (usually oral) should be used
 For continuous pain, around the clock (ATC) dosing should be
used .

25. General principles of pain management
 Frequent reassessment and monitoring for medication
effectiveness and side effects is essential
 Non-pharmacological measures are essential components of
a pain management program
 Non-physical pain (suffering) will never be relieved by
medication alone

26. General Guidelines for Analgesic
Medication Orders
Basic principles to guide practice:
– Administer medications routinely.
– Use the least invasive route of administration first
– Begin with a low dose. Titrate carefully until comfort is achieved
– Reassess and adjust dose frequently to optimize pain relief while
monitoring and managing side effects

27. Treatments May Include
Non-pharmacologic Methods
• Heat/cold
• Relaxation
• Distraction,
• Acupressure/acupuncture
• Repositioning

28. Acute vs. Chronic Pain Management
Acute Pain
• Most often treated with:
– NSAIDS
– Opioids
– Local anesthetics
– Splinting
– Positioning changes
– Ice
Chronic Pain
• Most often treated with:
– Anti-seizure medications
– Anti-depressant medications
– NSAIDS
– Implantable devices
– Psychological therapy
– Acupuncture
– Opioids

29. Analgesic Drugs
• Acetaminophen
• NSAIDs
– Non-selective COX inhibitors
– Selective COX-2 inhibitors
• Opioids
– Tramadol , Codeine,
Pentazocine,
• Others
– Antidepressants
– Anticonvulsants
– Substance P inhibitors
– Others

30. Pharmacological Interventions
• Opioids:
– for moderate or severe pain
– Tramadol ,Codeine, Pentazocine
• Nonopioids:
– Used alone or in conjunction with opioids for mild to moderate pain
– Acetaminophen
– NSAIDS
• Adjuvants:
– Used for analgesic reasons and for sedation and reducing anxiety.
– Multipurpose
– Tri-cyclic antidepressants
– Anticonvulsants

31. Pain
Step 1
Nonopioid
 Adjuvant
Pain persisting or increasing
Step 2
Opioid for mild to moderate pain
Nonopioid  Adjuvant
Pain persisting or increasing
Pain relief
Step 3
Opioid for moderate to severe pain
Nonopioid Adjuvant
WHO Analgesic Ladder
The WHO
Ladder
Deer, et al., 1999

32. 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
Quality of Life
Modified WHO Analgesic Ladder
Proposed 4th Step
The WHO
Ladder
Deer, et al., 1999

33. Non pharmacological treatment

34. Non pharmacological treatment(C0nt.)
• Immobilization
• Massage
• Acupuncture

35. Multimodal analgesic
• The concept of multimodal analgesic therapy was
introduced to provide effective postoperative pain
relief, reduce opioid-related adverse effects, reduce
surgical stress response and improve clinical
outcomes by combining various analgesic.
• Multimodal analgesic regimens have demonstrated
improved efficacy with improved tolerability.

36. SELF CARE
SELF EFFICACY
Employ multi-modal approach
Behavioral
therapies
Pharmacologic
treatment Physical activity

37. Multimodal Analgesia
“With the Multimodal analgesic approach there is additive or even
synergistic analgesia, while the side-effects profiles are different
and of small degree.”
Analgesia
Side-effects

38. Thank You