Top ten facts about acute pain management
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Discussion about multidisciplinary guidelines in acute pain management
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Top ten facts about acute pain management
- 1. TOP TEN FACTS ABOUT ACUTE PAIN MANAGEMENT Claudia Gomez, MD. FRCPC Department of Anesthesia and Pain Medicine University of Ottawa Twitter: @cpaolag
- 2. Perioperative Care Congress: Science, Evidence and Practice June 2-4, 2017 • Chelsea Hotel, Toronto No relevant financial relationships with any commercial interests Social media sharing is encouraged, find these slides at www.slideshare.com In twitter use the hashtags and user names to discuss: @periopcongress @cpaolag #periopcongress17 #FOAMed #MedEd #AcutePain Financial Disclosures (over past 24 months)
- 3. Objectives: At the end of this session, participants will be able to: 1. Adapt the recommendations from multidisciplinary guidelines on the management of postoperative pain in their own clinical practice. 2. Formulate plans to manage acute pain in a diverse patient population. 3. Describe some research gaps in perioperative acute pain management. 4. Use appropriate pain assessment scales for each population
- 5. Our patient: 85 years old female from home. Mechanical fall, 3 steps down on her side. Pain on her left side. No other injuries. Notes that is painful to breath. X-rays show left anterior rib fractures from 2-7 and moderate size pneumothorax. Past medical hx significant for hypertension and osteoporosis. Vitals: BP 136/76 HR 100, RR 20, SaO2 90% on room air. Chest tube inserted by trauma team. Perioperative Care Congress: Science, Evidence and Practice June 2-4, 2017 • Chelsea Hotel, Toronto
- 6. Fact 1. Treatment of acute pain is fundamental
- 7. Fact 2. There are patient variables that influence pain intensity and analgesic response Sensory→ Nociception. Underlying physical harm Affective: Negative emotions evoked by pain Distress, annoyance, fear Cognitive: Evaluation of problems, expectations. Behavioral: Overt behavioural expression of pain. Functional disability.
- 8. Fact 3. Psychologic factors matter • Anxiety • Fear • Catastrophising
- 10. Fact 4. Outcomes matter Postoperative pulmonary complications Respiratory depression Chronic pain Cancer recurrence?
- 11. Copyright © 2017 American Society of Anesthesiologists. All rights reserved. From: Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort Anesthes. 2010;113(6):1338-1350. doi:10.1097/ALN.0b013e3181fc6e0a
- 13. Fact 5. Acute pain is the main risk factor for the development of chronic pain Ref: Lancet 2011; 377: 2215–25
- 14. Fact 6. Pain assessment should occur with validated scales
- 15. Categories SCORING 0 1 2 Face No particular expression or smile Occasional grimace or frown; withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking Cry No cry (awake or sleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs; frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging, or being talked to; distractible Difficult to console or comfort. FLACC behavioural pain assessment scale
- 16. The PAINAD scale Behavior 0 1 2 Score Breathing independent of vocalization Normal Occasional labored breathing Short period of hyperventilation Noisy labored breathing Long period of hyperventilation Cheyne-Stokes respirations Negative vocalization None Occasional moan or groan Low-level speech with a negative or disapproving quality Repeated or troubled calling out Loud moaning or groaning Crying Facial expression Smiling or inexpressive Sad Frightened Frown Facial grimacing Body language Relaxed Tense Distressed pacing Fidgeting Rigid Fists clenched Knees pulled up Pulling or pushing away Striking out Consolability No need to console Distracted or reassured by voice or touch Unable to console, distract or reassure
- 18. Suggested elements of pain assessment Element Questions used for assessment Onset and pattern When did the pain start? How often it occur? Has its intensity changed? Location Where is the pain? It is local to the incision site, referred, or elsewhere? Quality of pain What does the pain feels like? Intensity How severe the pain is? Aggravating and relieving factors What makes the pain better or worse? Previous treatment What types of treatment have been effective or ineffective in the past to relieve the pain? Effect How does the pain affect physical function, emotional distress, and sleep? Barriers to pain assessment What factors might affect accuracy or reliability of pain assessments (e.g. Cultural or cognitive barriers, misconceptions about interventions)?
- 19. Fact 7. Multimodal analgesic techniques should be offered for the treatment of perioperative pain
- 20. The WHO ladder approach to pain management Weak opioid with non-opioid Strong opioid with non-opioid Ifpainpersistorincrease Withorwithout adjuvants Nonopioid
- 21. Adaptation of the analgesic ladder for acute pain Nonopioid analgesics NSAIDS, acetaminophen “Weak” opioids Strong opioids Nerve blocks, Epidurals PCA pumps STEP I STEP II STEP IV STEP III
- 22. “Cornerstone” perioperative analgesic techniques Patient-controlled analgesia Neuraxial analgesia: epidural and intrathecal analgesia Peripheral nerve blocks Practice guidelines for acute pain management in the perioperative setting. Anesthesiology 2012; 116:248 –73
- 24. Patient with rib fracture(s) Assess pain and oxygenation every 2 hours Ensure multimodal analgesia and bowel regimen prescribed for all patients High Risk? Or Severe Pain? Does the patient require > 4 L/min O2 to maintain SpO2 > 96% Refer to APS (consideration for epidural / paravertebral). Hold anti-thrombotic / anti-platelet agents Refer for Anesthesia / RT assessment (possible BiPAP/CPAP). Ensure NPO >6 hrs HIGH RISK PATIENTS are patients with any one of the following characteristics: • > 4 rib fractures • 65 years old or greater • History of: • Coronary Artery Disease • Congestive Heart Failure • Pulmonary Disease • Obesity BMI > 40 • Diabetes • Patient intolerant of opioidsYES NO NO YES The Ottawa Hospital Pathway For Early Intervention In Rib Fracture START HERE
- 25. Www.postoppain.org Fact 8. We should offer patients evidence- based analgesic techniques based on surgery
- 27. Fact 10. Future of pain assessment could rely in technology? Need for objective pain measurements when patient unable to communicate Analgesia-nociception index (ANI) Skin-conductance monitoring Surgical pleth index (SPI) Measures of sympathetic activity
- 28. Novel methods to assess pain: Pain and the Autonomic Nervous System (ANS) Analgesia nociception index (ANI): Heart rate variability computation Heart rate short-term fluctuations reflect the activity of sympathetic and parasympathetic nervous system Analgesia nociception index: evaluation as a new parameter for acute postoperative pain. Br. J. Anaesth. (2013) 111 (4): 627-629.
- 29. Novel methods to assess pain: Pain and the Autonomic Nervous System (ANS) Surgical Pleth Index (SPI) Br. J. Anaesth. (2011) 106 (1): 101-111. CARDEAN: beat-to-beat cardiovascular index Anesth Analg 2010;110:765–72 Pupillometry Anesth Analg 2015;120(6):1242–53 Skin conductance monitoring Br. J. Anaesth. (2006) 97 (6): 862–5
- 30. Conclusions • Patient education is an important pillar in perioperative pain management • Assessment is paramount to good pain management. Recognize importance of treating both the underlying disease and acute pain aggressively • Research gaps in acute pain management include the effect of acute pain in long-term outcomes, transition to outpatient care (ideal prescription modalities), technology to assess pain, new and safer pain medications.
Editor's Notes
- Safe and effective pain management in the perioperative setting is important for a number of reasons, including decrease risk of adverse outcomes related to both treatment and management of pain. To facilitate Enhanced Recovery After Surgery (ERAS), and fast-track surgery programs Some consequences of poorly managed acute pain include: Cardiovascular: tachycardia, hypertension, increase in cardiac work load. Pulmonary: respiratory muscle spasm, splinting, decrease in vital capacity, atelectasis, hypoxia, and increased risk of pulmonary infection. Gastrointestinal: postoperative ileus Renal: increased risk of oliguria and urinary retention Coagulation: increased risk of thromboemboli-DVT-PE. Immunologic: impaired immune function Muscular: muscle weakness and fatigue-decreased mobility can increase risk of thromboembolism. Psychological: anxiety, fear, and frustration which leads to poor patient satisfaction Poor managed pain is associated with increased immediate morbidity and mortality after surgery and trauma Sleep deprivation, Chronic Pain and Depression are newly appreciated intermediate to long term adverse effect of inadequate pain control. Aging population: Pain is a significant contributor to delirium and post-operative cognitive dysfunction which are further adverse consequences that increase length of hospital stay. Some adverse outcomes related with the management of perioperative pain include: respiratory depression, brain or neurological injury, sedation, nausea and vomiting, pruritus, urinary retention, impairment of bowel function, and sleep disruption.
- The 4 dimensions of pain: sensory, affective, cognitive and behavioural.
- Expectation of pain, fear, past memories, social environment, work, and levels of physical activity, all affect the response to noxious stimuli. Preoperative anxiety is correlated with postoperative pain experience. Fear of pain in the postoperative setting and the avoidance of such pain might also have a negative effect on how pain is perceived and resolved
- Postoperative pulmonary complications are defined heterogeneously and encompass any complication affecting the respiratory system after anaesthesia and surgery. Include: respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, aspiration pneumonitis, pneumonia, pulmonary Edelman, exacerbation of pre-existing lung disease, pulmonary embolism, death. Addition of epidural analgesia to GA significantly reduces the risk of postoperative pneumonia in the general surgical population when compared with systemic opioids alone. It is especially beneficial for patients with severe COPD having major abdominal surgery, presumably as a result of improved analgesia and reduced opioid consumption. Epidural analgesia improves respiratory function and reduces rates of pneumonia, postoperative ventilation, and unplanned re-intubation. Obese patients are more likely to have OSA, and those with OSA are at risk of respiratory depression after surgery because of increased sensitivity to opioids and sedatives. Reduced doses of opioids should therefore be administered to some patients with known or suspected OSA, because opioid dose is correlated with postoperative increases in OSA and therefore the potential for PPCs.
- Opioids are frequently prescribed for cancer patients for the management of acute postoperative pain and for chronic pain. In addition to their analgesic effects, opioids have well-established immunomodulatory effects. Evidence from experimental studies in cancer is conflicting.48 This is further complicated by the fact that the type of opioid, route, and duration of administration might all be relevant confounding factors. The implications of inadequately controlled pain on the stress response should be considered if future strategies seek to limit opioids perioperatively. Opioid analgesia and intrathecal bupivicaine significantly decreased postoperative LTR (lung tumour retention) compared with no analgesia in a live animal model of breast cancer,69demonstrating that effective perioperative analgesia can play a role in facilitating resistance to metastatic progression. Regional anaesthesia attenuates the neuroendocrine stress response, reducing opioid, and intraoperative volatile anaesthetic agent requirements. This combination of effects might allow enhanced preservation of perioperative immune function and possibly reduce the incidence of cancer recurrence. Addition of spinal to GA reduced lung metastasis following laparotomy compared with GA alone. Local anaesthetics (LAs) have proposed cytotoxic effects on neoplastic cells. An anti-proliferative effect on human tongue cancer cells, by inhibiting epidermal growth factor, was exhibited by lidocaine in vitro.43 Lidocaine, bupivacaine, and ropivacaine reduced mesenchymal stem cell proliferation in vitro and transcription pathways related to initiation of neoplasia and metastasis were also inhibited.44LAs have also been reported to alter the DNA methylation status of certain cancer cell types and have been associated with the reactivation of tumour suppressor genes.45 LAs have also been associated with cytotoxic effects on T-lymphoma cells in vitro. Apoptosis was observed at lower concentrations, while necrosis was seen at higher concentrations. Eight LAs were studied in total and each exhibited varying cytotoxic effects, which appeared to correlate with their lipophilicity and potency.46
- Acute pain is the main risk factor to develop chronic pain or for progression from acute to chronic pain . In this graphic we see the risk factors for persisting pain following surgery. My colleague will talk more in depth about it.
- Clinicians should use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly. A number of pain assessment tools have been validated for accuracy in detecting the presence, and quantifying the severe of pain and has been tested for intrapatient and inter-rater variability. Validated pain assessment tools use different methods to measure pain, including visual analog scales, numeric or verbal rating scales, symbols and others. The selection of a particular pain assessment tool should be on the basis of factors such as developmental status, cognitive status, level of consciousness, education level and cultural and language differences.
- In children, the paediatric initiative on methods, measurement and pain assessment in clinical trials, suggest the use of the FLACC postoperative pain measure for assessing acute pain in preverbal and non-verbal children, on the basis of reliability, validity and ease to use. Observe patient for 1 to 5 minutes if awake, for 5 min or longer if asleep. 0= relaxed and comfortable 1-3= mild discomfort 4-6= moderate pain 7-10= severe discomfort or pain or both.
- One tool used among cognitively impaired adults is the Pain Assessment in Advanced Dementia (PAINAD) Scale. Observe the patient for five minutes before scoring his or her behaviors. Score the behaviors according to the following chart. Scoring: The total score ranges from 0-10 points. A possible interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain. These ranges are based on a standard 0-10 scale of pain, but have not been substantiated in the literature for this tool.
- In our centre, we use the brief pain inventory. This is a multidimensional pain assessment instrument that assess not just the pain intensity and quality, but its impact in the patient’s daily life.
- Pain assessment involves more than just quantifying the intensity of pain. Assessment should determine what interventions have been effective for the pain, how the pain affects function, the type of pain, barriers to effective pain management. Pain should be assessed at rest and with activities, and include other clinical issues such as sedation, delirium, nausea and other side effects.
- One of the recommendations of the panel is that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with non-pharmacological interventions for the treatment of postoperative pain in children and adults. Multimodal analgesia is defined as the use of a variety of analgesic medication and techniques that target different mechanisms of action in the peripheral or central nervous system. The graphic represents the 4 elements of pain processing, and how different analgesics target different mechanisms both peripherally and centrally.
- In acute settings the intensity of pain is more severe during the 24-72 h following the surgery or traumatic injury. During this period pain is optimally controlled using step 4 interventional techniques including neuraxial analgesia and continuous peripheral neural blockade. As patient improves we can go downward step 3 to IV PCA or strong opioids and as bowel function returns, we can use oral medications.
- Clinicians should provide education to all patients, and primary caregivers on the pain treatment plan, including tapering of analgesics after hospital discharge. Research on methods and outcomes of discharge planning and follow-up are scarce and insufficient to provide strong guidance on optimal methods. Patients should be counselled on how to take pain medications safely and to manage side effects to optimize pain control and recovery with return to usual activities. Visual abstract from Annals of Surgery.
- It is based on ECG data derived from two single-use ANI electrodes applied in V1 and V5 positions to the chest. The ANI is finally computed from a frequency domain-based analysis of the high frequency com- ponent (HF: 0.15 – 0.5 Hz) of HRV which also incorporates the respiration rate (RR) as a potential confounder. It is displayed as a score from 0 – 100. Higher ANI values indicate prominent parasympathetic tone, as observed during adequate analgesia.18 In the case of nociception, the sympathetic tone increases and the parasympathetic tone decreases, leading to decreased ANI values. INDICATIONS/CAVEATS
- The calculation of SPI relies on a balanced sum of normalized heart beat intervals (HBIs) and plethysmographic pulse wave amplitudes,12 both of which are controlled by the balance between sympathetic and parasympathetic tone.