(Clinical Guidance for Acute Pain Management)

1 .. 2552 ( 1)
ISBN: 978-974-8285-72-6

ACUTEPAIN

Thai Association for the Study of Pain (TASP)

1 .. 2552 ( 1)
ISBN: 978-974-8285-72-6

*** ***

ii








(Clinical Guidance)
20

iii

1. ..

2. ..

3. ...

4. ..

5. ..

6. ..

7. ...

8. ..

9. ..

10. ..

11. ...

iv








. . .

:







:

vi

1
1
1
2
2
4
4
5
6
7
11
11
13
14
23
32
36
38





(Clinical Guidance:
) The American Society of Anesthesiologists (ASA:2004)1, The
American Pain Society (2005)2, Australian and New Zealand College of Anaesthetists (2005)3,
British Pain Society (2007)4, Institute for Clinical Systems Improvement (ICSI:2008)5

20

5 246
>7 28.77
228

(acute pain)
(chronic pain)

6





*** ***


epidural block patient-controlled analgesia (PCA)

()

8
2

*** ***

 1
1. 1:
:
2. 2: (pain assessment)
: 1)
2)
3)
3. 3:
:

4. 4: (acute pain treatment)

4.1 (pharmacological therapy)
: 1)

2)

3) (multimodal pain therapy)

4) (opioid) IM IV
4.2 (non-pharmacological therapy)
: 1)

5. 5:
:

6. 6:
:

7. 7:
: 1)
2)
8. 8:
:
( 2, 3 2)

*** ***

1. ( 1)
:

2. ( 2)9
: 1)
2)

3)




1

3. ( 3)
:

*** ***

Numerical
rating scale
(NRS)

9 10

Verbal
rating scale
(VRS)

Visual
analog scale
(VAS)

Face pain
assessment
scale
0

8
10

1
( European society of regional anaesthesia and pain therapy Newman CJ10)

4. ( 4)

*** ***






( ) ( )
( )

( 1)
( 2)
/ /
(multimodal analgesia)

(Pharmacological therapy)
paracetamol, nonsteroidal anti-inflammatory drugs, opioids,
local anesthetic adjuvants

1. ( 2)

3
2
1
2 3

*** ***

2.
3.

4.

Opioid
opioid (IV) (IM/SC)
2, 3 4

(Non-pharmacological therapy)
psychological therapy physical therapy
Psychological therapy
1. (Provision of information)
2. (Relaxation and attention strategies)
3. (Hypnosis)
4. (Cognitive-behavioral therapy)
psychological therapy

Physical therapy
1. (Applications of heat and cold)
2. (Manual and massage therapy)
3. Transcutaneous electrical nerve stimulation (TENS)
4. (Acupuncture)
physical therapy
-

non-pharmacological therapy

1.
2.
3.
4.

*** ***


2 opioid (IV titration)3

Morphine 1 mg/ml
Pethidine 10 mg/ml

Sedation score < 2

RR > 10/min1
hypotension

Sedation score < 2

RR > 10/min
naloxone
0.1 mg IV

< 3
15

TASP
( 1)

< 70
~ 5

pain score 7

pain score 7

1 .

0.5 .

1 .

2 .

1. RR = respiratory rate 10 /
Sedation score 0-3
(0 = , 1 = , 2 = , 3 = , S = )

*** ***

 3 opioid (IV around the clock)3

Sedation score < 2, RR > 10/min1

hypotension

Morphine IV
()
(
)
1-2 mg iv 2 hr
2-3 mg iv 3 hr
3-4 mg iv 4 hr

5-10

Sedation score < 2

RR > 10/min

Sedation score < 2

RR > 10/min

Sedation score < 2

RR > 10/min
naloxone
0.1 mg IV

BTP
3
50%

25%

1. RR = respiratory rate 10 /
2. opioid IV
3. BTP = breakthrough pain ( 25-50% )
Sedation score 0-3 (0 = , 1 = , 2 = , 3 = , S = )

*** ***


4 opioid (IM/SC PRN)3

Sedation score < 2

RR > 10 /min1

IM prn q 2 hr
() Morphine (mg) Pethidine (mg)
20-59
5.0-10.0
50-100
60-85
2.5-5.0
25-50
> 85
2.0-3.0
20-30

30

Sedation score < 2

RR > 10 /min

Sedation score < 2

RR > 10 /min

Sedation score < 2
RR > 10 /min
naloxone
0.1 mg IV

2 2 .

50%

25%

1. RR = respiratory rate 10 /
2. opioid IM prn q 2 hr ()
Sedation score 0-3
(0 = , 1 = , 2 = , 3 = , S = )

10

*** ***

 (Multimodal analgesia)


11 12


11 NSAIDs
opioids opioids peripheral, spinal
supraspinal NSAIDs peripheral NSAIDs
spinal cord

5. ( 5)
:

5 : none (0), slight (1), moderate (2), good or

lots (3) complete (4) numeric rating scale (0-10): 0
10 visual
analogue scale

4 13

6. ( 6)
:
( 7)

7. ( 7)
: 1)
2)
opioid

*** ***

11


opioids
1. sedative naloxone 0.001-0.004 mg/kg 2-3
0.003-0.005 mg/kg/hr
opioids sedation scores ()
2.
2.1 sedation scores (0-3) 0 = , 1 = ,
2 = , 3 =
2.2 opioids

1 ondansetron metoclopramide
opioids
2.3

8. ( 8)
:
( 2, 3 2)

opioid (IV) 5-10 opioid
(IM/SC) 30
60

12

*** ***


14

( prostaglandin, substance-P,
histamine, H+ )
C fiber A fiber
dorsal horn 2
spinothalamic tract
thalamus cerebral cortex ( 3)

3
(NSAIDs = Nonsteroidal anti-inflammatory drugs, COXIBs = COX-II specific inhibitors)

*** ***

13




peripheral sensitization dorsal horn

central sensitization
peripheral central sensitization

( 1)
1. Numerical rating scale (NRS)
0 1-9
10
2. Verbal rating scale (VRS)
5 0 , 1-3 , 4-6

, 7-9 10
3. Visual analog scale (VAS) 10 0
10 (X)

4. Face pain scale visual pain analogue
5-8

*
0, 2, 4, 6, 8, 10
*
()

*
5.
5.1 The FLACC behavioral pain scale ( 1)
5
(activity) (consolability) 0-2
10
5.2 The CHEOPS behavioral pain scale15 ( 2)
4-13

14

*** ***

 1 The FLACC behavioral pain scale15

Categories
Definition

( )

Scoring
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2

2 The CHEOPS behavioral pain scale15

()

1=
0= 0= 1= 1=
1=

2=/ 2= //
2=/ 1=
3= 2= 1= 2= //
/ //
,
// / /
2= +

06.00
10.00
14.00

6.


*** ***

15


(Pharmacological therapy)

1. Paracetamol Acetaminophen Paracetamol

()
paracetamol

Paracetamol descending
serotonergic pathways16 prostaglandins AM404
( COX ) fatty acid amide hydrolase (FAAH)
AM404 TRPV1 receptor ligand CB1 receptor
anadamide ( endogenous canabinoid) endogenous canabinoid
Paracetamol

paracetamol 2
: 500-1,000 . 4-6
4 / 8 ( 500 .)/ 10-20 .
1 . 4-6 3 paracetamol
codeine, NSAIDs tramadol
325 . 500 .
120 125 ./ 5 . 60 ./0.6 .

7

3 paracetamol 17

0 - 3
4 - 11
1 - 2
2 - 3
4 - 5

16

(.)
40
80
120
160
240

6 - 8
9 - 10
11
12 - 14
> 14

(.)
320
400
480
640
650

*** ***

2. Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs

NSAIDs
prostaglandins cyclooxygenase

cyclooxygenase 2 isoenzymes cyclooxygenase-1 (COX-1) cyclooxygenase-2 (COX-2) COX-1
COX-1 COX-2

NSAIDs COX-1 COX-2
COX-1 COX-2
NSAIDs conventional NSAIDs diclofenac,
aspirin, ibuprofen, ketoprofen, naproxen, mefenamic, piroxicam meloxicam COX-2
specific inhibitors18 celecoxib, valdecoxib, parecoxib, etoricoxib conventional
NSAIDs COX-1 COX-2
COX-2 specific inhibitors
COX-2 COX-1 conventional NSAIDs
COX-2 specific
inhibitors conventional NSAIDs

NSAIDs
NSAIDs
3-7

NSAIDs



*** ***

17





diclofenac, ketoprofen, ketorolac, piroxicam,
tenoxicam parecoxib
NSAIDs


()

NSAIDs


COX-2 specific inhibitors
conventional NSAIDs19
conventional NSAIDs COX-2 specific inhibitors

20

conventional NSAIDs
COX-1
conventional
NSAIDs 21 COX-2 specific inhibitors
thrombosis COX-2 specific inhibitors
22
conventional NSAIDs
aspirin-exacerbated respiratory disease
conventional NSAIDs COX-2 specific inhibitors 23
NSAIDs 2 opioid
opioid opioid 24,25
NSAIDs 2

18

*** ***

3. Opioids ( 7)
opioid 2 opioid
A. Opioids
A1. Codeine
Codeine opioid 5
1/10 morphine26 10 codeine morphine27
30-120 . 4 26 codeine 60 . paracetamol
600-1,000 . paracetamol 28
codeine 28

A2. Tramadol
Tramadol 2 -opioid receptor
2 serotonin norepinephrine 29,30
tramadol 2 tramadol 1/20-1/5 morphine tramadol 26
26,31 50-100 . 4 26 400 .
200 .
B. Opioids
Opioids morphine, pethidine fentanyl
equianalgesic dose ( 4) opioids

20 morphine 3
morphine ( 10 )
morphine
morphine
4 Equianalgesic doses of opioids5
Opioids
Morphine
Pethidine
Fentanyl
Tramadol

(Parenteral)
10 mg
100 mg
100 microgram
100 mg

*** ***

19


opioids
opioids 3
opioids 2, 3 4
B1. Morphine
Morphine opioid morphine
5-20 , 20-60
20-60 morphine 2-4 .
Morphine morphine-3-glucuronide (M3G) morphine-6-glucuronide (M6G) M6G morphine morphine

morphine metabolites (M6G) 32
B2. Pethidine
opioid anticholinergic
pethidine 2-2.5 . 2-4 . pethidine metabolite norpethidine
pethidine
32
B3. Fentanyl
opioid 2-3
30-60 fentanyl norfentanyl
( 7) 32
4. Local anesthetics ()
sodium channels
depolarization

spinal epidural
33,34
1.
lignocaine (lidocaine) prilocaine
(prilocaine methemoglobinemia 600 .)
Lidocaine
lidocaine (infusion)
(tachyphylaxis)

20

*** ***

2.
bupivacaine, levobupivacaine ropivacaine bupivacaine
racemic S-enantiomer R-enantiomer levobupivacaine
ropivacaine S-enantiomer bupivacaine
S-enantiomer R-enantiomer racemic
bupivacaine
ventricular fibrillation bupivacaine
sodium channel bupivacaine levobupivacaine
ropivacaine35

1. ester para aminobenzoic acid

2.

1. (topical anesthesia)
EMLA cream (eutectic mixture of local anesthetics)
2.5% lidocaine 2.5% prilocaine
1-2 10 .. 45-60 1-2 .
2-4% lidocaine, 4-10% cocaine

2. (local infiltration)
0.5-1% lidocaine, 0.25% bupivacaine, 0.2-0.5% ropivacaine

3. (peripheral nerve block)

brachial plexus block, intercostal nerve
block, femoral nerve block
1-1.5% lidocaine, 0.25-0.5% bupivacaine 0.5-1% ropivacaine
4. (intravenous regional anesthesia)
spinal epidural epidural analgesia

*** ***

21


5. (Adjuvants)

N-methyl-D-aspartate (NMDA)
receptor antagonists ( ketamine36,37 dextromethorphan37,38), antidepressant, anticonvulsant (gabapentin)39, membrane stabilizers (lidocaine), alpha-2 agonists (clonidine dexmedetomidine)38,40

5
6

22

*** ***

*** ***

23

Opioid

Codeine

paracetamol
Codeine
15/30 mg + codeine
Paracetamol
300 mg

NSAIDs
Cyclooxygenase-II (COX-II)

Celecoxib

paracetamol
codeine

- PO: 30-60 mg, 4-hourly

- Max dose 240 mg/day

- Infiltration/Epidural: - Infiltration/Epidural:
Toxicity:

2 mg/kg, 4-hourly
2 mg/kg, 4-hourly - Max dose

- Max dose

-
0.25-0.5%

- PO: 400 mg initially
200 mg od bid

- PO: 1 mg/kg,
6-hourly
- Max dose 3 mg/kg/

day

paracetamol
codeine

- sulfonamide
aspirin
-
-
-

- CABG/Stent
-

- cardiotoxicity
Bupivacaine amide,
local infiltration,
epidural block
- IV regional
spinal anesthesia
analgesia
duration 200-400
- adrenaline

5 ()

24

NSAIDs - aspirin
-
-

EMLA
2.5% lidocaine + -
2.5% prilocaine
(Eutectic
-
Mixture of
mucous memLocal Anesbrane
thetic)

Diclofenac

5 () ()

PO: ( > 1 )
1 mg/kg, 8-hourly
Max dose 3 mg/kg/
day

Methe-
1
moglobinemia

G6PD deficiency

- bronchospasm
-

- PO: 25-50 mg, 8-hourly

- deep IM: 75 mg od
- IV infusion:
:
75 mg IV infusion
15-30
75 mg
2-3
: 25-50
mg IV infusion 15-30
5 mg/hour
- Max dose 150 mg/day
- IV/IM 2
PO
1-2 .

*** ***

*** ***

25

NSAIDs
cyclooxygenase-II (COX-II)

Opioid

cardiostability
duration 30-60

Etoricoxib

Fentanyl

/
- aspirin
-
-
-

- CABG/Stent
-
-
-
Epidural/spinal:
delayed respiratory
depression

5 () ()

muscle rigidity

- PO: 60-120 mg od
( 120 mg

8 )

- IV bolus: - IV bolus:0.001-0.005 mg/

on venti- kg (up to 0.05 mg/kg)
lator :
- Epidural: 0.025-0.1 mg

( saline)
0.0003 - Spinal: 0.005-0.02 mg
mg/kg p.r.n. q 2 hr


0.0003-0.0005 mg/
kg p.r.n. q 2 hr
>1
0.00050.001 mg/kg p.r.n.
q 2 hr

26

Fentanyl

5 () ()

on ventilator

- IV Infusion:
on
ventilator :

0.0003 mg/kg/hr

0.00030.0005 mg/kg/hr
>1
0.00050.001 mg/kg/hr
on ventilator

*** ***

*** ***

27

-
-
-

Levobupiva- Levorotatory (S) enan bupivacaine

tiomer of bupivacaine
caine
cardiotoxicity
CNS toxicity

Phencyclidine derivative
dissociative
anesthesia

aspirin

Ketamine

/
aspirin

NSAIDs

NSAIDs

Indometha- NSAIDs
cin

Ibuprofen

5 () ()

- - PO: 6-10 mg/kg tid

5 mg/kg qid
(BW >7 kg)

- bronchospasm
-
-

- bronchospasm
-
-

-
-

bupivacaine
bupivacaine

- bupivacaine
Max dose 150 mg,
Max dose 400 mg/day

-
0.05-0.1 mg/kg/hr
opioid
( )

- PO: 50-100 mg bid

- PO: 400 mg qid

28

Naloxone

1. epidural/spinal


2. biliary colic
morphine
spasm sphincter of
Oddi pethidine
3. renal colic pain
morphine
spasm ureter
NSAIDs pethidine
Duration of action 30
Pure opioid antagonist
opioid
renarcotisaopioid
tion acute withdrawal
epidural opioid
opioid IM
opioid

Morphine

Opioid analgesic

/
amide, adrenaline
duration 30-90 preservative
adrenaline

Lidocaine

5 () ()

- IV bolus:-0.005-0.01 mg/kg
- Infusion: 0.005-0.02 mg/kg/hr
- IM in Newborn: 0.2
mg
- epidural
opioid: 0.005 mg/kg

Toxicity: - 0.5-2%
- Max dose

- 3 mg/kg, 4-hourly

(with adrenaline:
6 mg/kg, 4-hourly)
- histamine
- PO: 0.3-0.5 mg/kg,
-
4-hourly

- bronchospasm
- - IV bolus:
- > 1 : 0.030.05 mg/kg p.r.n. q
2-4 hr
- IV infusion
> 1 : 0.010.03 mg/kg/hr

0.5-2%
Max dose

3 mg/kg, 4-hourly
(with adrenaline: 6 mg/
kg, 4-hourly)
IV: 2-5 mg p.r.n. q 2 hr
IM/SC: 5-10 mg, 4-hourly
p.r.n. q 2 hr

PO: 10-30 mg, 4-hourly

Epidural: 2-4 mg*
Spinal: 0.1-0.3 mg*
(* preservative free)
IV bolus: 0.1-0.4 mg
titrated to desired effect
epidural opioid:
0.1 mg bolus + 0.3 mg
IV fluid

*** ***

*** ***

29

NSAIDs

Paracetamol
300 mg
+ codeine
15 /30 mg
Paracetamol
325 mg +
tramadol
37.5 mg

paracetamol
tramadol

paracetamol
codeine

Paracetamol

Naproxen

paracetamol

tramadol

/
aspirin

- - PO: 5 mg/kg bid

(>5 yr)

- bronchospasm
-

- PO: 10-20 mg/kg,

4-6 hourly

G-6-PD deficiency
- PR: loading dose
30-40 mg/kg
(>44 wk post
conception)
paracetamol

dose codeine
codeine

5 ()

paracetamol
tramadol

paracetamol
codeine

- PO: 0.5-1 g , 4-6 hourly

- Slow IV: 0.5-1 g qid
- Max dose 6 gm/day

- PO: 500 mg bid

30

NSAID

Piroxicam

Pethidine

- Pro-drug valdecoxib
NSAIDs
CyclooxygenaseII (COX-II)
-

-
3
Opioid
1.
2.
3. Biliary colic
4. Renal colic

Parecoxib

aspirin

porphyria

bronchospasm

- sulfonamide
aspirin
- CABG/Stent
-

-
-
-
-
- IV/IM/SC:

-
0.5-1 mg/kg
- Max dose 1g/day (20 mg/ -
kg/day)
- - Infusion:
5 mg/kg in 50 ml
MAOI
NSS
rate 1-3 ml/hr
(0.1-0.3 mg/kg/hr)

5 () ()

- IV: 20-50 mg p.r.n.

q 2 hr
: 10-25 mg
- IM/SC: 25-100 mg,
3-hourly p.r.n. q 2
hr

- PO: 10-30 mg od

- IV/IM: 40 mg, then

20-40 mg, 12-hourly
- Max dose 80 mg/day

*** ***

*** ***

31

- Opioid

euphoria
opioid
-
opioid non-opioid
paracetamol
tramadol

Tramadol

- bronchospasm
-
- PO: 1-2 mg/kg,

6-hourly

paracetamol

tramadol

- naloxone
30%
- epilepsy
-
MAOI

/
aspirin

:
od = once daily, bid = twice daily, tid = three times daily, qid = four times daily
Max = maximum, MAOI = monoamine oxidase inhibitors, NSS = normal saline
PO = per oral, PR = per rectal, SC = subcutaneous, SL = sublingual, IM = intramuscular, IV = intravenous
PR

Tramadol
37.5 mg +
paracetamol
325 mg

NSAIDs

Tenoxicam

5 () ()

paracetamol
tramadol

- PO: 50-100 mg, 4-hourly

- Slow IV/IM: 50-100 mg
4-hourly
- Max dose 400 mg/day

PO: 20 mg od

32

2.

(Relaxation
and Attention
Strategies)

Non-pharmacological
therapy
A: Psychological
therapy
1.
(Provision of
information)

(Sensory-procedural information)

Combined sensory-procedural information

Procedural information

Sensory information

procedural sensory

Attention techniques

6 5

*** ***

*** ***

33

4.

(CognitiveBehavioral therapy)

Non-pharmacological
therapy
3.
(Hypnosis)

(coping skills)

6 5 ()

34

2.
(Manual
and massage
therapy)

Non-pharmacological
therapy
B: Physical therapy
1. -
(Applications of
heat and cold)

-







physical modalities

(chiropractic)

6 5 ()

*** ***

*** ***

35

4.
(Acupuncture)

Non-pharmacological
therapy
3. Transcutaneous
electrical nerve
stimulation (TENS)

TENS

(amplitude) 15 mA

TENS (frequency) 50 Hz
100 Hz
TENS PCA morphine
morphine
PCA morphine


TENS

TENS noninvasive

TENS


neuropathic pain
TENS

TENS 3

6 5 ()

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6. , , , , .
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36

*** ***

arachidonic acid conjugation in the nervous system. J Biol Chem 2005; 280(36): 31405-31412.
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(Evidence-based resources)
1. Bandolier evidence based thinking about health care. Available from http://www.medicine.ox.ac.uk/bandolier/booth/
painpag/acute.html
2. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Acute Pain Management: Scientific
Evidence. 2nd ed. Melbourne: Australian and New Zealand College of Anaesthetists, Available from http://www.anzca.edu.au/
publications/acutepain.htm.
3. Institute for clinical systems improvement 6th edition; Available from http://www.icsi.org/pain_acute/
pain__acute__assessment_and_management_of__3.html
4. Procedure specific postoperative pain management (prospect). European society of regional anaesthesia and pain
therapy. Available from http://www.postoppain.org/frameset.htm
5. European society of regional anaesthesia and pain therapy. www.anaesthesia-az.com

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ACUTEPAIN
Thai Association for the Study of Pain
ISBN: 978-974-8285-72-6