Management of Pain

Dr U I Hapuarachchi Department of Surgery 01/07/2009

Learning objectives
At the end of this lecture, you should be able to demonstrate the;

Classification of pain Advantages of relief of pain WFSA & WHO Pain ladder Treatment options available Side effects of the options mentioned Management of common side effects

Content

Definition of Pain Types of pain Advantages of relief of pain Assessment of Pain Pharmacological interventions Regional techniques Therapeutic adjuncts

Definition

An unpleasant sensory & emotional experience resulting from a stimulus causing, or likely to cause, tissue damage (nociception), or expressed in terms of that damage

Advantages of pain relief

Humanitarian reasons Reduced cardiovascular complications Reduced respiratory complications Reduced gastro-intestinal effects Less salt/water retention Less impairment of sleep/mental function Early hospital discharge Economical

Classification

Pathophysiology

Nociceptive or Neuropathic Acute or Chronic

Onset

Etiology

Postoperative or Cancer
Headache or Low back pain

Affected area

Classification
Nociceptive pain

Originates in the presence of normal pain pathways Noxious stimuli stimulate peripheral receptors & messages relayed via the dorsal horn to higher brain centres to warn of impending or ongoing tissue damage

Classification
Neuropathic pain

Occurs when there abnormal activation of pain pathways as result of damage or dysfunction within the nervous system itself Sometimes pain persists despite healing of the damaged tissues Pain persisting >3 months Chronic Pain

Classification
Acute pain

Caused by noxious stimulation due to injury, a disease process or the abnormal function of muscle or viscera Usually nociceptive Typically associated with a neuroendocrine stress

Classification
Chronic pain

Pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur ( 01 to 06 months ) Nociceptive, neuropathic or mixed Psychological mechanisms or environmental factors play major role Often have attenuated or absent neuroendocrine stress response Have prominent sleep & mood disturbances

Assessment of Pain

Visual Analogue Scale

10 cm line Worst pain experienced

0_______________________________10
No pain

Numerical Scale
10 cm line Worst pain experienced

0__ 1__ 2__3__ 4__5__ 6__7__8__9__10

No pain

Assessment of Pain

Descriptive Scale
No pain - mild - moderate - severe - excruciating

McGill Pain Questionnaire

Check list of words describing symptoms Psychological questionnaires for analysis of personality & pain

Assessment of Pain

Wong-Baker FACES Pain Rating Scale

Is used in children

Management of Post operative Pain

Multimodal Approach

According to the WFSA ladder Systemic analgesics Regional techniques

WFSA Pain Ladder

Systemic analgesics

Opioids Morphine, pethidine, fentanyl, remifentanyl, NSAIDs Diclofenac sodium, ibuprofen, ketorolac Others Paracetamol, Tramadol

Opioids

Strong analgesic for moderate to severe pain Can be given as im, iv, sc, oral, Patient controlled analgesia (PCA), transdermal, spinal/epidural

PCA bolus dose, lockout interval +/- background infusion

PCA Pump

Opioids
Dose

Morphine 0.1 mg/kg

Pethidine 1 mg/kg
Fentanyl 1-3 g/kg Remifentanyl 0.025-0.1 g/kg/min

Opioids

Respiratory depression Hypotension Tachy / bradycardia Sedation Euphoria / dysphoria Nausea / vomiting Uriticaria Urine retention

Opioids
Respiratory depression

If RR < 10 /min Awaken the patient If RR < 8 /min O2 via face mask Naloxone 40 g iv boluses

Urticaria

Chlopheniramine 5-10 mg Naloxone 40 g iv

Opioids
Nausea & vomiting

Promethazine -12.5-25 mg im / iv Metoclopramide 5-10 mg slow iv / im Ondansetrone 4-8 mg iv

Urine retention

General measures

catheterization

NSAIDs

Can be given as oral, suppositories, iv Potent analgesic for mild to moderate pain
Can cause renal toxicity Precipitate bronchial asthma Peptic ulceration Fluid retention

NSAIDs
Dose

Diclofenac sodium 1 mg/kg tds (maximum 3 mg/kg/day) - > 1 yr

Ibuprofen 5-10 mg/kg tds

Other drugs
Paracetamol

Analgesic for mild to moderate pain Liver damage in overdose Can be given as oral, suppositories, iv Dose 20 mg/kg & then 15 mg/kg 4 hrly Maximum dose 90 mg/kg

Other drugs
Tramadol

Has opioid & non-opioid mechanism of action Has less respiratory depression, constipation, euphoria than other opioids Causes nausea, dizziness, dry mouth Increased S/E in conjunction with other opioids Can be given as oral, slow iv / im 50-100 mg 4 hrly

Regional techniques

Epidural Continuous infusion / boluses

PCEA, Caudal

Nerve plexus blocks Supraclavicular,

axillary, lumber plexus

Individual nerve blocks median, ulnar,

sciatic, femoral

Intra-pleural analgesia Infiltration

Regional techniques

Regional techniques

Less stress response Less bleeding Better organ perfusion Better gut motility Less DVT

Motor block CVS instability Hypotension Urine retention with spinal/epidural opioids

Regional techniques
Epidural / PCEA 0.1250.1% Bupivacaine
+ /- opioid

Other blocks 0.25-0.5% Bupivacaine

PCEA better pain relief less overdose

Regional techniques
Hypotension

Rapid iv fluid infusion Vasoconstrictors ephedrine 5-10 mg iv Inform the Pain relief team

Management of Neuropathic Pain

Pharmacological interventions

Antidepressants
Block presynaptic reuptake of serotonin, norephinephrine or both

AnticonvulsantsBlock voltage gated sodium channels & can suppress spontaneous neural discharges

Management of Neuropathic Pain

Pharmacological interventions

Neuroleptics
Block dopaminergic receptors in mesolimbic sites

Corticosteroids
Has anti-inflammatory & analgesic actions

2 Adrenergic agonists
Activate descending inhibitory pathways in the dorsal horn

Management of Neuropathic Pain

Therapeutic adjuncts

Psychological interventions
Cognitive therapy, Behavioral therapy, Biofeedback, Relaxation techniques & Hypnosis

Physical therapy
Heat & cold therapy, Exercise

Cognitive therapy

Management of Neuropathic Pain

Therapeutic adjuncts

Acupucture
In chronic pain chronic musculosketal disorders & headache

Electrical stimulation
TENS, Spinal cord stimulation, Intracerebral stimulation

TENS

WHO Pain Ladder

References

Management of Acute pain

National Guidelines-Anaesthesiology, Ministry of Healthcare & nutrition, Sri Lanka. Pg70-91

Atkinson RS, Rushman GB, Davies NJH. Acute pain

Lees Synopsis of Anaesthesia 11th Edition Chapter 26

Kirk RM, Ribbans WJ. Management of Post-operative pain

Clinical Surgery in General-RCS Course Manual 4th Edition

Pg 357-369

http://www.frca.co.uk Resources>Clinical Anaesthesia>Acute pain Morgan GE, Mikhail MS, Murray MJ. Pain Management Clinical Anaesthesiology 4th Edition Pg 359-411

Thank you