ACUTE PAIN MANAGEMENT

SHAHZEB IKRAM

DEFINITION OF ACUTE PAIN

It

is a pain of recent onset and probable limited duration.It usually has an identifiable temporal and causal relation with injury or disease. It is caused by noxious stimulation due to injury or a disease process or an abnormal function of muscle or viscera Four physiological processes are involved: -transduction -transmission -modulation -perception

FORMS OF ACUTE PAIN

Posttraumatic
Postoperative Obstetric

pain Pain a/w acute medical illnesses(eg.myocardial infarction,pancreatitis,renal calculi) -Most forms of acute pain are self-limited or resolve with treatment

TWO TYPES OF ACUTE PAIN

SOMATIC PAIN 1)Superficial:from skin,subcutaneous tissue and mucous membrane.Well localised.Sharp, pricking,throbbing or burning sensation 2)Deep:from muscles,tendons,joints,bones. Dull aching,lesser well localised. VISCERAL PAIN Due to an abnormal functioning of an internal organ or its covering.Poorly localised.Dull and vague.May be colicky,cramping or squeezing. Reffered often to somatic areas.

LOCATION

DERMATOME

Central diaphragm
lungs heart aorta esophagus Pancreas and spleen Stomach,liver,gallbladder

C4
T2-T6 T1-T4 T1-L2 T3-T8 T5-T10 T6-T9

adrenals
Small intestine colon Kidney,ovary,testis ureters uterus Bladder and prostrate

T8-L1
T9-T11 T10-L1 T10-L1 T10-T12 T11-L2 S2-S4

Urethra and rectum

S2-S4

SYSTEMIC RESPONSES
Acute pain is typically a/w neuroendoendocrine stress response that is proportional to pain intensity CARDIOVACSULAR EFFECTS -Hypertension,tachycardia,increased systemic vascular resistance and enhanced myocardial irritability -Cardiac work and myocardial consumption increases while myocardial oxygen delivery decreases.This can aggravate pain or cause myocardial ischemia.

RESPIRATORY EFFECTS
An

increase in body oxygen consumption causes an increase in minute ventilation which increase the work of breathing. Pain due to abdominal or thoracic incision further compromises lung function because of guarding/splinting. Decrease movement of chestwall reduces tidal volume and functional residual capacity thereby promoting atelectasis,intrapulmonary shunting , hypoxemia. Reduction in vital capacity impairs coughing and clearing of secretions.

GI AND URINARY EFFECTS

Enhanced

sympathetic tone increases sphincter tone and decreases the intestinal and urinary motility leading to urinary retention and ileus. Hypersecretion of gastric acid may lead to the stress ulcerations . Nausea,vomiting and constipation can occur.

ENDOCRINE AND METABOLIC

Increase

in catabolic hormones(catacholamine, cortisol,glucagon,ACTH,ADH) Decrease in anabolic hormones(testosterone, insulin) Patients develop negative nitrogen balance, increased lipolysis,carbohydrate intolerance. Retention of sodium and water,excretion of pottasium,secondary expansion of extracellular space.

HEMATOLOGICAL EFFECTS
Stress

causes an increase in adhesiveness of platelets,reduced fibrinolysis,hypercougability. This could lead to deep vein thrombosis and pulmonary embolism.

IMMUNE EFFECTS Stress response produces leucocytosis with lymphopenia with reticuloendothelial system depresion predisposing the patient to infections.

PSYCHOLOGICAL EFFECTS
Typical

behavioral response include concern and self absorbtion,withdrawl from interpersonal contact,increased sensitivity to all the external stimuli,grimacing,posturing,reduced activity, moaning,seeking help and attention. Initially feeling of fear and anxiety predominate followed by feeling of helpnessness,loss of control and depression if pain is unreleived. Anger and resentment may supervene.Sleep deprivation may occur.

PAIN MEASUREMENT
Reliable

quantitation of pain severity helps to determine the therapeutic interventions and evaluate the efficacy of treatment. Descriptive scales such as mild,moderate and severe pain or verbal numerical scales are non continious and generally unsatisfactory. The numerical rating scale,faces rating scale, visual analog scale(VAS) and the McGill Pain Questionnaire(MPQ) are most commonly used.

NUMERICAL RATING SCALE

O

corresponds to no pain and 10 designates the worst possible pain FACES PAIN SCALE More useful in patients in whom communication is difficult. The patient is asked to point to various facial expressions ranging from smiling face(no pain) to an extremely unhappy one with the worst possible pain.

VISUAL ANALOG SCALE

It is a 10cm horizontal line labeled no pain at one end worst pain imaginable at other end. The patient is asked to mark on this line where the intensity of pain lies. The distance from no pain to the patients mark numerically quantifies the pain. McGill PAIN QUESTIONNAIRE It is a checklist of words describing symptoms It attempts to define the pain in 3 dimensions 1)sensory discriminative 2)motivational affective 3)cognitive evaluative

 It

contains 20 sets of descriptive words that are divided into 4 major groups 1)10 sensory 2)5 affective 3)1 evaluative 4)4 miscellaneous The patient selects the sets that apply to his pain and circles the words in each set that best describes the pain.The words in each class are given rank according to severity of pain. It is completed in 5-15 minutes.

PSYCHOLOGICAL EVALUATION
MINNESOTA

MULTIPHASIC PERSONALITY INVENTORY(MMPI) BECK DEPRESSION INVENTORY Several tests have been developed to assess the functional limitations or impairment -Multidimensional pain inventory(MPI) -Medical outcome survey 36 Item short form (SF-36) -Pain disability index(PDI) -Oswestry disability questionnaire

ELECTROMYOGRAPHY AND NERVE CONDUCTION STUDIES

Can

be used for confirming the diagnosis of entrapment syndromes,radicular syndromes, neural trauma and polyneuropathies. They can often distinguish between neurogenic and myogenic disorders. Nerve conduction studies often distinguish between mono and polyneuropathies.

DIAGNOSTIC AND THERAPEUTIC NEURAL BLOCKADE

Neural

blockade with local anaesthetics can be useful in delineating pain mechanisms,but more importantly it plays a major role in management of patients with acute pain. Pain relief following diagnostic neural blockade often carries favorable prognostic implications for a therapeutic series of blockade.

SOMATIC BLOCKS
TRIGEMINAL

NERVE BLOCK -useful in trigeminal neuralgia and intractable cancer pain in the face FACIAL NERVE BLOCK -useful in relieving spastic contraction of the facial muscles and for treating herpes zooster affecting this nerve. GLOSSOPHARYNGEAL BLOCK -useful in relieving pain due to malignant growth at the base of the tongue,the epiglottis and palatine tonsils

OCCIPITAL NERVE BLOCK

Useful

diagnostically and therapeutacally in patients with occipital headaches and neuralgia. PHRENIC NERVE BLOCK -useful for relieving pain arising in the central portion of diaphragm. SUPRASCAPULAR NERVE BLOCK -useful for painful conditions arising from the shoulder(eg.arthritis and bursitis) CERVICAL PARAVERTEBRAL NERVE BLOCK -useful in cancer pain originating from cervical spine or shoulder

THORACIC PARAVERTEBRAL BLOCK -useful for pain originating from thoracic spine, thoracic cage or abdominal wall including acute herpes zoster,compression fracture,proximal rib fractures. LUMBAR PARAVERTEBRAL BLOCK -useful in evaluating pain due to disorders of lumbar spine or spinal nerves. LUMBAR MEDIAL BR. AND FACET BLOCK -these blocks may establish the contribution of lumbar facet (zygapophyseal) joint disease in back pain.

TRANS-SACRAL NERVE BLOCK -useful in diagnosis treatment and of pelvic and perineal pain. PUDENDAL NERVE BLOCK -useful in evaluating patients with perineal pain.

SYMPATHETIC BLOCKS
It

can be achieved by a variety of techniques including subarachnoid,epidural as well as paravertebral blocks.Unfortunately these approaches usually block both somatic and the sympathetic fibres. The folowing techniques specifically block the sympathetic fibres and can be used to define the role of sympathetic system in patients pain and possibly provide long term pain relief.

CERVICOTHORACIC(STELLATE) BLOCK -useful in patients with head,neck,arm and upper chest pain. -may also be useful in vasospastic disorder of the upper extrimity. CELIAC PLEXUS BLOCK -useful for pain arising from abdominal viscera, particularly abdominal malignant growths. LUMBAR SYMPATHETIC BLOCK -useful for painful conditions involving the pelvis or the lower extremity and possibly in some pts with peripheral vascular disease.

HYPOGASTRIC PLEXUS BLOCK -useful for pain that originates from the pelvis and that is unresponsive to lumbar or caudal epidural blocks. -useful for pts with cancer of cervix,uterus,rectum bladder and prostrate. GANGLION IMPAR BLOCK -useful for pts with visceral or sympathetically maintained pain in the perianal area. DIFFERENTIAL NEURAL BLOCKADE -Pharmacological or anatomic differential neural blockade has been advocated as a method of distinguishing somatic,sympathetic and the psychogenic pain mechanism.

RADIOFREQUENCY ABLATION
Commonly

used for trigeminal rhizotomy and medial branch rhizotomy. Also used for dorsal root rhizotomy and lumbar sympathectomy. Pain relief usually lasts for 3-12 months. CRYOANALGESIA Most commonly used for long term blockade of peripheral nerves. Can also be used for postthoracotomy pain.

ALCOHOL AND PHENOL NEUROLYTIC BLOCKS

Mostly

used for pts with severe intractable cancer pain. Can also be used in pts with refractory neuralgia,peripheral vascular disease. Neurolytic techniques are most commonly used with celiac plexus,lumbar sympathetic chain, hypogastric plexus and ganglion impar blocks in cancer pts.

PHARMACOLOGICAL INTERVENTIONS
ANTIDEPRESSANTS Older tricyclic agents are more effective analgesics and SSRIs are more effective antidepressants. Most useful for pts with neuropathic pain such as postherpetic neuralgia and diabetic neuropathy. ANTICONVULSANTS Extremely useful for pts with neuropathic pain such as diabetic neuropathy and trigeminal neuralgia. Most commonly used agents are phenytoin,valproate, carbamazepine,clonazepam,gabapentin,lamotrigine, topiramate.

NEUROLEPTICS Most commonly used for refractory neuropathic pain associated with marked agitation or psychotic symptom. Most commonly used agents are fluphenazine, haloperidol,chlorpromazine and perphenazine. CORTICOSTEROIDS Glucocorticoids are used in pain management due to their anti-inflammatory and analgesic actions. May be given topically,parenterally or orally.

SYSTEMIC LOCAL ANAESTHETICS Useful in neuropathic pain. Most commonly used agents are lidocaine, procaine and chlorprocaine. BOTULINUM TOXIN Useful in painful conditions associated with skeletal muscles such as focal dystonia and spasticity.

THERAPEUTIC ADJUNCTS
PSYCHOLOGICAL INTERVENTIONS Cognitive interventions Behavioral (operant) therapy Relaxation techniques Biofeedback Hypnotic techniques

PHYSICAL THERAPY
Heat

and cold can provide pain relief by reducing muscle spasm.Heat decreases joint stiffness and increases blood flow and cold vasoconstricts and can reduce tissue edema. TENS It may have a role for pts with mild to moderate acute pain and neuropathic pain. SPINAL CORD STIMULATION Most effective for neuropathic pain.

POSTOPERATIVE PAIN
OUTPATIENTS Mild to moderate pain following surgery can be managed with oral cox inhibitors,opiods or a combination of both. COX INHIBITORS Oral nonopioid analgesics include salicylates, acetaminophen and NSAIDS. Pain following orthopaedic and gynaecological surgery responds very well to these drugs Commonly used drugs are aspirin,diflunisal, acetaminophen,ibuprofen,naproxen,ketorolac indomethacin,celecoxib.

OPIOIDS Moderate postoperative pain should be treated with oral opioids either alone or in combination with oral cox inhibitors.Combination therapy enhances analgesia and decreases side effects. Most commonly used agents are codeine, oxycodone,hydrocodone,tramodol. INFILTRATION OF LOCAL ANAESTHETIC Direct infiltration of an incision or a field block with local anaesthetic provides good postop. Pain relief.Ilioinguinal and femoral nerve blocks can be used for hernia and scrotal procedures. Penile can be used for circumcision.

INPATIENTS Most inpatients with moderate to severe postop pain require parenteral analgesic or neural blockade with local anaesthetic during the first 1-6days following surgery. Once the patient resumes oral intake and pain intensity decreases oral analgesics are then initiated. Parenteral analgesics include NSAIDs,opioids, ketamine. Subcutaneous and intramuscular routes for opioids are less desirable than intravenous route.

PATIENT CONTROLLED ANALGESIA

By

pushing a button patients are able to self administer precise dose of opioid intravenously (or intraspinally) on an as needed basis. The physician programs the infusion pump to deliver a specific dose,the minimum interval between doses (lockout period),maximum amount of opioid that can be given in a given period(1-4h). When PCA is first initiated a loading dose of opioid must be given. Most adults require 2-3mg/h of iv morphine in the first 24-48 hrsand 1-2mg/h in the following 36-72 hrs.

 PCA

is a cost effective technique that provides superior analgesia with high pt satisfaction. Drug consumption is less Patients are able to adjust analgesia according to their pain severity.

General guidelines for PCA in adults

opioid morphine meperidine fentanyl Bolus dose 1-3mg Lockout(min) Infusion rate 10-20 0-1mg/h 0-20mg/h 0-50mic/h

10-15mg 5-15 15-25mic 10-20

hydromorphone .1-.3mg

10-20

0-0.5mg/h

PERIPHERAL NERVE BLOCKS

Intercostal,interpleural,brachial plexus and femoral nerve blocks can provide excellent postoperative analgesia. CENTRAL NEURAXIAL BLOCKADE AND INTRASPINAL OPIOIDS Administration of local anaesthetic opioid mixtures neuraxially(esp. epidurally) provides excellent pain relief following abdominal,pelvic thoracic or orthopaedic procedures on lower limbs. Patients have better preservation of pulmonary function and are able to ambulate early. Lower risk for postoperative venous thrombosis Epidural catheters are most commonly used because of reports of cauda equina syndrome with subarachnoid catheters

POSTOPERATIVE PAIN IN PEDIATRIC

All

the neurophysiological components required to experience pain are present by midgestation in the human fetus. Assessment of pain in children is more complex than in adults. Self reporting of pain appears to be reliable in children over 4yrs . Numerous pain rating scales have been devised for neonates(eg.CRIES) and young children(eg modified VAS such as POKER CHIP TOOL and WONG BAKER FACES)

PHARMACOLOGICAL STRATEGIES
Pain

following minor surgery can usually be managed with oral acetaminophen and NSAIDs.If acetaminophen is used as the sole analgesic higher doses are required. For major surgery parenteral opioids remain the mainstay of postoperative pain management. Local anaesthetic blocks initiated pre and intraop are being increasingly used for pain management following major surgery.

AMPUTEES
Perioperative

management of amputees employing neuraxial(notably epidural) and peripheral neural blockade helps to reduce the incidence of phantom limb and stump pains. ACUTE PAIN IN OPIOID TOLERANT PATIENTS Intravenous PCA with opioids is now regarded as a useful practise in these patients. Baseline opioid requirements can be provided by a background infusion(to prevent withdrawl) and additional opioid required to managethe acute postoperative pain can be provided by increased bolus requirement with the usual lockout period.

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