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ACUTE & CHRONIC PAINMANAGEMENT

GROUP 2 A1

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OBJECTIVES

1. Acute Pain Reliefa. Pain physiologyb. Advantages and

Disadvantagesc. Indicationsd. Types

• IM injections• SC injections• PCA• pidu!al

". Ch!onic Pain Reliefa. Indicationsb. Types

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ACUTE PAIN

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INTRODUCTION• Pain is defined by the Inte!national Association fo! the

Study of Pain *IASP+ as ,an unpleasant senso!y ande-otional e pe!ience associated /ith actual o! potentialtissue da-age0 o! desc!ibed in te!-s of such da-age*Me!s2ey 3 #ogdu20 1%%4+ .

• Acute pain is defined5 – as pain of sudden onset that is often seve!e. – as ,pain of !ecent onset and p!obable li-ited du!ation.

It usually has an identifiable te-po!al and causal!elationship to inju!y o! disease

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• Co--only associated /ith su!ge!y0 t!au-a0 non6su!gicalinte!ventions and so-e -edical conditions *e.g.-yoca!dial infa!ction0 u!ete!ic colic0 acute panc!eatitis0sic2le cell disease+.

• Ch!onic pain defined as5 – pain pe!sists despite the fact that an inju!y has healed – Pain that eithe! occu!s in disease p!ocess in /hich

healing does not ta2e place o! pe!sist beyond thee pected ti-e of healing *7 ) -onths+

• Co--on ch!onic pain co-plaints include5 8eadache0lo/ bac2 pain0 cance! pain and a!th!itis pain.

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ACUTE PAIN TYPESTYPES OF PAIN

:o!ciceptive pain So-atic Sha!p0 hot o! stinging painusually locali;ed.

<isce!al

Dull0 c!a-ping0colic2y poo!lylocali;ed.=ide a!eaa>/ nausea 3 s/eating

:eu!opathic pain

6 8 of pe!iphe!al> cent!al ne!vous syste- inju!yi.e. b!achial ple us avulsion6 vidence of da-age5 i.e.senso!y loss0 /ea2ness6Pain in a!ea of senso!y loss *not necessa!ily confined+6? sy-pathetic activity *s2in colou!0 te-p0s/eat+6Pain natu!e diff f!- no!ciceptive5bu!ning0 shooting0 stabbing6Pain pa!o ys-al> spontaneous6Responds poo!ly to opiods6Phanto- pheno-enon6Allodynia5pain to sti-ulus tht usually not painful *light touch+68ype!algesia5? pain to no!-ally painful6Dysesthesias 5 unpleasant sensations

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PHYSIOLOGY OF PAIN• The pain that occu!s afte! -ost types of no ious

sti-ulation is usually p!otective and uite distinct f!o-the pain !esulting f!o- ove!t da-age to tissues o!ne!ves.

• Is te!-ed physiologic pain> nociceptive pain because it isonly elicited /hen intense no ious sti-uli th!eaten toinju!e tissue

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• The 1 st order sensory neurons carrying pain &temperature ente! the spinal co!d th!ough the lateraldivision of t e posterior spinal nerve root .

• In the co!d these fibe!s ascend o! descend fo! 1 o! "seg-ents as dorsolateral tract of !issauer at the tip ofthe poste!io! ho!n. Relay in the poste!io! ho!n cells of

substantia gelatinosa.

• The a"ons of t e # nd order sensory neurons a!ise f!o-the posterior orns cells and cross over to t e opposite

side in t e anterior commissure in front of t e centralcanal and !each the opposite /hite colu-n . =he!e theytu!n up/a!ds fo!-ing the lateral spinot alamic tract . Thefibe!s of the t!act te!-inate in the cells of theventralposterolateral $%P! nucleus of t e t alamus .

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• The a"ons of t e ' rd order sensory neurons a!ise f!o-cells of the <PE nucleus of the thala-us and p!ojectto the primary sensory area of t e cere(ral corte"$area ')1)#* *

• The damage of t e tract causes loss of pain andtemperature sensation on t e opposite side of t e(ody one or t+o segments (elo+ t e level of lesion *

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ALTERNATE PAIN PATHWAYS

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ADVANTAGES &DISADVANTAGES

Paracetamol,NSAIDS &COX-2inhibitors

• T!eat -ild to -ode!atepain• (sually in tablet fo!-

• PCM F !is2 of side effect islo/• P!edispose to gast!ic ulce!s3 2idney p!oble-s.

Opiods

• Relieve seve!e pain• They do not causesto-ach ulce!s o!bleeding.

• Cause nausea and vo-iting0d!o/siness0 itching andconstipation.• 8as !espi!ato!y dep!essanteffect.

Local Anesthetics

• ffective fo! seve!e pain.• The!e is ve!y little !is2 ofd!o/siness o! b!eathingp!oble-s.

• At usual doses the!e a!e fe/

side effects.• So-e patients -ay feel di;;yo! get so-e sho!t6te!-

/ea2ness in thei! legs o!a!-s.• This usually disappea!s once

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Method o Pain !elie

"ablets or li#$id • They a!e often cheap• asy to be ad-iniste!ed• Can be used at ho-e

• Delay in pain !elief

In%ections IM orSC

• Delay in pain !elief

'pid$ral • =o!2s /ell /hen you havechest su!ge!y0 -ajo! uppe!abdo-inal su!ge!y o! anope!ation on the lo/e! pa!tsof you! body.• Afte! -ajo! su!ge!y ithelps people to b!eathedeeply0 cough and gene!ally-ove a!ound /ith -ini-alpain.

• :eeds an anaesthetist toinse!t the epidu!al cathete!.

In%ections into(eins ) PCA

• The !eaction ti-e is faste!• Seve!e acute pain can bet!eated p!o-ptly•

Patient cont!olled

• S-all tube should beinse!ted into the vein.

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Visual Analo Pain• :o pain /o!st pain i-aginable• 1$ c- line• Patient s -a!2ing on line -easu!ed in --.

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V!"#al Nu$!"i%al Ra&inS%al!

• Si-ila! to <AS• $ G :o pain• 1$ G =o!st pain•

Can also be used fo! pain !elief

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V!"#al '!s%"i(&o" s%al!• (S S ='RDS• :one0 -ild0 -ode!ate0 seve!e0 e c!uciating• Can also be used fo! pain !elief

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Ass!ss$!n& o) )un%&ion• Ability to ta2e deep b!eaths0 a-bulate0 cough0 coope!ate

and physiothe!apy afte! su!ge!y

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Pa&i!n& #!*a+iou"• Ho! /hen the!e is language ba!!ie!• &!i-aces0 g!oaning0 gua!ding0 !ubbing• Also co!!elate /ith vital signs

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ROUTES OFA,MINISTRATION

,-./ TYPE IN,I0ATIONS SI,E EFFE0TS

Mo!phine

'pioid Agonist

:ausea andvo-iting0constipation0-ental clouding0-uscula!!igidity0

eupho!ia0dyspho!ia0!espi!ato!ycent!edep!ession0-iosis

Hentanyl

Alfentanil

Sufentanil

In&"a$us%ula" In-!%&ions

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,-./ TYPES IN,I0ATIONS SI,E EFFE0TS

CodeineMode!ate to=ea2 'pioidAgonists

Itching f!o-hista-ine!elease

:albuphineMi edAgonist>Antagonist

Sedation0Di;;iness0S/eating0:ausea0an iety0hallucinations0

cause less!espi!ato!ydep!ession thanfull agonist

SUBCUTANEOUS In-!%&ions

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Epidural.seful follo+ing ma or surgeries*• Abdo-inal0• Tho!acic0•

<ascula! *i-p!ove lo/e! li-b ci!culation+• '!thopaedic su!ge!y *dec!ease the incidence of deep

vein th!o-bosis+

Co-bination of EA and opiods act syne!gistically toi-p!ove analgesic efficacy and !educe incidence of sideeffects.

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• pidu!al infusion !egi-en consists of bupivacaine $.1 /ith fentanyl " Jg>-l0 infusion at 961" -l>h! fo! lu-ba!

epidu!al o! )6 -l>h! fo! tho!acic epidu!al.

Alternative include2• $.1 !opivacaine /ith " Jg>-l fentanyl• Plain bupivacaine $.1"9• 'piod6only solution0 eg.0 pethidine " -g>-l0 given by

continuous infusion at 96 -l>h!0 o! bolus doses ofpethidine 9$ -g *9 -g>-l+ eve!y 46hou!ly.

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Patient3 controlled epidural analgesia*• May be used instead of continuous infusion o!

inte!-ittent bolus doses.

T e regimen2• Solution5 bupivacaine $.1 /ith fentanyl " Jg>-l.• PC A bolus5 9 -l• Eoc2out inte!val 5 1$619 -inutes• #ac2g!ound infusion5 9 -l>h!•

46hou! li-it5 usually not set since this is li-ited by theloc2out inte!val itself.

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A patient6cont!olledanalgesia infusionpu-p0 configu!ed

fo! epidu!alad-inist!ation of

fentanyl andbupivacaine fo!postope!ative

analgesia

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Intravenous Patient !ontrolledAnal"esia

• P!io! to co--ence-ent of PCA0 ensue that the patienthas !easonably ade uate analgesia by ad-iniste!ing I<bolus doses of an opiod.

• A sepa!ate and dedicated int!avenous cannula fo! PCA.

• If sha!ing0 an anti!eflu valve should be fitted to the fluid

infusion tubing to p!event accu-ulation of the opiodsthe!e should the int!avenous cannula beco-e bloc2ed.

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Setting for P0A morp ine are2• Concent!ation5 1 -g>-l.• PCA bolus5 1 -g *1 -l+0 o! $.9 -g *$.9 -l+ fo! patients

K@$ yea!s.• Eoc2out inte!val5 9 -inutes.• #ac2g!ound infusion5 usually none.•

46hou! li-it5 usually not set

Patients +it renal impairment*• 'piods have p!olonged du!ation of action in these

patients.• The loc26out inte!val should be e tended to 1$619

-inutes.• Monito!ed fo! !is2 of ove!sedation0 !espi!ato!y

dep!ession and o ygen desatu!ation.M##S $%1$ &R'(P " A1 )$

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Pet idine in place of morp ine*• 1$ -g pethidine fo! 1 -g -o!phine• P!olonged usage cause convulsions due to no!pethidine

*active -etabolite+ -ay accu-ulate and cause to icity.• P!esc!ibed antie-etic on a !egula! basis0 o! given

conco-itantly /ith int!avenous PCA -o!phine *".9 -g of

d!ope!idol added to 1$ -g of -o!phine in PCA pu-p+ fo!nausea and vo-iting.

4onitoring2• Chec2ing the PCA pu-p fo! a-ount of d!ug delive!y

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T e drug istory function include2• Total d!ug used• :u-be! of de-ands• :u-be! of successful delive!y• If nu-be! of de-ands fa! e ceeds d!ug delive!y0 patient

does not unde!stand.

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A patient6cont!olled analgesia infusion pu-p0 configu!edfo! int!avenous ad-inist!ation of -o!phine fo!

postope!ative analgesia

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CHRONIC PAIN

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T*! in&"o'u%&ion• Is a highly speciali;ed field in anesthesiology

• The ch!onic pain condition can be oncologic and non6oncologic

• 'pti-al -anage-ent involving -ultidisciplina!yapp!oaches

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T#PES O$

1. Cance! pain". #enign ch!onic pain

). Ch!onic postsu!gical pain4. Co-ple !egional pain synd!o-e

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1* 0ancer pain – Associated /ith unde!lying -alignancy. –

Result f!o- local tu-o! infilt!ation0 /idesp!ead-etastases to bones and pleu!a o! ne!veent!ap-ents and co-p!ession.

1* 5enign c ronic pain – :on6oncologic in natu!e – .g.56 he!pes ;oste! neu!algia0t!ige-inal neu!algia0

lo/ bac2 pain0 phanto- li-b pain0 ch!onic

postsu!gical pain

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'* 0 ronic postsurgical pain – C!ite!ia56

•

The pain develop afte! a su!gical ope!ation• The pain is at least " -onths du!ation• 'the! causes fo! the pain have been e cluded• The possibility that the pain is continuing f!o- a

p!ee isting p!oble- -ust be e plo!ed ande cluded.

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0omple" regional painsyndrome

–

A diso!de!cha!acte!i;ed by painand dysfunction of theSy-pathetic :S.

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Non.P*a"$a%olo i%al T"!a&$!n&

1. T!anscutaneous elect!ical ne!ve sti-ulation T :S". T!igge! point injection). Acupunctu!e

4. Inf!a!ed0 ult!asound the!apy9. C!yothe!apy@. 8ypnosis0 !ela ation e e!ciseB. Physiothe!apy

. Su!ge!y

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P*a"$a%olo i%al T"!a&$!n&

1. 'pioids". :SAIDs). Ste!oids

4. Psychoactive d!ug fo! adjuvant the!apy *an iolytics0antidep!essant0 sedative+9. Eocal anaesthetic@. Int!athecal clonidine

B. &uanethidine. :eu!olytics

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