Education on Pain Management for Anesthesiologist

Dr Alex Yeo Sow Nam

• awareness• education• research

Pain is not “just a symptom”. Pain is not “just a symptom”. It is a significant biomedical It is a significant biomedical problem that requires expertise, problem that requires expertise, and merits study in its own and merits study in its own rightright

Pain The th vital sign

Launched in Singapore April 2004

None Mild Moderate Severe

Faces

Numerical

Categorical

No Pain

FACES SCALE FACES SCALE Use the Pain Ruler as a personal guide Use the Pain Ruler as a personal guide DoDo Not ShowNot Show to the patient unless is to the patient unless is not able to score pain using the Numeric not able to score pain using the Numeric or Categoric Scale. or Categoric Scale.

Scope of Anesthesiology- American Board of Anesthesiology (2003) -

• Assessment of, consultation for, and preparation of, patients for anesthesia.

• Relief and prevention of pain during and following surgical, obstetric, therapeutic and diagnostic procedures.

• Monitoring and maintenance of normal physiology during the perioperative period.

• Management of critically ill patients.• Diagnosis and treatment of acute, chronic and cancer related pain.• Clinical management and teaching of cardiac and pulmonary

resuscitation. • Evaluation of respiratory function and application of respiratory

therapy. • Conduct of clinical, translational and basic science research. • Supervision, teaching and evaluation of performance of both medical

and paramedical personnel involved in perioperative care. • Administrative involvement in health care facilities and organizations,

and medical schools necessary to implement these responsibilities.

55% of European Anaesthetists are Dissatisfied with Pain Management

Survey of 105 hospitals (17 European countries)

Hos

pita

ls (%

)

Satisfied/very satisfiedDissatisfied/very dissatisfied

100

80

60

40

20

0

Janssen-Cilag Slide Presentation at Turkey/Rawal N et al. Eur J Anaesthesiol 1998;15:354–63

France Germany Italy Spain UK

Patient Concerns Before Surgery

Warfield CA, Kahn CH. Anesthesiology 1995;83:1090-1094. (Survey of 500 U.S. adults)

5751

42

3430

0

10

20

30

40

50

60

Pain after Improvement Full recovery Pain during Professional

Patient concerns

(%)

Pain after

Improvement Full recovery

Pain during

Professional

Patient Concerns (%)

Significant Proportions of Patients Experience Moderate or Severe Pain

Dolin SJ et al. Br J Anaesth 2002;89:409–23

70

60

50

40

30

20

10

0

Severe pain (NRS >7 on 0–10 scale orVAS >70 on 0–100 scale)

Moderate-to-severe pain (NRS >3 on 0–10 scale or VAS >30 on 0–100 scale)

Patie

nts

(%)

67.2

29.1

35.8

10.4

20.9

7.8

IM IV PCA morphine Epidural

Percentage of patients reporting moderate-to-severe pain by analgesic

technique

29 21 45 27 62 30No. of studies

Most patient still experience moderate-severe to severe pain

Dolin SJ et al. Br J Anaesth 2002;89:409–23

Pain assessed as combination of Visual Analog Sale and Verbal Response Scale with patients numbers adjustment

Persistent pain as an Persistent pain as an illness/diseaseillness/disease

• Particularly relates to neuropathic pain• “Rewiring” in the dorsal horn• Genetic changes at cellular level

– c-fos/c-jun balance• Changes in the sympathetic nervous system• PET scanning, fMRI

Disease/illnessDisease/illness

• Sleep disturbance• Anxiety• Depression

– 50% in patients with persistent pain– 90% of those that present to pain clinics– suicide risk increased

• Fear - avoidance behaviour and beliefs

Persistent pain after surgery

Surgery Pain type IncidenceLimb amputation phantom limb pain 30-81%

Thoracotomy postthoracotomy pain >50%

Breast surgery chest wall, breast or scar 50%

pain; phantom breast pain

Cholecystectomy chronic abdominal pain 3-56%

Inguinal hernia groin pain 11.5%

Perkins F et al. Chronic pain as an outcome of surgery. Anesthesiology 2000; 93: 1123-1133.

Chronic pain

• Chronic pain: a major cause of suffering and reduced quality of life

• Chronic pain is seen after e.g.: – Cancer, – Traumatic injuries, – Excessive exercise.– Nerve damage– Insufficient treatment of acute pain

• But, chronic pain: ”the invisible disease”.

Medical Mismanagement of Chronic Pain

• Inappropriate analgesics: 66%• Inappropriate sedatives: 54%• Inappropriate explanations : 70%• Encouragement of rest: 61%

Pither Nicholas, VI World Congress, 1991

Healthcare providers knowledge to pain intervention was poor

Deficient knowledge in drug indication, action and dosing intervals:

– Only 50% knew the conversion from oral to intravenous morphine.

– Only 31% knew the correct morphine dosing and frequency for inadequate pain management

– 20% believed that opioid are unsuitable for elderly patients.

– Only 20% confident that physician was consistent in prescribing pain medication.

Comley, AL. BUMC PROCEEDINGS 2000;13:230–235

Education Platforms

• Meetings/ Workshops• Societies– IASP; WIP/FIPP ;ASIPP; ISIS;

ASRA• Pain Fellowships– FANZCA; • Acupuncture course and exams• Attachments• Multidisciplinary

THE FIPP EXAM

Nagy Mekhail Chair of the board of examination

Maarten van Kleef Vice-chair

Purpose of Exam

To establish the knowledge domain of the practice of Pain Medicine for certification.

To assess the knowledge of interventional techniques of Pain Medicine physicians in a valid manner.

To encourage professional growth in the practice of interventional techniques.

Purpose of Exam

To recognize, formally, individuals who meet the requirements set forth by WIP-Section of Pain Practice.

To serve the public by encouraging quality patient care in the practice of Pain Medicine.

Competence and certification will be a part of the future pain practice

EXAM FORMAT

• The Examination in Interventional Techniques will be administered only in English. It will consist of three parts.

Part 1 will be a theoretical examination. Part 2 will be identification of anatomical

structures, equipment and x-ray equipment (C-arm).

Part 3A will be a practical examination. Part 3B will be an oral examination

Part I & Part II

Part III (Practical Exam)

The Exam is Scored SeparatelyThe Composite Passing Score

Determined by Statistical Analysis

60% Weight

FIPP ALUMNI(over 600 to date)

Argentina MexicoUK Australia Netherlands Ukraine

Belgium Phillipines USAEire Portugal LithuaniaEgypt Puerto Rico IranGermany Saudi Arabia CanadaHungary Singapore JapanIndia South Africa Greece

Israel Spain BrazilItaly Switzerland Columbia

Korea Taiwan Philippines MALTA GC Turkey

Information of Results

Results Mailed by 8 Weeks to Results Mailed by 8 Weeks to Each Each ExamineeExaminee

Option of Presenting the Certificate in

Person at an Official Ceremony

Certificate of FIPP Sent by Mail Later

Official Ceremony of the Presentation of the Certificates to all

FIPP Alumni,

Interscalene block

Femoral block

Img_0242.jpgImg_0242.jpg

AAOS Washington DC Feb 2005

Acupuncture Patel and Colleagues. All randomised

controlled trials for chronic pain. J Epidemiol 1989. “Results favourable to acupuncture were obtained significantly more often than chance alone would allow”

TL Lee. Acupuncture and Chronic Pain Management. Ann Acad Med Singapore 2000. “ There are reasonable studies showing relief of pain in diverse pain conditions. “

Expert opinions and RCTs

Average scores - SF 36 questionnaire for CBT #1

0

20

40

60

80

100

120

PF RFP BP GH V SF RFE MH

Components of SF-36 questionnaire

Scor

es M

ax=1

00 PrePostonemonthsixmonth

Success !