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Pain management by Dr Nesar

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Pain management by Dr Nesar

  1. 1. Pain Management D/O Jarahat A.K.T.C., AMU, Aligarh Presented by Nesar Ahmad
  2. 2. Definition Pain is derived from Latin word ‘Poena’ means Penalty or Punishment. “An unpleasant sensory and emotional experience associated with actual or potential tissue damage ordescribed in terms of such damage”. Pain is always subjective. InternationalAssociationfortheStudyof Pain “Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions”. Sternbach RA, ed. The Psychology of Pain. 1978. p 223-39.“ “Pain is whatever the experiencing person says it is, and exists whenever & wherever he says it does.” MargoMcCaffery Pain is multidimensional: physical, social, emotional, psychological
  3. 3. Why treat pain? • 50-75% of patients who die in the hospital die with pain1 • 25% of all cancer patients die with pain2 • It is estimated that 85-90% of pain is easily treated with medication, usually opioids and adjuvants • Pain impacts routine activities, mobility, nutritional intake • It is considered the “Fifth vital sign” 1-www.painmed.org/PatientCenter/Facts_on_Pain.aspx 2-Medtronics Cancer Pain Fact Sheet
  4. 4. Neurophysiology Of Pain Process of Pain ‘Nociception’ is the process where information about tissue damage is conveyed to the central nervous system through sensory receptors (nociceptors). There can be pain without nociception (such as phantom limb pain), or nociception without pain. Pain occurs through four activities:  Transduction: Energy is converted from a noxious stimulus (thermal, mechanical, or chemical) into electrical energy (nerve impulses) by nociceptors  Transmission: The transmission of the neural signals from the transduction site to the spinal cord and brain  Perception: In higher structures, the arriving signals are appreciated as pain  Modulation: Occurs at the spinal cord level; descending input from the brain influences (modulates) nociceptive transmission
  5. 5. February 2007
  6. 6.  Substance P acts on mast cells in the vicinity of sensory endings and release of histamine, which directly excites nociceptors.  Substance P and CGRP produces dilation of peripheral blood vessels. The resultant edema causes additional liberation of bradykinin.  Thus Nociceptors activate and cause pain. How Pain Occurs  Tissue damage releases bradykinin and prostaglandins, which activate or sensitize nociceptors.  Activation of nociceptors leads to the release of substance P and calcitonin gene related peptide (CGRP).
  7. 7. Types of Pain NOCICEPTIVE PAIN Pain stimulus transmitted by peripheral nociceptors Serves a protective function Typically responds well to opioids It may be somatic or visceral. Somatic pain receptors are located in skin, subcutaneous tissues, fascia, other connective tissues, periosteum, endosteum, and joint capsules. Stimulation of these receptors usually produces sharp or dull localized pain, but burning is not uncommon if the skin or subcutaneous tissues are involved. VISCERAL PAIN receptors are located in most viscera and the surrounding connective tissue. Visceral pain due to obstruction of a hollow organ is poorly localized, deep, and cramping and may be referred to remote cutaneous sites. Visceral pain due to injury of organ capsules or other deep connective tissues may be more localized and sharp. Neuropathic Pain Neuropathic or pathologic pain is caused by abnormal signals in the central or peripheral nervous systems, demonstrating injury or impairment. Causes of neuropathic pain may include inflammation, trauma, infections, tumors, metabolic diseases, toxins, or neurological disease 40% of cancer pain is neuropathic Is described as shooting, burning, tingling, lancinating, pins and needles sensation type, and can be difficult to describe Does not respond well to Mu agonist opioids
  8. 8. TYPES OF PAIN …… Physicians and neuroscientists generally classify pain in the following ways: Acute pain : caused by an injury to the body. It occurs when tissue injury or potential injury initiates nociceptors , and it can develop slowly or quickly. It can last for a few minutes to six months and goes away when the injury heals. Examples: surgery, infection, trauma, inflammation Chronic pain: persists for 6 months or longer. It does not warn the body to respond Cancer (or malignant) pain: associated with malignant tumors. Tumors invade healthy tissues and exert pressure on nerves or blood vessels, producing pain. Cancer pain can also be associated with invasive procedures or treatments. Some physicians classify cancer pain with chronic pain.
  9. 9. Pain Assessment Clinicians should evaluate the cause, severity, and nature of the pain and its effect on activities and psychologic well-being. A person’s self report is the most reliable measure of pain The history should include the following information about the pain: Original site of pain Origin and mode of onset Quality (e.g. burning, cramping, aching, deep, superficial, boring, shooting) Severity Radiation pattern Progression of pain Duration Exacerbating and relieving factors The patient's level of function should be assessed, focusing on activities of daily living (e.g. dressing, bathing), employment, avocations, and personal relationships.
  10. 10. Common Pain Scales There are a variety of pain scales used for pain assessment. The three most common scales recommended for use with pain assessment are: • The numeric scale • The Wong-Baker scale (also known as the FACES scale) • The FLACC scale The Numeric Scale The numeric scale is the most commonly used pain scale with adult patients, rating pain on a scale of 0-10. Wong-Baker Scale The Wong-Baker FACES Scale uses drawn faces for patients to express their level of pain. The faces are associated with numbers on a scale ranging from 0 to 10. This scale is most commonly used with children, and is appropriate to use with patients ages three and older. Adults who have developmental or communication challenges may benefit from using this scale. (Health Care Association of New Jersey, 2011) FLACC Scale FLACC is the acronym for Face, Legs, Activity, Cry, and Consolability. This scale is based on observed behaviors, and is most commonly used with pediatric patients less than three years of age. The behaviors that are described are associated with a number; each component is totaled for a number ranging from 0 to 10. This scale is also appropriate with patients who have developmental delays or are non-verbal (Health Care Association of New Jersey, 2011).
  11. 11.  Numeric Pain Intensity Scale  Pain Faces Scale  PAINAD Scale And for Palliative Care……
  12. 12.  The most commonly used pain measurement tool, used in the cognitively normal patient  The scale is from 0 (no pain) to 10 (the greatest intensity pain)  In general pain from 1-3 is mild pain, 4-7 is moderate pain and 8-10 severe pain Numeric Pain Intensity Scale 0 1 2 3 4 5 6 7 8 9 10 (None) (Mild 1-3) (Moderate 4-7) (Severe 8 – 10)
  13. 13.  The patient selects the face that best represents how they feel in relation to their pain condition, from the “happiest feeling face” to the “saddest feeling face”  The correlating number is actually the scoring card used to quantify the patient’s pain intensity Pain Faces Scale
  14. 14. Pain Faces Scale Pain Faces Scale 0 Very happy, no hurt 2 Hurts just a little bit 4 Hurts a little more 6 Hurts even more 8 Hurts a whole lot 10 Hurts as much as you can imagine (don't have to be crying to feel this much)
  15. 15.  PAINAD Scale is to be utilized in evaluating non-verbal patients  A score of 0 denotes no pain, and a score of 10 the worst possible pain  This scale is now used in place of the FLACC scale PAINAD Scale
  16. 16. Items 0 1 2 Score Breathing Normal Occasional labored Noisy labored breathing Independent breathing. Long periods of of Vocalization Short periods of hyperventilation hyperventilation. Cheyne-Stokes respirations Negative None Occasional moan or groan. Repeated trouble calling Vocalization Low level of speech with a out. negative or disapproving Loud moaning or groaning. quality. Crying. Facial Smiling Sad. Facial grimacing Expression or Frightened. inexpressive. Frown. Body Relaxed Tense. Rigid. Language Distressed pacing. Fists clenched. Fidgeting. Knees pulled up. Pulling or pushing away. Striking out. Consolability No need to Distracted or reassured by Unable to console, distract console. voice or touch. or reassure. PAINAD Scale
  17. 17. Pain Management General approach to pain management Use a multidimensional approach: physical, psychological, spiritual, social, cultural, situational Collect data: history, physical exam, medication review Location/radiation, onset, quality, severity What makes it better/worse? What is it associated with? What treatments have been tried/have been effective? Other symptoms associated with the pain? Pain timeline Treat, reassess, adjust
  18. 18. Importance of Pain Management • Adequate Pain Control • Reduce the Risk of Adverse Outcomes • Maintain the Patient’s Functional Ability, as well as Psychological Well-being • Enhance the Quality of Life • Shortened Hospital Stay and Reduced Cost
  19. 19. Adverse effects of unrelieved Pain Cardiovascular Heart Rate Blood Pressure Increased myocardial o2 demand Hypercoagulation Unstable angina Myocardial infarction DVT PE Respiratory LungVolumes Decreased cough Retension of secretion Atelectasis Pneumonia Hypoxemia GI Gastric Emptying  Bowel Motility Constipation Anorexia Ileus National Pharmaceutical Council (2001). Macintyre & Schug (2007).Cohen et al (2004)
  20. 20. Adverse effects of unrelieved Pain Neuroendocrine Altered release of multiple hormones Hyperglycemia Wt loss/ muscle wasting Impaired wound healing Impaired immune function MSK Muscle spasm Impaired muscle mobility & function Immobility Weakness Fatigue Psychological Anxiety Fear Sleep deprivation Post traumatic stress disorder
  21. 21. Non-Pharmacological Management There are a variety of approaches for decreasing pain that are non-pharmacological Non-pharmacological interventions may include: • Heat or cold (as appropriate) • Massage • Therapeutic touch • Decreasing environmental stimuli (e.g. sound, lighting, temperature) • Range of motion or physical therapy • Repositioning • Immobilization • Relaxation techniques and imagery • Distraction • Psychotherapy or cognitive behavioral therapy • Biofeedback • Music therapy • Aromatherapy • Acupressure or acupuncture • Transcutaneous electrical Nerve stimulus (TENS) • Cryoanalgesia of intercostal nerves (no longer used because of the high incidence of dysaesthesia)
  22. 22. WHO Step Ladder of Pain Management: One tool that was developed by the World Health Organization (WHO) in 1986 is the WHO analgesic ladder. This framework was originally developed to assist physicians in treatment choices for cancer pain. This tool continues to be validated, and used for not just cancer pain, but other forms of acute and chronic pain. The analgesic ladder is used as a guideline, and is described as follows: Step 1: Mild pain (e.g. rating of 0-3 on a scale of 0-10): Uses non-opioid and/or a nonsteroidal anti-inflammatory drug (NSAID), and other non- pharmacological strategies to improve quality of relief. Step 2: Moderate pain (e.g. rating of 4-6): Continue with medications and methods described in step 1, plus add a mild opioid. Step 3: Severe pain (e.g. rating of 7-10): Along with medications and strategies described in steps 1 and 2, add a more potent opioid (e.g., morphine, hydromorphone, fentanyl). (CPM Resource Center, 2010a; CPM Resource Center, 2010c; Schaffer, 2010).
  23. 23. “Traditional” WHO 3-step ladder 1 mild 2 moderate A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodone Tramadol + adjuvants 3 severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone + adjuvants ASA Acetominophen NSAIDs + adjuvants
  24. 24. Opioid v. non-opioid analgesics • Opioids • Morphine • Fentanyl • Oxycodone • Hydromorphone • Hydrocodone • Methadone • Codeine • Tramadol • Oxymorphone • Tapentadol • Buprenorphine • Non-opioids • NSAIDs • Acetominophen • Cox-2 inhibitors • Tri-cyclic antidepressants • Steroids • Anti-convulsants • SNRIs( serotonin and Nor epinephrine reuptake inhibitors • other
  25. 25. Class Drug Usual Dosage Range* Indoles Diclofenac 50–100 mg, followed by 50 mg q 8 h Indomethacin Sulindac 150–200 mg q 12 h Tolmetin 200–400 mg q 6–8 h Propionic acids Fenoprofen 200–600 mg q 6 h Ibuprofen 400 mg q 4 h to 800 mg q 6 h Ketoprofen 25–50 mg q 6–8 h Naproxen 250–500 mg q 12 h Naproxen Na 75–550 mg q 12 h Oxaprozin 600–1200 mg q 24 h Salicylates Aspirin 650–1000 mg q 4–6 h Diflunisal 250–500 mg q 8–12 h Salsalate 750–2000 mg q 12 h Oxicam Piroxicam 20–40 mg q 24 h Non Opioidal Drugs
  26. 26. Fenamates Meclofenamate 50–100 mg q 6–8 h Mefenamic acid 250 mg q 6 h Pyrazole Phenylbutazone 100 mg q 6–8 h up to 7 days Pyrrolo-pyrrolo derivative Ketorolac 15–30 mg IV or IM q 6 h or 20, followed by 10 mg q 4–6 h for maximum 5 days Selective COX-2 inhibitor Celecoxib 100–200 mg q 12 h
  27. 27. DRUGS FOR NEUROPATHIC PAIN Class/Drug Dose* Comments ANTICONVULSANTS† Carbamazepine 200–400 mg bid Monitor WBCs when starting treatment GabapentinS 300 mg bid Preferred drug in this class; starting dose usually 300 mg once/day Phenytoin 300 mg once/day Limited data; 2nd-line drug Pregabalin 75–300 mg bid Mechanism similar to gabapentinS but more stable pharmacokinetics Valproate 250–500 mg bid Limited data, but strong support for treatment of headache
  28. 28. DRUGS FOR NEUROPATHIC PAIN CONT…… ANTIDEPRESSANTS Amitriptyline 10–25 mg at bedtime May increase dose to 75–150 mg over 1–2 wk, particularly if significant depression is present; may not need high doses; not recommended for the elderly or patients with a heart disorder because it has strong anticholinergic effects Desipramine 10–25 mg at bedtime Better tolerated than amitriptyline May increase dose to 150 mg or sometimes higher Duloxetine 30 mg bid Better tolerated than tricyclic antidepressants CENTRAL Α2-ADRENERGIC AGONISTS Clonidine 0.1 mg once/day Also can be used transdermally or intrathecally Tizanidine 2–20 mg bid Less likely to cause hypotension than clonidine
  29. 29. DRUGS FOR NEUROPATHIC PAIN -CONTD CORTICOSTEROIDS Dexamethasone 0.5–4 mg qid Used only for pain with an inflammatory component Prednisone 5–60 mg once/day Used only for pain with an inflammatory component NMDA-RECEPTOR ANTAGONISTS Memantine 10–30 mg once/day Limited evidence of efficacy Dextromethorphan 30–120 mg qid Usually considered 2nd-line ORAL NA CHANNEL BLOCKERS Mexiletine 150 mg once/day to 300 mg q 8 h Used only for neuropathic pain For patients with a significant heart disorder, cardiac evaluation considered before the drug is started
  30. 30. DRUGS FOR NEUROPATHIC PAIN -CONTD TOPICAL Capsaicin 0.025–0.075% tid Some evidence of efficacy in neuropathic pain and arthritis EMLA® tid, under occlusive dressing if possible Usually considered for a trial if lidocaine patch is ineffective; expensive Lidocaine5% Daily Available as patch OTHER Baclofen 20–60 mg bid May act via GABAB receptor Helpful in trigeminal neuralgia; used in other types of neuropathic pain Pamidronate 60–90 mg/mo Evidence of efficacy in complex regional pain syndrome *Route is oral unless otherwise indicated. †Newer anticonvulsants have fewer adverse effects. EMLA = eutectic mixture of local anesthetics; GABA = γ-aminobutyric acid; NMDA = N-methyl-d-aspartate.
  31. 31. NEURAL BLOCKADE Interrupting nerve transmission in peripheral or central pain pathways via drugs or physical methods provides short-term and sometimes long-term relief. Neuroablation (pathway destruction is used rarely; it is typically reserved for patients with an advanced disorders and a short life expectancy. Local anesthetic drugs (eg, lidocaine) can be given IV, intrathecally, intrapleurally, transdermally, sc, or epidurally. Epidural analgesia using local anesthetics or opioids is particularly useful for some types of postoperative pain. Long-term epidural drug administration is occasionally used for patients with localized pain and a short life expectancy. Generally, for long-term neuraxial infusion, an intrathecal route via an implanted pump is preferred. NEUROMODULATION Stimulation of neural tissues may decrease pain, presumably by activating endogenous pain modulatory pathways. The most common method is transcutaneous electrical nerve stimulation (TENS), which applies a small current to the skin. Also, electrodes may be implanted along peripheral nerves or along the dorsal columns in the epidural space. Stimulation of brain structures (deep brain stimulation and motor cortex stimulation) has also been used, but evidence of benefit is slight.
  32. 32. post operative pain management When to start pain management? • Pre-operatively • Discuss options with patients • Teach about assessment, treatment options • Pre medication with paracetamol • Intra-operatively • Wound infiltration with local anaesthetic (surgeon) • Administer analgesics (IV or rectally)
  33. 33. Pharmacological Postoperative Pain Management • Multimodal Analgesia • The combination of drugs from different classes to achieve more effective analgesia with less side effects Advantages: • May be opioid sparing • May result in decreased side effects • More effective analgesia • World Health Organisation (WHO) analgesic step ladder approach to pain relief • Accurate pain assessment is key to providing adequate pain relief
  34. 34. Mild pain 1 – 3 Paracetamol + NSAID (if no CI) + infiltration with LA Moderate pain 4 – 6 Paracetamol + NSAID (if no CI) + Codeine or Tramadol + infiltration with LA Severe pain 7 – 10 Paracetamol + NSAID (if no CI) + Morphine + infiltration with LA CI= contraindication; LA = local anaesthetic How to treat post-surgical pain?
  35. 35. Non-pharmacological Postoperative Pain Management • Psychological strategies • Distraction ( toys, books, iPad ) • parental presence in recovery room • Education • Physical Strategies • TENS • Ice/heat • Elevation/positioning • Simple distraction techniques that divert attention away from the painful stimulus • Positive incentive techniques which provide a small reward (e.g stickers, prizes) • These strategies aim to decrease anxiety but are not adequate as a sole means of post operative pain management
  36. 36. Thanks for attention!