Transcript Slide 1

Demographics
• Ballarat Health service:893 beds across:
Acute, Sub-Acute, Aged Care & Mental Health
• Acute site: 221 beds:-medical/surgical,
paediatric, maternity, Ed/short stay beds, ICU/ CCU
• Operating Suite theatres:6 Major; 2 Day
procedure & 2 Cath Lab’s
• Operation preformed (excluding Cath lab)
Category
Theatre Cases
Endoscopy
Discharge Births
June YTD 2012 =2013
June YTD 2013-2014
8945
2098
1315
9960 1015
2388 286
1385 70
Pain Management in PACU
different ways
of thinking, ‘from little things BIG
things grow’
Presented by: Jenny Dodson
CNS PACU Ballarat Health Service,
Oct 18th 2014
With acknowledgement of the traditional land owners of the Ballarat area the
“Wathaurong ”
Aim of this presentation is
to provide:
• Quick over view from the experts on pain
– Definition/ Overview: Pain Pathways / Types &
presentation / How do we negotiate it (assess/Rx) /
Why it’s important to Rx appropriately
• Recent advances effects on pharmacology: The
old & the new
– Recognised drugs & ways of doing things
– Recent innovations in pain management
• The old drugs a new, drugs non traditionally
considered
• Different dosing, timing, route
– New ones
What is pain?
Definition: Technically pain is:
– Always subjective
– Learnt application of the word through (early) life
experiences to perceived situation
– Unquestionably a sensation, may/may not have
pathophysiological cause! It nevertheless elicits a pain
response
• Acute pain: ‘..recent… limited duration.. usually
…identifiable… relationship to injury/disease’.
• Chronic pain: ‘…..persists beyond… healing …. may
not…. clearly identifiable cause’
• Continuum recognized between acute & chronic pain
rather than distinct entities.
(International Association for the Study of Pain 1994)
((Ready & Edwards, 1992)ANZCA 2010).
(ANZCA 2010)
• “whatever ..person says it is,whenever ..says it "
(by Margo McCaffrey in 1968).
Statement of Evidence for
clinical practice (ANZCA 2010)
• Specific early analgesic interventions reduce the
incidence of chronic (persistent) pain after
surgery. (level 11)
• Persistent post surgical pain risk factors include:
– severity of pre & postoperative pain, intraoperative
nerve injury & psychological vulnerability. (level 1V)
• Pre-emptive vs preventive analgesia:
– i.e. Epidural, Ketamine, Gadapentin, Clonidine
• Poorly targeted pain management may result in
ongoing patient pain
WHO analgesic ladder.
Acute pain exacerbations may result in
neural sensitization & release of mediators
both peripherally & centrally
(2) N. Vadivelu, S. Mitra, & D. Narayan, (2010)c
Recent Advances in Postoperative Pain Management ,Yale J Biol Med. Mar 2010; 83(1): 11–25. Published online Mar 2010)
()
• Recent advances in postoperative pain
management aim to target specific areas of
‘pain processing’ & are loosely grouped in the
following areas
( 2)
– Molecular Mechanisms (extremely complex, for me @ least )
– Pharmaceutical products (old – anew & new)
– Altered routes and modes of delivery
– Other modes of analgesia, (adjunctives)
– Organizational and procedural aspects
Pain Processing has 4
Elements
• Transduction
– Noxious mechanical, chemical and thermal stimuli are converted
to action potential
• Transmission
– AP conducted through nervous system
• Modulation
– Alteration of neural transmission along the pain pathway,
principally at dorsal horn
• Perception
– Final common pathway. Integration of painful input into
somatosensory and limbic cortex.
• Traditional analgesic approaches may target only perception
Rational: Pain management
pharmacology i.e. targeting
‘pain processing’
mechanism with
specifically targeted drugs
allows accumulative
synergistic effect of
pharmacology. ‘a little bit of
a lot lessens the load’ .
This reduce the risk of both
ongoing pain sensation
with it physiological &
psychological effects. But
potentially more
importantly the risk of ‘wind
up’ formulation & minimize
adverse effects in critical
structure including but not
restricted to: NMDA;
receptors, PAG & RVM
centres in the Brain.
Practical concepts in Pain
• Not Controlling post operative
pain has negative effects:
– Physiologically & Psychological effects
– Combined these two an exacerbations
of acute; acute on chronic; or chronic
pain can lead to clinical “wind up’ a
debilitating ongoing pain condition
(complex mechanisms: reversible (early
LTP) or irreversible (late LTP).
Not Controlling post operative pain has negative
effects: Physiologically & Psychological effects
Domains Effected
Specific Responses to pain
Endocrine
↑ Adrenocorticotrophic hormone (ACTH), ↑ Cortisol, ↑ antidiuretic hormone
(ADH), ↑ epinephrine, ↑ norepinephrine, ↑ growth hormone (GH), ↑
catecholamines, ↑renin, ↑ angiotensin II, ↑ aldosterone, ↑ glucagons, ↑interleukin
– 1, ↓ insulin, ↓ testosterone
Gluconeogenesis, hepatic glycogenolysis, hyperglycemia, glucose intolerance,
insulin resistance, muscle protein catabolism, ↑ lipolysis
↑ Heart rate, ↑ cardiac output, ↑peripheral vascular resistance, ↑ systemic
vascular resistance, hypertension, ↑ coronary vascular resistance, ↑ myocardial
oxygen consumption, hyper coagulation, deep vein thrombosis
↓ Flows and volumes, atelectosis, shunting, hypoxemia, ↓ cough, sputum
retention, infection
↓ Urinary output, urinary retention, fluid overload, hypokalemia
↓ Gastric and bowel motility
Muscle spasm, impaired muscle function, fatigue, immobility
Reduction in cognitive function, mental confusion
Depression of immune response
↑ Behavioral and Physiologic responses to pain, altered temperaments, higher
somatization, infant distress behavior; possible altered development of the pain
system, ↑ vulnerability to stress disorders, addictive behavior and anxiety states
Debilitating chronic pain syndromes: post mastectomy pain, post thoracotomy
pain, phantom pain, post hepatic neuralgia
Sleepiness, anxiety, fear hopelessness, ↑ thoughts of suicide.
Metabolic
Cardiovascular
Respiratory
Genitourinary
Gastrointestinal
Musculoskeletal
Cognitive
Immune
Developmental
Future Pain
Quality of Life
Reference B. Bowlus (Editor, 2 Ed) , Mosby (1999), PAIN: CLINICAL MANUAL Harmful Effects of Unrelieved Pain
Practical concepts in Pain Cont’d
Patient comfort/Functional ability/activity =
+ 1. Basic Pain Assessment (thorough)
+ 2. Present / Past History
+ 3. Patient expectations: Fact or Fiction
+ 4. Positioning
+ 5.Pharmacology
Patient Comfort
• What is patient comfort?
• A balance between
– pain registration (their score & FAS)
– what’s perceptually physiologically,
emotionally, & pharmacologically achievable
• The more complex the situation, the more
effective pre operative education & pain
management will be in enhancing post
operative outcomes
1.Comprehensive assessment of
pain 2. Past history/ comorbidities
• What are the elements of a comprehensive
pain assessment
– Standardised Scoring system + FAS
– Directed Rx of specific type & intensity of
registered pain, in combination with the patients
3 P’s history.
1.Comprehensive assessment of
pain. & 2. Past history / comorbitities
cont’d
• The Patient’s 3 P’s: Present, Past &
Projected situation
– acknowledge individuality & normalise to
expected outcomes, mindful of prior
pharmacology exposure, tolerance, physical
dependence, addiction:
– anatomically,
– physiologically
– & psychologically
Patchwork Quilt
of effective pain management
3.Patient expectation:
Fact or fiction
• Practical Components to Effective Treatment
– thoughts
– actions
– reality
• Always try to be mindful that …”activity induced in the
nociceptor and the nociceptive pathways by a noxious
stimulus is NOT pain; rather it is always a psychological
state; even though we may well appreciate that pain most
often has a proximate physical cause…..” ANZCA 2010
3.Patient expectation: Fact or
fiction:cont’d
• Past/Present/Future interplay
• Past injury/scaring or chronic pain, Rx for
same (tolerance)
• Elicit drug / Alcohol use (tolerance), often
no stated , at times patient in denial &
unaware
• Renal/Liver impairment effects
pharmacology metabolism & excretion
(consideration particularly in the elderly)
4.Positioning
• Positioning: importance of support &
reassurance
• Optimized supportive patient position will
greatly assist pain management, it’s
simple and often overlooked.
– Abdominal surgery knee’s up takes tension of
the abdominal muscles.
– Elevation of limbs reduces swelling
– Sitting as upright as possible takes weight off
the diagram.
– Limbs supported in position of comfort
– Other supportive devices
5.Targeted
Pharmacology
– ANZCA (1) Appropriate to pain type, &
importance of adjunctive therapy ‘a little bit of a
lot reduces side effects & increase relieve’.
– Appropriate deliver method: available parental
or oral
– Pain window maintenance - Onset action, peak
effect & efficiency (pre/intra & post operatively,
APP, IV vs Oral)
– Dosing considerations Age/ Gender/ tolerance/
sensitivity (1,5)
– Dose x Pt specific Wt x 24hrs (6)COMPLICATED
Pain Window
The Tree Of
Analgesia
Anticonvulsantst
Simple
Analgesia
Alpha
Adrenergic
Agonist
i.e. Clonidine
NSAID
NMDA
blockers i.e.
Ketamine
Local
Anaesthetics
Magnesium
Calcitonin
Opioid
Steriods
Dexmethasone
Gabapentin
Pregablin
Asprin
Not used
in surgical
setting
Carbamazepine
/Sodium
Valproate
Tricyclic antidepressants
ie Amitryptiline
Natural
Morphine
Cox2
paracoxib
Synthetic
Cox 1&2
Ketorlac
Panadol
Partial
Agonist ↑
affinity to
Mu receptor
sites
Fentanyl
Alfentanil
Remifentanil
Morphine &
derivatives
Oxycontin’s
MS Contin
Targin
SSRI
Agonist i.e
Tramadol
So what does pain
management look like at BHS
•Are statistics from our APS & Operational
statistics
•Our PACU APP
•And a discussion of the drugs, & how
they’re used currently @ BHS & those
around the corner
Analgesia trends at BHS
1200
1000
800
ketamine &
Opioid
600
Opioid(PCAS or
Oral)
400
200
100
0
Epidural
90
2009 2010 2011 2012 2013
80
Epidural with PCA
70
60
16
14
12
10
8
6
4
2
0
Paravertebral
50
%
ketamine
& Opioid
to PCAS
2009
2010
2011
2012
2013
40
30
Paravertebral with
PCA
Peripheral Nve cath
20
10
TAP catheters
0
2009
2010
2011
2012
2013
Some innovations in care
• L.A. Different ways of administering:
– IV & Regional
• Adjunctive therapies
– Old drugs used differently & New ones
• Different Narcotic’s
– Old drug new route: Topical: Buprenorphine
/fentanyl patch
– APP dosing
• New: Targin: & Tapentadol
Some of the Adjunctive
Pharmacology
• Anticonvulsants: Gabapentin
– binds to the alpha-2 delta sub-unit of the
presynaptic voltage gated-calcium channels
responsible for the inhibition of the calcium
influx.(2) prevents release of excitatory
neurotransmitters in Pain Pathway Pregaablin
also reduces narcotic requirement and
tolerance
Adjunctive Pharmacology
• NMDA receptor antagonists:Ketamine
doses (0.15–1 mg/kg),
– exerts a specific NMDA blockade & hence,
modulates central sensitization .(2)
• Magnesium:30–50 mg/kg,
– followed by 7–15 mg/kg/h IV
– In the Peripheral Nervous System it interferes
with the release of neurotransmitters at all
synaptic junctions & potentiates the action of
local anesthetics(3)
Adjunctive’s continued
• NSAID’s: Cox 2, :
– benefits of coxibs include improved quality of
analgesia; reduced incidence of GI side effects
& no platelet inhibition (note Cox 1 & 2:
Ketorolac )
• Paracetamol: is antipyretic & analgesic but
has little, if any, anti-inflammatory action.
– Its analgesic action is believed to inhibit COX3. At the spinal cord level, it also antagonize
neurotransmission by NMDA, substance P,
and nitric oxide pathways IV 100 ml: 10 mg/ml @ 15/60min;
Onset of action <5 -10/60, peak at 1- 2hrs (6hrly order)
Adjunctive’s continued
• Central alpha2 agonist Clonidine:
– Its sedative, pro-anesthetic, and pro-analgesic
effects ability to blunt the central sympathetic
response by as yet unknown mechanism(s).
– It also minimizes opioid-induced muscle rigidity,
lessens postoperative shivering, causes minimal
respiratory depression, and has hemodynamic
stabilizing effects(2)
Adjunctive’s continued
• Lignocaine by IV route an innovations in
care
– Intravenous Lignocaine (practice in territory
institution with APS, upskilling)
– Increase Regional LA use:
• continuous or intermittent bolusing (new research
suggest higher efficacy than continuous infusion
Epidural PCA & TAP; femoral; wound;elastomeric
pump e.t.c
New Narcotics preparations
• Targin: Oxycondone/Narloxone (10/5mg)
• Tapentadol: (oxycondone/ tramadol):
– centrally acting analgesic; an agonist at μ-opioid
receptor & a norepinephrine reuptake inhibitor
– 18-fold affinity- μ opioid receptor compared to
morphine;2 -3 less potent than morphine
– improved G/I tolerability compared to classical
opioids.
– Dose unchanged in renal impairment. No
Hepatoxicity
– IR oral: 50, 75 & 100 mg 4-6/24 <daily dose 600700 mg.
Narcotics used topically
• Different routes Topical
– Old :Narcotic’s Buprenorphine /fentanyl patch
New Adjunctive drugs
• Capsaicin (8-methyl-N-vanillyl-6nonenamide) acts as a TRPV-1 agonist
TRPV1 receptor markedly reduced in
inflammatory conditions & is present on
unmyelinated C fiber endings in the
periphery.
– Activation of the TRPV receptors releases high
intensity impulses & releases substance P, which
results in the initial phase of burning. Continued
release of substance P in the presence of capsaicin
leads to the depletion of capsaicin and a subsequent
decrease in C fiber activation.
Latest research Adjunctive
not seen in action
(6)
• Neostigmine (2,4), & recently, adenosine
• Drugs on the horizon:Prialt,(ziconotide) IT only non opioid
(used Uk & USA),
Advances In Organisational
Aspects Of Post operative Pain
Control
– Surgery Type i.e. Laparoscopic surgery, anterior
hip replacement
– Pre/interoperatively maximized use of L.A. &
NMDA receptor antagonists agents
– CBT pre hospitalization education
– Early rehabilitation
– Use of alternative therapies i.e. Acupuncture,
meditation, mindfulness concepts(although
presently not strongly supported – research
occurring in this area)
Just to mention any thing not already
mentioned in summary
From the Old to the New
‘From little things, BIG things grow’
Change
is
inevitable
“Thoughts become Action which become Reality”
And thank you for your attention
Recommendation from research
of presentation
• Functional knowledge benchmarked to
individual pain situation
• Effective communication within & without
• Openness to change: Years ahead will see much
pharmacological/ delivery method/ surgical technique change as
patient throughput &complicated co moieties increase in the face of
falling health $
• Nursing R&D: doctoral study anyone? Nursing /neuroscience
/psychology; what other adjunctive therapies are out there?
– “How does the PAR environment impact on thought-action-reality patient
journey? Does music play a role – noxious or nurturing. Is this an individual
perception of do all brains subconsciously respond similarly to different
harmony? Some of my thoughts 
References
•
•
•
•
•
•
•
1) Acute Pain Management:Scientific Evidence, 3rd Ed 2010,Australian &
New Zealand College of Anaesthetists & Faculty of Pain Medicine
2) N. Vadivelu, S. Mitra, & D. Narayan, (2010)c Recent Advances in
Postoperative Pain Management ,Yale J Biol Med. Mar 2010; 83(1): 11–
25. Published online Mar 2010)
3) D. Kerr & L. Kohan (2008), Local infiltration analgesia: a technique for the
control of acute postoperative pain following knee and hip surgery, Acta
Orthopaedica 2008; 79 (2): 174–183
4) Miller's Anesthesia, 7th ed.Copyright © 2009 Churchill Livingstone, An
Imprint of Elsevier
5) WHITE; ANESTH ANALG b NON-OPIOID ANALGESICS AND ACUTE
POSTOPERATIVE PAIN 2005;101:S5–S22 (4)
6 ) G Cheymol (1993), Clinical Pharmacokinetics of Drugs in Obesity .
Clinical Pharmacokinetics August 1993, Volume 25, Issue 2, pp 103-114
Date: 04 Nov 2012
7) Woolf, Clifford J, (2007) Central Sensitization: Uncovering the
Relation between Pain and Plasticity, Anesthesiology:April 2007 Volume 106 - Issue 4 - pp 864-867
• Ms Jenny Dodson: Currently a CNS Recovery
Ballarat Health Services (1995), part time
Perioperative Clinical Undergraduate Educator
(2008), with a special interest in all areas of pain
management. During this time Jenny has had
several short secondment as the Clinical
Consultant Acute Pain Management at Ballarat
Health Services.