Transcript 11. Acute Pain.ppt

ACUTE PAIN
MANAGEMENT
Salah N. El-Tallawy
Prof. of Anesthesia and Pain Management
Faculty of Medicine - Minia Univ & NCI - Cairo Univ - Egypt
Assc Prof. KKUH, King Saud Univ., KSA
http://faculty.ksu.edu.sa/salaheltallawy
Objectives
1.
Introduction
2.
Classification
3.
Assessment of Acute Pain
4.
Management of Acute Pain

Summary
ACUTE PAIN MANAGEMENT
Definition
 Pain:
“An unpleasant sensory and/or emotional experience
associated with actual or potential tissue damage or
expressed in such terms”
(Ready & Edwards, 1992). IASP Press
(2) Classification of Pain
According to the “Duration”
1. Acute pain
2. Subacute pain
3. Chronic Pain
Classification of Pain
According to the “Cause”
1. Postoperative pain,
2. Labor pain,
3. Trauma,
4. Sickle cell crisis,
5. Cancer,
6.
LBP,
7.
Musculoskeletal pain,
8.
Others.
PAIN MEASUREMENTS
Visual Analogue Scale (VAS)
0
10
Verbal Rating Score
No
Pain
Mild
Moderate
Severe
Pain
PAIN MEASUREMENTS
Pediatric Scores “Facial expression”
Management of
Acute Pain
Modalities of the “ACUTE PAIN MANAGEMENT”
Pharmaco - Therapy
1.
Non Opioid Analgesics
 Paracetamol
 NSAIDs
2.
Opioids
 Weak Opioids.
 Strong Opioids.
 Mixed agonist-antagonists
3.
Adjuvants
Modalities of the “ACUTE PAIN MANAGEMENT”
Regional Anesthetic Techniques
1.
Local infiltration
2.
USG-RA
3.
Neuraxial:
Epidural:
Spinal
CSE
ACUTE POSTOPERATIVE MANAGEMENT TOOLS
Regional Techniques
Pharmaco - Therapy
1.
Non Opioid Analgesics
1.
Local infiltration
 NSAADs
2.
Wound perfusion
3.
Intra-abdominal inj. of LA/Analg.
4.
Intercostal & Interpleural
Opioids
5.
Paravertebral
 Weak Opioids.
 Strong Opioids.
 Mixed agonist-antagonists
6.
USG-RA: e.g. TAP
7.
Neuraxial:
 Analgesic /Antipyretic
 Analgesic/Anti-inflam/Antipyretic
 NSAIDs
 Non-selective COX inhibitors
 Selective COX-2 inhibitors
2.
3.
Adjuvants









-2 Agonists
LA
SP inhibitors
NMDA inhibitors
Anticonvulsant / Antidepressants
Calcitonin
Relaxants
Cannabinoids
Others
 Epidural:
 Thoracic
 Lumbar
 Spinal
 Single shot
 CSA
 CSE
WHO IV Interventional
WHO Ladder
Updated
Severe pain (7-10)
WHO III
Strong opioids
± Adjuvant
Moderate pain (4-6)
WHO class II Weak opioids
± Adjuvant
Mild pain (0-3)
WHO class I
NSAIDs
± Adjuvant
By the mouth
By the clock
By the ladder
1.
Non Opioid Analgesics
 NSAADs
 Analgesic / Anti-inflam / Antipyretic / Anticoagulant
 ASA
 Analgesic /Antipyretic
 Paracetamol
Severe pain (7-10)
WHO III Strong opioids
± Adjuvant
 NSAIDs
 Non-selective COX inhibitors:
Moderate pain (4-6)
WHO class II Weak opioids
 Diclofenac & Ketoprofen
 Selective COX-2 inhibitors
 Celecoxib & Rofecoxib
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
Scientific Evidence – NON OPIOID ANALGESICS
1.
2.
Paracetamol:
1.
is an effective analgesic for acute pain; the incidence of adverse effects
comparable to placebo (Level I [Cochrane Review]).
2.
Paracetamol / NSAIDs given in addition to PCA Opioids   Opioid
consumption (Level I).
NSAIDs:
1.
are effective in the treatment of acute postoperative
2.
With careful patient selection and monitoring, the incidence of renal
impairment is low (Level I [Cochrane Review]).
3.
NSAIDs + Paracetamol improve analgesia compared with paracetamol
alone (Level I).
(Level I ).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010
WHO Ladder II - Weak Opioids:
1. Tramadol:
–
Tramadol : Morphine:
•
•
2.
Parenteral = 1 : 10 & Oral = 1 : 5
Dose: 200 – 400 mg/d
Severe pain (7-10)
Codeine:
–
–
WHO III Strong opioids
± Adjuvant
Metabolized to morphine.
Codeine : Morphine = 1 : 10
Moderate pain (4-6)
WHO class II Weak opioids
3.
Dextro-propoxyphene:
–
–
Methadone Derivative
Prolongation of Q-T interval.
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
Scientific Evidence – WEAK OPIOIDS
1.
Tramadol:
 has a lower risk of respiratory depression & impairs GIT motor
function < other opioids
(Level II).
 is an effective treatment for neuropathic pain
(Level I [Cochrane Review]).
2.
Dextropropoxyphene:
 has low analgesic efficacy
(Level I [Cochrane Review]).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010
WHO Ladder III - Strong Opioids
1. Morphine:
1.
Sedation
2.
PONV
3.
Respiratory Depression
2. Fentanyl
1.
Rapid action, Short duration.
2.
Fentanyl : Mophine = (1:100)
Severe pain (7-10)
3. Pethidene:
1.
Active metabolite:  t½ .
2.
Prolongs Q-T interval.
3.
Pethidine : Mophine = (1:10)
WHO III Strong opioids
± Adjuvant
Moderate pain (4-6)
WHO class II Weak opioids
4. Hydromorphone:
1. Powerful, rapidly acting.
2. Release is in distal gut.
3. Hydromorphone : Morphine = 1 : 5
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
WHO Ladder IV – Regional Anesthetic Techniques
1.
2.
3.
4.
5.
6.
7.
8.
Local infiltration
Wound perfusion
Intra-abdominal LA
Intercostal
Interpleural
Paravertebral
USG - RA: e.g. TAP
Neuraxial:



Epidural:
 Thoracic
 Lumbar
Spinal
 Single shot
 CSA
CSE
WHO IV Interventional
Severe pain (7-10)
WHO III Strong opioids
± Adjuvant
Moderate pain (4-6)
WHO class II Weak opioids
± Adjuvant
Mild pain (0-3)
WHO class I NSAIDs
± Adjuvant
Neuraxial (Spinal / Epidural)
(LA / Opioids / others)
l
Advantages:
– Provide prolonged & effective analgesia
l
Side effects
– Respiratory depression.
– N/V.
– Pruritis.
– Urinary retention.
WHO Algorithm for Management of Pain
+ Multidisciplinary:
• Adjuvant therapy.
WHO III
• Psychotherapy.
Strong opioids
• Physioltherapy.
Neuraxial LA
Opioids
Plexus block
• Causal diag. & ttt.
Paravertebral / PNB
WHO class II Weak opioids
Non-pharmacological
LA infiltration
WHO class I NSAIDs
Routes of Administration
 Oral
 Rectal
 S.C.
 Intranasal
 Sublingual
 IM
 IV
 Neuraxial
 Spinal
 Epidural

Others
Patient Controlled Analgesia “PCA”
 Systemic: IV & SC
 Regional: Neuraxial, Plexus & PNB.
 Sitting:
 Pre-set by the physician.
 Activated by the patient.
 Programming modalities.
Roman S et al. Perioperative Care & Pain Management in Weight Loss Surgery. OBESITY RESEARCH 2005;13(2):254-266
Side Effects in Opioids

Sedation / Dizziness

Nausea / Vomiting

Respiratory depression

Itch / Rash

Tolerance

Urinary retention

Drug interactions

Constipation (30-70%)

Dependence

Addiction

Opioid induced pain
SUMMARY
o
WHO Ladder System should be followed
o
Analgesia should be selected depending on the initial Pain
Assessment.
o
If the disease is not controlled on a given step 
 Move directly to the Next Step.
o
For continuous pain:
o
o
Analgesics should be prescribed on a Regular Basis.
Only one strong opioid should be ordered at a given time.
ACUTE PAIN MANAGEMENT