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Pain Management.pdf
- 3. CONTENTS INTRODUCTION ANATOMY PATHOPHYSIOLOGY CLASSIFICATION TYPES EFFECTS OF PAIN PAIN ASSESSMENT REASSESSMENT OF PAIN MANAGEMENT OF PAIN
- 4. INTRODUCTION Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. -International Association for the study of pain (Merskey,1979) Pain is always subjective. The patient's self-report of pain is the single most reliable indicator of pain.
- 5. CONTI... protective mechanism localized sensation as a result of noxious stimulation now recognized as being more of an experience than a sensation.
- 7. PHYSIOLOGY OF PAIN Transduction Transmission Perception Modulation
- 8. PATHOPHYSIOLOGY Nociceptive pain (stimuli from somatic and visceral structures) Neuropathic pain (stimuli abnormally processed by the nervous system)
- 9. NOCICEPTIVE PAIN Caused by invasion &/or destruction &/or pressure on superficial somatic structures like skin, deeper skeletal structures such as bone & muscle and visceral structures and organs.
- 10. NEUROPATHIC Caused by pressure on &/or destruction of peripheral, autonomic or central nervous system structures. Radiation of pain along dermatomal or peripheral nerve distributions. Often described as burning and/or deep aching & associated with dysesthesia or lancinating pain
- 11. CLASSIFICATION ON BASIS OF DURATION Transient Pain Short duration Severe Self limiting Acute Associated with postoperative, post injury Requires pharmacological assistance(analgesics) Persistent Long term duration Eg.: Cancer & neurogenic pain Pharmacological assistance(analgesics) and cognitive approach Chronic or Disabling Continue beyond expectation for disease process Pain and pain therapy dominate the life Depression, anxiety Depending On Duration 15
- 12. ACUTE PAIN Acute pain presents most often with a clear cause, relatively brief in duration and subsides as healing takes place. Acute pain is often accompanied by observable objective signs of pain increased pulse rate increased blood pressure Non-verbal signs and symptoms such as facial expressions and tense muscles.
- 13. CHRONIC PAIN Pain that is persistent and recurrent. When pain persists, it serves no useful purpose and may dramatically decrease the quality of life and function. Chronic pain rarely has any observable or behavioral signs although persons may appear anxious or depressed.
- 14. Somatic Visceral Bone Neuropathic Emotional/Spiritual TYPES OF PAIN
- 15. EFFECTS OF PAIN Sympathetic responses Pallor ,Increased blood pressure Increased pulse ,Increased respiration Skeletal muscle tension ,Diaphoresis Parasympathetic responses Decreased blood pressure ,Decreased pulse Nausea & vomiting Weakness o Pallor o Loss of consciousness
- 16. PAIN ASSESSMENT Pain Histroy Pain Assessment Tools Verbal Analogue Scales Visual Analogue Scales The Faces Scale
- 17. PAIN HISTORY The site of pain Type of pain Exacerbating & Relieving factors How frequently Impact on daily life What is the response to past and current analgesic therapy?
- 20. REASSESSMENT Every 8 hours minimally Followinh the admiinistation of pain Medications to determine the effectiveness of the medication. Iv within 15 mins of administration PO/IM/SC within 1 hours of administration
- 21. GOALS OF PAIN MANAGEMENT THERAPY 1) Decreased pain 2) Decreased healthcare utilization o Decreased shopping for care o Decreased emergency room visits 3) Improved functional status o Increased ability to perform activities of daily living Return to employment
- 22. MANAGEMENT Non-Pharamcological treatment Pharmacological treatment: Analgesics Adjuvants Others
- 23. NON-PHARMACOLOGICAL INTERVENTIONS Exercise Weight reduction Counseling Smoking cessation Massage ,Relaxation therapy Heat & cold applications
- 24. PHARMACOLOGICALINTERVENTIONS Analgesics Non-opioid e.g. aspirin,paracetamol Opioids e.g. codeine, morphine Adjuvant e.g. muscle relaxant, antidepressant, anti-epileptic
- 25. WHO 3 STEP ANALGESIC LADDER
- 26. ACETAMINOPHEN (PARACETAMOL) First-line treatment if no contraindication Mechanism: thought to inhibit prostaglandin synthesis in CNS analgesia, antipyretic Typical dose: 650 to 1000mg PO every 6H Max dose: 4 g / 24 hrs from all sources Warning: dose / avoid in those with liver damage
- 27. NSAIDS First-line treatment Mechanism Block cyclooxygenase (COX) enzyme prostaglandin synthesis COX-2 Prostaglandins pain, inflammation, fever COX-1 Prostaglandins gastric protection, hemostasis No physical dependence No tolerance
- 28. NSAID
- 29. TRAMADOL Multiplemechanism Weak 袖-receptoragonist Inhibit serotonin& NE reuptake Application : Mild to ModeratePost-op pain Dose : 50-100mg PO q 4-6 hr. Max. 400 mg/d Side effect: Nausea and Vomitting
- 30. OPIOIDS Essential element of pain management Mechanism Action on opioid receptor Located mainly in spinal cord & brainstem, some in peripheral tissue.
- 31. STRONG OPIOIDS .Agonists : stimulate receptor no ceiling effect ( no limit mg/kg) moderate to severe pain Codiene, morphine, pethidine, fentanyl, methadone. Partialagonists : ceiling effects eg. Buprenorphine
- 32. OPIOIDS Agonists-antagonists: can used in mild to moderate pain ceiling effects precipitatewithdrawal in opioids dependent E.g: Pentazocine, Nalbuphine, Nalorphine
- 33. LOCAL ANAESTHETICS LA bind sodium channels preventing propagationof action potentials along nerves Wide variety of LA with different characteristics: Lidocaine fast onset, short duration of action Bupivacaine slow onset, longer duration Ropivacaine: longer duration, less cardiotoxic
- 34. COANALGESIC AGENTS Anxiolytic drugs Anticonvulsants Antidepressants Ketamine Ketamine Potent analgesic effect Small doses in combination of opioids substantially improve pain control Bolus dose of 100 mcg/kg followed by a continuous drip of 1-3 mcg/kg/min is ideal for chronic opioid users postoperatively
- 35. ANTI-EPILEPTIC DRUGS in Acute Pain Every surgical incisional pain has Neuropathic component Studies showed giving 1200 mg of Gabapent in 1 h prior to surgery decreases the opioidsrequirement post-op and result in better pain control without increased sedation Combining Gabapentin with opioidsis ideal for re-do back surgery cases with chronic opioidsusage These class of drugs are also mode stabilizers
- 36. CONCLUSION Painmanagement is a comprehensive, patient-centered process including pharmacologicalagent, psychosocialcounseling,and non-pharmacological treatments when appropriate. Always start with the lowest dose, least side-effect agents and reassess frequently with patients input. Use conversion chart for IV to PO, and this transitionshould be done as soon as possible. Only the patient can describe characteristicsand rate the severity of his or her pain. All non-opioids medicationhave ceiling effects. Do not combine multiple NSAIDs. Use alternative treatments to minimizepotentialside-effects. Consider adjuvants for specific pains such as bone pain or neuropathic. When in doubt, always ask for help from the experts.