ACute Pain Management; Transforming evidence into practice

7/24/2019 ACute Pain Management; Transforming evidence into practice

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Acute Pain Management:

Transforming Evidence into Practice

Dr Surjya Prasad upadhyay; MDSpecialist Anaesthesiology

NMC hospital DIPDubai


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Acute pain

There is No Painthat can not be treated


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Common myth for acute pain Treatment

Oligo-analgesia

Analgesic may mask abnormal finding

Sever ain !ill cause abnormal vitals signs

Patient !ill be addicted to narcotics Patient !ill be sedate after narcotics

Some kind of ain can"t be relieved

Effective pain management can be done on SOS basis .


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Importance of Acute pain management

Pain control human right

Indicator of !uality of care

"ntreated pain ad#ersely affects other systems;

Physiological and psychological upset $ stress

"ntreated$poorly treated pain progress into chronic pain

Increased morbidity$ mortality$ cost$ %&S


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Conse!uences of poorly treated pain


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Pain Algorithm

Patient in Acute pain $anticipated postoperati#e pain

'rief pain Assessment(mergent use of opioid if clinical condition dictate

Comprehensi#e pain assessment

Appropriate Therapy)eferral


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)(%I(* Approach for Acute pain Treatment

)+ )ecord Pain before and after T,

(+ (#idence based treatment

%+ %oo- and listen to Patient+ 'elief your Patient

I+ In!uire if Patient need Pain Medicine (+ (ducate Staff

*+ *acilitate$*ormulate multidisciplinary APS


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Assessment$ .hich scale/


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0o. Acute Pain differ from Chronic

Pathology + clear 1s unclear

Duration + short

Mechanism+ adapti#e #s maladopti#e

Prognosis+ good 1s unpedictable

Treatment + simple #s comple,


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Acute 1s chronic pain; 0it fast and hit hard


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Changing concept of pain management

Traditional Modern concept

Palliate pain

Administered single analgesics

*i,ed dose of opioid

P)N or S&S analgesic

No protocol$ guideline for Acute

pain

Pre#ent pain

Multimodal analgesia

2udicious use of opioid

3indi#idualised4

Continuous $ )egularAnalgesics

Acute pain ser#ice+ Ad#ancedpain inter#entions; bloc-s


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Pain Path.ay and Analgesic Actions


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Treatment modalities

Non harmacologic

Pharmacologic

56Nonopioid

76&pioid

86Adju#ants

#nvasive interventions

$iagnose and treat as er underlying cause


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Nonpharmacologic pain management

Massage T(NS

Acupuncture

(,ercise 0eat$cold massage

Neurostimulation

Scrambler therapy

Dry needling 'eha#ioural

Cogniti#e

'iofeedbac-


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&pioids

'est a#ailable analgesics9 but not ideal

Act #ia different opioid receptors in brain9 spinal cord

and peripheral tissue6

Classified according to potency .ea- to strong

Choice of opioid depends on patient9 pain9 associated

conditions


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:here do opioid act /


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:ea- &pioid

Codeine prodrug;

metabolised to acti#e drug morphine #ia Cytochrome

5 population+ deficiency in con#erting en?yme; no action

Dihydrocodeine prodrug9 again a .ide #ariation in patientresponse6

Tramadol acti#e drug6 Dual action Mu agonist @ SSN)I

Penta?ocin$ butorphenol$buprenorphine partial agonist$

agonist antagonist ceiling analgesic effect


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Tramadol

Dual mode of action; opioid Mu agonist @ selecti#e serotoninand noradrenaline reupta-e inhibitor 3SSN)I46

(ffecti#e in mild to moderate pain

Can be gi#en IM9I19&ral good bioa#ailability

Can be combined .ith PCM9 NSAID

Dose in adult B5BB mg hrly; Ma, dose =BB mg in 7=

Dry mouth9 di??iness9 sedation in high dose

Nausea #omiting only if gi#en fast boluses6


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Strong opioid

Act directly $ no need to con#ert into acti#e form

Agonist at opioid receptors

0as dose dependent analgesic and other ad#erse effects

No ceiling effects to analgesia

:ide indi#idual dose #ariation

Di#erse route of administration

Morphine; pethidine9 fentanyl9 alfentanil9 sufentanil


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Morphine

A#ailable in #arious form; Consider as )eference opioid+

Initial dose B65B67 mg$-g

Metabolism li#er; 8B=B> oral bioa#ailability Metabolite Morphine 8 Elucoronide no analgesic

morhine glucoronide more analgesic than morphine

(limination+ )enal

&nset after I15B min9 pea- 5 hrs9 Duration+ = hrs


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Meperidine$ Pethidine

Synthetic opioid

Atropine li-e effect

Metabolism li#er

metabolite normeperidine CNS e,citation9

Antishi#ering action

Interaction .ith antidepressant9 SS)I; MA&I serotoninsyndrome 30TN9 rigidity9 hyperpyre,ia9 sei?ure9 Coma4

Psychiatric patients a#oid


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*entanyl

Synthetic opioid ; 5BB times more potent than morphine

Short duration; suitable for PCA or continuous infusion

0igh fast pass metabolism

Most cardiostable

%oading Dose57 mcg$-g; onset 8 min9 duration+8B=B min

A#ailable in #arious form+ lollipop9 lo?enge9 transdermal9intranasal spray9 Injectable


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&pioid precaution

0ypotension$ shoc-

CNS issues+ head injury9 delirium9 dementia9 psychiatric illness

Concomitant CNS depressant+ Alcohol $ drugs

%i#er$ -idney impairment

Morbidly obese9 &SA

)espiratory illness C&PD$'r Asthma 0$o drug addiction$abuse


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&pioid tolerance$ addiction$pseudoaddiction

)arely a problem in acute setting6

Tolerance+

Pseudo addiction+

Addiction+

Oioid induced hyeralgesia+


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Dra.bac- of opioids

Nausea $#omiting

'ladder$ bo.el function

Sedation+ delayed mobilisation; discharge

)espiratory+ &bstructi#e breathing9 Silent aspiration

Immuno suppressant effects .ould infection6

Cancer recurrence$ metastasis

Persistent postop pain into chronic pain


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Nonopioid Analgesics

Paracetamol NSAIDs

Adju#ants

*irst line drug therapy for any pain

(ffecti#e alone for mild to moderate pain

0ighly effecti#e .hen combined .ith opioids


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Acetaminophen and NSAIDS

*oundation for pain treatment protocol6

*irst on and last off

Sole agent in mild to moderate pain

8BB> opioid sparing effects

Analgesic efficacy has ceiling effects limiting factor

&pioid add on therapy .hen re!uire


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Paracetamol

Mechanism similar to NSAIDs but act centrally

Analgesic9 antipyretic9 but no antiinflamatory

Safest analgesic of all

Can be gi#en oral $ I1$ P)

5stline therapy in mild to moderate pain

Central part of MMA6

Ma, dose = gm in 7= hrs in adult 3BFB mg$-g in children4


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NSAIDS

Most e,tensi#ely used medicine in .orld in all age group

Analgesic9 antipyretic and antiinflammatory

NSAID related hospital admission

0igher the potency 3less amount re!uirement4 more to,ic

'roadly t.o sub class Co,5 and Co,7 inhibitor6

Combination of NSAIDS+ no benefit; Paracetamol @ NSAID+ additi#e effects


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NSAIDs selecti#ity


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NSAIDs+ side effects

EI side effects Salt G .ater retention

0epatoto,icity

Nephroto,icity 'leeding tendency

Prolongation of labour

Asthma and allergy

C1 ris-$ MI+ co,ib


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Adju#ants

T%A & SS'# & SN'# neuropathic pain .ith concomitantdepression

Anticonvulsant gabapentanoid

Muscle re(ant 3baclofen9 'HD4 relie#e muscle spasm

)idoderm herpetic pain

%alcitonin osteoprotic fracture pain

%orticosteroid tissue edema9 neuropathic pain

%entral symatholytic+ clonidine$ de,medetomidine

Potentiate * imrove analgesia reduce side effects

T.o Most impressi#e Adju#ants for


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T.o Most impressi#e Adju#ants foracute pain management

etamine

De,amethasone


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etamine

NM$A- antagonist

Antihyeralgesic+ anti-allodynic

Pre-emtive use- revent conversion into chronic ain

$issociative anaesthesia:, -. mg&kg/ 0the lights are on+

but no one is home1

Po!erful analgesia even in very lo! dose 23-234 mg&kg

Preserve haemodynamic& resiration

$isadvantages:mood+ cognition+ salivation+ nausea


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Comparable analgesia .ith B68 mg $-g -etamine1s

B65 mg$-g morphine for Short term pain relief in (D


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:hen to "se etamine/

&SA

Dose+ B65 mgB68 mg$g(ither as Sole agent or as Adju#ant to opioid

De,amethasone


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De,amethasoneAntiinflammatory$ anti emetic

I1 single dose B65 mg$-g at the time of induction

)educed postop pain score

)eduction in opioid consumption

)eduction in rescue analgesic

)A+ Intra#enous $ perineural de,amethasone

Prolonged sensory motor bloc-ade

Pre#ent neuroto,icity and rebound hyperalgesia6

'eg Anesth Pain Med3 .25 6ul-Aug782,8/:4.-93 r 6 Anaesth3 .247,./:9-.223 'eg Anesth Pain Med3 .25 Mar-Ar782,./:.5-4.3


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Inter#entions in Acute Pain

Continuous ner#e$ple,us bloc-

(pidural Analgesia 3%A@$ &pioid4

Intrathecal Analgesia

PCA Intra#enous$ epidural

Ne.er truncal bloc-ade+ 3Alternati#e to epidural4 TAP9 P1'9

J%'9 fascia trans#ersalis9 )ectus sheath9 P(CS

i l bl - f i


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)egional bloc- for acute pain

Superior !uality of analgesia

"ltrasound has re#olutionised regional bloc-

No major systemic side effects

1irtually eliminate opioid use

Can pro#ide continued analgesia

0igher patient satisfaction (arly ambulation$ discharge

Transdermal fentanyl iontophoresis


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Transdermal fentanyl iontophoresis3I&NSKS4

&ne of the ne.est ad#ancement6 Credit card si?e fentanyl reser#oir

Can be put in arm9 chest6

Programmable li-e PCA

"p to doses per hour

:or- for 7= hrs or upto B doses

Appro#ed by *DA in April; 7B5

Ket to be a#ailable in middle east

i l l d i i


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%iposomal encapsulated 'upi#acaine

MMA $ ) ti l l h


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MMA $ )ationale poly pharmacy

M lti d l A l i 3MMA4


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Multimodal Analgesia 3MMA4

T f i id i t P ti


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Transforming e#idence into Practice

('M Pro#en and e#aluated treatment Practice

('P transition of -no.ledge

no.ledge translation L 5< years

1arious sources of -no.ledge

:hy the Eap bet.een e#idence and practice


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:hy the Eap bet.een e#idence and practice

8 main cause of Eap in the !uality of pain caredeli#ery

560ealthcare professionals6

760ealth care system

86Patients

Problem related to healthcare professionals


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Problem related to healthcare professionals &ut of date or inade!uate attitudes and -no.ledge;

56 Pain control mas- recognition of surgical complications76 Surgery has to be associated .ith pain

86 Patient complaining pain+ fussy

Clinical inertia

Incomplete -no.ledge

*ear of side effects$ addiction

Problem related to health care system


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Problem related to health care system

)egulatory impediment

*ailure to capture short and long term !uality outcomes

Cost shifting to patients 3eg insurers4

Inade!uate e!uipment9 manpo.er or drug deli#ery system

Practice restriction9 3eg nurse are permitted only for im9 sc9 no

I1; use of narcotics 4

Problem related to patients


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Problem related to patients

&ut of date or mista-en ideas

'elief that nice patients do not complain of pain or suffering

*ear of side effects$ addictions

%ac- of a.areness of the importance of pain control

Tendency to be satisfied .ith inade!uate pain control

Acute Pain ser#ice


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Acute Pain ser#ice

Comprehensi#e pain ser#ices Multidisciplinary team

Anaesthesiologist based$

Nursed based anaesthesia super#ised

No consensus as to be best model

1ery .ide #ariation in APS structure

Most APS initially pro#ide postop $ trauma analgesia

APS acti#ities


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APS acti#ities

Appropriate selection of analgesic regimens

Standardized protocols and Guidelines

Advanced interventional techniques

Audit and quality improvement programs

Education

Summary+ Treatment modality for Acute Pain


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Summary+ Treatment modality for Acute Pain

Case 5


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Case 5

B year male )TA ;polytrauma

Multiple fracture

'rought in emergency

Agitated9 restless; disoriented

Complaining of se#ere pain

Issues


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Issues

CNS status

0aemodynamics

"n-no.n Comborbid illness

0o. to address pain


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0o. to address pain

&pioid not a good choice Acetaminophen safe if li#er function is o-

(pidural not a choice

NSAIDs difficult choice e#en )*T is normal

'est choice ner#e$ ple,us bloc-ade9 cont infusion

Case 7


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Case 7


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*IC'

Conclusion


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Conclusion

Assess pain properly 'elief your patient

Ne#er gi#e up

Multimodal analgesia techni!ue

Preempti#e analgesia

)egular analgesic Ereater use of regional analgesia

'e open to ne. ideas and embrace them

)eferences


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)eferences

56 Practice Euidelines for Acute Pain Management in the Perioperati#e Setting; An update reportby American Society of Anaesthesiology tas- force on acute pain management6Anesthesiology7B57; #ol 55; no 7

76 'londell )D9 A?adfard M and :isnies-i AM6 Pharmacologic therapy for acute pain6 Am *amPhysician6 7B58 2un 5;


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)eferences

6 Eambling D9 0ughes T9 Martin E9 0orton :9 Man#elian E6 A comparison of Depodur9 ano#el9 singledose e,tendedrelease epidural morphine9 .ith standard epidural morphinefor pain relief after lo.er abdominal surgery6 Anesth Analg6 7BB Apr;5BB3=4+5B

ACute Pain Management; Transforming evidence into practice

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