Pain Management Olivier Cuignet, MD (responsible) Gregory Minguet, MD Jan Muller, MD Kirsten...
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Pain Management Olivier Cuignet, MD (responsible) Gregory Minguet, MD Jan Muller, MD Kirsten Colpaert, MD
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Transcript of Pain Management Olivier Cuignet, MD (responsible) Gregory Minguet, MD Jan Muller, MD Kirsten...
Pain ManagementPain Management
Olivier Cuignet, MD (responsible)Gregory Minguet, MD
Jan Muller, MDKirsten Colpaert, MD
pre-hospital care (su)fenta or piritramide iv
Treat as fast and as strong as possible to avoid mechanisms to be discussed
What kind of Burn patients ?
Opioids and FLUID CREEPBurns 2004; 30(6):583-90.
Pre-hospital care of burn patient
(su)fenta or piritramide iv(su)fenta or piritramide iv
Treat as fast and as strong as possible to Treat as fast and as strong as possible to avoid mechanisms to be discussedavoid mechanisms to be discussed
Opioids and FLUID CREEPLocal cooling and water gel
Treat the pain fast and strong with the minimum opioids needed :
« Cocktail de Djibouti » (Ketamine / Bzd / Atropine iv)
What kind of Burn patients ?
Aims Aims
Pain characteristics and analgesics
Lessons learned from our 6 years experience
New approach of burn pain nociceptive hyperalgesia
opioid-induced hyperalgesia
New strategy based on a new pain assessment
Pain CharacteristicsPain Characteristicsdressing changes, post-operative periods, physiotherapynursing care
Procedural Pain (PP): repetitivefrequentexcrutiating
Burn
Background Pain (BgP): constant breakthrough painexcruciating soundeasily defined diffuseresponds well to therapeutics increased therapeutic needs
Wind-ups: Complicated Pain (CP)
Pain control strategy : WHO Scale
Pain control strategy : WHO Scale
STEP 1 : Paracetamol ?
NSAID (Taradyl/Brufen) “10 mg”
STEP 2 : Tramadol 10 mg
Codeine 6.6 mg
STEP 3 : Piritramide 1.25 mg
Hydromorphone 0.134 mg
Morphine 1 mg
Sufentanyl 0.001 mg
Lessons learned from 6 years of Pain Management...
Lessons learned from 6 years of Pain Management...
Pain assessment is mandatory to meet patient’s need.
Appropriate Burn Pain therapy requires huge doses of morphine equivalent
Huge doses Opioids : burns are very painful
burn pain is a long-term process
burn pain is more and more painful
opioid become less efficient over time
Burn Pain therapyBurn Pain therapy
Background PainBackground Pain
Huge doses morphine-equivalent:Intensive Care : iv 100 à 168 mg/24h (sufenta) + bath
Medium Care : oral 65 à 200 mg /24h (tramadol + MSDirect +/- hydromorphone)
Potential problems:Fluid creep Burns 2004; 30(6):583-90.
Immunological Am J Ther 2004; 11(5):354-65.
Endocrine J Clin Endocrinol Metab 2000; 85(6):2215-22.
Tolerance Anasthesiol Intensivmed 2003; 38(1):14-26.
Hyperalgesia J Neurobiol 2004; 6(1):126-48.
Background PainBackground Pain
How to reduce high doses of morphine-equivalent?
Avoid the early hyperalgesia due to
burn and its inflammatory response
Avoid opioid tolerance / opioid hyperalgesiaby limiting the initial opioid doses
New comprehensive physio-pathology
of burn pain
Physio-pathology of burn pain.Physio-pathology of burn pain.
Three periods of Hyperalgesia:Activation (receptors recruitment)Modulation (NMDA, receptors
phosphorylation)Modification (new genes, apoptosis)
Three levels of Burn-induced Hyperalgesia:Peripheral (receptors/ nerves ending)Spinal (dorsal horn)Supra-spinal (brainstem, thalamus, cortex)
time
Non reversibility
Modified from O.H Wilder Smith. Anesthesiology 104, 2006; 601-7
Burn
Treat the pain as soon as possible(before activation of pain amplification mechanisms)
Treat the pain as completely as possibleat the periphery
at the spinal level
at the supra-spinal level
Physio-pathology of burn pain.Physio-pathology of burn pain.
Treat the pain as soon as possible(before pain amplification mechanisms activated)
Treat the pain as completely as possibleat the periphery
at the spinal levelat the supra-spinal level
Treat the pain with as few opioids as possibleto avoid opioid-induced hyperalgesia
to avoid opioid-tolerance
Physio-pathology of burn pain.Physio-pathology of burn pain.
Physio-pathology of burn pain.Physio-pathology of burn pain.
Modified from O.H Wilder Smith. Anesthesiology 104, 2006; 601-7
Pain Control StrategyPain Control Strategy
Peripheral hyperalgesiaHydro-colloids dressing, homografts, antiseptic ointments. Early excisionLoco-regional anesthesia
Procedural Pain: post-operativeProcedural Pain: post-operative
Post-operative:loco-regional anesthesia for donor sites
long-term opioid-sparing effects J Burn Care Rehabil. 2005 Sep-Oct;26(5):409-15
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Pain Control StrategyPain Control Strategy
Peripheral hyperalgesiaHydro-colloids dressing, homografts, antiseptic ointments. Early excisionLoco-regional anesthesia
Spinal and supraspinal hyperalgesiaAnti-hyperalgesic drugs : kétamine, lidocaine, pregabalinOpioid-sparing agent : clonidine
Pain Control StrategyPain Control Strategy
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ControlGabapentin
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Gabapentin reduces opioid-consumption during and up to 3 weeks after its administrationBurns. 2007 Feb;33(1):81-6
Pain Control StrategyPain Control Strategy
Peripheral hyperalgesiaHydro-colloids dressing, homografts, antiseptic ointments. Early excisionLoco-regional anesthesia
Spinal and supraspinal hyperalgesiaAnti-hyperalgesic drugs : kétamine, lidocaine, pregabalinOpioid-sparing agent : clonidine
Opioid-induced hyperalgesiaAssessment of hyperalgesia Judicious use of antihyperalgesic drugs (ketamine, lidocaine, pregabalin)Loco-regional anesthesia
To do
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