8/2/2009

Pain Management

PACU Nursing Meeting

August 2009

Introduction

• Dr Duncan McKay
– Anaesthetist & Pain Medicine Specialist
– Bunbury Regional Hospital & SJOGH
– Majority of training New Zealand & Sir Charles
Gairdner Hospital Perth
– Interests
• Procedures for chronic pain
• Cancer pain

Recognised as a Specialty
• Pain medicine recognised as a specialty by
Australian Medical council in 2005

• Lobbying ongoing in NZ

• Training
• Post primary diploma eg ANZCA/ Psych/ Rehab
• 2 years – 1 year in an accredited pain unit
• Horrible exam/ mentor assessments/case report

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The International Association

for the Study of Pain®

DEFINITION OF PAIN

– ‘…unpleasant sensory & emotional experience

associated with actual or potential tissue
damage, or described in terms of such damage’

The International Association

for the Study of Pain®

• ‘pain is subjective & – BIOPSYCHOSOCIAL

individuals learn model
application of the word – Pain is an individual,
through experiences multi-factorial
relating to injury in experience
early life’ influenced by
• Experiences of pain culture, previous
influenced by social pain events, beliefs,
factors & previous mood & ability to
learning cope

BIOPSYCHOSOCIAL MODEL

‘fast moving particles of fire – pass along

nerve to brain…’
‘ONION RINGS’ Descartes (1664) French philospher
THIS IS VERY WRONG!

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Biopsychosocial Model of Pain

• Biomedical
– explained solely by biological/medical terms
• More complete understanding incorporates
medical, psychological & social factors
• Biological – medical/ physical aspects of pain
• Psychological – thoughts/emotional/behavourial
• Social – interactions with other people

• Biomedical - seperates body & mind

• Biopsychosocial - holistic perspective - mind
& body seen as intertwined

PAIN RELIEF SHOULD BE A

UNIVERSAL HUMAN RIGHT

• Pain m ay be interpreted as the 6 th

vital sense

“For all the happiness

Mankind can gain:

Is not in pleasure,

But in rest from pain.”

John Dryden (1631-1701) –

English poet

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The International Association

for the Study of Pain®

DEFINITION OF CHRONIC PAIN

Pain without apparent biological value that has

persisted beyond the normal tissue healing time
(considered to be 3 months)
Some use 6 months

Why is post operative pain still under-

managed?
• Major psychological
obstacles
• Strong misconceptions
– Acute pain vanishes in a
few days, & as long as
operation successful, acute
postop pain will soon be
forgotten
– So why bother with costly
acute pain services & high
tech analgesic techniques
which are not free of
complications?
• Ironic situation – surgeon
begs for help with postop
neuropathic pain that will
not go away, or surgeon
themselves or a relative
had surgery
• They do not expect acute
pain to persist for
weeks/months
• Pain – a disease in its own
right?

Wake up call! Under-managed acute

pain causes major health care problem
• CPSP = Chronic Post Surgical Pain
• 1 in 10 postop patients
• Severe & intolerable in 1 in 100
• Irrespective of type of surgery
• Severe unrelieved pain after surgery a risk factor
• Immobilisation after surgery - risk factor
• Severe pain provoked by movements hinders pts
in moving about after surgery, thus increasing the
risk of CPSP

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Some Painful Facts:

One in five (20%) Australians suffer from persistent pain

Approx. 70% say daily life ruled by pain

Persistent pain – psychological distress, poor health, need

for income support, greater use health care resources

Persistent pain – major health, socio-economic issues

More Painful Facts:

None of the available treatments for chronic pain have

been demonstrated to eliminate all pain

More typically reductions in pain average 20% to 40%

Mean pain reduction with opiates is approx. 32%

TCAs & anticonvulsant drugs - 30 to 40% people report

at least 50% reduction in pain

Why is it so complicated?

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OVERVIEW OF PAIN

LOSS OF JOB FRUSTRATION INCREASED FURTHER

FINANCIAL DIFFICULTY ANGER INVESTIGATIONS ACTIVITY
DRUG INTAKE
DOMESTIC PROBLEMS ANXIETY & PROCEDURES

SOCIAL DEPRESSION ADVERSE REPEATED PHYSICAL

WITHDRAWAL UNHELPFUL BELIEFS EFFECTS TREATMENT DETERIORATION
LOSS OF SELF ESTEEM DEPENDENCE FAILURES

AMPLIFIED DISTRESS

Pain Cycle
• Consequences of the pain cycle
– fear of activity & avoidance
– Flare-ups in pain OVERACTIVITY
– Muscle tension & fatigue
– confidence in ability to do
things MORE PAIN
– Difficult to plan ahead
– Mood-feelings – frustration, EASING OF PAIN
failure, depression
– Restricted lifestyle – over
sedentary
– Impact on family & friends
– use of medications REST/FRUSTRATION

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Acute postop pain

• Acute postop pain management not only

humanitarian
• suffering/ distress

• Substandard acute pain management has far

reaching implications for quality of life &
health resource consumption

Acute pain in PACU

• Professional bodies recommend an APS in
hospitals with pain nurses & anaesthetists able to
implement epidural & peripheral nerve block
services, supervise PCIA’s, & upgrade basic,
pharmacological techniques.
• APS responsible for education of staff involved in
care of surgical patients
• APS supervises & audits monitoring of acute pain
& the effects of pain relief
• APS ‘makes pain VISIBLE’/aims for improvement

Approaches to Pain Management

• Pharmacological
• Non-pharmacological - emphasis
• Interventional/Advanced Modalities
• Epidurals/ PCA’s/ Nerve Catheters&blocks

DRUGS ALONE NOT THE ANSWER!

Doctors pour drugs, of which they know little, for diseases of which they
know less, into patients - of whom they know nothing.
[Voltaire]

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Effects of Severe Acute Pain

• CNS – anxiety/sleeplessness
• RESP - TV FRC Cough, atelectasis
PO2/ PCO2
• CVS – altered BP/peripheral resistance,
Cardiac Work, O2 consumption
• GIT - motility & gastric stasis
• Stress response +++

The patient who wakens from

surgery pain-free, is easy to
keep comfortable -
Agony is much harder to treat!

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Management in Recovery Room

Non-Pharmacological

• Remove excess electrodes, skin prep

• Warm the patient
• Reorient to time & place
• Reassure surgery is over
• Position to avoid stress on incisions
• Promote adequate ventilation

Management in Recovery Room

Non-Pharmacological
• Check bladder status
• Reduce sensory stimulation
• Comfort - A back rub may help
• Presence of nurse important to allay anxiety
• Education/reassurrance
• Empathy
• Monitor anxiety & mood
• Monitor & treat SE’s

Management in Recovery Room

Look at Anaesthetic Chart & Pre-op Assessment

for:-
• Pre-emptive measures used
• Amount of opioid given intra-op
• Pre-op anxiety or pain likely to affect post-op

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Pain Assessment – the 1st step

• Regular assessment improved
pain management
• Good correlation between visual
analogue&numerical rating scales
• Self reporting used whenever
possible as pain is subjective
• Pain measurement tool
appropriate to individual patient:
developmental, cognitive,
emotional & cultural factors
should be considered
• Scoring should include different
components of pain eg static &
dynamic pain
• Uncontrolled/unexpected pain
requires reassessment of
diagnosis & consideration of
alternative causes

Common Techniques
• Oral – paracetemol, NSAIDs, Tramadol,
Opioids
• Epidural/regional
• IV opioid & ketamine infusions
• IV PCA
• Wound infiltration/ Topical LA
• Entonox

PCA
• More satisfactory analgesia
• More immediate relief of pain
• No negotiation
• Patient preference is higher for PCA
• PCA is really the only way we know how much the
patient needs
• Small IV bolus
• Patient titrates amount needed against pain
experienced
• Lockout interval appropriate to route of administration
• Safer than continuous opioid infusions

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Epidurals
• Superior pain relief
• Improve oxygenation & reduce pulmonary infections
• Lower drug doses
• Improves bowel recovery after abdo surgery
• May reduce incidence of MI – reduced stress response
• Reduces graft occlusion rates after PVD surgery
• Provision of epidural analgesia is safe on general
hospital wards provided it is supervised by an
anaesthetic based pain service with 24 hour medical
cover and is monitored by well trained nursing staff

Complications of Epidurals

• Dural Puncture & Headache

• Infection, Epidural Abscess, Haematoma
• Parasthesias
• Cord, Nerve Root Damage
• Total Spinal Block
• I.V. Injection - LA Toxicity
• Profound Hypotension
• FAILURE

Ketamine?
• NOT ‘normal’ somatic pain
• BUT
– Pathological pain
– Neuropathic pain
– Pain poorly responsive to opioids
– Patients with opioid tolerance
• Best used as a continous infusion

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Opioids – facts & myths

• In acute pain – one opioid is not superior to others but
some opiods are better in some patients
• The incidence of SE’s is dose related
• Pethidine is not superior in biliary/renal colic
• Assessment of sedation level is a more reliable way of
detecting early opioid induced respiratory depression than
a decreased resp rate
• The use of pethidine should be discouraged in favour of
other opioids
• Tramadol is a good alternative and has a lesser resp
depression and effect on GI function
• Adjuvant drugs provide an ‘opioid sparing’ effect eg
paracetemol/ ketamine/NSAIDs

We can anaesthetise anyone and

anything!
• But it is not the answer!!!
• What about QUALITY OF LIFE
• The objective of chronic pain management is
to allow
allow patients
patientstotocope
cope& &get
getonon
with
with
living
living
& to obtain realistic goals & expectations

anesthesia
the art of lovingly, carefully, and reversibly
poisoning your patient…into a controlled
coma.

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Optimising Pain Management

• Monitor & treat SE’s
• Multi-modal analgesia
• Regular review & assessment
• M onitor anxiety & mood
• Pharm & NON-PHARMACOLOGICAL
interventions should be used
• Heat/cold packs/position/relaxation/stress
management/social
worker/physio/OT/acupuncture/exercise/movement/st
retching/ reassurrance/education/empathy/TENS………

• Primary preventive focus

awareness among surgeons of ways to
avoid intra-operative nerve injury eg.
careful dissection, reduction of
inflammatory responses,
inflammatory responses, & use
& use
of of
minimally invasive techniques
AND
multi-modal analgesia

Good Acute Pain Management

• Prevents suffering in patients (humane

argument)
• incidence & severity of postoperative
complications (outcome argument)
• May also prevent development of chronic
pain states with immense implications for
both – humane & outcome perspectives

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Opiophobia!
• Major barriers to opioid use
– Insufficient knowledge
– Inappropriate attitudes
– Regulatory & organisational issues
– Economics
• OPIOPHOBIA = ‘customary under-utilisation of
opioids based on irrational & undocumented fear’
• Behaviour modelled, reinforced & perpetuated at
all levels of health & legal system
– Attitudes of governmental bodies
– Attitudes of Dr’s, nurses, pharmacists & allied health
– Attitudes of patient’s, relatives, general population

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