ACUTE & CHRONIC PAIN MANAGEMENT

GROUP 2 A1

OBJECTIVES
1. Acute Pain Relief a. Pain physiology b. Advantages and Disadvantages c. Indications d. Types IM injections SC injections PCA pidu!al ". Ch!onic Pain Relief a. Indications b. Types

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ACUTE PAIN
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INTRODUCTION
Pain is defined by the Inte!national Association fo! the Study of Pain *IASP+ as ,an unpleasant senso!y and e-otional e.pe!ience associated /ith actual o! potential tissue da-age0 o! desc!ibed in te!-s of such da-age1 *Me!s2ey 3 #ogdu20 1%%4+ . Acute pain is defined5 as pain of sudden onset that is often seve!e. as ,pain of !ecent onset and p!obable li-ited du!ation. It usually has an identifiable te-po!al and causal !elationship to inju!y o! disease1

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 Co--only associated /ith su!ge!y0 t!au-a0 non6su!gical inte!ventions and so-e -edical conditions *e.g. -yoca!dial infa!ction0 u!ete!ic colic0 acute panc!eatitis0 sic2le cell disease+. Ch!onic pain defined as5 pain pe!sists despite the fact that an inju!y has healed Pain that eithe! occu!s in disease p!ocess in /hich healing does not ta2e place o! pe!sist beyond the e.pected ti-e of healing *7 ) -onths+ Co--on ch!onic pain co-plaints include5 8eadache0 lo/ bac2 pain0 cance! pain and a!th!itis pain.

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ACUTE PAIN TYPES

TYPES OF PAIN :o!ciceptive pain So-atic Sha!p0 hot o! stinging pain usually locali;ed. Dull0 c!a-ping0colic2y poo!ly locali;ed. =ide a!ea a>/ nausea 3 s/eating

<isce!al

:eu!opathic pain

6 8. of pe!iphe!al> cent!al ne!vous syste- inju!y i.e. b!achial ple.us avulsion 6 vidence of da-age5 i.e.senso!y loss0 /ea2ness 6Pain in a!ea of senso!y loss *not necessa!ily confined+ 6? sy-pathetic activity *s2in colou!0 te-p0s/eat+ 6Pain natu!e diff f!- no!ciceptive5bu!ning0 shooting0 stabbing 6Pain pa!o.ys-al> spontaneous 6Responds poo!ly to opiods 6Phanto- pheno-enon 6Allodynia5pain to sti-ulus tht usually not painful *light touch+ 68ype!algesia5? pain to no!-ally painful 6Dysesthesias 5 unpleasant sensations
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PHYSIOLOGY OF PAIN
The pain that occu!s afte! -ost types of no.ious sti-ulation is usually p!otective and Auite distinct f!othe pain !esulting f!o- ove!t da-age to tissues o! ne!ves. Is te!-ed physiologic pain> nociceptive pain because it is only elicited /hen intense no.ious sti-uli th!eaten to inju!e tissue

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LATERAL SPINOTHALAMIC TRACT

Carries pain and temperature D Cells of o!igin in the poste!io! g!ey ho!n D Contain second o!de! neu!ons of the cell bodies of the contra lateral *opposite+ poste!io! ho!n. D A.ons ca!!ying pain and te-pe!atu!e decussate /ithin one o! t/o seg-ents of thei! o!igin.

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 The 1st order sensory neurons carrying pain & temperature ente! the spinal co!d th!ough the lateral division of t e posterior spinal nerve root . In the co!d these fibe!s ascend o! descend fo! 1 o! " seg-ents as dorsolateral tract of !issauer at the tip of the poste!io! ho!n. Relay in the poste!io! ho!n cells of substantia gelatinosa. The a"ons of t e #nd order sensory neurons a!ise f!othe posterior orns cells and cross over to t e opposite side in t e anterior commissure in front of t e central canal and !each the opposite /hite colu-n . =he!e they tu!n up/a!ds fo!-ing the lateral spinot alamic tract. The fibe!s of the t!act te!-inate in the cells of the ventralposterolateral $%P!& nucleus of t e t alamus .
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 The a"ons of t e 'rd order sensory neurons a!ise f!ocells of the <PE nucleus of the thala-us and p!oject to the primary sensory area of t e cere(ral corte" $area ')1)#*&* The damage of t e tract causes loss of pain and temperature sensation on t e opposite side of t e (ody one or t+o segments (elo+ t e level of lesion *

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ALTERNATE PAIN PATHWAYS

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ADVANTAGES & DISADVANTAGES

Paracetamol, NSAIDS & COX-2 inhibitors T!eat -ild to -ode!ate pain (sually in tablet fo! Relieve seve!e pain They do not cause sto-ach ulce!s o! bleeding. PCM F !is2 of side effect is lo/ P!edispose to gast!ic ulce!s 3 2idney p!oble-s. Cause nausea and vo-iting0 d!o/siness0 itching and constipation. 8as !espi!ato!y dep!essant effect. At usual doses the!e a!e fe/ side effects. So-e patients -ay feel di;;y o! get so-e sho!t6te!/ea2ness in thei! legs o! a!-s. This usually disappea!s once the d!ug sta!ts to /ea! off.
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Opiods

Local Anesthetics

ffective fo! seve!e pain. The!e is ve!y little !is2 of d!o/siness o! b!eathing p!oble-s.

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Method o Pain !elie "ablets or li#$id They a!e often cheap asy to be ad-iniste!ed Can be used at ho-e Delay in pain !elief

In%ections & IM or SC 'pid$ral

Delay in pain !elief =o!2s /ell /hen you have :eeds an anaesthetist to chest su!ge!y0 -ajo! uppe! inse!t the epidu!al cathete!. abdo-inal su!ge!y o! an ope!ation on the lo/e! pa!ts of you! body. Afte! -ajo! su!ge!y it helps people to b!eathe deeply0 cough and gene!ally -ove a!ound /ith -ini-al pain. The !eaction ti-e is faste! Seve!e acute pain can be t!eated p!o-ptly Patient cont!olled S-all tube should be inse!ted into the vein.
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In%ections into (eins ) PCA

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Visual Analo Pain

:o pain /o!st pain i-aginable 1$ c- line Patient1s -a!2ing on line -easu!ed in --.

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V!"#al Nu$!"i%al Ra&in S%al!

Si-ila! to <AS $ G :o pain 1$ G =o!st pain Can also be used fo! pain !elief

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V!"#al '!s%"i(&o" s%al!

(S S ='RDS :one0 -ild0 -ode!ate0 seve!e0 e.c!uciating Can also be used fo! pain !elief

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Ass!ss$!n& o) )un%&ion
Ability to ta2e deep b!eaths0 a-bulate0 cough0 coope!ate and physiothe!apy afte! su!ge!y

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Pa&i!n& #!*a+iou"
Ho! /hen the!e is language ba!!ie! &!i-aces0 g!oaning0 gua!ding0 !ubbing Also co!!elate /ith vital signs

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ROUTES OF A,MINISTRATION
In&"a$us%ula" In-!%&ions
,-./ Mo!phine Hentanyl Alfentanil 'pioid Agonist TYPE IN,I0ATIONS SI,E EFFE0TS :ausea and vo-iting0 constipation0 -ental clouding0 -uscula! !igidity0 eupho!ia0 dyspho!ia0 !espi!ato!y cent!e dep!ession0 -iosis
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Sufentanil
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SUBCUTANEOUS In-!%&ions
,-./ Codeine TYPES Mode!ate to =ea2 'pioid Agonists IN,I0ATIONS SI,E EFFE0TS Itching f!ohista-ine !elease Sedation0 Di;;iness0 S/eating0 :ausea0 an.iety0 hallucinations0 cause less !espi!ato!y dep!ession than full agonist
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:albuphine

Mi.ed Agonist>Antagon ist

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Epidural
.seful follo+ing ma1or surgeries* Abdo-inal0 Tho!acic0 <ascula! *i-p!ove lo/e! li-b ci!culation+ '!thopaedic su!ge!y *dec!ease the incidence of deep vein th!o-bosis+ Co-bination of EA and opiods act syne!gistically to i-p!ove analgesic efficacy and !educe incidence of side effects.
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pidu!al infusion !egi-en consists of bupivacaine $.1I /ith fentanyl " Jg>-l0 infusion at 961" -l>h! fo! lu-ba! epidu!al o! )6C-l>h! fo! tho!acic epidu!al.

Alternative include2 $.1I !opivacaine /ith " Jg>-l fentanyl Plain bupivacaine $.1"9I 'piod6only solution0 eg.0 pethidine " -g>-l0 given by continuous infusion at 96C -l>h!0 o! bolus doses of pethidine 9$ -g *9 -g>-l+ eve!y 46hou!ly.

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Patient3 controlled epidural analgesia* May be used instead of continuous infusion o! inte!-ittent bolus doses. T e regimen2 Solution5 bupivacaine $.1I /ith fentanyl " Jg>-l. PC A bolus5 9 -l Eoc2out inte!val 5 1$619 -inutes #ac2g!ound infusion5 9 -l>h! 46hou! li-it5 usually not set since this is li-ited by the loc2out inte!val itself.

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A patient6 cont!olled analgesia infusion pu-p0 configu!ed fo! epidu!al ad-inist!ation of fentanyl and bupivacaine fo! postope!ative analgesia

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Intravenous Patient !ontrolled Anal"esia

P!io! to co--ence-ent of PCA0 ensue that the patient has !easonably adeAuate analgesia by ad-iniste!ing I< bolus doses of an opiod. A sepa!ate and dedicated int!avenous cannula fo! PCA. If sha!ing0 an anti!eflu. valve should be fitted to the fluid infusion tubing to p!event accu-ulation of the opiods the!e should the int!avenous cannula beco-e bloc2ed.

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Setting for P0A morp ine are2 Concent!ation5 1 -g>-l. PCA bolus5 1 -g *1 -l+0 o! $.9 -g *$.9 -l+ fo! patients K@$ yea!s. Eoc2out inte!val5 9 -inutes. #ac2g!ound infusion5 usually none. 46hou! li-it5 usually not set Patients +it renal impairment* 'piods have p!olonged du!ation of action in these patients. The loc26out inte!val should be e.tended to 1$619 -inutes. Monito!ed fo! !is2 of ove!sedation0 !espi!ato!y dep!ession and o.ygen M##S desatu!ation. $%1$ &R'(P " A1

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Pet idine in place of morp ine* 1$ -g pethidine fo! 1 -g -o!phine P!olonged usage cause convulsions due to no!pethidine *active -etabolite+ -ay accu-ulate and cause to.icity. P!esc!ibed antie-etic on a !egula! basis0 o! given conco-itantly /ith int!avenous PCA -o!phine *".9 -g of d!ope!idol added to 1$ -g of -o!phine in PCA pu-p+ fo! nausea and vo-iting. 4onitoring2 Chec2ing the PCA pu-p fo! a-ount of d!ug delive!y

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e drug istory function include2 Total d!ug used :u-be! of de-ands :u-be! of successful delive!y If nu-be! of de-ands fa! e.ceeds d!ug delive!y0 patient does not unde!stand.

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A patient6cont!olled analgesia infusion pu-p0 configu!ed fo! int!avenous ad-inist!ation of -o!phine fo! postope!ative analgesia

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CHRONIC PAIN
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T*! in&"o'u%&ion
Is a highly speciali;ed field in anesthesiology The ch!onic pain condition can be oncologic and non6 oncologic 'pti-al -anage-ent involving -ultidisciplina!y app!oaches

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T#PES O$
1. Cance! pain ". #enign ch!onic pain ). Ch!onic postsu!gical pain 4. Co-ple. !egional pain synd!o-e

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1* 0ancer pain Associated /ith unde!lying -alignancy. Result f!o- local tu-o! infilt!ation0 /idesp!ead -etastases to bones and pleu!a o! ne!ve ent!ap-ents and co-p!ession. 1* 5enign c ronic pain :on6oncologic in natu!e .g.56 he!pes ;oste! neu!algia0t!ige-inal neu!algia0 lo/ bac2 pain0 phanto- li-b pain0 ch!onic postsu!gical pain

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'* 0 ronic postsurgical pain C!ite!ia56 The pain develop afte! a su!gical ope!ation The pain is at least " -onths du!ation 'the! causes fo! the pain have been e.cluded The possibility that the pain is continuing f!o- a p!ee.isting p!oble- -ust be e.plo!ed and e.cluded.

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0omple" regional pain syndrome A diso!de! cha!acte!i;ed by pain and dysfunction of the Sy-pathetic :S.

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Non.P*a"$a%olo i%al T"!a&$!n&

1. ". ). 4. 9. @. B. C. T!anscutaneous elect!ical ne!ve sti-ulation T :S T!igge! point injection Acupunctu!e Inf!a!ed0 ult!asound the!apy C!yothe!apy 8ypnosis0 !ela.ation e.e!cise Physiothe!apy Su!ge!y

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P*a"$a%olo i%al T"!a&$!n&

1. ". ). 4. 9. @. B. C. 'pioids :SAIDs Ste!oids Psychoactive d!ug fo! adjuvant the!apy *an.iolytics0 antidep!essant0 sedative+ Eocal anaesthetic Int!athecal clonidine &uanethidine :eu!olytics

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