Pain & Its Management

Anaesthetic House Officer Training Module

Kementerian Kesihatan Malaysia

Those who do not feel pain seldom think that it is felt.

Dr. Samuel Johnson (1709-1784)

Definition of Pain
An unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage
IASP Subcommitee on Taxonomy. Pain 1980; 8:249-252

Definition of Pain

Pain is what the patient says, hurts

Nociceptors
1. A-delta fibers myelinated 2-30 m/sec (1st pain) 2. C-fibers unmyelinated <2 m/sec (2nd pain)

The Pain Pathway

First Order Neurons Second Order Neurons

Ascending Pain Pathway (Acute Pain)

Cerebral cortex 3rd Order Thalamus Midbrain Pons Medulla 2nd Order Dorsal Root 1st Order Nociceptors Sensory Cortex

Spinothalamic

Spinomesencephalic

Spinoreticular

Pain Pathway
PAG / RAS
Descending inhibitory fibres

PAIN
Sensory cortex
Thalamus

Ascending ST tracts

Free nerve endings Spinal cord

Dorsal horn Afferent nerve ( A / c)
5th Vital Sign: Doctors training module: Pain Physiology

Effects of Pain
I. Physiological
- Cardiovascular System - Respiratory system - Gastrointestinal system - Genitourinary system - Central Nervous System - Endocrine system

II. Psychological III. Economic

Cardiovascular System
Increased Heart Rate Increased Blood Pressure
increased myocardial work load myocardial oxygen consumption increased risk of myocardial ischaemia

5th Vital Sign: Doctors training module: Pain Physiology

Respiratory system
Inhibition of normal respiration (unable to take deep breaths)
Atelectasis Hypoxia

Inability to cough
Retention of secretions Increased risk of lung infection / pneumonia

5th Vital Sign: Doctors training module: Pain Physiology

Gastrointestinal System
Increased sympathetic and reduced parasympathetic activity
Reduced smooth muscle + sphincter tone Reduced gut motility Ileus, nausea + vomiting Impedes early feeding

5th Vital Sign: Doctors training module: Pain Physiology

Genitourinary System
Increased sympathetic and reduced parasympathetic tone
reduced smooth muscle + sphincter tone urinary retention

5th Vital Sign: Doctors training module: Pain Physiology

Musculoskeletal system
Prevent mobilisation & increases muscle tone Increased risk of deep vein thrombosis

5th Vital Sign: Doctors training module: Pain Physiology

Central Nervous System

sympathetic activity parasympathetic activity Hyperalgesia
scarring of pain pathways

Increased risk of developing chronic pain

5th Vital Sign: Doctors training module: Pain Physiology

Endocrine System
Stimulation of stress response
Increased sympathoadrenal activation Metabolic response to stress Hyperglycemia Catabolic state

Immunosuppression
risk of infection
5th Vital Sign: Doctors training module: Pain Physiology

Psychological
Anxiety Agitation
poor sleep uncooperative patient

5th Vital Sign: Doctors training module: Pain Physiology

Economic
Delayed ambulation and feeding Increased postoperative complications Delayed recovery Prolonged hospital stay Increased cost

5th Vital Sign: Doctors training module: Pain Physiology

Spectrum of Pain
ACUTE PAIN
Healing

NO PAIN

Insidious onset

CHRONIC PAIN
post-surgical syndromes / cancer

ACUTE PAIN
5th Vital Sign: Doctors training module: Pain Physiology

CHRONIC PAIN

Acute vs Chronic Pain

Acute Pain
Onset and timing Signal Severity Sudden onset, short duration. Resolves/disappears when tissues heal. A warning sign of actual or potential tissue damage Severity is correlates with amount of damage. CNS intact acute pain is a symptom Less, but unrelieved pain anxiety & sleeplessness (which improves when pain is relieved)

Chronic Pain
Onset may be insiduous. Pain persists despite tissue healing. Not a warning signal of damage : a false alarm Severity not correlated with damage.Good days and Bad days. CNS may be dysfunctional chronic pain is a disease Often associated with depression, anger, fear, social withdrawal, etc

CNS involvement Psychological effects

Common causes / examples

Surgery, fracture, burns, myocardial infarct, labour and childbirth, inflammatory conditions e.g. abscess

5th Vital Sign: Doctors training module: Pain Physiology

Chronic headache, back pain, chronic pelvic / abd pain, cancer pain, neuropathic pain PHN, DPN, post stroke pain, etc

Assessment of Pain
Pain is both a physical and a psychological
phenomenon
The pain experience is subjective Meaningful evaluation and successful treatment of a patient with pain requires quantification of the patients pain

Pain as the 5th Vital Sign Guidelines for Doctors (Management of Adult Patients)

Pain as the 5th Vital Sign Guidelines for Doctors (Management of Paediatric Patients)

How to assess pain:

P : Place or site of pain
Where does it hurt? (a body chart might help describe their pain)

A : Aggravating factors
What makes the pain worse?

I : Intensity
How bad is the pain?

N : Nature and neutralizing factors

What does it feel like What makes the pain better?
5th Vital Sign: Doctors training module: Pain Assessment

Guideline 1 Pain Assessment Guide: Taking a Brief Pain History

TELL ME ABOUT YOUR PAIN P Place A Aggravating factors I Intensity Where is your pain? What makes the pain worse? If 0 is no pain and 10 is the worst pain imaginable: What is your pain score now? What is the worst level of pain (score) you experience in a day? What is the least pain (score) you experience in a day? Describe your pain e.g. aching, throbbing, burning, shooting, stabbing, sharp, dull, deep, pressure, etc What makes the pain better?

N Nature Neutralizing factors

Pain Measurement Tools : Adults

Combined NRS/ VAS Scale
Combined NRS/ VAS Scale (KKM)

NRS/

NRS : Numerical Rating Scale VAS : Visual Analog Scale

Pain Measurement Tools : Paediatrics

FLACC Scale

Wong-Baker Faces Scale

WHICH TOOL TO USE to measure pain?

Use the standard tool for pain assessment as recommended by Ministry of Health, Malaysia
adult patients : combined NRS / VAS scale paediatric patients 1 month to 3 years old : FLACC paediatric patients > 3-7 years : Wong-Baker FACES scale paediatric patients >7 years : combined NRS/VAS scale (same as for adults)
*Always use the same tool for the same patient
5th Vital Sign: Doctors training module: Pain Assessment

Flow Chart : Pain as the 5th Vital Sign (Nurses)

Flow Chart for Pain Management in Adult Patient: (Doctors)

Analgesics
Non Opioids
Paracetamol NSAIDS COX 2 inhibitors

Opioids
Weak Strong

31 5th Vital Sign: Doctors training module: Pharmacology

Formulations And Dosage Of Commonly Used Analgesics

DRUG Paracetamol FORMULATION AVAILABLE Tablet 500mg, Suspension 500mg/5ml, Suppositories DOSAGE 500 mg 1gm qid

NSAID Diclofenac Tablet 50mg & 25mg, Suppositories 12.5mg, 25mg, (50mg & 100mg)* Gel Capsule 250mg Tablet 200mg & 400mg* Tablet 250mg, 550mg Capsule 100mg *, Injection 100mg, Patch 30mg, Gel Injection 30mg/ml Tab 7.5mg Oral: 50mg tds, Sup: 50mg-100mg stat Topical: PRN 250 mg 500mg tds 200 mg 400 mg tds 500mg-550 mg bd Oral: 100mg daily, IV: 100mg bd Patch: 30mg - 60mg bd, Topical: PRN 10mg - 20 mg bd max 3 days Daily or bd

Mefenamic Acid (Ponstan) Ibuprofen ( Brufen) Naproxen (Naprosyn, Synflex) Ketoprofen (Orudis, Oruvail)

Ketorolac (Toradol) Meloxicam ( Mobic)

DRUG
COX 2 inhibitors Celecoxib Etoricoxib Parecoxib WEAK OPIOID Tramadol Dihydrocodeine (DF118)

FORMULATION AVAILABLE

DOSAGE

Capsule 200 mg Tablet 90 mg & 120 mg Injection 20 mg/ml

200 mg bd (max 1 week) 120 mg daily (max 1 week) 40 mg bd ( 20 mg bd for elderly) max for 2 days 50mg -100mg tds or qid (max 400mg/day) 30mg-60mg qid (max 360mg/day)

Capsule 50mg, Injection 50mg/ml Tablet 30 mg

DRUG
STRONG OPIOID

FORMULATION AVAILABLE

DOSAGE

Nalbuphine (Nubain)
Morphine

Injection 10mg/ml

Fentanyl

Pethidine

Oxycodone (Oxycontin)

Stat dose only: 10mg (equivalent to Morphine 10mg). Do not use in patients on regular Morphine/ Pethidine/ Fentanyl. Tablet SR 10mg,30mg SR and Aqueous to be used for cancer pain Aqueous 10mg / 5ml IV and Subcut : Injection 10 mg/ml, < 65yrs : 5mg -10mg 3-4hrly > 65yrs : 2.5mg -5mg 3-4hrly Reduce dose in renal and hepatic impairment Injection 50 mcg/ml, IV only to be prescribed by APS team. Patch 25 mcg, 50 mcg Patch to be used in cancer pain; NOT in Acute Pain Injection IV and Subcut : 50mg/ml,100mg/2ml < 65yrs : 50mg -100mg 3-4hrly > 65yrs : 25mg -50mg 3-4hrly Reduce dose in renal and hepatic impairment. Use not encouraged because of Norpethidine toxicity and high risk of addiction. Tablet SR 10mg & Mainly used for cancer pain 20mg

Guideline 4 Drugs in Acute Pain Management: The Analgesic Ladder

Analgesic Ladder for Acute Pain Management

SEVERE 7-10 Regular Higher dose of weak opioid Or IV/SC Morphine 510mg 4 hrly OR Aqueous morphine 10-20 mg PCM 1gm QID oral / rectal NSAID / COX2 inhibitor PRN IV/SC Morphine 5-10mg OR Aqueous morphine *Oral or SC Morphine may be safely given at hourly intervals

UNCONTROLLED

MODERATE 4-6 Regular Weak Opioid PCM 1gm QID oral NSAID / COX2 inhibitor PRN Additional weak opioid

To refer to APS for: PCA or Epidural or other form of analgesia

MILD 0-3 Regular No medicati on or PCM 1gm 6hrly PRN PCM &/or NSAID / COX2 inhibitor

Post Operative Pain Management

1.Conventional Methods i. Oral Analgesics Opioids NSAIDS ii. IV Injections Opioids NSAIDS 2. Common Methods i. Patient Controlled Analgesia (PCA) ii. Epidural Analgesia iii. Patient Controlled Epidural Analgesia (PCEA) iv. Subcutaneous Morphine

3. Other Methods i. Nerve & Nerve Plexus Blocks ii. Transcutaneous Electrical Nerve Stimulation (TENS) iii. Rectal NSAIDS 4. Multi-modal Concepts

PATIENT CONTROLLED ANALGESIA (PCA)

Method of analgesic delivery : computerised syringe pump is set to deliver bolus doses whenever patient presses button (patient demand) Allows small amounts of analgesic to be given at frequent intervals Patient titrates according to individual needs

DILUTION OF PCA DRUGS

Morphine: Adults: 5 amp (50 mg) = 5 mls Dilute with N/S 45 mls Concentration : 1mg/ml (50mls) Paeds: 0.5mg/kg of morphine and make upto 50mls with N/S. Concentration: 1ml = 10mcg/kg

Recommended settings (example )

Drug concentration: morphine 1mg/ml Mode: PCA Loading dose: usually zero for post operative patients Bolus dose: <60 years morphine 1mg >60 years morphine 0.5mg

Lockout interval :5 minutes

4 hour limit : usually not set

EPIDURAL ANALGESIA

Introduction of analgesic drugs into epidural space via an indwelling catheter

EPIDURAL ANALGESIA : DRUGS USED

LOCAL ANAESTHETICS ALONE

- BUPIVACAINE
OPIODS ALONE

- FENTANYL
- MORPHINE

MIXTURES (COCKTAIL)
- FENTANYL + BUPIVACAINE