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Pain Scenarios
Sue Millerchip
Lead Nurse Pain Team
Pain Ma nage ment S ervice Novembe r 2 005
What do you need to
know?
• How to manage severe acute pain
• How to manage respiratory
depression
• How to manage post-op pain
• How to manage cancer pain
• How to manage chronic pain
Severe acute pain
• Mr Smith (38yrs
old) is admitted to
ED with severe
abdominal pain and
back pain. He has
been vomiting, is
pale and sweaty
and has a history
of alcohol abuse.
• What do you do?
• Mrs Williams (62)
is admitted with
severe central
chest pain,
radiating to jaw
and down left arm.
• How do you manage
her?
Management Points
• The safest and most effective way to
manage severe acute pain is by an IV bolus
of morphine / diamorphine
• Always dilute to 1mg/ml
• Always administer slowly
• Always titrate to effect
• Always monitor closely for side effects
• What are you not going to use?
Side effects of opiates
• Respiratory
depression
• Depressed
conscious level
• Hypotension
• Nausea and
vomiting
• Constipation
• Itch
Treating side effects of
opiate analgesia
Respiratory rate < 8 and sedation score
= 3 or sedation score 3 regardless of
respiratory rate
• give naloxone 100 micrograms IV
every 5 minutes
• Call for anaesthetic help
• Prevent vomiting with regular
antiemetics
Case 3
• 3 days post hemicolectomy a 62 year
old woman reports severe abdo pain
that is increasing in intensity. She
also has a rapid rise in temperature,
is tachycardic and feels sick. The
PCA 100mg morphine analgesia that
has previously been effective is not
helping.
Management points
• Always investigate sudden unexpected
pain, especially later in the post-op period
• Effective analgesia does not interfere
with the ability to diagnose surgical
conditions either before or after surgery
• Examination showed clinical signs of
peritonism and AXR revealed gas under
the diaphragm - theatre for leaking
anastamosis
Solution
• Intravenous morphine to achieve
comfort
• Increase dose of PCA to 200mg/50ml
or convert to a morphine infusion
• Add IV paracetamol if not already
prescribed
Case 4
• A 23 yr old woman – RTA
• Compound # of the tibia and fibula
• Extensive soft tissue trauma, vascular
injury and neuropraxia of the common
peroneal nerve – needs surgery
• Severe pain lateral aspect of leg with
burning and sensitivity, deep aching leg and
foot
• Very anxious and tearful
Management points
•
•
•
•
IV morphine titrated to comfort then PCA
IV paracetamol 1g qds
PR/ oral NSAID if no contra-indications
Gabapentin for persistent burning pain start at
300mg - od/bd/tds
• Step down to oral morphine and paracetamol
• Convert to slow release preparation for rehab
• Refer to chronic pain clinic if necessary
Key points
• Patients with burns / trauma may require a range
of strategies which vary during emergency,
healing and rehab phases
• Combination of nociceptive / neuropathic pain is
common
• Psychological and environmental issues
• Use of long acting opioids is appropriate
• Treatment of neuropathy may need to continue
after healing
• Prolonged need for opiates should prompt referral
to Pain Service
Case 5
• An 65 year old female is admitted from a
residential home with a # NOF
• H/O dementia
• Quiet and withdrawn pre-op
• Post-op noisy and disruptive
• No formal pain assessment but analgesia
given 4 hours previously
• IM morphine prescribed 4-6 hourly – nil
else
Management Points
• Poor prescribing with regard to
frequency
• No adjuvant therapy – IV
paracetamol
• Poor pain management had changed
normal quiet behaviour to noisy and
disruptive
Case 6
• Mrs Y, Stills disease admitted pre
THR
• Currently uses MST 180mg am,
120mg pm with regular voltarol and
paracetamol.
• Consider optimal analgesia
postoperatively
Discussion
• How long has this patient used
opiates for?
• Why is she using opiates?
• Will her pain be relieved or will it
increase postoperatively?
• Will she be suitable for IV PCA?
• Will her mst need to be decreased if
she uses IV PCA?
• What will you use for prn analgesia?
Case 8
• 30 year old male, post refashioning
above knee amputation stump
• Illicit drug user – Heroin
• Rx drugs recently included
Dihydrocodeine and diclofenac
• Discuss this patient’s postoperative
pain assessment and management
Options
• Epidural infusion
• PCA / Paracetamol / NSAID
• Ketamine infusion
Aims of treatment
• Provide analgesia
• Prevent withdrawal
• Management of withdrawal from
other drugs/ alcohol /nicotine
• Treatment of co-morbidities
• Manage aberrant drug-taking
behaviours - CDT
Case 9
• Mr Jones, 65, is admitted with right sided
chest pain, SOB and a cough, vomiting and
weight loss. He has a history of rectal
carcinoma and had a resection 6 months
ago. He has recently been diagnosed with
liver mets. His current analgesia is a
Fentanyl patch 50mcg but this is
inadequate.
• How do you manage this?
Plan
• Manage nausea / vomiting – cyclizine /
ondansetron / dexamethasone
• Consider converting patch to a sc driver to
establish analgesia and requirements
• Add rescue parenteral analgesia
• Ensure correct doses are prescribed to
manage background and breakthrough pain
Fentanyl patches
• Fentanyl / Durogesic 12, 25, 50, 100mcg
• Approximate conversion –50mcg = 5.0mg
parenteral morphine / hr OR 2.5mg
parenteral diamorphine / hr So pt would
need 60mg diamorphine / 24 hrs in a sc
driver
• Rescue sc injection = 1/6th of 24 hr dose =
10mg
Other patches
• Butrans
Buprenorphine
• Transtec
Case 10
• Miss Harris, 34, is admitted with a
sudden onset of severe low back pain
radiating down her left leg.
• ? Cause
• Treatment options?
Options
• Morphine / Paracetamol / NSAID /
diazepam
• ? MRI
• ? Epidural steroid
Key messages
• Pain is an individual, multifactorial experience
influenced by culture, previous experience, mood
and ability to cope
• Successful acute pain management involves
teamwork
• Regular assessment of pain = improved outcomes
• Uncontrolled or unexpected pain requires
reassessment of diagnosis / reinvestigation
• Assessment of sedation level is a more reliable
indicator of early opioid-induced respiratory
depression
• The use of pethidine should be discouraged
• Paracetamol is an effective analgesic for acute
pain
• Adverse effects of NSAIDs are significant and
may limit their use
• Provision of analgesia does not interfere with the
diagnostic process in acute abdominal pain
• Reduction in dose of analgesics may be required in
elderly patients
• Consideration of drug and dosages in patient with
concurrent hepatic and renal impairment is
required
• Other than in the treatment of severe acute pain,
and providing there are no contra-indications to
its use, the oral route is the route of choice for
the administration of most analgesic drugs
• Controlled release (CR) opioid preparations should
only be given at set time intervals
• Immediate release opioids should be used for
breakthrough pain and titration of CR opioids
• Do not forget rectal routes when other routes
are unavailable but bioavailability is unpredictable
and consent should be obtained
To conclude….
• Effective pain management results
from appropriate education and
organisational structures for the
delivery of pain relief rather than
the analgesic techniques themselves
Thank you