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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