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Pain management
Dr Malith Kumarasinghe
MBBS (Colombo)
Pain management
Definition
pain is an, unpleasant sensory and emotional
experience associated with actual or potential tissue
damage
According to Katz and Melzack, pain is a personal
and subjective experience that can only be felt by the
sufferer.
According to McCaffery pain is whatever the
experiencing person says it is and exists whenever
they say it does.
PAIN PHYSIOLOGY
Process of pain physiology
nociceptor
TRANSDUCTION
TRANSMISSION
PERCEPTION
MODULATION
Pain physiology contd..
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Pain stimuli is converted to electrical
energy. This electrical energy is known
as Transduction. This stimulus sends
an impulse across a peripheral nerve
fiber (nociceptor).
Pain physiology contd..
Transmission:
 A delta fibers (myelinated) send sharp,
localized and distinct sensations.
 C fibers (unmyelinated) relay impulses
that are poorly localized, burning and
persistent pain.
 Pain stimuli travel- spinothalamic
tracts.
Pain physiology contd..
Perception:
 Person is aware of pain –
somatosensory cortex identifies the
location and intensity of pain
 Person unfolds a complex reactionphysiological and behavioral responses
is perceived.
Physiology contd..
Modulation:
 Inhibitory neurotransmitters like
endogenous opioids work to hinder
the pain transmission.
 This inhibition of the pain impulse is
known as modulation
Neurophysiology of pain
(excitatory)
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Bradykinin- most potent pain
producing chemical
Prostaglandins- increase sensitivity to
pain experience . Is a potent
vasodilator and increase the
production of bradykinin resulting
edema
Neurophysiology contd..
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Substance P- transmits pain impulses
to brain centers and causes
vasodilatation and edema
Serotonin- causes pain by altering
sodium flow—neuron to fire
Histamine,Leukotrienes and nerve
growth factor are released
Neuromodulators
(inhibitory)
Endorphins& dynorphins- morphine like
substances.
 Located in the brain, spinalcord&GIT
 Produce analgesia when attached with
opiate receptors in the brain
Effects of pain
Sympathetic responses
 Pallor
 Increased blood pressure
 Increased pulse
 Increased respiration
 Skeletal muscle tension
 Diaphoresis
Effects of pain
Parasympathetic responses
 Decreased blood pressure
 Decreased pulse
 Nausea & vomiting
 Weakness
 Pallor
 Loss of consciousness
Behavioral characteristics
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Facial expressions- grimace, clenched
teeth, wrinkled forehead, crying
Body movements -restlessness,
immobilization, muscle tension,
protective movement of body parts
Social interaction- avoidance of
conversation & contacts
TYPES OF PAIN
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ACUTE PAIN
CHRONIC PAIN
CUTANEOUS PAIN
DEEP SOMATIC PAIN
VISCERAL PAIN
REFERRED PAIN
NEUROPATHIC PAIN
PHANTOM PAIN
FACTORS INFLUENCING
PAIN
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PHYSIOLOGICAL
SOCIAL
SPIRITUAL
PSYCHOLOGICAL
CULTURAL
PAIN ASSESSMENT
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PAIN RATING
SCALES- NRS,
VAS,VAT,FACES
RATING SCALE,
PAIN-0-METER
McGill PAIN
QUESTIONNAIRE
BODY MAP
ABCDE for pain assessment
&management
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Ask about pain regularly
Believe the patient and family in their
reports &what relieves it
Choose pain control options
appropriate for the patient
Deliver interventions timely, logical
&coordinated fashion
Empower patient and their families
JCAHO Standards for postoperative
pain management are:
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Recognize patients’ rights to appropriate
assessment and management of pain
Screen for pain and assess the nature and
intensity of pain in all patients
Record assessment results in a way that
allows regular reassessment and follow-up
Determine and ensure that staff are
competent in assessing and managing pain.
Address pain assessment and management
when orienting new clinical staff
Standards Contd..
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Establish policies and procedures that
support appropriate prescribing of pain
medications
Ensure that pain doesn’t interfere with
a patient’s participation in
rehabilitation
Educate patients and their families
about effective pain management
PRICIPLES OF PHARMACEUTICAL
PAIN MANAGEMENT
 Provide medication in adequate doses.
 Utilize a preventive approach to pain relief. Use
round the clock dosing with rescue medication
available.
 Closely assess clients with particular diligence
with first doses or when medication dose or the
type is changed
 Combinations of analgesics may be more
effective than those given singularly.
PRINCIPLES CONTD.
Understand and be prepared to treat
side effects of medications
 avoidance of non-life threatening side
effects (such as constipation, nausea,
pruritis) more important that providing
pain relief. These concomitant
conditions are easily treated.
 Additions of adjuvant medications
enhance pain relief.
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Principles contd.
Believe the patient’s report of pain.
 Maintain a therapeutic relationship that
facilitates mutual trust.
 Do not use placebos for pain.
 incorporate the goal of total pain
relief into the pain management
regimen
 operate as a team to provide the
most effective pain relief outcomes
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PRINCIPLES CONTD.
Asking for pain medication reflects the
need for pain relief in 99.9% of people
with pain and doses does not reflect an
addictive personality.
 Recognize that respiratory depression is a
rare occurrence, occurring most commonly
among clients who are over sedated.
Respiratory depression rarely occurs after
the first few doses of an opioid.
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Principles contd.
 Only the patient and no one else can
determine the amount of pain
experienced
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There are no objective indicators that
can be observed by another
Pain management
Medications to control pain
(Pharmacological)
 Anesthetic agents
 Analgesic agents
 NSAIDs
Anesthetic agents
Local Anesthetics Lidocaine
 Bupivacaine
 Ketamine
Analgesics
Opioid Analgesics
 Fentanyl
 Morphine
 Codeine
 Demerol (Meperidine)
 Benzodiazepines
Commonly used drugs
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Inj.Morphine(50mg) &
Inj.Lorazepam(16mg) in 37 ml of 5%
dextrose@ 4-8ml/hr
Inj.Medazolam2mg/hr
If agitated -Halopperidol
Patient receiving Epidural
Analgesia
Epidural Analgesia
syringe
Patient Controlled
Analgesia (PCA)
Analgesics contd..
Non-Opioid Analgesics
 Paracetamol
 Aspirin
 NSAIDs- ketorolac
 Celecoxib
 Brufen
WHO Analgesic Ladder
NSAIDs
NSAID
Management contd..
Non-pharmacological
interventions
 Massage
 Diversion therapy
 Relaxation therapy
 TENS
 Heat & cold
applications
 Yoga
Management contd…
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Meditation
Humor
Touch
Magnets
Magnets
Yoga
Meditation
Humor
Conclusion
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Patient’s pain report should be considered
Assessment of pain should be regularly
carried out and managed promptly
Intervention of pain relief should be
individualized
Not to postpone pain relief but to consider
Inter-disciplinary team approach