Download PAIN MANAGEMENT IN SURGERY

PAIN MANAGEMENT IN
SURGERY
Dr:Arshad M.Malik
Associate Professor Surgery
LUMHS
Introduction
• There is a wide
variation in the
individual perception of
pain.
• Under treatment
• Over treatment
• General fear of opiods
Introduction
• The optimum pain requirement have some
basic requirement.
• There should be an expert team approach
• Pain may be measured regularly
• Pain killers should be given before the pain
develops.
• A combination of pain killers is usually more
effective.
• Analgesic dose should be adequate.
Royal college of anesthetist and surgeons
guidelines
• Establishment of acute pain management
services comprising trained personnel to
assure
• Routine recording of pain levels
• Education of both staff and patients
• Encourage “Multimodal” analgesia comprising
local anesthesia with simple analgesics like
paracetamol or NSAIDS.
Simple analgesics
• Usually prescribed in minor surgery when the
patient is orally allowed
• Paracetamol, NSAIDS and other such drugs
are good enough to control minor pains.
• NSAIDS are excellent for moderate pain and
can be used as an adjuct with opiods for
severe pain.
NSAIDS
• These drugs cause non-specific cyclooxygenase inhibition. This removes gastric
cyto-protection and gastritis. There are other
side effects like platelet dysfunction etc.
• Patients with a tendency of peptic ulceration
may need proton pump inhibitor cover.
• Rectal preparations of NSAIDS are also in use
• Recently Cox-2 inhibitors are introduced with
less GIT upsets.
Stronger Analgesics.
• Morphine given intramuscular along with
other analgesics can provide excellent and
effective control of moderate to severe pain
Pain and Analgesics
• Pain
”an unpleasant sensory and
emotional experience with
actual or potential tissue
damage or described in
terms of such damage.
• Analgesia
of pain
absence
8
Pain pathways
• Specialized receptors = free nerve endings
• Stimulation
– Mechanical damage
– Extreme temperature
– Chemical irritation
• Two types of neurons
– A-delta: first pain, sharp
– C: second pain, dull
• Four distinct processes
– Transduction, transmission, modulation, perception
9
10
Pain management
•
•
•
•
Prevention: preemptive approach
Recognition of pain
Choice of substance
Drug dose and duration
11
Tissue damage
• Release of chemical substances and enzymes
(mediators) that alter the activity and sensitivity of
sensory neurons
– Prostaglandins, leukotriens: sensitization of receptors
– Bradykinin and PGs: stimulate the neurons directly
– Histamine: pain, itching
• Result
– increase in nociceptor activity
– Hyperalgesia
– Neurogenic edema
12
Principles of pain management
In order to apply the principles of effective pain
management, you must first have done a pain
assessment. In order to do so, you need to know
the components for assessment.
Pain assessment
• The components of assessment are:
–
–
–
–
–
–
Location/s of pain
Description of pain
Type of pain
Impact on ADL
Intensity (0-10, 0-5, etc.)
Pattern:
–
–
–
–
–
–
–
–
Onset
Duration
What makes pain worse?
What makes pain better?
Patient's perception of pain
Patient's goal for pain relief
Analgesics that have been used in the past
Analgesics receiving in past 24 hours
• Continuous?
• Intermittent?
Types of pain
•
There are 6 primary types of pain:
1)
2)
3)
4)
5)
6)
Visceral Pain
Muscle Pain
Bone Pain
Neuropathic Pain
Pleuritic Pain
Colic Pain
Visceral Pain
– Usually localized to the site of the injury/tumor.
Pain can be referred to the somatic area supplied
by the same nerve root.
– Description/clue to this kind of pain:
• “I ache all the time.”
Muscle Pain
– Sometimes difficult to isolate as it may be due to
an underlying disorder, a systemic or metabolic
cause.
– Description/clue to this kind of pain:
• “I’m sore and stiff.”
Bone Pain
– Local bone pain can range from a dull ache to
deep, intense pain. Usually well localized and
worse on movement and weight-bearing, it may
be worse at night. Bone pain can be masked by
muscle pain arising from involuntary, protective
spasm of the surrounding muscles.
– Description/clue to this kind of pain:
• “It hurts when I move.”
• “It aches at night.”
Neuropathic Pain
– Constant, superficial burning pain is usually caused by
actual damage to peripheral nerve, plexus, root, or spinal
chord. When a specific nerve is involved, pain is in
relatively constant are of the body surface (dermatome)
but may also be referred to the somatic area supplied by
the nerve. The degree of nerve pain will be effected by the
degree of nerve compression or infiltration.
– Description/clue to this kind of pain:
• “It feels like my skin is burning.”
• “It feels like someone stabbed me.”
• “It’s a shooting pain.”
Pleuritic Pain
– Patient may complain of pain on inspiration of
my present with guarded, shallow breathing.
– Description/clue to this kind of pain:
• “The pain is worse when I breathe in.”
Colic Pain
– Partial or complete obstruction of a hollow viscus
can result in intermittent cramps.
– Description/clue to this kind of pain:
• “The pain comes and goes like cramps.”
Keep it simple: The WHO “Analgesic Ladder”
"STEP 1
– - patients with mild to moderate pain should be treated
with nonopioid analgesic, which should be combined with
adjuvant drugs if indication for one exists.
"STEP 2
• - patients who have limited opioid exposure and present with
moderate to severe pain or who fail to achieve adequate relief
after a trial of a nonopioid analgesic should be treated with
an opioid conventionally used for moderate pain.
"STEP 3
– - patients who present with severe pain or who fail to
achieve adequate relief following appropriate
administration of drugs on the second step of the
analgesic ladder should receive an opioid conventionally
used for severe pain.
Critical Points for Analgesic Medication Orders
– The character (quality) of the pain has been documented
on assessment (e.g.- burning/shooting pain) so that the
health care provider can determine the type of pain (e.g.neuropathic pain).
– The oral route is the first choice for analgesic orders. If a
patient is unable to take PO medications, buccal,
sublingual, rectal and transdermal routes are considered
before intravenous or subcutaneous routes.
– Patients who report constant moderate to severe pain
receive a long-acting medication and have a short acting
medication ordered prn for breakthrough pain.
– Patients who report intermittent pain have medications
ordered on a prn basis.
Recently introduced more sophisticated
methods of pain management
• Patient Controlled
Analgesia.(PCA).
• Local anesthetic blocks
Patient controlled Analgesia
• Opiods are injected intravenously or through
epidural cannula.
• The patient is trained to give a bolus of dose
when needed by pressing a button on the
machine.
• The medical staff presets the strength and
dose and frequency .
• This is a very popular method as patient can
control his pain by himself.
Local anesthetic blocks
• These give excellent
short-term results but
require skill and have a
small failure rates.
Chronic Pain
• Inadequate control of acute pain leads to
chronicity. Chronic stimulation of
nocioceptors produces sensitization
• Dysfunction in nerve produces neuropathic
pain.
Pain control in Malignant disease.
1st- Simple analgesics
(Aspirin,Paracetamol,Nsaids)
2nd Intermediate strengh.
(opiods,codine,Tramadol)
3rd .Strong opiods.(Morphine,pethedine
Technique for managing chronic pain
• Oral opioids. Can lead to nasea and
constipation.
• Opioid infusion. If cant take orally.
• Neurolysis. Only when life expectancy is short
Subcostal injection of phenol in rib mets
percutaneous anterolateral chordotomy
to divide spinothalamic tracts
Thanks for your attention