Acute Pain Management:
Transforming Evidence into Practice
Dr Surjya Prasad upadhyay; MD
Specialist Anaesthesiology
NMC hospital DIP
Dubai
Acute pain
There is No Pain
that can not be treated
Common myth for acute pain Treatment
Oligo-analgesia
Analgesic may mask abnormal finding
Sever pain will cause abnormal vitals signs
Patient will be addicted to narcotics
Patient will be sedate after narcotics
Some kind of pain cant be relieved
Effective pain management can be done on SOS basis .
Importance of Acute pain management
Pain control- human right
Indicator of quality of care
Untreated pain- adversely affects other systems;
Physiological and psychological upset / stress
Untreated/poorly treated pain- progress into chronic pain
Increased morbidity/ mortality/ cost/ LOS
Consequences of poorly treated pain
Pain Algorithm
Patient in Acute pain /
anticipated postoperative pain
Brief pain Assessment
Emergent use of opioid if clinical condition dictate
Comprehensive pain assessment
Appropriate Therapy
Referral
RELIEF Approach for Acute pain Treatment
R: Record Pain before and after Tx
E: Evidence based treatment
L: Look and listen to Patient: Belief your Patient
I: Inquire if Patient need Pain Medicine
E: Educate Staff
F: Facilitate/Formulate multidisciplinary APS
Assessment/ which scale?
How Acute Pain differ from Chronic
Pathology : clear Vs unclear
Duration : short
Mechanism: adaptive vs maladoptive
Prognosis: good Vs unpedictable
Treatment : simple vs complex
Acute Vs chronic pain; Hit fast and hit hard
Changing concept of pain management
Traditional
Modern concept
Palliate pain-
Prevent pain
Administered single analgesics
Multimodal analgesia
Fixed dose of opioid
Judicious use of opioid
(individualised)
PRN or SOS analgesic
Continuous / Regular
Analgesics
No protocol/ guideline for Acute
pain
Acute pain service: Advanced
pain interventions; blocks
Pain Pathway and Analgesic Actions
Treatment modalities
Non pharmacologic
Pharmacologic
1.Non-opioid
2.Opioid
3.Adjuvants
Invasive interventions
Diagnose and treat as per underlying cause
Non-pharmacologic pain management
Massage
TENS
Acupuncture
Exercise
Heat/cold massage
Neurostimulation
Scrambler therapy
Dry needling
Behavioural
Cognitive
Bio-feedback
Opioids
Best available analgesics, but not ideal
Act via different opioid receptors in brain, spinal cord
and peripheral tissue.
Classified according to potency- weak to strong
Choice of opioid- depends on patient, pain, associated
conditions
Where do opioid act ?
Weak Opioid
Codeine pro-drug;
metabolised to active drug morphine via Cytochrome
17-34% population: deficiency in converting enzyme; no action
Dihydrocodeine pro-drug, again a wide variation in patient
response.
Tramadol active drug. Dual action Mu agonist + SSNRI
Pentazocin/ butorphenol/buprenorphine- partial agonist/
agonist- antagonist- ceiling analgesic effect
Tramadol
Dual mode of action; opioid Mu agonist + selective serotonin
and noradrenaline reuptake inhibitor (SSNRI).
Effective in mild to moderate pain
Can be given IM,IV,Oral- good bioavailability
Can be combined with PCM, NSAID
Dose in adult- 50-100 mg 6-8 hrly; Max dose 400 mg in 24
Dry mouth, dizziness, sedation in high dose
Nausea vomiting- only if given fast boluses.
Strong opioid
Act directly / no need to convert into active form
Agonist at opioid receptors
Has dose dependent analgesic and other adverse effects
No ceiling effects to analgesia
Wide individual dose variation
Diverse route of administration
Morphine; pethidine, fentanyl, alfentanil, sufentanil
Morphine
Available in various form;
Consider as Reference opioid:
Initial dose 0.1-0.2 mg/kg
Metabolism- liver; 30-40% oral bio-availability
Metabolite- Morphine 3 Glucoronide- no analgesic
morhine 6 glucoronide- more analgesic than morphine
Elimination: Renal
Onset after IV-5-10 min, peak 1 hrs, Duration: 4 hrs
Meperidine/ Pethidine
Synthetic opioid
Atropine like effect-
Metabolism -liver
metabolite- normeperidine- CNS excitation,
Anti-shivering action
Interaction with antidepressant, SSRI; MAOI- serotonin
syndrome (HTN, rigidity, hyperpyrexia, seizure, Coma)
Psychiatric patients- avoid
Fentanyl
Synthetic opioid ; 100 times more potent than morphine
Short duration; suitable for PCA or continuous infusion
High fast pass metabolism
Most cardio-stable
Loading Dose-1-2 mcg/kg; onset 3-5 min, duration:30-40 min
Available in various form: lollipop, lozenge, transdermal,
intranasal spray, Injectable
Opioid precaution
Hypotension/ shock
CNS issues: head injury, delirium, dementia, psychiatric illness
Concomitant CNS depressant: Alcohol / drugs
Liver/ kidney impairment
Morbidly obese, OSA
Respiratory illness- COPD/Br Asthma
H/o- drug addiction/abuse
Opioid tolerance/ addiction/pseudoaddiction
Rarely a problem in acute setting.
Tolerance:
Pseudo addiction:
Addiction:
Opioid induced hyperalgesia:
Drawback of opioids
Nausea /vomiting--
Bladder/ bowel function
Sedation: delayed mobilisation; discharge
Respiratory: Obstructive breathing, Silent aspiration
Immuno - suppressant effects- would infection.
Cancer recurrence/ metastasis
Persistent post-op pain into chronic pain
Non-opioid Analgesics
Paracetamol
NSAIDs
Adjuvants
First line drug therapy for any pain
Effective alone for mild to moderate pain
Highly effective when combined with opioids
Acetaminophen and NSAIDS
Foundation for pain treatment protocol.
First on and last off
Sole agent in mild to moderate pain
30-60% opioid sparing effects
Analgesic efficacy- has ceiling effects- limiting factor
Opioid- add on therapy when require
Paracetamol
Mechanism similar to NSAIDs but act centrally
Analgesic, antipyretic, but no anti-inflamatory
Safest analgesic of all
Can be given oral / IV/ PR
1st line therapy in mild to moderate pain
Central part of MMA.
Max dose 4 gm in 24 hrs in adult (60-90 mg/kg in children)
NSAIDS
Most extensively used medicine in world in all age group
Analgesic, antipyretic and anti-inflammatory
NSAID- related hospital admission 7-11%
Higher the potency (less amount requirement)- more toxic
Broadly two sub class- Cox-1 and Cox-2 inhibitor.
Combination of NSAIDS: no benefit;
Paracetamol + NSAID: additive effects
NSAIDs selectivity
NSAIDs: side effects
GI side effects
Salt & water retention
Hepatotoxicity
Nephrotoxicity
Bleeding tendency
Prolongation of labour
Asthma and allergy
CV risk/ MI: coxib
Adjuvants
TCA / SSRI / SNRI - neuropathic pain with concomitant
depression
Anticonvulsant- gabapentanoid
Muscle rexant (baclofen, BZD) - relieve muscle spasm
Lidoderm- herpetic pain
Calcitonin- osteoprotic fracture pain
Corticosteroid- tissue edema, neuropathic pain
Central sympatholytic: clonidine/ dexmedetomidine
Potentiate & improve analgesia
reduce side effects
Two Most impressive Adjuvants for
acute pain management
Ketamine
Dexamethasone
Ketamine
NMDA- antagonist
Antihyperalgesic, anti-allodynic
Pre-emptive use- prevent conversion into chronic pain
Dissociative anaesthesia:( 1-2 mg/kg) the lights are on,
but no one is home
Powerful analgesia even in very low dose 0.1-0.3 mg/kg
Preserve haemodynamic/ respiration
Disadvantages:mood, cognition, salivation, nausea
Comparable analgesia with 0.3 mg /kg ketamine
Vs
0.1 mg/kg morphine for Short term pain relief in ED
When to Use Ketamine?
OSA
Dose: 0.1 mg-0.3 mg/Kg
Either as Sole agent or as Adjuvant to opioid
Dexamethasone
Anti-inflammatory/ anti emetic
IV single dose 0.1 mg/kg at the time of induction
Reduced postop pain score
Reduction in opioid consumption
Reduction in rescue analgesic
RA: Intravenous / perineural dexamethasone-
Prolonged sensory motor blockade
Prevent neurotoxicity and rebound hyperalgesia.
Reg Anesth Pain Med. 2015 Jul-Aug;40(4):321-9. Br J Anaesth. 2013;1(2):191200. Reg Anesth Pain Med. 2015 Mar-Apr;40(2):125-32.
Interventions in Acute Pain
Continuous nerve/plexus block
Epidural Analgesia (LA+/- Opioid)
Intrathecal Analgesia
PCA- Intravenous/ epidural
Newer truncal blockade: (Alternative to epidural) TAP, PVB,
QLB, fascia transversalis, Rectus sheath, PECS
Regional block for acute pain
Superior quality of analgesia
Ultrasound has revolutionised regional block
No major systemic side effects
Virtually eliminate opioid use
Can provide continued analgesia
Higher patient satisfaction
Early ambulation/ discharge
Transdermal fentanyl iontophoresis
(IONSYS)
One of the newest advancement.
Credit card size fentanyl reservoir
Can be put in arm, chest.
Programmable like PCA
Up to 6 doses per hour
Work for 24 hrs or upto 80 doses
Approved by FDA in April; 2015
Yet to be available in middle east
Liposomal encapsulated Bupivacaine
MMA / Rationale poly pharmacy
Multimodal Analgesia (MMA)
Transforming evidence into Practice
EBM- Proven and evaluated treatment Practice
EBP- transition of knowledge
Knowledge translation = 17 years
Various sources of knowledge
Why the Gap between evidence and practice
3 main cause of Gap in the quality of pain care
delivery
1.Healthcare professionals.
2.Health care system
3.Patients
Problem related to healthcare professionals
Out of date or inadequate attitudes and knowledge;
1. Pain control- mask recognition of surgical complications
2. Surgery has to be associated with pain
3. Patient complaining pain: fussy
Clinical inertia-
Incomplete knowledge
Fear of side effects/ addiction
Problem related to health care system
Regulatory impediment
Failure to capture short and long term quality outcomes-
Cost shifting to patients (eg insurers)
Inadequate equipment, manpower or drug delivery system
Practice restriction, (eg- nurse are permitted only for im, sc, no
IV; use of narcotics )
Problem related to patients
Out of date or mistaken ideas
Belief that nice patients do not complain of pain or suffering
Fear of side effects/ addictions
Lack of awareness of the importance of pain control
Tendency to be satisfied with inadequate pain control-
Acute Pain service
Comprehensive pain services
Multidisciplinary team
Anaesthesiologist based/
Nursed based anaesthesia supervised
No consensus as to be best model
Very wide variation in APS structure
Most APS initially provide postop / trauma analgesia
APS activities
Appropriate selection of analgesic regimens
Standardized protocols and Guidelines
Advanced interventional techniques
Audit and quality improvement programs
Education
Summary: Treatment modality for Acute Pain
Case 1
60 year male
RTA ;polytrauma
Multiple fracture
Brought in emergency
Agitated, restless; disoriented
Complaining of severe pain
Issues
CNS status
Haemodynamics
Unknown Comborbid illness
How to address pain
Opioid- not a good choice
Acetaminophen- safe if liver function is ok
Epidural- not a choice
NSAIDs- difficult choice even RFT is normal
Best choice- nerve/ plexus blockade, cont infusion
Case 2
75 year/ male
HTN, DM, COPD
# neck of femur in ED
Severe pain-10/10.
Splinting ,PCM, voltarin, pethidine
No relief
What next?
FICB
Conclusion
Assess pain properly
Belief your patient
Never give up
Multimodal analgesia technique
Pre-emptive analgesia
Regular analgesic
Greater use of regional analgesia
Be open to new ideas and embrace them
References
1. Practice Guidelines for Acute Pain Management in the Perioperative Setting; An update report
by American Society of Anaesthesiology task force on acute pain management.
Anesthesiology2012; vol 116; no 2
2. Blondell RD, Azadfard M and Wisnieski AM. Pharmacologic therapy for acute pain. Am Fam
Physician. 2013 Jun 1;87(11):766-772
3. Elsa Wuhrman, Maureen F. Cooney. Acute Pain Assessment and treatment; Medscape;
January 03; 2011.
4. Australian Govt National Health and medical Research Council. Acute Pain Management;
scientific evidences. CP104;2010
5. Polomano RC, Rathmell JP, Krenzischek DA, Dunwoody CJ.Emerging trends and new
approaches to acute pain management. J Perianesth Nurs. 2008 Feb;23(1 Suppl):S43-53. doi:
10.1016/j.jopan.2007.11.006.
6. Viscusi ER. Patient-controlled drug delivery for acute postoperative pain management: a review
of current and emerging technologies. Reg Anesth Pain Med. 2008 Mar-Apr;33(2):146-58. doi:
10.1016/j.rapm.2007.11.005.
7. Reynolds RA, Legakis JE, Tweedie J, Chung Y, Ren EJ, Bevier PA, Thomas RL, Thomas
ST.Postoperative pain management after spinal fusion surgery: an analysis of the efficacy of
continuous infusion of local anesthetics. Global Spine J. 2013 Mar;3(1):7-14. doi: 10.1055/s-00331337119. Epub 2013 Mar 2.
References
8. Gambling D, Hughes T, Martin G, Horton W, Manvelian G. A comparison of Depodur, a
novel, single-dose extended-release epidural morphine, with standard epidural morphine
for pain relief after lower abdominal surgery. Anesth Analg. 2005 Apr;100(4):1065-74.
9. Sumida S1, Lesley MR, Hanna MN, Murphy JD, Kumar K, Wu CL. Meta-analysis of the
effect of extended-release epidural morphine versus intravenous patient-controlled
analgesia on respiratory depression. J Opioid Manag. 2009 Sep-Oct;5(5):301-5.
10. Bujedo BM. Current evidence for spinal opioid selection in postoperative pain. Korean
J Pain. 2014 Jul;27(3):200-9. doi: 10.3344/kjp.2014.27.3.200. Epub 2014 Jun 30.
11. Karamese M, Akda O1, Kara , Yldran GU, Tosun Z. The Comparison of Intrathecal
Morphine and IV Morphine PCA on Pain Control, Patient Satisfaction, Morphine
Consumption, and Adverse Effects in Patients Undergoing Reduction Mammoplasty.
Eplasty. 2015 May 5;15:e15. ECollection 2015.
12. Cherian JJ, Barrington J, Elmallah RK, Chughtai M, Mistry JB, Mont MA. Liposomal
Bupivacaine Suspension, Can Reduce Length of Stay and Improve Discharge Status of
Patients Undergoing Total Hip Arthroplasty. Surg Technol Int. 2015 Nov;27:235-9.
13. Baeriswyl M, Kirkham KR, Kern C, Albrecht E.The Analgesic Efficacy of UltrasoundGuided Transversus Abdominis Plane Block in Adult Patients: A Meta-Analysis. Anesth
Analg. 2015 Dec;121(6):1640-54.
