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Definition of Pain

Acute Pain Management Parisa Partownavid, MD Assistant Clinical Professor David Geffen School of Medicine at UCLA Department of Anesthesia. Definition of Pain. An Unpleasant Sensory and Emotional Experience Associated with Actual or Potential Tissue Damage, or Described in Terms of Such Damage.

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Definition of Pain

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  1. Acute Pain ManagementParisa Partownavid, MDAssistant Clinical ProfessorDavid Geffen School of Medicine at UCLADepartment of Anesthesia

  2. Definition of Pain An Unpleasant Sensory and Emotional Experience Associated with Actual or Potential Tissue Damage, or Described in Terms of Such Damage.

  3. Acute Pain • Pain in Perioperative Setting • Pain in Patients with Severe or Concurrent Medical Illnesses (Pancreatitis) • Acute Pain Related to Cancer or Cancer Treatment • Labor Pain

  4. Acute Perioperative Pain Pain that is Present in a Surgical Patient Because of Preexisting Disease, the Surgical Procedure, or a Combination of Both

  5. Importance of Pain Management • Adequate Pain Control • Reduce the Risk of Adverse Outcomes • Maintain the Patient’s Functional Ability, as well as Psychological Well-being • Enhance the Quality of Life • Shortened Hospital Stay and Reduced Cost

  6. Adverse Outcomes Associated with Management of Acute Pain • Respiratory Depression • Circulatory Depression • Sedation • Nausea and Vomiting • Pruritus • Urinary Retention • Impairment of Bowel Function

  7. Adverse Outcome of Undertreatment of Acute Pain • Thromboembolic or Pulmonary Complications • Needless Suffering • Development of Chronic Pain

  8. The Incidence of Moderate to Severe Pain with Cardiac, Abdominal, and Orthopedic Inpatient Procedures has been Reported as High as 25%-50%, and Incidence of Moderate Pain after Ambulatory Procedures is 25% or Higher.

  9. Goal • Pain Management Interventions Should be Offered Around the Clock • Pain Management is to Provide Continuous Pain Relief • Patient Should be Assessed for Adequacy of Pain Control

  10. Preoperative Evaluation of the Patient • Type of Surgery • Expected Severity of Postoperative Pain • Underlying Medical Condition (Respiratory or Cardiac Disease)

  11. Preoperative Preparation of the Patient • Adjustment or Continuation of Medications (Sudden Cessation may Provoke a Withdrawal Syndrome) • Treatment to Reduce Preexisting Pain and Anxiety • Patient and Family Education

  12. Pain Assessment Tools

  13. Pain Assessment Tools • In Adults: Self Report Measurement Scales, such as Numerical Scales

  14. Pain Assessment Tools • In Pediatric Patients: • Physiologic and Behavioral Indicators of Pain ( Infants, Toddlers, Nonverbal or Critically Ill Children) • Face Scale (Age 3-10 yrs) • Visual Analogue Scales (Age 10-18)

  15. Management of Acute Pain Pharmacologic Interventional

  16. Pharmacologic Management • Alter Nerve Conduction (Local Anesthetics) • Modify Transmission in the Dorsal Horn (Opioids, Antidepressants)

  17. Routes of Administration • PO • PR • IV • IM • Transdermal • Transmucosal • Epidural • Intrathecal

  18. Opioid Analgesics • Bind to Opioid Receptors: Mu, Delta and Kappa • Morphine, Hydromorphone, Meperidine, Fentanyl, Codeine, Methadone, Oxycodone, Hydrocodone, Tramodol • Opioids may be Combined with NSAIDs to Enhance the Opioid Analgesic Effect

  19. Opioid Analgesics • Equianalgesic Conversion Charts are used when Converting form one Opioid to Another, or Converting from Parenteral to Oral Form • Respiratory Monitors may be Used Depending on the Patients Age, Co-existing Medical Problems, or Route of Opioid Administered

  20. Opioid Analgesics Conversions: Morphine Oral Parenteral Epidural Intrathecal 300 100 10 1

  21. Opioids

  22. Opioids

  23. Patient Controlled Analgesia • Small Doses of Analgesic Drug (Usually Opioids), are Administered (IV) by Patient • Allows Basal Infusion and Demand Boluses • Over Dosage is Avoided by Limiting the Amount and Number of Boluses in a Set Period of Time

  24. Dose Regimens for PCA

  25. Non-Opioid Analgesics • Acetaminophen • NSAIDs (Aspirin, Ibuprofen, Ketorolac, COX-2 Inhibitors) • Lidocaine Patch (Lidoderm)

  26. NSAIDs • Relieve of Mild to Moderate Pain • Complication: • GI Discomfort • GI Bleeding (Inhibition of COX-1) • Nephrotoxicity • Inhibition of Platelet Aggregation • Osteogenesis

  27. Ketorolac • Potent Analgesic • Parenteral (IV or IM) • 15-30 mg Q 6hr • Patients Older than 16 yrs • Should not Exceed 5 days

  28. Cox-2 Inhibitors

  29. Lidoderm

  30. Lidoderm • 5% Lidocaine Patch • Indicates for Pain Relief in Post-herpetic Neuralgia • Each Patch Contains 700 mg of Lidocaine • Should be Applied to Intact Skin • About 3% is Absorbed • 1-3 Patches Once a Day for 12 hrs

  31. Interventional Management • Epidural Analgesia (Continuous Lumbar or Thoracic Epidural Catheter Placement, PCEA) • Spinal Analgesia • Peripheral Nerve Block ( Single Shot or Continuous)

  32. Anatomy of Epidural Space • Surrounds the Dural Sac • Anteriorly: Post. Long. Ligament • Posteriorly: Ligamentum Flavum • Laterally: Pedicles and Intervertebral Foramina

  33. Anatomy of Epidural Space • AP Dimension of the Epidural Space is Largest in the Lumbar Region, 5-6 mm • In Thoracic Region the AP Dimension Decreases but the Space is More Continuous

  34. MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE

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