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Acute Pain Management
Parisa Partownavid, MDAssistant Clinical Professor
David Geffen School of Medicine at UCLADepartment of Anesthesia
Definition of Pain
An Unpleasant Sensory and An Unpleasant Sensory and Emotional Experience Associated Emotional Experience Associated
with Actual or Potential Tissue with Actual or Potential Tissue Damage, or Described in Terms of Damage, or Described in Terms of
Such Damage. Such Damage.
Acute Pain
Pain in Perioperative SettingPain in Perioperative Setting Pain in Patients with Severe or Pain in Patients with Severe or
Concurrent Medical Illnesses Concurrent Medical Illnesses (Pancreatitis)(Pancreatitis)
Acute Pain Related to Cancer or Acute Pain Related to Cancer or Cancer TreatmentCancer Treatment
Labor PainLabor Pain
Acute Perioperative Pain
Pain that is Present in a Pain that is Present in a Surgical Patient Because of Surgical Patient Because of
Preexisting Disease, the Preexisting Disease, the Surgical Procedure, or a Surgical Procedure, or a
Combination of BothCombination of Both
Importance of Pain Management Adequate Pain ControlAdequate Pain Control Reduce the Risk of Adverse OutcomesReduce the Risk of Adverse Outcomes Maintain the Patient’s Functional Maintain the Patient’s Functional
Ability, as well as Psychological Well-Ability, as well as Psychological Well-beingbeing
Enhance the Quality of LifeEnhance the Quality of Life Shortened Hospital Stay and Reduced Shortened Hospital Stay and Reduced
CostCost
Adverse Outcomes Associated with Management of Acute Pain Respiratory DepressionRespiratory Depression Circulatory DepressionCirculatory Depression Sedation Sedation Nausea and VomitingNausea and Vomiting PruritusPruritus Urinary RetentionUrinary Retention Impairment of Bowel FunctionImpairment of Bowel Function
Adverse Outcome of Undertreatment of Acute Pain
Thromboembolic or Pulmonary Thromboembolic or Pulmonary ComplicationsComplications
Needless SufferingNeedless Suffering Development of Chronic PainDevelopment of Chronic Pain
The Incidence of Moderate to The Incidence of Moderate to Severe Pain with Cardiac, Severe Pain with Cardiac,
Abdominal, and Orthopedic Abdominal, and Orthopedic Inpatient Procedures has been Inpatient Procedures has been
Reported as High as 25%-Reported as High as 25%-50%, and Incidence of 50%, and Incidence of
Moderate Pain after Moderate Pain after Ambulatory Procedures is Ambulatory Procedures is
25% or Higher. 25% or Higher.
Goal
Pain Management Interventions Pain Management Interventions Should be Offered Around the Should be Offered Around the ClockClock
Pain Management is to Provide Pain Management is to Provide Continuous Pain ReliefContinuous Pain Relief
Patient Should be Assessed for Patient Should be Assessed for Adequacy of Pain ControlAdequacy of Pain Control
Preoperative Evaluation of the Patient
Type of SurgeryType of Surgery Expected Severity of Postoperative Expected Severity of Postoperative
PainPain Underlying Medical Condition Underlying Medical Condition
(Respiratory or Cardiac Disease)(Respiratory or Cardiac Disease)
Preoperative Preparation of the Patient Adjustment or Continuation of Adjustment or Continuation of
Medications (Sudden Cessation Medications (Sudden Cessation may Provoke a Withdrawal may Provoke a Withdrawal Syndrome)Syndrome)
Treatment to Reduce Preexisting Treatment to Reduce Preexisting Pain and AnxietyPain and Anxiety
Patient and Family EducationPatient and Family Education
Pain Assessment Tools
Pain Assessment Tools
In Adults: Self Report Measurement In Adults: Self Report Measurement Scales, such as Numerical ScalesScales, such as Numerical Scales
Pain Assessment Tools In Pediatric Patients:In Pediatric Patients:
Physiologic and Behavioral Physiologic and Behavioral Indicators of Pain ( Infants, Indicators of Pain ( Infants, Toddlers, Nonverbal or Critically Ill Toddlers, Nonverbal or Critically Ill Children)Children)
Face Scale (Age 3-10 yrs)Face Scale (Age 3-10 yrs) Visual Analogue Scales (Age 10-18)Visual Analogue Scales (Age 10-18)
Management of Acute Pain
Pharmacologic Pharmacologic InterventionalInterventional
Pharmacologic Management Alter Nerve Conduction (Local Alter Nerve Conduction (Local
Anesthetics)Anesthetics) Modify Transmission in the Dorsal Modify Transmission in the Dorsal
Horn (Opioids, Antidepressants) Horn (Opioids, Antidepressants)
Routes of Administration POPO PRPR IV IV IMIM TransdermalTransdermal TransmucosalTransmucosal EpiduralEpidural IntrathecalIntrathecal
Opioid Analgesics Bind to Opioid Receptors: Bind to Opioid Receptors:
Mu, Delta and KappaMu, Delta and Kappa Morphine, Hydromorphone, Morphine, Hydromorphone,
Meperidine, Fentanyl, Codeine, Meperidine, Fentanyl, Codeine, Methadone, Oxycodone, Hydrocodone, Methadone, Oxycodone, Hydrocodone, TramodolTramodol
Opioids may be Combined with NSAIDs Opioids may be Combined with NSAIDs to Enhance the Opioid Analgesic Effectto Enhance the Opioid Analgesic Effect
Opioid Analgesics
Equianalgesic Conversion Charts Equianalgesic Conversion Charts are used when Converting form one are used when Converting form one Opioid to Another, or Converting Opioid to Another, or Converting from Parenteral to Oral Formfrom Parenteral to Oral Form
Respiratory Monitors may be Used Respiratory Monitors may be Used Depending on the Patients Age, Co-Depending on the Patients Age, Co-existing Medical Problems, or Route existing Medical Problems, or Route of Opioid Administered of Opioid Administered
Opioid Analgesics
Conversions: MorphineConversions: Morphine
OralOral Parenteral Epidural Parenteral Epidural Intrathecal Intrathecal
300300 100100 10 10 11
OpioidsDrugDrug PO PO
mgmgIV IV mgmg
Starting Starting Oral Dose Oral Dose mgmg
CommentsComments
MorphineMorphine 3030 1010 15-3015-30 MS Contin, Release 8-12 MS Contin, Release 8-12 hrshrsMSIR for BTPMSIR for BTP
Hydro-Hydro-morphonmorphonee
7.57.5 1.51.5 4-8 4-8 Duration Slightly Shorter Duration Slightly Shorter than Morphine than Morphine
MeperidinMeperidinee 3030
007575 Duration Slightly Shorter Duration Slightly Shorter
than Morphine than Morphine Normeperidine Causes Normeperidine Causes CNS ToxicityCNS Toxicity
MethadoMethadonene 2020 1010 5-10 Qd5-10 Qd Long Half-Life, 24-36 hrsLong Half-Life, 24-36 hrs
Accumulates on Days 2-3Accumulates on Days 2-3FentanylFentanyl 0.02-0.02-
0.050.05Fentanyl Patch, 12 hrs Fentanyl Patch, 12 hrs Delay Onset and OffsetDelay Onset and Offset
OpioidsDrugDrug PO mgPO mg CommentsComments PrecautioPrecautio
nsnsCodeineCodeine 30-6030-60 Combined With Combined With
Nonnarcotic AnalgesicsNonnarcotic AnalgesicsMaximal Dose Maximal Dose for for Acetaminophen Acetaminophen 4gm/d4gm/d
OxycodonOxycodonee
5-105-10 PercocetPercocetPercodanPercodanOxycodone 10-30mg Q Oxycodone 10-30mg Q 4h4hOxycontin 10mg Q 12hOxycontin 10mg Q 12h
Acetaminophen Acetaminophen or Aspirin or Aspirin toxicitytoxicity
Hydro-Hydro-codonecodone
5-105-10 Vicodin or LortabVicodin or Lortab Acetaminophen Acetaminophen ToxicityToxicity
TramodolTramodol 50-100 50-100 Q4-6hrQ4-6hr
Central Acting, Affinity Central Acting, Affinity for Mu Receptorsfor Mu Receptors
Maximal Dose Maximal Dose 400 mg/d400 mg/d
Patient Controlled Analgesia Small Doses of Analgesic Drug (Usually Small Doses of Analgesic Drug (Usually
Opioids), are Administered (IV) by PatientOpioids), are Administered (IV) by Patient Allows Basal Infusion and Demand Allows Basal Infusion and Demand
BolusesBoluses Over Dosage is Avoided Over Dosage is Avoided by Limiting the Amount by Limiting the Amount and Number of Boluses and Number of Boluses in a Set Period of Timein a Set Period of Time
Dose Regimens for PCADrugDrug Bolus Dose Bolus Dose
(mg)(mg)Lock-Out Lock-Out (Minutes)(Minutes)
MorphineMorphine 0.5-20.5-2 5-155-15
HydromorphonHydromorphonee
0.1-0.20.1-0.2 5-105-10
FentanylFentanyl 0.01-0.020.01-0.02 5-105-10
Non-Opioid Analgesics AcetaminophenAcetaminophen NSAIDs (Aspirin, Ibuprofen, NSAIDs (Aspirin, Ibuprofen,
Ketorolac, Ketorolac, COX-2 Inhibitors)COX-2 Inhibitors) Lidocaine Patch (Lidoderm)Lidocaine Patch (Lidoderm)
NSAIDs Relieve of Mild to Moderate PainRelieve of Mild to Moderate Pain Complication: Complication:
GI DiscomfortGI Discomfort GI Bleeding (Inhibition of COX-1)GI Bleeding (Inhibition of COX-1) NephrotoxicityNephrotoxicity Inhibition of Platelet Aggregation Inhibition of Platelet Aggregation OsteogenesisOsteogenesis
Ketorolac Potent AnalgesicPotent Analgesic Parenteral (IV or IM)Parenteral (IV or IM) 15-30 mg Q 6hr15-30 mg Q 6hr Patients Older than 16 yrsPatients Older than 16 yrs Should not Exceed 5 daysShould not Exceed 5 days
Cox-2 InhibitorsDrugDrug DoseDose
Celecoxib (Celebrex)Celecoxib (Celebrex) 100-200mg PO Bid100-200mg PO Bid
Rofecoxib (Vioxx)Rofecoxib (Vioxx)
Valdecoxib (Bextra)Valdecoxib (Bextra) 10-20mg PO Qd10-20mg PO Qd
ParecoxibParecoxib 20-40mg IM20-40mg IM20-100mg IV20-100mg IV
Lidoderm
Lidoderm 5% Lidocaine Patch5% Lidocaine Patch Indicates for Pain Relief in Post-Indicates for Pain Relief in Post-
herpetic Neuralgiaherpetic Neuralgia Each Patch Contains 700 mg of Each Patch Contains 700 mg of
LidocaineLidocaine Should be Applied to Intact SkinShould be Applied to Intact Skin About 3% is AbsorbedAbout 3% is Absorbed 1-3 Patches Once a Day for 12 hrs1-3 Patches Once a Day for 12 hrs
Interventional Management Epidural Analgesia (Continuous Epidural Analgesia (Continuous
Lumbar or Thoracic Epidural Lumbar or Thoracic Epidural Catheter Placement, PCEA)Catheter Placement, PCEA)
Spinal AnalgesiaSpinal Analgesia Peripheral Nerve Block ( Single Peripheral Nerve Block ( Single
Shot or Continuous)Shot or Continuous)
Anatomy of Epidural Space
Surrounds the Dural Surrounds the Dural SacSac
Anteriorly: Post. Anteriorly: Post. Long. LigamentLong. Ligament
Posteriorly: Posteriorly: Ligamentum FlavumLigamentum Flavum
Laterally: Pedicles and Laterally: Pedicles and Intervertebral ForaminaIntervertebral Foramina
Anatomy of Epidural Space
AP Dimension of the Epidural AP Dimension of the Epidural Space is Largest in the Lumbar Space is Largest in the Lumbar Region, 5-6 mm Region, 5-6 mm
In Thoracic Region the AP In Thoracic Region the AP Dimension Decreases but the Dimension Decreases but the Space is More Continuous Space is More Continuous
MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE
Epidural Anesthesia Anesthestizes the Emerging Nerve Roots Anesthestizes the Emerging Nerve Roots
of the Spinal Cordof the Spinal Cord Epidural Injection of Anesthetic Produces Epidural Injection of Anesthetic Produces
a Regional Dermatomal “band” of a Regional Dermatomal “band” of Anesthesia Spreading Cephalad and Anesthesia Spreading Cephalad and Caudad from the Site of InjectionCaudad from the Site of Injection
Level of Anesthesia Depends on :Level of Anesthesia Depends on : Volume of the DrugVolume of the Drug Level of InjectionLevel of Injection
Epidural Anesthesia Lumbar Epidural: Lower Extrimity, Lumbar Epidural: Lower Extrimity,
Pelvic, and Lower Abdominal Pelvic, and Lower Abdominal ProceduresProcedures
Thoracic Epidural: Upper Abdomen Thoracic Epidural: Upper Abdomen and Thoracic Proceduresand Thoracic Procedures
Caudal Injection: More Commonly Caudal Injection: More Commonly Used for Pediatric Patients Used for Pediatric Patients (Genitourinary and Lower Abdominal (Genitourinary and Lower Abdominal Procedures)Procedures)
Advantages Superior Pain ReliefSuperior Pain Relief Less Systemic Side EffectsLess Systemic Side Effects Lower Incidence of DVT and Pulmonary EmboliLower Incidence of DVT and Pulmonary Emboli Decrease Blood Loss Intraoperatively during Decrease Blood Loss Intraoperatively during
Orthopedic, Urologic, Gynecologic and Obstetric Orthopedic, Urologic, Gynecologic and Obstetric ProceduresProcedures
More Rapid Recovery of Bowel FunctionMore Rapid Recovery of Bowel Function Earlier AmbulationEarlier Ambulation Better PFTBetter PFT Suppression of Neuroendocrine Stress ResponseSuppression of Neuroendocrine Stress Response Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative Outcome. Anesthesiol Outcome. Anesthesiol
Clin North America 01-JUN-2000; 18(2): 407-28Clin North America 01-JUN-2000; 18(2): 407-28
Contraindications AbsoluteAbsolute Patient RefusalPatient Refusal CoagulopathyCoagulopathy Increased ICPIncreased ICP Skin InfectionSkin Infection
RelativeRelative Uncooperative Uncooperative
Patient Patient Pre-existing Pre-existing
Neurologic Neurologic DisorderDisorder
Anatomical Anatomical AbnormalitiesAbnormalities
Factors Affecting Epidural Dosage Patient Factors: Age , Height, Patient Factors: Age , Height,
Weight, PregnancyWeight, Pregnancy Site of InjectionSite of Injection
Drugs Used for Epidural Anesthesia
Local AnestheticsLocal Anesthetics OpioidsOpioids
Local Anesthetics in Epidural Space
Lidocaine: 1-2% , 45-90 min.Lidocaine: 1-2% , 45-90 min. Bupivacaine: 0.25-0.5% , 90-120 Bupivacaine: 0.25-0.5% , 90-120
min. min.
Opioids in Epidural SpaceDrugDrug DosageDosage Onset Onset
(min)(min)Duration Duration (hrs)(hrs)
MorphineMorphine 2-3 mg2-3 mg 30-9030-90 6-246-24
HydromoHydromor-phoner-phone
0.4-0.8 mg0.4-0.8 mg 20-3020-30 6-186-18
FentanylFentanyl 50-100 50-100 mcgmcg
5-155-15 2-42-4
Hydrophilic Opioids Morphine, Hydromorphone Slow Onset, Long Duration, High CSF Solubility AdvantagesAdvantages Prolonged Single Prolonged Single
Dose AnalgesiaDose Analgesia Thoracic Analgesia Thoracic Analgesia
with Lumbar with Lumbar AdministrationAdministration
Minimal Dose Minimal Dose Compared with IV Compared with IV AdministrationAdministration
DisadvantagesDisadvantages Delayed Onset of Delayed Onset of
AnalgesiaAnalgesia Unpredictable Unpredictable
DurationDuration Delayed Respiratory Delayed Respiratory
DepressionDepression
Lipophilic Opioids FentanylRapid Onset, Short Duration, Low CSF Solubility AdvantagesAdvantages Rapid AnalgesiaRapid Analgesia Ideal for Continuous Ideal for Continuous
Infusion or PCEAInfusion or PCEA
DisadvantagesDisadvantages Systemic AbsorptionSystemic Absorption Brief Single Dose Brief Single Dose
AnalgesiaAnalgesia Limited Thoracic Limited Thoracic
Analgesia with Analgesia with Lumbar Lumbar AdministrationAdministration
PCEA Technique that Allows Basal Infusion and Technique that Allows Basal Infusion and
Demand Boluses into the Epidural SpaceDemand Boluses into the Epidural Space Solutions Used:Solutions Used:
Local Anesthetics: 0.05-0.125%Local Anesthetics: 0.05-0.125% Bupivacaine BupivacaineOpioids: Morphine 50 mcg/mlOpioids: Morphine 50 mcg/mlHydromorphone 10 mcg/mlHydromorphone 10 mcg/mlFentanyl 2-5 mcg/mlFentanyl 2-5 mcg/ml
Complications of Epidural Analgesia Failure of Block (Patchy or Unilateral Failure of Block (Patchy or Unilateral
Block)Block) Injury to NerveInjury to Nerve InfectionInfection Epidural Hematoma or AbscessEpidural Hematoma or Abscess Dural Puncture (Total Spinal or PDPH)Dural Puncture (Total Spinal or PDPH)
Complications of Epidural Analgesia Side Effect of Drugs in Epidural SpaceSide Effect of Drugs in Epidural Space
- Hypotension Secondary to Sympathetic - Hypotension Secondary to Sympathetic BlockadeBlockade- Intravascular Injection (Local Anesthetic - Intravascular Injection (Local Anesthetic Toxicity) Toxicity) - Respiratory Depression- Respiratory Depression- Sedation- Sedation- Bladder Distention- Bladder Distention- - Difficulty in AmbulationDifficulty in Ambulation
Spinal Anesthesia
Spinal Anesthesia is Induced by Spinal Anesthesia is Induced by Injecting Small Amount of Local Injecting Small Amount of Local Anesthetic (Bupivicaine) in the CSFAnesthetic (Bupivicaine) in the CSF
Results in Rapid Onset of BlockResults in Rapid Onset of Block More Rapid Onset and Requiring More Rapid Onset and Requiring
less Medicine Compared to less Medicine Compared to Epidural AnalgesiaEpidural Analgesia
Spinal Anesthesia
CSE, Used in LaborCSE, Used in Labor Preservative Free Morphine Preservative Free Morphine
(Duramorph) Provides Pain Relief (Duramorph) Provides Pain Relief for Abdominal, Pelvic, or Lower for Abdominal, Pelvic, or Lower Extrimity SurgeriesExtrimity Surgeries
Complications Similar to Epidural Complications Similar to Epidural Technique Except for Higher Risk Technique Except for Higher Risk of PDPHof PDPH
Peripheral Nerve Block
Anesthetizing the Nerve that is Anesthetizing the Nerve that is Innervating Surgical or Painful AreaInnervating Surgical or Painful Area
Single Shot or Continuous Infusion Single Shot or Continuous Infusion through Catheterthrough Catheter
Upper Extrimity: Brachial Plexus, Upper Extrimity: Brachial Plexus, Median, Ulnar or Radial NerveMedian, Ulnar or Radial Nerve
Peripheral Nerve Block
Lower Extrimity: Sciatic, Femoral, Lower Extrimity: Sciatic, Femoral, Posterior Tibial, Sural, Saphenous, Posterior Tibial, Sural, Saphenous, Deep and Superficial Peroneal Deep and Superficial Peroneal Nerve Nerve
Intercostal Nerve Block Intercostal Nerve Block Surgical Wound Infiltration of Local Surgical Wound Infiltration of Local
AnestheticAnesthetic
Acute Pain Management for Pediatric Patients
Consider Physiologic and Anatomic Consider Physiologic and Anatomic DifferencesDifferences
Pain Assessment and Pain Assessment and CommunicationCommunication
Pain and Anxiety Associated with Pain and Anxiety Associated with Minor Procedures or Unfamiliar Minor Procedures or Unfamiliar SituationsSituations
Caudal Block Single Injection or Continuous Infusion Single Injection or Continuous Infusion
through a Catheterthrough a Catheter Excellent Intraoperative and Excellent Intraoperative and
Postoperative Pain ControlPostoperative Pain Control Easier to Perform in ChildrenEasier to Perform in Children Analgesia that Last About 12 hrs if Analgesia that Last About 12 hrs if
Bupivacaine UsedBupivacaine Used Performed Following Induction of Performed Following Induction of
General AnesthesiaGeneral Anesthesia
Indications for Caudal Block Surgeries in Sacral Segments, Surgeries in Sacral Segments,
(Circumcision and other Urologic (Circumcision and other Urologic Surgeries, Rectal Dilation)Surgeries, Rectal Dilation)
Combined with Light General Combined with Light General Anesthesia Provides Adequate Anesthesia Provides Adequate Intraoperative AnalgesiaIntraoperative Analgesia
Complications of Caudal Block InfectionInfection Dural Puncture and Spinal Dural Puncture and Spinal
AnesthesiaAnesthesia Intravascular Injection of Local Intravascular Injection of Local
AnestheticsAnesthetics
Acute Pain Management in Elderly Patient Population Older than 65 yrs Patient Population Older than 65 yrs
of Age is Growingof Age is Growing Age Related Physiologic Changes Age Related Physiologic Changes
(Decreased Muscle Strength): (Decreased Muscle Strength): Decreased CoughDecreased Cough
Decreased Mental Status (Dementia): Decreased Mental Status (Dementia): Decreased Narcotic DoseDecreased Narcotic Dose
Acute Pain Management in
Elderly
Age Related Anatomic Changes: Age Related Anatomic Changes: Difficulty in Placing Epidural CatheterDifficulty in Placing Epidural Catheter
Multiple Drug Therapy: Withdrawal or Multiple Drug Therapy: Withdrawal or Interaction with Other DrugsInteraction with Other Drugs