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7/24/2019 ACute Pain Management; Transforming evidence into practice
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Acute Pain Management:
Transforming Evidence into Practice
Dr Surjya Prasad upadhyay; MDSpecialist Anaesthesiology
NMC hospital DIPDubai
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Acute pain
There is No Painthat can not be treated
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Common myth for acute pain Treatment
Oligo-analgesia
Analgesic may mask abnormal finding
Sever ain !ill cause abnormal vitals signs
Patient !ill be addicted to narcotics Patient !ill be sedate after narcotics
Some kind of ain can"t be relieved
Effective pain management can be done on SOS basis .
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Importance of Acute pain management
Pain control human right
Indicator of !uality of care
"ntreated pain ad#ersely affects other systems;
Physiological and psychological upset $ stress
"ntreated$poorly treated pain progress into chronic pain
Increased morbidity$ mortality$ cost$ %&S
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Conse!uences of poorly treated pain
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Pain Algorithm
Patient in Acute pain $anticipated postoperati#e pain
'rief pain Assessment(mergent use of opioid if clinical condition dictate
Comprehensi#e pain assessment
Appropriate Therapy)eferral
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)(%I(* Approach for Acute pain Treatment
)+ )ecord Pain before and after T,
(+ (#idence based treatment
%+ %oo- and listen to Patient+ 'elief your Patient
I+ In!uire if Patient need Pain Medicine (+ (ducate Staff
*+ *acilitate$*ormulate multidisciplinary APS
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Assessment$ .hich scale/
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0o. Acute Pain differ from Chronic
Pathology + clear 1s unclear
Duration + short
Mechanism+ adapti#e #s maladopti#e
Prognosis+ good 1s unpedictable
Treatment + simple #s comple,
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Acute 1s chronic pain; 0it fast and hit hard
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Changing concept of pain management
Traditional Modern concept
Palliate pain
Administered single analgesics
*i,ed dose of opioid
P)N or S&S analgesic
No protocol$ guideline for Acute
pain
Pre#ent pain
Multimodal analgesia
2udicious use of opioid
3indi#idualised4
Continuous $ )egularAnalgesics
Acute pain ser#ice+ Ad#ancedpain inter#entions; bloc-s
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Pain Path.ay and Analgesic Actions
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Treatment modalities
Non harmacologic
Pharmacologic
56Nonopioid
76&pioid
86Adju#ants
#nvasive interventions
$iagnose and treat as er underlying cause
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Nonpharmacologic pain management
Massage T(NS
Acupuncture
(,ercise 0eat$cold massage
Neurostimulation
Scrambler therapy
Dry needling 'eha#ioural
Cogniti#e
'iofeedbac-
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&pioids
'est a#ailable analgesics9 but not ideal
Act #ia different opioid receptors in brain9 spinal cord
and peripheral tissue6
Classified according to potency .ea- to strong
Choice of opioid depends on patient9 pain9 associated
conditions
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:here do opioid act /
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:ea- &pioid
Codeine prodrug;
metabolised to acti#e drug morphine #ia Cytochrome
5 population+ deficiency in con#erting en?yme; no action
Dihydrocodeine prodrug9 again a .ide #ariation in patientresponse6
Tramadol acti#e drug6 Dual action Mu agonist @ SSN)I
Penta?ocin$ butorphenol$buprenorphine partial agonist$
agonist antagonist ceiling analgesic effect
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Tramadol
Dual mode of action; opioid Mu agonist @ selecti#e serotoninand noradrenaline reupta-e inhibitor 3SSN)I46
(ffecti#e in mild to moderate pain
Can be gi#en IM9I19&ral good bioa#ailability
Can be combined .ith PCM9 NSAID
Dose in adult B5BB mg hrly; Ma, dose =BB mg in 7=
Dry mouth9 di??iness9 sedation in high dose
Nausea #omiting only if gi#en fast boluses6
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Strong opioid
Act directly $ no need to con#ert into acti#e form
Agonist at opioid receptors
0as dose dependent analgesic and other ad#erse effects
No ceiling effects to analgesia
:ide indi#idual dose #ariation
Di#erse route of administration
Morphine; pethidine9 fentanyl9 alfentanil9 sufentanil
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Morphine
A#ailable in #arious form; Consider as )eference opioid+
Initial dose B65B67 mg$-g
Metabolism li#er; 8B=B> oral bioa#ailability Metabolite Morphine 8 Elucoronide no analgesic
morhine glucoronide more analgesic than morphine
(limination+ )enal
&nset after I15B min9 pea- 5 hrs9 Duration+ = hrs
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Meperidine$ Pethidine
Synthetic opioid
Atropine li-e effect
Metabolism li#er
metabolite normeperidine CNS e,citation9
Antishi#ering action
Interaction .ith antidepressant9 SS)I; MA&I serotoninsyndrome 30TN9 rigidity9 hyperpyre,ia9 sei?ure9 Coma4
Psychiatric patients a#oid
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*entanyl
Synthetic opioid ; 5BB times more potent than morphine
Short duration; suitable for PCA or continuous infusion
0igh fast pass metabolism
Most cardiostable
%oading Dose57 mcg$-g; onset 8 min9 duration+8B=B min
A#ailable in #arious form+ lollipop9 lo?enge9 transdermal9intranasal spray9 Injectable
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&pioid precaution
0ypotension$ shoc-
CNS issues+ head injury9 delirium9 dementia9 psychiatric illness
Concomitant CNS depressant+ Alcohol $ drugs
%i#er$ -idney impairment
Morbidly obese9 &SA
)espiratory illness C&PD$'r Asthma 0$o drug addiction$abuse
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&pioid tolerance$ addiction$pseudoaddiction
)arely a problem in acute setting6
Tolerance+
Pseudo addiction+
Addiction+
Oioid induced hyeralgesia+
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Dra.bac- of opioids
Nausea $#omiting
'ladder$ bo.el function
Sedation+ delayed mobilisation; discharge
)espiratory+ &bstructi#e breathing9 Silent aspiration
Immuno suppressant effects .ould infection6
Cancer recurrence$ metastasis
Persistent postop pain into chronic pain
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Nonopioid Analgesics
Paracetamol NSAIDs
Adju#ants
*irst line drug therapy for any pain
(ffecti#e alone for mild to moderate pain
0ighly effecti#e .hen combined .ith opioids
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Acetaminophen and NSAIDS
*oundation for pain treatment protocol6
*irst on and last off
Sole agent in mild to moderate pain
8BB> opioid sparing effects
Analgesic efficacy has ceiling effects limiting factor
&pioid add on therapy .hen re!uire
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Paracetamol
Mechanism similar to NSAIDs but act centrally
Analgesic9 antipyretic9 but no antiinflamatory
Safest analgesic of all
Can be gi#en oral $ I1$ P)
5stline therapy in mild to moderate pain
Central part of MMA6
Ma, dose = gm in 7= hrs in adult 3BFB mg$-g in children4
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NSAIDS
Most e,tensi#ely used medicine in .orld in all age group
Analgesic9 antipyretic and antiinflammatory
NSAID related hospital admission
0igher the potency 3less amount re!uirement4 more to,ic
'roadly t.o sub class Co,5 and Co,7 inhibitor6
Combination of NSAIDS+ no benefit; Paracetamol @ NSAID+ additi#e effects
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NSAIDs selecti#ity
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NSAIDs+ side effects
EI side effects Salt G .ater retention
0epatoto,icity
Nephroto,icity 'leeding tendency
Prolongation of labour
Asthma and allergy
C1 ris-$ MI+ co,ib
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Adju#ants
T%A & SS'# & SN'# neuropathic pain .ith concomitantdepression
Anticonvulsant gabapentanoid
Muscle re(ant 3baclofen9 'HD4 relie#e muscle spasm
)idoderm herpetic pain
%alcitonin osteoprotic fracture pain
%orticosteroid tissue edema9 neuropathic pain
%entral symatholytic+ clonidine$ de,medetomidine
Potentiate * imrove analgesia reduce side effects
T.o Most impressi#e Adju#ants for
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T.o Most impressi#e Adju#ants foracute pain management
etamine
De,amethasone
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etamine
NM$A- antagonist
Antihyeralgesic+ anti-allodynic
Pre-emtive use- revent conversion into chronic ain
$issociative anaesthesia:, -. mg&kg/ 0the lights are on+
but no one is home1
Po!erful analgesia even in very lo! dose 23-234 mg&kg
Preserve haemodynamic& resiration
$isadvantages:mood+ cognition+ salivation+ nausea
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Comparable analgesia .ith B68 mg $-g -etamine1s
B65 mg$-g morphine for Short term pain relief in (D
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:hen to "se etamine/
&SA
Dose+ B65 mgB68 mg$g(ither as Sole agent or as Adju#ant to opioid
De,amethasone
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De,amethasoneAntiinflammatory$ anti emetic
I1 single dose B65 mg$-g at the time of induction
)educed postop pain score
)eduction in opioid consumption
)eduction in rescue analgesic
)A+ Intra#enous $ perineural de,amethasone
Prolonged sensory motor bloc-ade
Pre#ent neuroto,icity and rebound hyperalgesia6
'eg Anesth Pain Med3 .25 6ul-Aug782,8/:4.-93 r 6 Anaesth3 .247,./:9-.223 'eg Anesth Pain Med3 .25 Mar-Ar782,./:.5-4.3
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Inter#entions in Acute Pain
Continuous ner#e$ple,us bloc-
(pidural Analgesia 3%A@$ &pioid4
Intrathecal Analgesia
PCA Intra#enous$ epidural
Ne.er truncal bloc-ade+ 3Alternati#e to epidural4 TAP9 P1'9
J%'9 fascia trans#ersalis9 )ectus sheath9 P(CS
i l bl - f i
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)egional bloc- for acute pain
Superior !uality of analgesia
"ltrasound has re#olutionised regional bloc-
No major systemic side effects
1irtually eliminate opioid use
Can pro#ide continued analgesia
0igher patient satisfaction (arly ambulation$ discharge
Transdermal fentanyl iontophoresis
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Transdermal fentanyl iontophoresis3I&NSKS4
&ne of the ne.est ad#ancement6 Credit card si?e fentanyl reser#oir
Can be put in arm9 chest6
Programmable li-e PCA
"p to doses per hour
:or- for 7= hrs or upto B doses
Appro#ed by *DA in April; 7B5
Ket to be a#ailable in middle east
i l l d i i
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%iposomal encapsulated 'upi#acaine
MMA $ ) ti l l h
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MMA $ )ationale poly pharmacy
M lti d l A l i 3MMA4
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Multimodal Analgesia 3MMA4
T f i id i t P ti
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Transforming e#idence into Practice
('M Pro#en and e#aluated treatment Practice
('P transition of -no.ledge
no.ledge translation L 5< years
1arious sources of -no.ledge
:hy the Eap bet.een e#idence and practice
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:hy the Eap bet.een e#idence and practice
8 main cause of Eap in the !uality of pain caredeli#ery
560ealthcare professionals6
760ealth care system
86Patients
Problem related to healthcare professionals
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Problem related to healthcare professionals &ut of date or inade!uate attitudes and -no.ledge;
56 Pain control mas- recognition of surgical complications76 Surgery has to be associated .ith pain
86 Patient complaining pain+ fussy
Clinical inertia
Incomplete -no.ledge
*ear of side effects$ addiction
Problem related to health care system
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Problem related to health care system
)egulatory impediment
*ailure to capture short and long term !uality outcomes
Cost shifting to patients 3eg insurers4
Inade!uate e!uipment9 manpo.er or drug deli#ery system
Practice restriction9 3eg nurse are permitted only for im9 sc9 no
I1; use of narcotics 4
Problem related to patients
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Problem related to patients
&ut of date or mista-en ideas
'elief that nice patients do not complain of pain or suffering
*ear of side effects$ addictions
%ac- of a.areness of the importance of pain control
Tendency to be satisfied .ith inade!uate pain control
Acute Pain ser#ice
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Acute Pain ser#ice
Comprehensi#e pain ser#ices Multidisciplinary team
Anaesthesiologist based$
Nursed based anaesthesia super#ised
No consensus as to be best model
1ery .ide #ariation in APS structure
Most APS initially pro#ide postop $ trauma analgesia
APS acti#ities
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APS acti#ities
Appropriate selection of analgesic regimens
Standardized protocols and Guidelines
Advanced interventional techniques
Audit and quality improvement programs
Education
Summary+ Treatment modality for Acute Pain
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Summary+ Treatment modality for Acute Pain
Case 5
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Case 5
B year male )TA ;polytrauma
Multiple fracture
'rought in emergency
Agitated9 restless; disoriented
Complaining of se#ere pain
Issues
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Issues
CNS status
0aemodynamics
"n-no.n Comborbid illness
0o. to address pain
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0o. to address pain
&pioid not a good choice Acetaminophen safe if li#er function is o-
(pidural not a choice
NSAIDs difficult choice e#en )*T is normal
'est choice ner#e$ ple,us bloc-ade9 cont infusion
Case 7
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Case 7
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*IC'
Conclusion
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Conclusion
Assess pain properly 'elief your patient
Ne#er gi#e up
Multimodal analgesia techni!ue
Preempti#e analgesia
)egular analgesic Ereater use of regional analgesia
'e open to ne. ideas and embrace them
)eferences
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)eferences
56 Practice Euidelines for Acute Pain Management in the Perioperati#e Setting; An update reportby American Society of Anaesthesiology tas- force on acute pain management6Anesthesiology7B57; #ol 55; no 7
76 'londell )D9 A?adfard M and :isnies-i AM6 Pharmacologic therapy for acute pain6 Am *amPhysician6 7B58 2un 5;
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)eferences
6 Eambling D9 0ughes T9 Martin E9 0orton :9 Man#elian E6 A comparison of Depodur9 ano#el9 singledose e,tendedrelease epidural morphine9 .ith standard epidural morphinefor pain relief after lo.er abdominal surgery6 Anesth Analg6 7BB Apr;5BB3=4+5B