2 Management of Pain a New Standard in Clinical Practice

8/14/2019 2 Management of Pain a New Standard in Clinical Practice

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Management of Pain:

A New Standard In ClinicalPractice

Suggested Guidelines for Compliancewith the New Standard & Improved

Patient Care

Pain as a Vital Sign!!!


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Why Have a Standardfor Management of Pain?

! Most patients experience acute or chronic pain atsometime during their life

! Pain is an indication of injury, pathologicconditions, or disease

! Management of pain reduces stress and providesimproved patient comfort

! Management of pain is a humane concept

! Management of pain is good medicine


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Management of Animal Pain

is a Global Concern of:! Animal Healthcare Professionals

! Animal Owners! Animal Care Providers (trainers, handlers,

ranchers, breeders " .)

! Any Concerned Humanitarians! The General Population of the World


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Stress & Pain are Multi SpeciesConcerns


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Pain assessment is considered part of every patientevaluation regardless of the presenting complaint

Step One


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! By careful examination of each patient, weare able to determine if there are any

conditions that may exist which are

painful.

! Even if it is an elective procedure, we need

to know that the patient is free of painbefore surgery or other medical

involvement takes place.


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Pain as a Vital Sign

Patient evaluation based on:

! Temperature

! Pulse (heart rate)

! Respiratory rate

! Blood pressure(in humans, but lessoften in animals)

! Pain


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! Pain assessment using a standardized scale orscoring system is recorded in the medical recordfor every patient evaluation

Pain Scores:!

Physiological parameters TPR (traditional measurements)

! Sensitivity measurements

Pain scales such as:

No Pain Mild Moderate Severe Pain

0------1------2------3------4------5------6------7------8------9------10

Step Two


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Factors Influencing Pain Scores

! Change in temperament

! Increased vocalization

! Abnormal posture

! Altered locomotion

! Other behavioralchanges


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Step Three

! Pain management is individualized for eachpatient

All patients are not alike, not even within the same species or even within the same breed nor do they respond the same.


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Threshold & Responseto Pain Varies

Species

Breed

Age

Health Status

Professional Concept: Animals have pain = Treat it


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! The practice utilizes preemptive pain management

Preemptive Medication Anesthetic Induction

Step Four


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! The practice of veterinary medicine in our clinicsand hospitals now utilizes preemptive painmanagement.

! This consists of the administration of apreanesthetic, normally a sedative or analgesicprior to induction of anesthesia for surgical andother procedures involving painful conditions.

! Utilizing preemptive measures before a painful

stimulus is elicited in the patient, will reduce theamount of medication necessary to control painby avoiding the build up of pain responses.


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! Purposeful

! Short duration

! Responsive totreatment

Acute Pain (trauma, surgery)

PNS CNS

A delta &C fibers

A : ! fibers

Acute Pain(protection)

NociousSensation

High Intensity Stimulus

Low Intensity Stimulus


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As illustrated on the previous slide Acutepain is the type that can be present either during

surgery without adequate pain management orfollowing trauma.

In the awake patient, acute pain elicits a

purposeful response which is of short duration.Whenever the pain sensation occurs, there is a high-intense stimulus which affects A-delta and C-bers inthe peripheral nervous system.

There is a related acute pain response in thecentral nervous system. The pain response to lowintensity stimulation, is to the alpha-beta bers. Werefer to this as a noxious sensation.


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! Appropriate pain management is provided for theanticipated level and duration of pain

Chronic

Step Five

Acute

vs.


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The administration of analgesics for 5 to 7

days after surgical correction in cases of injury is

usually adequate to control acute pain. The level of

pain has dropped by that time and further use of

potent analgesics is usually not needed.

In contrast, in chronic pain such as in cancer,

the level of pain may not be as immediately obvious,

but we can anticipate that it will be of long duration

and may become more severe.

As a result, extended measures for the

treatment of chronic pain are necessary.


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Treatment Related toSeverity of Animal Pain

Mild! NSAID's! Steroids! Local anesthetics

! Physical therapy

Moderate

! Opioid agonists! Opioid agonists/antagonists! Alpha 2 agonists

Severe: treatable

! Potent opioids with/withoutconcurrent medications

! Permanent nerve blocks

Neurectomies

Implantable opioid pump

Severe:uncontrollable

! Euthanasia


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There is a fourth part of the treatment ladder of mild,

moderate, severe, and severe uncontrollable pain which we

can use in veterinary medicine. This is in contrast to the

three-part ladder which is used in treatment of people. In

humans, in some cases there is severe unmanageable pain

in the patient. Quality of life for the patient is unbearable.

There is a need for further management. In

veterinary medicine; we have an answer. The use of high-

doses of analgesics with or without an anesthetic to the

point of loss of vital functions. Some may refer to it as

euthanasia. We consider this as the FINAL step in the

treatment of uncontrollable severe pain and suffering .


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Step Six

P N

! Pain management accompanies all surgicalprocedures


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Pain management should accompany all

surgical procedures from either minor to majorsurgery.

This was more obvious to us in the past, to

prevent pain during the perioperative and post-

operative periods for major surgical procedures .

We have now found that pain management for

elective procedures, thus reducing stress during

surgery and enhancing recovery of the patient to

return to normal activities.


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! Balanced perioperative management

Step Six (cont.)


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Balanced Analgesia! Similar to balanced anesthesia, also

referred to as multimodal analgesia

! Combination of complimentary methods

or drug classes! Maximize effectiveness and minimize

side effects

Analgesics Anesthetics

P N


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Step SevenThe patient is reassessed for evidence of pain throughout any

procedure that has the potential to cause patient discomfort

We are able to adjust anesthetic concentrationsand adjunct medications .


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Systems Affectedby Pain need to be evaluated

! Neurological

! Cardiovascular

! Respiratory! Skeletal

! Digestive

! Urinary

! Endocrine


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Many systems are affected by pain, they should be evaluated

during all procedures. These include:

Neurologic Skeletal

ardiovascular Digestive

Respiratory UrinaryPain or inadequate analgesia during a surgical procedure can

change heart rates and blood pressure. It can affect the

respiratory responses. Inadequate management during the

perioperative procedure may compromise the skeletal

muscles. When there are responses from inadequate

perioperative analgesia, the peripheral and central nervous

system parameters will be stimulated.


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Post-operatively, normal digestion and urinary

function will return to a stabilized levels more rapidly if we

have provided the appropriate level of pain management. Ifduring the process of painful procedures, inadequate

management of pain exists, there will be an increase in the

secretions by the endocrine system. These include:

epinephrine

norepinephrine

cortisol

The elevation of these parameters has been shown

in research to be an index of inadequate management of

painful conditions.


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! Patients with persistent or recurring conditions such asperiodontal disease, pancreatitis, neoplasia,osteoarthritis, and otitis are evaluated to determinetheir pain management needs

Step Eight


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! Non-purposeful

! Long-standing

! Less responsive to treatment

! Physiologically different

Chronic Pain(osteoarthritis, cancer, chronic otitis)

Pathological Pain:


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In chronic pain, there are certain indicators that

this is a pathological condition. These conditions maybe induced by:

Following traumatic conditions which do not

heal properly or in which there are long-term effects,chronic pain may often develop. Inammatory painwhich is not controlled will escalate into a chroniccondition. This is seen in cases of osteoarthritis.


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Pathological Pain

Mechanical Inflammatory Traumatic


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Low IntensityStimulus

Pathological Pain

Hyperalgesia

Allodynia

Tissue Damage, Inflammation

Sensitizing Soup

of Neuropeptides

Stimulation ofHigh & Low Threshold

A delta & C fibers

Transduction Sensitivity

Stimulation ofLow Threshold

A: ! fibers

Mechanical

Inflammatory

Traumatic


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As illustrated on the previous slide, in chronic pain there are

mechanical, inammatory, and traumatic pathways. When thesefactors cause a stimulation to the nervous system due to tissue

damage and inammation, we have a condition that is called

sensitizing soup of neuropeptides. This is due to stimulation of

high and low threshold A-delta and C bers. It produces a condition

of hyperalgesia. Under these conditions, the patient is extremely

distressed.

Chronic low intensity stimulation of low threshold alpha-

beta bers, causes a transduction sensitivity and a condition

referred to allodynia.


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Chronic Pain:Needs careful evaluation & extended management


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Pain Management Protocol

in Osteoarthritis! Diagnosis and evaluation of pain

! Nutrition and weight control! Exercise and physical therapy! NSAID therapy! Surgical correction


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! Analgesic therapy is used as a tool to confirm theexistence of a painful condition when pain issuspected but cannot be confirmed by other objectivemethods

Systemic

Step Nine

vs.

Regional Analgesics


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Analgesic therapy can be used as a tool to confirm

the existence of pain, when pain symptoms are observed

but cannot be confirmed by other objective methods.

This can be done systemically by evaluating the

patient for undesirable changes in the neurologic,

cardiovascular, and respiratory parameters.

Using regional analgesics, one can diagnose the

location of pain in the extremities. The patient is evaluated

for pain levels before and after joint or local nerve blocks.


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CAUTION! Pain induces neurological activity, which will

increase arterial blood pressure & heart rate

! It also creates stress &its related impact onfunction

! It causes changes intemperament


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What Is Your Diagnosis?

Intense Pain or Biting Dog!


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Step Ten! A written pain management protocol is utilized

and addresses

1) Methods for preemptive control of pain

2) Events or circumstances known to beassociated with pain

3) Means by which pain and the degree of paincan be recognized in patients

4) Names and actions of medicationsdispensed, prescribed, or administered forpain management


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Step Ten (cont.)! A written pain management protocol is utilized &

addresses

5) Side effects, complications, concurrent druginteractions, and contraindications associated with

specific analgesics and general pain management6) Ancillary methods for treating pain, such as massage

and warm or cold compresses

7) How practice team members are trained to identify

causes, level of pain, and medications and methodsto control pain

8) How clients are taught to recognize signs of pain intheir pets


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Classes of Pain Medications

! Local anesthetics

! Corticosteroids

! Non-steroidal anti-inflammatory drugs

! Alpha 2 agonists

! Opioid agonists(agonist-antagonists)

! Others including anticonvulsants


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Local Anesthetics for examplemay be used for regional analgesia


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Corticosteroidsmay be used in inflammatory mediated pain


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! Corticosteroids have been used in the pastand currently in selective conditions.

! They may be used orally, or by injection

for systemic relief of pain.

! Regional benets such as intra-articularinjections may be advantageous.

! Should not be used concurrently withNSAIDs

N S id l


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Non SteroidalAnti-Inflammatory Drugs:

Commonly used in humans

Frequently used in animals


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! Nonsteroidal anti-inflammatory drugs werecommonly used in humans for many years.

! We now have many nonsteroidal anti-inflammatory medications which have been

proven to be very effective in small and largeanimals.

! The use of these medications can be verybeneficial in both acute and chronicinflammatory pain brought on by injury orvarious disease processes.


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Available NSAIDs

! Carprofen! Deracoxib! Etodolac! Firacoxib! Mavacoxib! Meclofenamic Acid! Meloxicam! Robenacoxib! Tolfenamic Acid

Rimadyl

Deramaxx

Etogesic

Previcox or Equioxx

Trocoxil

Meclofenamic AcidMetacam

Onsior

Tolfedine

Also Known As Trade Names Generic


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Alpha 2 Agonists:use for sedation & analgesia


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! Alpha 2 agonists have been used for sedation andanalgesia in horses. In more recent years thedevelopment of xylazine, medetomidine,dexmedetomidine for sedation and/or analgesia inthe small animals was sucessful.

! They can be part of the management of the patientwhen predominantly sedation with analgesia isneeded, as premedication, or as part of post-surgicalpain management.

! The combination of the alpha2 agonist with injectable

anesthetics will reduce anesthetic dosagerequirements, can improve the quality of analgesiaand prolong the effect of the anesthetic.

O i id i i


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Opioid Agonist Antagonist:May be used in mild to moderate pain


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Currently Available Agonist-Antagonists

Butorphanol *

Pentazocine

Nalbuphine

Buprenorphine **

(partial mu agonist)

Naloxone (antagonist)

* Marketed in Europe as Butomidor ** Marketed in Europe as Bupaq

O i id Ag i t


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Opioid Agonists:Are used in moderate to severe pain

Pentobarbital may be used in conjunction with opioids in severeuntreatable pain in terminal cases.

*It is also a Schedule II substance, but not an opioid.


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! Opioid agonists are more effective for use inmoderate to severe pain than the opioidagonist-antagonist.

! Included in this group are the morphine-likeopioids and those newly developed which areeffective with less side effects.

! Either opioid agonists or agonist-antagonist

reduce anesthetic requirements for effectiveperioperative pain management.


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Currently Available Opioids *

* Will Vary By Country ** To Replace Traditional Opioids

Fentanyl Morphine

Hydrocodone Oxycodone

Hydromorphone Oxymorphone

Meperidine Remifentanil

Methadone

Sufentanil

Tramadol **

P i R d


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Patient RecordsShould Include Pain Issues

! Pain scores

! Controlled substances

! Financial

! Discharge instructions

! Signs

! Diagnosis

! Treatments

! Prognosis


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Doctor/ Staff Relationsin Pain Management

! Understanding

! Communicating

! Involving

! Supporting

K F i D l i


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You should :

! Discuss the symptoms of discomfort &pain with the staff

! Have a treatment plan to manage pain

! Involve the client in the treatment program

! Provide follow up information

Key Factors in Developinga Management Protocol


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Step Eleven! In cases where pain management is part of the

therapeutic plan, the client is effectively educated, inwriting and verbally, regarding medical issues suchas potentially beneficial and adverse effects of thetherapy ! Expected responses &

benefits! Signs of ineffective pain

management therapies

! Anticipated side effects! Client responsibilities! Follow up communication

& re-evaluation


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Buck- AdenocarcinomaA Sample Case Management Protocol


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! Labrador Retriever

! 8 year old castrated male

! Weight 45.4 kg! Vital signs normal,

no evidence of pain

! Behavior: friendly & alert

! Routine rectal exam revealed rough, palpable mass

Case Study


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! Buck was presented to the referring veterinarianfor routine physical examination and annualhealth care

! He was asymptomatic and not showing outwardsigns of pain or disease on 2/14/02

Case Study


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! 02/26/02! Colonoscopy - rectal biopsy by referring

veterinarian

! Routine recovery

Pre-Op Medication AcepromazineButorphanol

AnestheticInduction

DiazepamKetamine

AnestheticMaintenance

Isoflurane (1 hr)

Anesthetic/ Analgesic Protocol


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Histological Findings

! Path # 02-608 DB(completed UTCVM/McEntee)

! Diagnosis:Colorectal adenocarcinoma

! Comments:These tumors oftenmetastasize via thelymphatics

R di hi /


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! Ultrasonic examof abdomen

" No evidenceof metastasis

! Ultrasonic examof thorax

" No evidenceof metastasis

! Cleared for surgical removal of primary rectal tumor

Radiographic/Imaging Diagnostics


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03/20/02

EVENT DRUG/DOSE TIMEPremedication Fentanyl patch (50 g) 08:30

Acepromazine (0.01 mg/kg) 13:07

Hydromorphone (0.05 mg/kg) 13:07

Glyopyrrolate (0.01 mg/kg) 13:07

Induction Propofol (4.5 mg/kg) to effect 14:13

Maintenance Isoflurane (2.0-2.5% settings) 16:10

Perioperative AnestheticManagement for Mass Removal


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Perioperative Pain Management! Epidural Technique! Bupivicaine (0.5%) 3 cc! Morphine (1 mg/ml) 3 cc

(total volume limited to 6 cc)

S


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Heart rate, blood pressure & respiratory rate remainedwithin clinically acceptable values during the entire

procedure. The pain scores were within the desirable

range.

Surgery

P t ti P i


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EVENT DRUG DOSE(mg/kg IV )

TIME

Extubation Hydromorphone 0.05 16:45

Recovery roomanalgesics

Hydromorphone 0.05 20:00

Hydromorphone 0.05 24:00

Fentanyl patch: 50 g still in place

No further analgesics required

Postoperative PainManagement Protocol

P i Di h


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! Date: 03/23/02! 3 days post surgery

! Pain medicationdiscontinued, fentanyl patchremoved

! Buck not showing evidence

of pain! Clavamox antibiotic

15 mg/kg BID for 7 days

! Buck at release doing well

Patient Discharge


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L e t s k i c k t h e p a i n

o u t o f a c u t e a n

d

c h r o n i c

c o n d i t i o n s .

Buck!

A recoveredcancer patient!


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Management of animal pain is encouraged by theInternational Veterinary Academy of Pain

Management

Animal Pain is a GLOBAL Concern!

Provided by Charles E. Short DVM, PhD


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y ,Emeritus Professor of Anesthesiology & Pain Management,

Cornell University

Center for the Management of Animal PainUniversity of Tennessee

Prepared using the accreditation standards of the American Animal

Hospital Association, Copyright 2012

2 Management of Pain a New Standard in Clinical Practice

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