Acute Pain Management. Objectives/Discussion Topics Appropriate assessment of acute pain Appropriate...
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Transcript of Acute Pain Management. Objectives/Discussion Topics Appropriate assessment of acute pain Appropriate...
Acute Pain Acute Pain ManagementManagement
Objectives/Discussion Objectives/Discussion TopicsTopics
Appropriate assessment of acute painAppropriate assessment of acute pain Concept of multi-modal analgesiaConcept of multi-modal analgesia
Indications and side effects of analgesicsIndications and side effects of analgesics How to rationally prescribe opioidsHow to rationally prescribe opioids
side effects and complications of opioidsside effects and complications of opioids Special populations ie elderly, opioid Special populations ie elderly, opioid
toleranttolerant Neuraxial/regional analgesiaNeuraxial/regional analgesia
side effects and complications of neuraxial side effects and complications of neuraxial analgesiaanalgesia
interaction of various anticoagulant medications interaction of various anticoagulant medications and neuraxial analgesiaand neuraxial analgesia
GoalGoal
To provide patients with a level of pain To provide patients with a level of pain control that allows them to actively control that allows them to actively participate in recoveryparticipate in recovery This level will be individual to each patientThis level will be individual to each patient
To minimize nausea and vomitingTo minimize nausea and vomiting To minimize other side effects of analgesicsTo minimize other side effects of analgesics
SedationSedation IleusIleus WeaknessWeakness HypotensionHypotension
Why all the fuss?Why all the fuss?
Pain is a miserable experiencePain is a miserable experience Pain increases sympathetic outputPain increases sympathetic output
Increases myocardial oxygen demandIncreases myocardial oxygen demand Increases BP, HRIncreases BP, HR
Pain limits mobilityPain limits mobility Increases risk for DVT/PEIncreases risk for DVT/PE Increases risk for pneumonia, Increases risk for pneumonia,
atelectasis secondary to splintingatelectasis secondary to splinting
AssessmentAssessment
IntensityIntensity LocationLocation Onset Onset DurationDuration RadiationRadiation ExacerbationExacerbation AlleviationAlleviation
How do we do it?How do we do it?
Multimodal analgesia: Multimodal analgesia: Several analgesics Several analgesics with different mechanisms of action, each with different mechanisms of action, each working at different sites in the nervous working at different sites in the nervous systemsystem
AcetaminophenAcetaminophen Non-steroidal anti-inflammatory drugs (NSAIDs)Non-steroidal anti-inflammatory drugs (NSAIDs) OpioidsOpioids AnticonvulsantsAnticonvulsants AntidepressantsAntidepressants Local anaestheticsLocal anaesthetics NMDA AntagonistsNMDA Antagonists Non-pharmacologic methodsNon-pharmacologic methods
OPIOIDSOPIOIDS Efficacy is limited by Side-Efficacy is limited by Side-
EffectsEffects The harder we “push” with single mode The harder we “push” with single mode
analgesia, the greater the degree of side-analgesia, the greater the degree of side-effectseffects
Analgesia
Side-effects
Multimodal AnalgesiaMultimodal Analgesia Lower doses of each drug can be used Lower doses of each drug can be used
therefore minimizing side effectstherefore minimizing side effects With the With the multimodal analgesic approachmultimodal analgesic approach
there is additive or even synergistic analgesia, there is additive or even synergistic analgesia, while the side-effects profiles are different while the side-effects profiles are different and of small degree and of small degree (Pasero & Stannard, 2012)(Pasero & Stannard, 2012)..
Analgesia
Side-effects
Systemic AnalgesiaSystemic Analgesia
OpioidsOpioids Potent analgesicsPotent analgesics Drug of choice for moderate to severe Drug of choice for moderate to severe
painpain Unfortunately, they are often the Unfortunately, they are often the onlyonly
drug ordereddrug ordered Side effects:Side effects:
OpioidsOpioids
10 fold variability 10 fold variability betweenbetween patients patients All opioids have same side effects but All opioids have same side effects but
efficacy:side effect ratio is different for efficacy:side effect ratio is different for everyoneeveryone
Stick with what works and keep it Stick with what works and keep it simplesimple
Always by mouth if possibleAlways by mouth if possible Avoid pro-drugs ie. codeineAvoid pro-drugs ie. codeine Avoid combo preparationsAvoid combo preparations
EquianalgesiaEquianalgesia
OpioidOpioid POPO Parenteral Parenteral (IV/SC)(IV/SC)
MorphineMorphine 10 mg10 mg 5 mg5 mg
CodeineCodeine ~ 60-100mg ~ 60-100mg (4-fold (4-fold
variability)variability)
N/AN/A
HydromorphoHydromorphonene
2 mg2 mg 1 mg1 mg
OxycodoneOxycodone 5 mg5 mg N/AN/A
NALOXONE (Narcan)NALOXONE (Narcan)
Mu opioid antagonistMu opioid antagonist Dilute 1 mL of naloxone 0.4 mg/mL Dilute 1 mL of naloxone 0.4 mg/mL
(ie. one vial) with 9 mL of NS for a (ie. one vial) with 9 mL of NS for a total of 10 mL of solution and a final total of 10 mL of solution and a final concentration of 0.04 mg/mLconcentration of 0.04 mg/mL
Administer 0.04 mg at a time until Administer 0.04 mg at a time until reversal of respiratory depression reversal of respiratory depression has been achieved, ie. when they’re has been achieved, ie. when they’re sitting up awake and talking to you!sitting up awake and talking to you!
NALOXONE (Narcan)NALOXONE (Narcan)
REMEMBER: the half-life of REMEMBER: the half-life of naloxone is only 30 minutes, while naloxone is only 30 minutes, while the half-life of opioid is 2-3 hr so you the half-life of opioid is 2-3 hr so you may have to repeat dosing OR place may have to repeat dosing OR place pt on naloxone infusion until all pt on naloxone infusion until all opioid has been metabolized to opioid has been metabolized to prevent further respiratory prevent further respiratory depressiondepression
Elderly PatientElderly Patient
Pronounced effect therefore, lower Pronounced effect therefore, lower dosesdoses
Cognitive dysfunction is a major Cognitive dysfunction is a major issueissue
Organ dysfunction/insufficiency Organ dysfunction/insufficiency affects metabolismaffects metabolism
Interaction with other medications, Interaction with other medications, increased incidence of polypharmacyincreased incidence of polypharmacy
AddictionAddiction
Primary, chronic, neurobiologic Primary, chronic, neurobiologic disease, with genetic, psychosocial, disease, with genetic, psychosocial, and environmental factors influencing and environmental factors influencing its development and manifestations. its development and manifestations.
Characterized by behaviors that Characterized by behaviors that include one or more of the following: include one or more of the following: impaired control over drug useimpaired control over drug use compulsive use compulsive use continued use despite harmcontinued use despite harm cravingcraving
Definitions Related to the Use of Opioids for the Treatment of Pain. American Academy of Pain Medicine; American Pain Society; American Society of Addiction Medicine. 2001.
Physical DependencePhysical Dependence
SState of adaptation that is tate of adaptation that is manifested by a drug class-specific manifested by a drug class-specific withdrawal syndrome that can be withdrawal syndrome that can be produced by abrupt cessation, rapid produced by abrupt cessation, rapid dose reduction, decreasing blood dose reduction, decreasing blood level of the drug, and/or level of the drug, and/or administration of an antagonistadministration of an antagonist
ToleranceTolerance
The body's physical adaptation to a The body's physical adaptation to a drug: drug: Greater amounts of the drug are Greater amounts of the drug are
required over time to achieve the initial required over time to achieve the initial effect as the body adapts to the intakeeffect as the body adapts to the intake
Pseudo AddictionPseudo Addiction
Term used to describe patient behaviors Term used to describe patient behaviors that may occur that may occur when pain is undertreatedwhen pain is undertreated
May become focused on obtaining May become focused on obtaining medications, "clock watch," seem medications, "clock watch," seem inappropriately "drug seeking." inappropriately "drug seeking."
Illicit drug use and deception can occur in Illicit drug use and deception can occur in the patient's efforts to obtain relief the patient's efforts to obtain relief
Distinguished from true addiction in that the Distinguished from true addiction in that the behaviors resolve when pain is effectively behaviors resolve when pain is effectively treated.treated.
NSAIDSNSAIDS
Work at site of tissue injury to prevent Work at site of tissue injury to prevent the formation of the nociceptive the formation of the nociceptive mediators Prostaglandinsmediators Prostaglandins
Can decrease opioid use ~30% Can decrease opioid use ~30% therefore decreasing opioid-related therefore decreasing opioid-related side effectsside effects
Minor surgeries can use NSAIDs Minor surgeries can use NSAIDs instead instead of opioids to completely of opioids to completely eliminate opioid-associated side effectseliminate opioid-associated side effects
Side effects:Side effects:
NSAIDSNSAIDS
Newer NSAIDS selectively Newer NSAIDS selectively (primarily) inhibit cyclooxygenase-2 (primarily) inhibit cyclooxygenase-2 (COX-2) which is induced by surgical (COX-2) which is induced by surgical trauma with minimal effect on COX-trauma with minimal effect on COX-1 which is responsible for GI and 1 which is responsible for GI and platelet side effectsplatelet side effects Celecoxib (Celecoxib (CelebrexCelebrex))
Neuraxial TechniquesNeuraxial TechniquesWho Gets Them?Who Gets Them?
Patient factors:Patient factors: Low pain tolerance, opioid tolerance Low pain tolerance, opioid tolerance Sleep apnea Sleep apnea Narcolepsy Narcolepsy Obesity Obesity COPDCOPD Cardiac disease Cardiac disease Elderly – those at risk for post-operative Elderly – those at risk for post-operative
cognitive dysfunctioncognitive dysfunction
…………..
Epidural InfusionsEpidural Infusions
Used for major surgery ie. oncologic Used for major surgery ie. oncologic TAH BSO, thoracotomy TAH BSO, thoracotomy
Ideally placed pre-operatively and Ideally placed pre-operatively and used in combination with a GA for used in combination with a GA for surgery and continued ~ 2 dayssurgery and continued ~ 2 days
Usually patient is tolerating diet and Usually patient is tolerating diet and ambulation to chair when epidural is ambulation to chair when epidural is D/CD/C
Ideal Epidural InfusionsIdeal Epidural Infusions When placed at the level of the incision and with a When placed at the level of the incision and with a
constant infusion of LA and opioid:constant infusion of LA and opioid: Minimal or no pain at all, particularly with movementMinimal or no pain at all, particularly with movement No motor blockNo motor block
Can ambulateCan ambulate Speedier return of bowel function Speedier return of bowel function
With more LA and less opioid –Cochrane review 2003With more LA and less opioid –Cochrane review 2003 Less nauseaLess nausea Less sedationLess sedation Less deleriumLess delerium Do not require supplemental IV opioids and associated Do not require supplemental IV opioids and associated
side effectsside effects Less pulmonary complicationsLess pulmonary complications
Quicker extubation, better oxygen saturation, less pneumonia Quicker extubation, better oxygen saturation, less pneumonia
Side Effects of Epidural Side Effects of Epidural Infusions Infusions
HypotensionHypotension LA causes a sympathectomy which LA causes a sympathectomy which
leads to vasodilatationleads to vasodilatation Mild volume depletion, which can Mild volume depletion, which can
normally be compensated for with normally be compensated for with vasoconstriction, will be unmasked with vasoconstriction, will be unmasked with an epiduralan epidural
Pts require adequate volume status Pts require adequate volume status with an epiduralwith an epidural
Side EffectsSide Effects HypotensionHypotension
Pts will initially c/o dizzyness, Pts will initially c/o dizzyness, lightheadedness and nausea when sitting lightheadedness and nausea when sitting up or standingup or standing
Can document orthostatic hypotensionCan document orthostatic hypotension Will then progress to supine hypotension Will then progress to supine hypotension
if not correctedif not corrected Major problem POD #1 when 3Major problem POD #1 when 3rdrd spacing spacing
still occurring, minimal IV fluids infusing still occurring, minimal IV fluids infusing and pt NPOand pt NPO
Side EffectsSide Effects
Leg weakness or numbnessLeg weakness or numbness Can occur if catheter is too low (low thoracic Can occur if catheter is too low (low thoracic
or lumbar) or if it is one-sidedor lumbar) or if it is one-sided Inhibits ambulation and distressing to pt Inhibits ambulation and distressing to pt
therefore must be fixedtherefore must be fixed Infusion can be adjusted or catheter pulled Infusion can be adjusted or catheter pulled
backback Must be addressed as this is the first sign Must be addressed as this is the first sign
of epidural hematoma leading to of epidural hematoma leading to permanent paralysis permanent paralysis
ComplicationsComplications
Post dural puncture headache 1:100Post dural puncture headache 1:100 Only if dura is unintentionally Only if dura is unintentionally
puncturedpunctured More likely in younger peopleMore likely in younger people
InfectionInfection Some reports of epidural abscess as Some reports of epidural abscess as
high as 1:1900high as 1:1900 Usually just superficial skin infectionsUsually just superficial skin infections Increased risk in immunosuppressed Increased risk in immunosuppressed
ComplicationsComplications
Epidural hematomaEpidural hematoma Most feared complicationMost feared complication Incidence of 1:180 000 – 1:220 000Incidence of 1:180 000 – 1:220 000
Increased with heparin, age, gender, ASA, Increased with heparin, age, gender, ASA, NSAIDs, traumatic placement, spinal stenosisNSAIDs, traumatic placement, spinal stenosis
Leg weakness, numbness and Leg weakness, numbness and bladder/bowel disturbance are first signsbladder/bowel disturbance are first signs
If not evacuated within 8-12 hours, usually If not evacuated within 8-12 hours, usually leads to permanent paralysisleads to permanent paralysis
ComplicationsComplications
Epidural HematomaEpidural Hematoma RisksRisks
Abnormal coagulationAbnormal coagulation ElderlyElderly FemaleFemale Debilitated patientsDebilitated patients Traumatic insertionTraumatic insertion Unknown spinal pathologyUnknown spinal pathology
ComplicationsComplications
Anticoagulation and Epidurals:Anticoagulation and Epidurals: ASA – OKASA – OK NSAIDS – OKNSAIDS – OK UFH 5000 sc bid – OK if no other antiplateletsUFH 5000 sc bid – OK if no other antiplatelets UFH 5000 sc tid – sort of OK, but not really UFH 5000 sc tid – sort of OK, but not really
(according to ASRA)(according to ASRA) LMWH (Dalteparin)– increased risk – not really LMWH (Dalteparin)– increased risk – not really
OKOK IV heparin – not OKIV heparin – not OK Clopidigrel, ticlodipine – not OK Clopidigrel, ticlodipine – not OK Coumadin – not OK Coumadin – not OK
Ideal Patient CareIdeal Patient Care
Surgeons, APMS, nursing all Surgeons, APMS, nursing all working for same goalworking for same goal
Pre-operative optimizationPre-operative optimization Intra-operative careIntra-operative care Post-operativePost-operative
Ambulation, pain, bowels, voidingAmbulation, pain, bowels, voiding
Improved patient recoveryImproved patient recovery
Acute Pain Management Acute Pain Management Service (APMS)Service (APMS)
Consulting service, mostly post-op patientsConsulting service, mostly post-op patients PCAs, non-labour epidurals, regional PCAs, non-labour epidurals, regional
techiquestechiques Don’t need to co-sign our ordersDon’t need to co-sign our orders Can’t order any analgesics, anti-emetics, Can’t order any analgesics, anti-emetics,
antihistamines, neuropathic pain agents, or antihistamines, neuropathic pain agents, or sedatives while patient being followed by sedatives while patient being followed by APMSAPMS
““Suggest Orders” once APMS signs off DO Suggest Orders” once APMS signs off DO need to be co-signedneed to be co-signed