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DR FATMA AL DAMMAS
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DR FATMA AL DAMMAS
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The management of pain is a multidisciplinary team effort involving physicians, psychologists, nurses, and
physical therapists.
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
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Anesthesiologists are physicians and are experts in the diagnosis and
treatment of acute and chronic pain disorders.
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
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Causes of Post-Operative PainCauses of Post-Operative Pain
• incisional skin and subcutaneous tissue• deep cutting, coagulation, trauma • positional bed sore, nerve compression & traction• IV site needle trauma, extravasation, venous irritation• tubes drains, nasogastric tube, ETT• respiratory from ETT, coughing, deep breathing• rehab physiotherapy, movement, ambulation• surgical complication of surgery• others cast, dressing too tight, urinary retention
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CAUSES OF VARIATION IN ANALGESIC CAUSES OF VARIATION IN ANALGESIC REQUIREMENTSREQUIREMENTS
• Site and type of surgery• Age, gender • Psychological factors • Pharmacokinetic variability• Pharmacodynamic variability
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Site and type of surgery
• general upper abdominal surgery produces greater pain than lower abdominal surgery
• operation on the richly innervated digits associated with severe pain.
• The type of pain differ with different types of surgery.
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Age, gender and body weight• analgesic requirements of males and females are
identical for similar types of surgery.
• There is a reduction in analgesic requirements with
advancing age.
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Psychological factors
• The patient’s personality affects pain perception and response to analgesic drugs.
• Patients with a less anxiety exhibit less postoperative pain and require smaller doses of opioid than patients who rate highly on anxiety scales.
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TREATMENT OF PAINTREATMENT OF PAINGOALS OF THERAPYGOALS OF THERAPY
• Decrease the frequency and / or severity Decrease the frequency and / or severity of the painof the pain
• General sense of feeling betterGeneral sense of feeling better• Increased level of activityIncreased level of activity• Return to workReturn to work• Decreased health care utilizationDecreased health care utilization• Elimination or reduction in medication Elimination or reduction in medication
usageusage
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
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PainPain
• Pain is subjective and difficult to quantify
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PAINPAIN
• An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.( International association of study of pain)
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CLASSIFICATION OF PAINCLASSIFICATION OF PAIN
S U P E R F IC IA L D E E P
S O M A TIC
TR U E V IS C E R A L TR U E P A R IE TA L R E F E R E D V IS C E R A L R E F E R E D P A R IE TA L
V IS C E R A L
A C U TE
D E A F F E R E N TA TIO NP A IN
S Y M P A TH E TIC A L L YM E D IA TE D P A IN
C H R O N IC
P A IN
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TYPES OF PAINTYPES OF PAINAccording to durationAccording to duration
Acute
Chronic
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TYPES OF PAINTYPES OF PAINAccording to PathophysiologyAccording to Pathophysiology
• Nociceptive;
Due to activation, sensitization of peripheral nociceptors.
• Neuropathic:
Due to injury or acquired abnormalities of peripheral OR central nervous system.
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TYPES OF PAINTYPES OF PAINAccording to EtiologyAccording to Etiology
• Post operative
OR • cancer pain
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TYPES OF PAINTYPES OF PAINAccording to Type of the organ affectedAccording to Type of the organ affected
–Toothache
–Earache
–Headache
–Low backache
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PAINPAIN PATHWAYPATHWAY
12 3
4
1.Transduction-changing of the noxious stimuli in sensory nerve ending to impulse.
2.Transmission-movement of impulse from site of transduction.
3.Perception –recognizing, defining and responding.
4.Modulation-involves activation of the descending pathway that exert inhibitory effect on pain transmission.
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ACUTE PAINACUTE PAIN
• Caused by noxious stimulation due to injury, a disease process or abnormal function of muscle or viscera
• It is nearly always nociceptive• Nociceptive pain serves to detect, localize
and limit the tissue damage.
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TYPES OF ACUTE PAINTYPES OF ACUTE PAIN
• Somatic OR
• Visceral
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SOMATIC PAINSOMATIC PAIN
• SuperficialOR
• Deep
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SUPERFICIAL SOMATIC PAINSUPERFICIAL SOMATIC PAIN
• Nociceptive input from skin, sub-cutaneous tissue and mucous membranes
• Well localized and described as sharp, pricking, burning and throbbing
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DEEP SOMATIC PAINDEEP SOMATIC PAIN
• Arise from Muscles, Tendons and Bones• Dull, aching quality and is less well
localized• Intensity and Duration of stimulus affects
the degree of localization
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VISCERAL PAINVISCERAL PAIN
• Due to disease process, abnormal function of internal organ or its covering e.g Parietal pleura, Pericardium or Peritoneum
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SUBTYPES OF SUBTYPES OF VISCERAL PAINVISCERAL PAIN
– True localized visceral pain
– Localized parietal pain– Referred Visceral pain– Referred parietal pain
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TRUE VISCERAL PAINTRUE VISCERAL PAIN
• Dull, diffuse and in midline• Frequently associated with abnormal sympathetic
activity causing nausea, vomiting, sweating and changes in heart rate and blood pressure.
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PARIETAL PAINPARIETAL PAIN
• Sharp, often described as stabbing sensation either localized to the area around the organ or referred to a distant site.
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PATTERNS OF REFERRED PAINPATTERNS OF REFERRED PAIN
Lungs T2 – T6
Heart T1 –T4
Aorta T1 –L2
Esophagus T3 – T8
Pancreas & Spleen T5 –T10
Stomach, liver and gall bladder T6 –T9
Adrenals T6 – L1
Small intestine T6 – T9
Colon T10 – L1
Ureters T10 – T12
Uterus T11 – T12
Bladder and prostate S2 – S4
Urethra & Rectum S2 – S4
Kidneys, Ovaries & Testis T10 – L1
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SYSTEMIC RESPONCES TO ACUTE SYSTEMIC RESPONCES TO ACUTE PAINPAIN
Efferent limb of the pain pathway is
• Sympathetic nervous system • Endocrine system.
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Cardiovascular effectsCardiovascular effects
Tachycardia
Hypertension
Increased systemic vascular resistance
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RESPIRATORY SYSTEMRESPIRATORY SYSTEM
• Increased oxygen demand and consumption• Increased minute volume• Splinting and decreased chest excursion • Atelactasis, increased shunting, hypoxemia• Reduced vital capacity, retention of secretions
and chest infection
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GASTROINTESTINAL AND URINARY EFFECTSGASTROINTESTINAL AND URINARY EFFECTS
• Increased sympathetic tone• Decreased motility, ileus and urinary retention• Hypersecretion of stomach• Increased chance of aspiration• Abdominal distension leads to decreased chest
expansion
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ENDOCRINE EFFECTSENDOCRINE EFFECTS
• Increase secretion of Catecholamine, Cartisol and Glucagon
• Decreased secretion of Insulin and testosterone
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HEMATOLOGICAL EFFECTSHEMATOLOGICAL EFFECTS
1. Increased platelet adhesiveness
2. Reduced fibrinolysis and hypercoagulatability
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IMMUNE EFFECTSIMMUNE EFFECTS
Leukocytosis
Lymphopenia
Depression of reticuloendothetial system
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GENERAL SENSE OF WELL-BEINGGENERAL SENSE OF WELL-BEING
• Anxiety
• Sleep disturbances
• Depression
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There are many different techniques,non-pharmacological &pharmacological , both regional and non-regional to provide post op analgesia.
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Nonpharmacologic Approaches toNonpharmacologic Approaches toRelieve Pain and Prevent SufferingRelieve Pain and Prevent Suffering
hydrotherapy
intradermal water blocks
movement and
Positioning
touch and massage
acupuncture
transcutaneous electrical nerve stimulation (TENS
aromatherapy
heat and cold
music and audioanalgesia.
J Midwifery Womens Health 49(6):489-504, 2004. © 2004 Elsevier Science, Inc.
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PHARMACOLEGICAL PHARMACOLEGICAL
WHO Ladder
An essential principle in using medications to manage pain is to individualize the regimen
to the patient
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WHO analgesic guidelinesWHO analgesic guidelines
• Oral medications whenever possible
• Dose “by the clock” – but always have “as
needed”medications for breakthrough pain
• Titrate the dose
• Use appropriate dosing intervals
• Be aware of relative potencies
• Treat side effects
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Pharmacological approachPharmacological approach
• Acetamenophen • NSAIDs• Tramal• Opioids• Adjuvents therapy
– Anticonvulsantants – Antideperssants – NMDA antagonists– Muscle relaxants– Clonidine – Corticosteroids– Local Anesthetics– Sedatives
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AcetaminophenAcetaminophen
• The most widely used analgesic• Non acidic and a phenol derivative • Readily crosses the BBB.• Its action mainly in the CNS, where prostaglandin
inhibition produces analgesia and antipyresis.• Its peripheral and anti-inflammatory effects are weak.
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AcetaminophenAcetaminophen
• Doses of 10 to 15 mg/kg every 4 hours up to a daily maximum of 100 mg/kg
• For the treatment of mild to moderate pain.
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Perfalgan
Making paracetamol (hydrophobic) soluble
Use of hydrophilic ingredients (mannitol and disodium phosphate)
Ensuring its stability in solution
- By controlling hydrolysis
Use of a pH buffer (disodium phosphate and sodium hydroxide)
- By preventing oxidation
Addition of cysteine hydrochloride
Oxygen-free manufacturing process
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Perfalgan 1g indications
Short-term treatment of moderate pain, especially following surgery
Short-term treatment of fever
Alone or in combination
In adults or children over 33kg
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1. Take the cap off
2. Link the bottle to a drip with an air intake
3. Hook the bottle with the built-in calliper
How to handle Perfalgan
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First administration in the operating theatre
Frequency of administration:15-minute infusion every 4 to 6 hours
Dosages
- Adolescents and adults weighing more than 50kg: 1 g / 4 times a day
- Children weighing more than 33kg, adolescents and adults weighing less than 50kg:
15 mg/kg (4 times a day )
How to infuse Perfalgan
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NSAIDsNSAIDs
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NSAIDsNSAIDs• The NSAIDs are weak organic acids (PKa3 to 5.5)• Act mainly in the periphery• Bind extensively to plasma albumin (95% to 99%
bound)• Do not readily cross the BBB• Extensively metabolized by the liver• Have low renal clearance «10% .
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NSAIDsNSAIDs
NSAIDs are powerful inhibitors of prostaglandin synthesis through their effect on cyclooxygenase (COX)
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The adverse effects of NSAIDs in surgical patients The adverse effects of NSAIDs in surgical patients
• gastrointestinal hemorrhage • renal dysfunction or failure• hematoma formation• asthma in susceptible individuals• anaphylaxis • decreased healing of gastrointestinal
anastomoses
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TramalTramal®® (Tramadol) (Tramadol)
is a
with
for
centrally acting analgesic
opioid and non-opioid activity
moderate to severe pain associated with acute and chronic conditions
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Dual mode of action of TramadolDual mode of action of Tramadol
Two complementary mechanisms of action:
Opioid action:weak µ-receptor agonist
Monoaminergic action:weak, indirect 2-receptor agonist
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TramalTramal®® presentations (I) presentations (I)
Prolonged-release tablets 100 mg, 150 mg, 200 mg
Drops Soluble tabletsCapsules
Ampoules
Suppositories
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Adverse events (AEs)Adverse events (AEs)
• Most common reported AEs: headache, nausea, vomiting, dizziness and somnolence
Moore RA, McQuay HJ. Pain 1997
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Opioids
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TERMINOLOGY TERMINOLOGY
• Opiates are drugs derived from opium,
• Opioid applies to substances with morphine-like activity• Endorphin is endogenous opioid peptides.
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CLASSIFICATION OF OPIOIDSCLASSIFICATION OF OPIOIDS
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• There are alternative classifications
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Agonist A drug that, when bound to the receptor, stimu lates the receptor to the maximum level; by defi nition the intrinsic, .activity of a full agomstis unity.
Morphine
Antagonist A drug that, when bound to the receptor, fails completely to produce any stimulation of that receptor; by definition, the intrinsic activity of a pure antagonist is zero.
Naloxone
Partial agonist A drug that, when bound to the receptor, stimu lates the receptor to a level below the maxi mum level; by defini tion the intrinsic, . activity of a partIal ago nist lies between zero and unity.
Buprenorphine (partial mu agonist)
Mixed agonist antagonist
A drug that acts simulta neously on different subtypes, with the potential for agonist action on one or more subtypes and antago nist action on one
or more subtypes
Nalbuphine (partial mu agonist, kappa agonist, delta antagonist)
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Transdermal therapeutic systems
Advantages– constant blood levels– long duration of effect– avoidance of the gastrointestinal tract (no first-pass
effect)– high patient compliance
Disadvantages– risk of dermal irritation
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MORPHINEMORPHINE
• Oldest ,safe .• Water soluble , works longer.• No upper limit to dose.• Metabolized by liver and extra hepatic site ,excreted by
kidney.• Metabolite M6G very potent. • Causes respiratory depression, nausea, vomiting,pruritus
and urinary retention
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DemerolDemerol
• Most commonly used opioid• 10mg is equal to 1mg of morphine• fat soluble therefore short duration of action.• Metabolite nor meperidine is a potent CNS stimulant.• Side effects same as other opioids.
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Therapeutic approaches in side effects of opioid therapy
Therapeutic approachesTherapeutic approaches
HaloperidolOpioid rotation-Ca. 1%Hallucina-tions
AntihistaminesOpioid rotation-Ca. 2%Pruritus
Application close to the spinal cord
Opioid rotationCa. 20%Sedation
Opioid rotationAnti-emeticsCa. 30%Nausea/ vomiting
Change the mode of administration
Laxatives- Ca. 95%Constipation
Second stepFirst stepToleranceIncidenceSide-effect
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Co AnalgesicsCo Analgesics
Classification
– Anticonvulsantants – Antideperssants – Muscle relaxants– Clonidine – Corticosteroids– Local Anesthetics– Sedatives
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Methods of Acute Postoperaive Pain Methods of Acute Postoperaive Pain ReliefRelief
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Methods of Acute Postoperaive Pain ReliefMethods of Acute Postoperaive Pain Relief
• Intramuscular
• Intravenous - Intermittent Bolus
• Intravenous-Continuous Infusion
• Patient Control Analgesia (PCA)
• Epidural analgesia
• Peripheral Blocks
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POSTOPERATIVE PAIN MANAGEMENT
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POSTOPERATIVE PAIN MANAGEMENTPOSTOPERATIVE PAIN MANAGEMENT
• Pain management continues to be a challenge to anaesthetist .
• PCA ; epidural and nerve block are advance in analgesia that may assist this challenge.
• Post op Pain management can be evaluated in terms of its ability to meet 2 main goals:
To relieve postoperative pain. To relieve patient of inhibition of respiratory
movement without sedation.
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IMPORTANCE OF POSTOPERATIVE IMPORTANCE OF POSTOPERATIVE ANALGESIAANALGESIA
• Pain relief is desirable not only for humane and moral reasons,but also because
pain relief improves the patients physiological and psychological status
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• 3. Number?: What is the severity of the pain?
0 1 2 3 4 5 6 7 8 9 10
Visual analog scale -
Numerical intensity scale -
Descriptive intensity scale -
No pain Mild painModerate
painSevere
painWorst possible
pain
No painPain as bad as it could possibly be
Pain Assessment: the 6 N’sPain Assessment: the 6 N’s
11 of 16
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Pain Intensity Rating ScalesPain Intensity Rating Scales
• Pain Faces Scale
00
No No hurthurt
22
Hurts Hurts just a just a
little bitlittle bit
44
Hurts a Hurts a little bit little bit moremore
66
Hurts Hurts even even moremore
88
Hurts a Hurts a whole whole
lotlot
1010
Hurts as Hurts as much as much as you can you can imagineimagine
• Brief Pain Inventory
Shade areas of worst painShade areas of worst pain
Put an X on area that hurts mostPut an X on area that hurts most
(Cleeland, 1991; Wong et al, 2001)
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Pre-emptive analgesiaPre-emptive analgesia
The administration of analgesic agents prior to an injury in order to prevent development of central nervous system hyperexcitability or
sensitization
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PATIENT CONTROLLED ANALGESIAPATIENT CONTROLLED ANALGESIA
• PCA is based on the belief that patients are the best judges of their pain.
• They should be allowed an active role in controlling their pain.
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PCAPCA
• PCA are modified infusion pumps that allow patient to self administer a small dose of opioid when pain is present , thus allowing patients to titrate their level of analgesia against the amount of pain they are experiencing.
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PCAPCA
• PCA is well tolerated.• Offer flexibility in dose size and dose interval in individual
patients.• Therapeutic serum level can be reached relatively quickly
because the drug is administered into the vascular system directly.
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PCAPCA
• Patient can secure an early therapeutic serum level with repeated doses titrated to individual pain needs.
• A steady state plasma level occurs because the elimination of the drug from the plasma is balanced by the
patients self administered drug injection.
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Relationship of mode of delivery of analgesia to serum Relationship of mode of delivery of analgesia to serum analgesic levelanalgesic level
• IM and IV PCA
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PCAPCA
• PCA allows patient control over their pain and therefore gives greater satisfaction.
• PCA also eliminates the lag time between pain sensation and administration of analgesia.
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PAIN CYCLE
I.M PRN ANALGESIA
PATIENT FEELS PAIN
Nurse Screen
Meds PreparedI.M Given
Calls Nurse
Drug Absorbed
Sedation
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PAIN CYCLE
I.M PRN ANALGESIA
PATIENT FEELS PAIN
Nurse screen
Meds preparedI.M Given
Calls Nurse
absorbed
Sedation
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BENEFITSBENEFITS
• Decreased nursing time• Increased patient satisfaction.• Used in a variety of medical and post-op surgical
conditions.• Decreased narcotic usage.• Decreased level of sedation.• Earlier ambulation.
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BENEFITSBENEFITS
• Decreased overall pain scores reported by patients.• Increased compliance to post op care.• Less anxiety.• More autonomy regarding pain control.• Improved rest and sleep pattern
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PCA FEATURES.PCA FEATURES.
• Drug concentration.• Drug reservoir volume.• Demand dose-amount patient will receive each time patient self
administer.• Delay(lockout)-period of time no drug is available to the demand
button.• Basal-continuous infusion of drug/hour,is optional.
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DRUG CONCENTRATIONSDRUG CONCENTRATIONS
• Morphine =1mg/1ml. (0.1 -0.2 mg/kg).
• Tramadol =10mg/1ml. (1-2 mg/kg ).
• Fentanyl = 10 mcg/1ml. (10 mcg/kg).
• Demerol = 10mg/1ml. (1-2 mg/kg).
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Epidural AnalgesiaEpidural Analgesia
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INSERTION OF EPIDURAL CATHETERINSERTION OF EPIDURAL CATHETER
• The site is dependent upon the area of pain• Fixing the catheter
Incision LevelThoracic T4-T6
Upper abdo T6-T8
Lower abdo T8-T10
Pelvic T8-T10
Lower extremity L1-L4
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MEDICATION COMMONLY USEDMEDICATION COMMONLY USED
• OPIOIDS-Fentanyl +Morphine
(affect the pain transmission at the
opioid receptors)
• L.A.-Bupivacaine(marcaine)
(inhibits the pain impulse
transmission in the nerves with
which it comes in contact)
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Epidural AnalgesiaEpidural Analgesia
• Mode of administration– intermittent opioid bolus– PCA opioid– continuous infusion - LA+opioid
• Advantages– most effective analgesia– systemic effect of opioid minimal– pre-empty analgesia– reduce incidence of thromboembolism
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Epidural Analgesia - Side EffectsEpidural Analgesia - Side Effects
• From the technique– dural puncture– epidural haematoma– epidural abscess– nerve root trauma
• From LA– hypotension– paraesthesia– motor weakness
• From opioid– delay resp depress– urinary retention– pruritus
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Caudal AnaesthesiaCaudal Anaesthesia
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Brachial Plexus BlockBrachial Plexus Block
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IVRA (BIER’S BLOCK)IVRA (BIER’S BLOCK)
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