Management of Acute Pain - Hand Foundationhandfoundation.org/wp-content/uploads/2015/02/220pm... ·...

2/13/2015

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L. Andrew Koman, MD

.

Management of Management of

Acute PainAcute Pain

Wake Forest Baptist Health

Disclosures

“The authors have no

conflicts to disclose

related to the subject

of this presentation.”

Post-traumatic Pain Management

Discussion:

•Pain—“mandated” 5th vital sign

•Definitions

•Pre-emptive treatment

•Blocks and pain catheters

•Patient –controlled anesthesia

•Diagnosis and treatment of CRPS

Acute Pain Management

Goals:

•Pain—“mandated” 5th vital sign

•Impact on your practice


“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”damage”

International Association for the Study of PainInternational Association for the Study of Pain

Pain


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Post Traumatic Pain:Post Traumatic Pain:

inflammation inflammation

cell damagecell damage

Anxiety Anxiety

Vasoconstriction Vasoconstriction

Impaired QOLImpaired QOL

Delayed rehabilitationDelayed rehabilitationWake Forest Baptist Health

Post Traumatic Pain Post Traumatic Pain (chronic pain)(chronic pain)::

Reflex Sympathetic DystrophyReflex Sympathetic Dystrophy

Complex Regional Pain Complex Regional Pain

SyndromeSyndrome

In the absence of In the absence of

identifiable cell identifiable cell

damagedamage

An Overview of Neuropathic Pain: Syndromes,

Symptoms, Signs, and Several Mechanisms.

Dworkin The Clinical Journal of Pain 18:343-349;2002

Types of pain:

•Nociceptive

•Neuropathic


Posttraumatic Pain Management

Neuropathic Pain:Neuropathic Pain:••NeuromaNeuroma

••NeuromaNeuroma--inin--continuitycontinuity

••CRPS type 2CRPS type 2

••Spinal originSpinal origin

Definitions:

•Hyperpathia

•Hyperalgesia

•Allodynia


Sensitization


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Pre-emptive Treatment

•Reduction post-operative pain

•Alteration

CNS plasticity after nociception

•Antinociceptive treatment

•Alters central sensory processing

•Decrease incidence of hyperalgesia and allodynia

Post-traumatic Pain Management

Pre-emptive treatment:

�Prophylactic

�Single types

�Multimodal



•Prophylactic

•Single

•Multimodal

EpiduralEpidural

Local Local

NMDA agonistsNMDA agonists

NSAIDSNSAIDS

Opiods Opiods



•Prophylactic

•Single types

•Multimodal

The Efficacy of Pre-emptive Analgesia for Acute Pain

Management: a Mea-Analysis

Cliff et al.. Anest Analg 100:757; 2005

66 studies (3261 patients):

pain / analgesic consumption / time to anesthesia

Effect size best for:

• Epidural – all 3

• Local wound infiltration- 2 & 3

• NSAIDs - 2 & 3

••NMDA & NMDA & opiodsopiods ––equivicalequivical

Multi-modal, Pre-emptive Analgesia Decreases the Length

of Hospital Stay Following total joint Arthroplasty .

Duellman et al.. Orthopaedics 32: 167; 2009

Retrospective analysis

127 patientsb

••Decreased LOSDecreased LOS

••NMDA & opiods NMDA & opiods ––equivicalequivical

PrePre--emptive vs PCA emptive vs PCA

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The Pre-emptive Analgesic Effect of Intraarticular

Bupivicaine and Morphine after ambulatory

Arthroscopic Surgery. Reuben SS et al.. Anes Analg 92: 923; 2001

Randomized –controlled trial

40 patients

Group I Group I –– prolonged analgesicprolonged analgesic

duration & less narcotic use duration & less narcotic use

morphine/bupivicainemorphine/bupivicaine

Group I preGroup I pre--incisionincision

Group II postGroup II post--incisionincision

The Pre-emptive Analgesic Effect of Intraarticular

Bupivicaine and Morphine after ambulatory

Arthroscopic Surgery. Reuben SS et al.. Anes Analg 92:

923; 2001

Pre-incision

important

NMDA antagonists:

•Dissociate state

•Decrease central sensitization

•Preferable in children

•Fewer nightmares


Ketamine

NEW


Patient –controlled analgesia

•Reduction anxiety

•Better access

•Decrease total

narcotic use



Continuous Blocks:

Plexus / epidural / caudal

• Effect in pain reduction

• Expensive

• Important dystrophic

responses

• Potential mask

complications

Beware Compartment syndrome Wake Forest Baptist Health

Local Infusion:

(continuous filed blocks)

• Delivery of local

anesthetic to soft tissue

• Mutiple commercial

devices

• Bupivicaine 0.25%

• Continuous

• On-demand


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Local Infusion:

(continuous filed blocks)

• Delivery of local anesthetic to soft tissue

• Mutiple commercial devices

• Bupivicaine 0.25%

• Continuous

• On-demand


• Complex Regional Pain Syndrome 1

• Reflex sympathetic dystrophy

• Complex Regional Pain Syndrome 2

• Causalgia (neuropathic)

Sympathetically-maintained vs. Independent

(a descriptor of CRPS 1 or 2)

Posttraumatic Pain ManagementPosttraumatic Pain Management


Clinical Definition:

• Regional pain

• Autonomic dysfunction

• Vasomotor

• Atrophy (trophic)

• Functional impairment


Complex Regional Pain Syndrome Complex Regional Pain Syndrome

�Acute / Obvious

�--pain - “burning”,

“tearing”

�--severe numbness

�--mild to moderate

edema

Presentation:

Complex Regional Pain Syndrome

•Indolent

�“poor” patient

�problem

sleeping

�stiffness /

atrophy

�delayed healing

Presentation:


�Difficulty sleeping ?

�Narcotics – “no Help”

�“burning”

Diagnosis:

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•Massive Edema

•Clenched Fist

•“Spread”

•Blisters, Sores

Beware:

FictitiousFictitious

Psychiatric Psychiatric


•Document

not “CRPS”

•Treat

•Refer



Treatment Strategies:

• Block harmful effects of pain

• Multiple levels of initiation & perception

• Interventions

- Physical modalities

- Pharmaceutical

- Surgical

MultiMulti--modal modal

Treatment:

• Non-operative primary

• Oral meds

• Parenteral

• Therapy

• Surgery

• Salvage


Pharmacologic agents:� Vitamin C� Steroids� Antidepressants� Calcium channel blockers

� Anticonvulsants� Adrenergic agents


Drug Selection

High Total Flow

Nutritional Deprivation

� Amitriptyline

� Phenytoin


Edema / Hyperalgesia

High Total Flow

Clonidine

Drug Selection

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Low Total Flow

Nutritional Deprivation

� Calcium channel blockers

Drug Selection

Treatment:

• Non-operative primary

• Oral meds

• Parenteral

• Therapy

• Surgery

• Salvage

Optimizing Outcomes: Pain Management

Kirk WatsonKirk Watson–– stress loading stress loading

Therapy:

• Active motion

• Passive motion

• Gentle

• Intrinsics

• Edema control




Intrinsic Minus

Hand Position

Joint Contracture



Intrinsic Minus

Hand Position

collateral ligaments

Volar plate

intrinsics & cartilage


Bunnell or

Intrinsic Test

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•Technique

•sequential

compression

•rapid

•long-term


Intermittent Positive Pressure:Modalities:

•Contrast baths

•Tens unit

•H-wave


Jury Verdicts related to Reflex Sympathetic

Dystrophy Crick JC & Crick BC Poster #3; 26th SOA Meeting , Amelia Island, Florida 2009

58 lawsuits

Westlaw database; Westlaw database;

Florida; RSD bFlorida; RSD b

45 jury verdicts45 jury verdicts

Plaintiff 13 (substantial)Plaintiff 13 (substantial)



Surgery on Patients with CRPS is appropriate and is within the

standard of care:

•Assuming recognition of CRPS

•Informed consent risk-benefit

•Prophylactic considerations



CRPS occurs 5-21 days post injury in the majority of patients

The therapist is often the The therapist is often the

primary provider during primary provider during

this period this period


Thank You

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