Acute Pain Management Parisa Partownavid, MD Assistant Clinical Professor David Geffen School of Medicine at UCLA Department of Anesthesia

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Acute Pain ManagementParisa Partownavid,
MDAssistant Clinical ProfessorDavid Geffen
School of Medicine at UCLADepartment of
Anesthesia
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Definition of Pain

• An Unpleasant Sensory and Emotional Experience
  Associated with Actual or Potential Tissue
  Damage, or Described in Terms of Such Damage.

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Acute Pain

• Pain in Perioperative Setting
• Pain in Patients with Severe or Concurrent
  Medical Illnesses (Pancreatitis)
• Acute Pain Related to Cancer or Cancer Treatment
• Labor Pain

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Acute Perioperative Pain

• Pain that is Present in a Surgical Patient
  Because of Preexisting Disease, the Surgical
  Procedure, or a Combination of Both

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Importance of Pain Management

• Adequate Pain Control
• Reduce the Risk of Adverse Outcomes
• Maintain the Patients Functional Ability, as
  well as Psychological Well-being
• Enhance the Quality of Life
• Shortened Hospital Stay and Reduced Cost

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Adverse Outcomes Associated with Management
of Acute Pain

• Respiratory Depression
• Circulatory Depression
• Sedation
• Nausea and Vomiting
• Pruritus
• Urinary Retention
• Impairment of Bowel Function

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Adverse Outcome of Undertreatment of Acute Pain

• Thromboembolic or Pulmonary Complications
• Needless Suffering
• Development of Chronic Pain

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• The Incidence of Moderate to Severe Pain with
  Cardiac, Abdominal, and Orthopedic Inpatient
  Procedures has been Reported as High as 25-50,
  and Incidence of Moderate Pain after Ambulatory
  Procedures is 25 or Higher.

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Goal

• Pain Management Interventions Should be Offered
  Around the Clock
• Pain Management is to Provide Continuous Pain
  Relief
• Patient Should be Assessed for Adequacy of Pain
  Control

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Preoperative Evaluation of
the Patient

• Type of Surgery
• Expected Severity of Postoperative Pain
• Underlying Medical Condition (Respiratory or
  Cardiac Disease)

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Preoperative Preparation of the
Patient

• Adjustment or Continuation of Medications (Sudden
  Cessation may Provoke a Withdrawal Syndrome)
• Treatment to Reduce Preexisting Pain and Anxiety
• Patient and Family Education

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Pain Assessment Tools
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Pain Assessment Tools

• In Adults Self Report Measurement Scales, such
  as Numerical Scales

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Pain Assessment Tools

• In Pediatric Patients
• Physiologic and Behavioral Indicators of Pain (
  Infants, Toddlers, Nonverbal or Critically Ill
  Children)
• Face Scale (Age 3-10 yrs)
• Visual Analogue Scales (Age 10-18)

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Management of Acute Pain

• Pharmacologic Interventional

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Pharmacologic Management

• Alter Nerve Conduction (Local Anesthetics)
• Modify Transmission in the Dorsal Horn (Opioids,
  Antidepressants)

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Routes of Administration

• PO
• PR
• IV
• IM
• Transdermal
• Transmucosal
• Epidural
• Intrathecal

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Opioid Analgesics

• Bind to Opioid Receptors
  Mu, Delta and Kappa
• Morphine, Hydromorphone, Meperidine, Fentanyl,
  Codeine, Methadone, Oxycodone, Hydrocodone,
  Tramodol
• Opioids may be Combined with NSAIDs to Enhance
  the Opioid Analgesic Effect

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Opioid Analgesics

• Equianalgesic Conversion Charts are used when
  Converting form one Opioid to Another, or
  Converting from Parenteral to Oral Form
• Respiratory Monitors may be Used Depending on the
  Patients Age, Co-existing Medical Problems, or
  Route of Opioid Administered

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Opioid Analgesics

• Conversions Morphine
• Oral Parenteral Epidural Intrathecal
• 300 100 10 1

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Opioids
Drug PO mg IV mg Starting Oral Dose mg Comments
Morphine 30 10 15-30 MS Contin, Release 8-12 hrs MSIR for BTP
Hydro-morphone 7.5 1.5 4-8 Duration Slightly Shorter than Morphine
Meperidine 300 75 Duration Slightly Shorter than Morphine Normeperidine Causes CNS Toxicity
Methadone 20 10 5-10 Qd Long Half-Life, 24-36 hrs Accumulates on Days 2-3
Fentanyl 0.02-0.05 Fentanyl Patch, 12 hrs Delay Onset and Offset
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Opioids
Drug PO mg Comments Precautions
Codeine 30-60 Combined With Nonnarcotic Analgesics Maximal Dose for Acetaminophen 4gm/d
Oxycodone 5-10 Percocet Percodan Oxycodone 10-30mg Q 4h Oxycontin 10mg Q 12h Acetaminophen or Aspirin toxicity
Hydro-codone 5-10 Vicodin or Lortab Acetaminophen Toxicity
Tramodol 50-100 Q4-6hr Central Acting, Affinity for Mu Receptors Maximal Dose 400 mg/d
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Patient Controlled Analgesia

• Small Doses of Analgesic Drug (Usually Opioids),
  are Administered (IV) by Patient
• Allows Basal Infusion and Demand Boluses
• Over Dosage is Avoided
• by Limiting the Amount
• and Number of Boluses
• in a Set Period of Time

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Dose Regimens for PCA
Drug Bolus Dose (mg) Lock-Out (Minutes)
Morphine 0.5-2 5-15
Hydromorphone 0.1-0.2 5-10
Fentanyl 0.01-0.02 5-10
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Non-Opioid Analgesics

• Acetaminophen
• NSAIDs (Aspirin, Ibuprofen, Ketorolac,
• COX-2 Inhibitors)
• Lidocaine Patch (Lidoderm)

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NSAIDs

• Relieve of Mild to Moderate Pain
• Complication
• GI Discomfort
• GI Bleeding (Inhibition of COX-1)
• Nephrotoxicity
• Inhibition of Platelet Aggregation
• Osteogenesis

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Ketorolac

• Potent Analgesic
• Parenteral (IV or IM)
• 15-30 mg Q 6hr
• Patients Older than 16 yrs
• Should not Exceed 5 days

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Cox-2 Inhibitors
Drug Dose
Celecoxib (Celebrex) 100-200mg PO Bid
Rofecoxib (Vioxx)
Valdecoxib (Bextra) 10-20mg PO Qd
Parecoxib 20-40mg IM 20-100mg IV
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Lidoderm
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Lidoderm

• 5 Lidocaine Patch
• Indicates for Pain Relief in Post-herpetic
  Neuralgia
• Each Patch Contains 700 mg of Lidocaine
• Should be Applied to Intact Skin
• About 3 is Absorbed
• 1-3 Patches Once a Day for 12 hrs

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Interventional Management

• Epidural Analgesia (Continuous Lumbar or Thoracic
  Epidural Catheter Placement, PCEA)
• Spinal Analgesia
• Peripheral Nerve Block ( Single Shot or
  Continuous)

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Anatomy of Epidural Space

• Surrounds the Dural
• Sac
• Anteriorly Post.
• Long. Ligament
• Posteriorly
• Ligamentum Flavum
• Laterally Pedicles and
• Intervertebral Foramina

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Anatomy of Epidural Space

• AP Dimension of the Epidural Space is Largest in
  the Lumbar Region, 5-6 mm
• In Thoracic Region the AP Dimension Decreases but
  the Space is More Continuous

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                              MIDLINE SAGITTAL
VIEW OF THE LUMBAR SPINE
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Epidural Anesthesia

• Anesthestizes the Emerging Nerve Roots of the
  Spinal Cord
• Epidural Injection of Anesthetic Produces a
  Regional Dermatomal band of Anesthesia
  Spreading Cephalad and Caudad from the Site of
  Injection
• Level of Anesthesia Depends on
• Volume of the Drug
• Level of Injection

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Epidural Anesthesia

• Lumbar Epidural Lower Extrimity, Pelvic, and
  Lower Abdominal Procedures
• Thoracic Epidural Upper Abdomen and Thoracic
  Procedures
• Caudal Injection More Commonly Used for
  Pediatric Patients (Genitourinary and Lower
  Abdominal Procedures)

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Advantages

• Superior Pain Relief
• Less Systemic Side Effects
• Lower Incidence of DVT and Pulmonary Emboli
• Decrease Blood Loss Intraoperatively during
  Orthopedic, Urologic, Gynecologic and Obstetric
  Procedures
• More Rapid Recovery of Bowel Function
• Earlier Ambulation
• Better PFT
• Suppression of Neuroendocrine Stress Response
• Grass JA. The Role of Epidural
  Anesthesia and Analgesia in Postoperative
  Outcome. Anesthesiol Clin North America
  01-JUN-2000 18(2) 407-28

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Contraindications

• Absolute
• Patient Refusal
• Coagulopathy
• Increased ICP
• Skin Infection

• Relative
• Uncooperative Patient
• Pre-existing Neurologic Disorder
• Anatomical Abnormalities

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Factors Affecting Epidural Dosage

• Patient Factors Age , Height, Weight, Pregnancy
• Site of Injection

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Drugs Used for Epidural Anesthesia

• Local Anesthetics
• Opioids

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Local Anesthetics in Epidural Space

• Lidocaine 1-2 , 45-90 min.
• Bupivacaine 0.25-0.5 , 90-120 min.

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Opioids in Epidural Space
Drug Dosage Onset (min) Duration (hrs)
Morphine 2-3 mg 30-90 6-24
Hydromor-phone 0.4-0.8 mg 20-30 6-18
Fentanyl 50-100 mcg 5-15 2-4
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Hydrophilic Opioids
Morphine, Hydromorphone
Slow
Onset, Long Duration, High CSF Solubility

• Advantages
• Prolonged Single Dose Analgesia
• Thoracic Analgesia with Lumbar Administration
• Minimal Dose Compared with IV Administration

• Disadvantages
• Delayed Onset of Analgesia
• Unpredictable Duration
• Delayed Respiratory Depression

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Lipophilic Opioids
FentanylRapid Onset, Short Duration, Low CSF
Solubility

• Disadvantages
• Systemic Absorption
• Brief Single Dose Analgesia
• Limited Thoracic Analgesia with Lumbar
  Administration

• Advantages
• Rapid Analgesia
• Ideal for Continuous Infusion or PCEA

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PCEA

• Technique that Allows Basal Infusion and Demand
  Boluses into the Epidural Space
• Solutions Used
• Local Anesthetics 0.05-0.125
  Bupivacaine
• Opioids Morphine 50 mcg/ml
• Hydromorphone 10 mcg/ml
• Fentanyl 2-5 mcg/ml

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Complications of Epidural
Analgesia

• Failure of Block (Patchy or Unilateral Block)
• Injury to Nerve
• Infection
• Epidural Hematoma or Abscess
• Dural Puncture (Total Spinal or PDPH)

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Complications of Epidural
Analgesia

• Side Effect of Drugs in Epidural Space
• - Hypotension Secondary to Sympathetic Blockade
• - Intravascular Injection (Local Anesthetic
  Toxicity)
• - Respiratory Depression
• - Sedation
• - Bladder Distention
• - Difficulty in Ambulation

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Spinal Anesthesia

• Spinal Anesthesia is Induced by Injecting Small
  Amount of Local Anesthetic (Bupivicaine) in the
  CSF
• Results in Rapid Onset of Block
• More Rapid Onset and Requiring less Medicine
  Compared to Epidural Analgesia

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Spinal Anesthesia

• CSE, Used in Labor
• Preservative Free Morphine (Duramorph) Provides
  Pain Relief for Abdominal, Pelvic, or Lower
  Extrimity Surgeries
• Complications Similar to Epidural Technique
  Except for Higher Risk of PDPH

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Peripheral Nerve Block

• Anesthetizing the Nerve that is Innervating
  Surgical or Painful Area
• Single Shot or Continuous Infusion through
  Catheter
• Upper Extrimity Brachial Plexus, Median, Ulnar
  or Radial Nerve

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Peripheral Nerve Block

• Lower Extrimity Sciatic, Femoral, Posterior
  Tibial, Sural, Saphenous, Deep and Superficial
  Peroneal Nerve
• Intercostal Nerve Block
• Surgical Wound Infiltration of Local Anesthetic

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Acute Pain Management for Pediatric
Patients

• Consider Physiologic and Anatomic Differences
• Pain Assessment and Communication
• Pain and Anxiety Associated with Minor Procedures
  or Unfamiliar Situations

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Caudal Block

• Single Injection or Continuous Infusion through a
  Catheter
• Excellent Intraoperative and Postoperative Pain
  Control
• Easier to Perform in Children
• Analgesia that Last About 12 hrs if Bupivacaine
  Used
• Performed Following Induction of General
  Anesthesia

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Indications for Caudal Block

• Surgeries in Sacral Segments, (Circumcision and
  other Urologic Surgeries, Rectal Dilation)
• Combined with Light General Anesthesia Provides
  Adequate Intraoperative Analgesia

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Complications of Caudal Block

• Infection
• Dural Puncture and Spinal Anesthesia
• Intravascular Injection of Local Anesthetics

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Acute Pain Management in Elderly

• Patient Population Older than 65 yrs of Age is
  Growing
• Age Related Physiologic Changes (Decreased Muscle
  Strength) Decreased Cough
• Decreased Mental Status (Dementia) Decreased
  Narcotic Dose

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Acute Pain Management in Elderly

• Age Related Anatomic Changes Difficulty in
  Placing Epidural Catheter
• Multiple Drug Therapy Withdrawal or Interaction
  with Other Drugs

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