Managing Pain in the Surgical Patient

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Managing Pain in the Surgical Patient

• LUCILLE LUTZ, RN, MSN, APRNBC
• CLINICAL NURSE SPECIALIST
• PAIN MANAGEMENT

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Objectives

• Discuss preop pain assessment
• Discuss intraop pain management
• Discuss postop pain management

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Background

• Acute Pain
• Immediate
• Serves as a warning
• Easier to treat (generally)
• Has an end (generally)

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Background

• Chronic Pain
• Lasts longer than 3-6 months
• Serves no purpose
• Cannot identify a cause
• Can lead to pain behaviors
• Very difficult to treat

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Pain Conduction

• Injury triggers release of bio-chemicals
• Inflammation takes place
• Stimulation of nerve fibers
• Bio-chemicals causes pain impulses to begin

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Pain Perception

• Impulse is sent to the brain via ascending tracts
  in spinal cord
• Neurotransmitters released by C fibers (substance
  P)
• Message to the brain (Thalamus)
• Sends message down descending pathway pain
  response

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Why Pain Control

• Persistent acute postoperative pain
• Decreases the bodys physiologic
• reserves
• May exacerbate co-morbid conditions (e.g.)
  increase risk of MI in patients with CAD
• Contributes to pulmonary complications.

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• Impairs rehabilitation and functional
• outcome
• May lead to development of chronic pain
• syndromes and long-term disability.
• Increases hospital stay and the cost of
• patient care
• Decreases patient satisfaction.

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Metabolic Stress Response

• Surgical insult results in post op pain
• Increased circulating catecholamines
• Resulting in tachycardia and hypertension
• Leading to increased cardiac work
• Resulting in increased myocardial oxygen
  consumption

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• Cardiovascular
• ? HR, ? BP, ? SVR, altered regional blood flow,
  ?CMO2, ? DVT
• Respiratory
• ? VL (atelectasis), ? cough (sputum retention)
• hypoxemia and infection

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• Gastrointestinal
• ? gastric and bowel motility, nausea, vomiting
• Genitourinary urinary retention
• Neuroendocrine ? catabolic hormones
• ? blood glucose, Na H20 retention

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• Musculoskeletal Muscle spasm, immobility (? DVT)
• Psychological fear, anxiety, insomnia
• Chronic pain

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Pre Op Assessment

• Indication for surgical procedure
• Allergies and intolerances to medications,
  anesthesia, or other agents
• Known medical problems
• Surgical history
• Trauma (major)
• Current medications (incl.OTC herbal dietary
  supplements,and illicit drugs)
• Gayatri,P (2005). Post-op pain services. Indian
  J.    Anaesth. 49 (1) 17-19

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• Discuss History of Acute or Chronic Pain
• Identify history of pain control methods
• What has worked
• How long on pain meds
• Do they work
• True allergies, ask what happens

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• Differentiate between tolerance and
• physical dependence
• Discuss pain management problems
• (ie) anxiolytic therapy with pain meds
• Identify if there is a need to wean from any pain
  medications prior to surgery
• Do not stop suddenly

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• Consider Patients with
• Multiple back operations
• Abdominal pain patients (ie) Crohns disease
• Recurrent cancer
• Chronic joint pain, (ie) RA or DJD

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• If with a history of chronic opioid use for pain
  management may require higher doses for pain
  control
• This will include using PCA and/or meds for
  break through pain
• May not get adequate relief with standard
  doses of standard post op pain orders

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• Do a directed pain history
• Type of pain
• Location, description, duration, exacerbation and
  relieving factors
• Directed pain examination
• Discussion of post-op pain control plan

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What about the Elderly

• Evaluate each patient individually
• Do not assume that aging is the same in all
  patients
• Evaluate for side effects of narcotics
• Need complete list of meds to check for
  interactions

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• Dispel myths
• Concerns about opioids
• Concerns about addiction
• Fear of tolerance
• Age related expectation of pain

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Pre Op Teaching

• Educate patient/family/staff
• Pain plan
• How when to evaluate
• Use of alternative methods of pain control
• Patient and/or Family education on use of PCA

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• Explain blocks !!!!!!
• Provide pre-anesthetic evaluation, brochures, and
  videotapes to educate patients about therapeutic
  options (music and/or guided imagery, other)

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Preoperative Preparation of the Patient

• Instruct on bedside postoperative evaluation
• Include instruction in behavioral modalities to
  control anxiety
• Distraction, deep breathing, visualization (etc)

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Preoperative Preparation of the Patient

• Instruct on pain ranking tools prior to surgery
• Use age appropriate tools, why, when and how to
  be used.
• Instruct S.O., parents if needed.
• May want to use personalized tool (i.e.Randall)

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• Generally there is decreased cardiac and
  pulmonary reserve with increased age
• Opioids may produce confusion or cause some
  delirium postoperatively in some patients
• An elderly patient taking six medications is
  likely to have adverse reactions 14 times more
  than a younger person taking the same number of
  medications.

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• Consider additive respiratory depressant effect
  of both opiates and anxiolytics
• Most elderly patients metabolize drugs at a
  slower rate and may require less-frequent dosing
  or a reduction in dosage
• Certain medications should be avoided in elderly
  patients, based on their adverse effects
• (Beers list)

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• Sedative effects with an increased risk of falls
• Constipation related to opiates NSAIDS
• May have reduced gastrointestinal
• motility
• Stool softener with stimulant
• Start pain meds at a lower dose and increase to
  pain relief if opioid naive

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Special Populations

• Pediatrics
• Use pain scales specific to age
• FLACC (pre-op instruction)
• Observe frequently
• Medication dose wt specific
• Guided Imagery
• Distraction
• Music/video

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Special Populations

• Pediatrics
• Allergies
• Sensitivities
• Comfort frequently
• If non verbal anticipate painful procedures
  result in pain
• Be an advocate

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Special Populations

• Special needs
• Identify what works for this patient
• Ask the family or caregiver
• Comfort frequently
• If non verbal anticipate painful procedures
  result in pain
• Again be an advocate

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Cultural Considerations

• Be aware of specific needs and beliefs
• Respect the patient/family tradition
• Internalize (how would I feel if)
• Do not pre judge
• Explain need for pain control

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Intra Op Consideration

• Therapy selected should reflect the individual
  needs of the patient.
• Ability to recognize and treat adverse effects
  during surgery
• Special caution during continuous infusion
  modalities
• Drug accumulation may contribute to adverse
  events

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• Patients who are pretreated with pain meds,
  anxiolytics or NSAIDS prior to surgery
• Have a greater decrease in postoperative pain
• Decrease in postoperative anxiety
• Olorunto,W Galandiuk, S. 2006. Managing the
  Spectrum of Surgical Pain
• Acute Management of the Chronic Pain Patient.
  American College of Surgeons

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• Surgeries to upper abdominal and thoracic areas
  associated with severe pain can lead to
• Restrictive lung defect
• Depressed diaphragmatic activity
• Gayatri,P (2005). Post-op pain services. Indian
  J.    Anaesth. 49 (1) 17-19

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• Study
• Early and aggressive use of pain medications
  after surgery results in shorter hospital stays,
  fewer chronic pain problems later, and use less
  pain medication overall than people who avoid
  pain medication.
• Taylor, M. (2001).Managing postoperative pain. 
  Hosp Med 62  560-563.

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Intra Op Consideration

• Patient Advocate
• Continue to assess for anxiety/pain
• Provide comfort
• Positioning
• Guided imagery
• Music

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• Adequately treating Post-surgical Pain
• Increased Comfort quicker healing
• Increased activity
• increased strength
• Decreased complication improved post-op period

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• The risk of addiction to pain medication is low
  for patients using such medications for
  post-surgical pain
• Addictive personality leads to addiction
• Dependency is another issue

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Effective Pain Control

• Listen to the patient
• Believe the patients pain ranking
• Support the patient/family
• Answer questions
• Provide information
• Instruct re need for pain control

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Sources of postoperative pain

• Acute nociceptive pain from incision.
• Musculoskeletal pain from abnormal body
  positioning and immobility during and after
  surgery
• Neuropathic pain from excessive stretching or
  direct trauma to peripheral nerves

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Post Operative Pain Control

• Decreases risk of
• Myocardial ischemia
• Tachycardia and dysrhythmia
• Impaired wound healing
• Atelectasis
• Thromboembolic events
• Peripheral vasoconstriction

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Post Operative Pain

• Near the surgical site.
• Acute exacerbation of pain may be added to the
  basal pain
• Increases with activities such as coughing,
  turning, dressing changes
• Generally self limiting
• Progressive improvement over a relatively short
  period

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With Special Populations

• Geriatric
• Be aware of renal/hepatic function
• Sensitivities/allergies
• Be pro-active with medication
• Opioids
• Combination meds
• Be aware of drugs to be avoided in the elderly

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ASSESS RE-ASSESS

• Before and after pain medications
• Put it in the patients own words
• Assess for non verbal cues
• Be aware of special needs of the cognitively
  impaired patient
• Use appropriate pain scale
• Document, Document, Document,

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ASSESSMENT TOOLS

• VAS
• PAIN FACES
• PAINAD
• FLACC

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Post Op of Special Populations

• Geriatric
• If with Cognitive Impairment
• PAINAD scale
• Observe re-assess frequently
• Guard/observe for delirium
• superimposed on dementia
• Know drug side effects
• Know method of elimination

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Medication Use

• Review information gathered during pre op
  assessment
• If something has not worked in the past dont use
  it.
• Explain what you are doing and what you are
  giving
• When in doubt, follow the WHO guidelines

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World Health Organization (WHO)

• 3- Step Ladder approach to pain management
• Step 1- Mild Pain (1-3/10)
• Nonopioid
• Add adjuvant analgesic agent
• (i.e.) Ice, heat

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WHO contd

• Step 2 Mild to moderate pain (4-7/10)
• This step builds on step 1
• Treat with opioid combination drug
• (hydrocodone/acetaminophen)
• Watch ceiling effect of adjuvant drug
• Peds are dosed by weight
• Watch special needs patients/elderly

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WHO contd

• Step 3- Severe pain (8-10/10)
• Use opioids
• Add adjuvant (i.e.)anti-anxiety,anti-emetics,
  muscle relaxants
• Start with short acting opioids to determine pain
  relief, breakthrough needs and frequency.
• Switch to long acting use equianalgesic dosing
  chart for conversion

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POINTS TO REMEMBER

• The pain intensity determines the step at which
  to begin.
• Opioids are the only group of analgesics with no
  ceiling on dose with careful titration.
• Most opioid side effects resolve within a few
  days.
• ExceptiongtgtgtgtConstipation-- need to write for
  this immediately

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Commonly used first line opioids

• Codeine
• Morphine
• Hydromorphone
• Oxycodone

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Share the following characteristics

• Half-life of immediate release preparations is 2
  to 4 hours
• Duration of analgesic effect between 4 to 5 hours
  when given at effective doses.
• Sustained release formulations have duration of
  analgesic effect of 8 to 12 hours

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• Equianalgesic doses need to be calculated when
  switching from one drug to another
• when changing routes of administration or both.
• An equianalgesic table should be used as a guide
  in dose calculation
• Due to incomplete cross-tolerance clinicians
  should consider reducing the dose by 20 to 25
  when ordering.

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Morphine

• Onset 15 to 60 minutes
• Peak Effect 30 minutes to 1 hr
• Half Life 1.5 to 2 hr
• IV 0.05 to 0.1 mg/kg
• 5 minutes prior to procedure max 15 mg/dose

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Morphine

• Sedation, somnolence, respiratory distress or
  depression, pruritis
• Reversal
• Naloxone 5 to 10 mcg/kg/dose Single dose should
  not exceed max recommended adult dose of 0.2 mg

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Fentanyl

• Fentanyl is 80 to 100 times more potent than
  morphine.
• Studies report less constipation and somnolence
  in patients using transdermal fentanyl compared
  to those using SR morphine.

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Fentanyl

• Fentanyls high lipophilic properties provide a
  sufficient sublingual bioavailability of 90,
  thus making it a suitable opioid for use
  sublingually.
• Conditions that may effect absorption, bl levels
  clinical effects if the drug
• Morbid obesity
• Ascites
• opioid-naïve patients

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Fentanyl

• Onset 1 to 5 minutes
• Peak Effect (no data available)
• Half Life 1.5 to 6 hr
• IV 0.5 to 3 mcg/kg/dose may repeat after 30 to
  60 minutes max 50 mcg/dose
• Use lower doses (0.5 to 1 mcg/kg/dose) when used
  in combination with other agents, such as
  midazolam

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Fentanyl

• Respiratory distress or depression, apnea,
  seizures, shock, chest wall rigidity (most likely
  to occur with rapid infusion or high doses)
• Reversal
• Naloxone 5 to 10 mcg/kg/dose Single dose should
  not exceed max recommended adult dose of 0.2 mg

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Sufentanil

• 5 to 10 times more potent than fentanyl.
• Injectable sufentanil (like fentanyl) is readily
  absorbed through the mucous membranes
• Early onset of action of about 5 to 10 minutes,
  when used sublingually

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Sufentanil

• Good for incident pain control.
• Peak analgesic effect of 15 to 30 minutes
• Duration of the analgesic effect is 30 to 40
  minutes.
• Use for incident pain control, dosing 10 to 15
  minutes prior to the painful event.

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Methadone

• Long half life of methadone prevent it being a
  first-line opioid.
• When converting to methadone dose reduction of 75
  to 90 should be considered
• Initiation for pain management is 5mg bid or tid
  depending on age

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Dilaudid

• 10mg IV morphine is equivalent to 1.3-2mg
  Hydromorphone
• IV Dilaudid has a half life of 2.5 hours,
  duration of effect varies
• Administering 1 mg or more of IV Dilaudid every
  1 - 2 hours leads to a build up of the drug
  (stacking) and can increase adverse effects like
  respiratory depression. Know elimination

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• Stacking from delayed peak effect
• Occurs when additional doses are given prior to
  peak effect leads to multiple doses, resulting
  in over dosage.
• Caution
• Administration of a benzodiazepine with narcotic
  analgesics increases the risk of respiratory
  depression. (ie Xanax, Lorazepam, Versed,
  Valium)

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Midazolam CNS Depressant

• Onset 1 to 5 minutes (short acting)
• Peak Effect 3 to 5 minutes (IV)
• Half Life 1.5 to 12 hr
• Oral 0.2 to 1 mg/kg 30 to 45 minutes before
  procedure max 20 mg
• IV 0.05 mg/kg 3 minutes before procedure (may
  repeat dose X 2) max 2 mg/dose

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Midazolam CNS Depressant

• Respiratory distress, depression, apnea, PVC's,
  amnesia, blurred vision, or hyperexcitibility
• Reversal
• Flumazenil(Romazacon) 0.2 mg/dose q 1 minute
  max cumulative 1 mg

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POINTS TO REMEMBER

• Dosing intervals are determined by the duration
  of action as well as the half-life of the drug
• Know the route of elimination
• Adjust dose and frequency for special
  populations.
• Be aware of prior surgeries involving bowel,
  stomach, liver, kidneys

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Opioid-induced Neurotoxicity (OIN)

• Hyperalgesia (heightened sensitivity to the
  existing pain)
• Allodynia (a normally non-noxious stimuli
  resulting in a painful sensation),
• Agitation/delirium with hallucinations and
  possibly seizures.
• Due to the accumulation of toxic metabolites and
  impaired renal

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Post Op Documentation

• Document response to medication
• Pain relief
• Increased agitation
• Be pro-active if patient unable to verbalize
• Painful procedures result in pain
• (Treat as you would a family member)

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GOAL

• Promote optimal pain management
• Reduce anxiety
• Support the patient
• Improve post op outcomes
• Promote patient satisfaction

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• QUESTIONS????

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• THANK YOU