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Acute Pain Management: Clinical Decision Making and Responsibility

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Title: Acute Pain Management: Clinical Decision Making and Responsibility


1
Acute Pain Management Clinical Decision Making
and Responsibility
  • Lynda Wells, M.D., DABPM
  • Associate Professor of Anesthesiology
  • UTHSC-SA

2
Acute Pain
  • Present less than 3 months
  • Usually occurs as a consequence of deliberate or
    accidental trauma, or an acute illness associated
    with primary or secondary inflammation
  • 50 75 of all patients underprescribed and
    undermedicated

3
Importance of Pain Control
  • Humane (social)
  • Learned experience (behavioral)
  • Wind up (biological)
  • Gene induction (anatomical)
  • Physiological stress response

4
Schechter et al
  • Pediatric oncology patients
  • Repeated invasive procedures
  • Gp A - fentanyl Gp B placebo
  • VAS Gp A 2-4/10 Gp B 8-10/10
  • Gps A B fentanyl
  • VAS Gp A 2-4/10 Gp B 8-10/10

5
Wind up
  • Enhanced afferent transmission
  • Expansion of receptor fields
  • Progressive facilitation of neuronal firing
  • NMDA receptor mediated
  • Blocked by ketamine, methadone, propoxyphene, LA
  • Leads to gene induction

6
Gene induction
  • Increased synthesis of cellular mediators of pain
  • Altered post-synaptic morphology

7
Neuroendocrine Stress Response
  • Reduced body mass tissue reserve
  • Immunosuppression
  • Increased myocardial O2 demand
  • Diminished respiratory function
  • Increased thromboembolic risk
  • Increased post-op morbidity and mortality

8
WHO Ladder
  • An essential principle in using medications to
    manage pain is to individualize the regimen to
    the patient

9
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10
WHO analgesic guidelines
  • Oral medications whenever possible
  • Dose by the clock but always have as
    neededmedications for breakthrough pain
  • Titrate the dose
  • Use appropriate dosing intervals
  • Be aware of relative potencies
  • Treat side effects

11
Pre-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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15
Selecting an analgesic regimen
  • Rapport
  • Severity of pain
  • Location of pain
  • Anticipated duration of pain
  • Routes of administration

16
Selecting an analgesic regimen
  • Side effects
  • Metabolites pro-drugs
  • Physical status, age, etc
  • Goals of management
  • Availability of resources

17
Severity of Pain
  • Short acting v long acting drugs
  • Opiate v non-opiate
  • Local anesthetic
  • Infiltration
  • Nerve block
  • Plexus block
  • Neuraxis block

18
Routes of administration
  • Oral
  • Transmucosal
  • Rectal
  • Transdermal
  • Parenteral sc im iv
  • Intermittent bolus v PCA
  • Regional analgesia peripheral v neuraxis

19
Side effects - NSAIDs
  • Platelet inactivation
  • Gastric erosions
  • High-output renal failure
  • Bronchospasm
  • Ankle swelling
  • Exacerbation of HTN and CHF

20
Side effects - Opiates
  • Constipation
  • Nausea/vomiting
  • Sedation
  • Dysphoria
  • Pruritus
  • Urinary retention

21
Metabolites
  • None hydromorphone fentanyl
  • Potentially good methadone
  • Potentially bad morphine acetaminophen
  • Bad - meperidine

22
Prodrugs
  • Codeine to morphine
  • Hydrocodone to hydromorphone
  • Oxycodone to oxymorphone

23
Pharmacogenetics
  • P450 3A4
  • Major isoform for drug metabolism
  • Inducible
  • P450 2D6
  • Bimodal distribution
  • Extensive and poor metabolizers
  • Conversion inhibited by concurrent metabolism of
    other drugs, e.g. SSRIs

24
Physical status
  • Babies immature function
  • Toddlers enhanced function
  • Elderly degenerative function
  • Illness adversely effects drug metabolism
  • Elderly more likely to experience mental status
    changes

25
Availability of Resources
  • Drugs
  • Pumps
  • Pharmacy
  • Nursing supervision
  • Physician supervision
  • Hospital infrastructure resuscitation
  • Acute Pain Management Service

26
Patient Controlled Analgesia
  • Applies to any analgesic given by any route on
    immediate patient demand in plentiful doses
  • 1968 concept of self-administration introduced
    by Sechzer
  • 1971 first mechanical pumps for drug
    administration introduced.

27
PCA popular because
  • Appreciation that intermittent IM opiates do not
    provide adequate analgesia
  • Safe, sophisticated, user-friendly pump
    technology
  • Enormous patient satisfaction
  • Only method of opiate administration that results
    in significant cost savings

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29
Studies show
  • Patients titrate their own analgesics better than
    ward staff
  • Analgesic requirements vary enormously between
    individuals
  • Patients do not over use the device
  • Many patients do not attempt to achieve total
    analgesia knowing that they can if they wish

30
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31
PCA Rules
  • ONLY the patient presses the button
    oversedation precedes respiratory depression
  • Intended to maintain an effective level of
    analgesia
  • Dosing bolus must be large enough for patient
    to perceive something is happening
  • Ideal PCA drug rapid onset, moderately long
    duration of action, no side effects

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33
PCA Rules
  • Background infusion controversial
  • Any child who can meaningfully play a
    computer/video game can use a PCA
  • Nurse/parent controlled analgesia for younger
    children and adults with disabilities

34
Epidural analgesia
  • Introduced in the 19th century
  • Spinal action of opiates discovered in the late
    1970s

35
Epidural local anesthestics
  • Hypotension
  • Sensory loss
  • Blockade of motor function
  • Tachyphylaxis

36
Epidural opiates
  • Pruritus
  • Nausea/vomiting
  • Urinary retention
  • Sedation
  • Respiratory depression

37
Contra-indications
  • Patient refusal
  • Coagulopathy
  • Local sepsis
  • Systemic sepsis
  • Raised intracranial pressure

38
Worwag et al
  • 100 patients RRP
  • Gp I Epidural LA intra-op
  • Epidural MSO4 post-op
  • Acetaminophen ibuprofen discharge meds
  • Gp 2 CSE LA fentanyl
  • Methadone 10mg 20mg IM
  • Acetaminophen ibuprofen discharge meds

39
Worwag et al
  • No differences in pain intensity
  • No differences in M M
  • No differences in satisfaction scores
  • Home post-op day 1

40
Gottschalk et al
  • 100 patients RRP
  • Pre-emptive v post-operative epidural
  • No differences in-patient stay
  • Post discharge pre-emptive analgesia gp
  • Increased activity
  • 86 no pain at 9 weeks v 47 controls

41
Brodner et al
  • 45 patients radical cystectomy
  • Gp I GA, PCA opiates, TPN
  • Gp II GA epidural, PCA opiates, TPN
  • Gp III GA epidural, PCEA, oral nutrition,
    early ambulation
  • Serum/urine indicators catabolic stress
  • Mobility, fatigue, recovery bowel function

42
Brodner et al
  • Gp III best outcome
  • ? urinary catecholamine excretion
  • ? mobility
  • ? subjective ratings of recovery
  • ? fatigue
  • ? dynamic pain scores
  • Earlier first defecation

43
Brodner et al
  • Epidural block minimum 24-48 h to ? catabolic
    hormonal response and improve protein economy
  • Decreasing the stress response associated with
    early enteral nutrition
  • Multi-modal approach patients met discharge
    criteria earlier

44
Pain is dynamic
  • Assess each intervention
  • Titrate analgesia to comfort (lt4/10)
  • Simple comfort measures ALWAYS
  • Manage side effects

45
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46
Bibliography
  • Broder G, Van Aken H, Hertle L, et al.
    Multimodal Perioperative Management Combining
    Thoracic Epidural Analgesia, Forced Mobilization,
    and Oral Nutrition Reduces Hormonal and
    Metabolic Stress and Improves Convalescence After
    Major Urologic Surgery. Anesth Analg
    2001921594-1600

47
Bibliography
  • Ferrante FM. Acute Postoperative Pain
    Management. In Longnecker DE, Tinker JH, Morgan
    GE, editors Principles and Practice of
    Anesthesiology, Mosby, 1998
  • Kissin I. Preemptive Analgesia. Anesthesiology
    2000931138-43
  • Macrae WA. Chronic Pain after Surgery. Br J
    Anaesth 20018788-98
  • Rawal N. Analgesia for Day-case Surgery. Br J
    Anaesth 20018773-87

48
Bibliography
  • Gottschalk A, Smith DS, Jobes DR, et al.
    Preemptive Epidural Analgesia and Recovery From
    Radical Prostatectomy A Randomized Controlled
    Trial. JAMA 19982791076-1082
  • Worwag E, Chodak GW. Overnight Hospitalization
    After Radical Prostatectomy The Impact of Two
    Clinical Pathways on Patient Satisfaction, Length
    of Hospitalization, and Morbidity. Anesth Analg
    19988762-7

49
Bibliography
  • US Department of Health and Human Services.
    Acute Pain Management Operative or Medical
    Procedures and Trauma. 1992 AHCPR Publication
    No. 92-0032

50
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