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

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

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Title: 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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