alifspain.ppt

8/9/2019 alifspain.ppt

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PAIN & ITS MANAGEMENTBased On Anaesthetic House Officer

Training Module

Kementerian KesihatanMalaysia

Edited by Dr Alif Ramli


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Those who do not feel painseldom think that it is felt.

Dr. Samuel Johnson

(1709-1784)
http://en.wikipedia.org/wiki/File:Johnson_Wife.jpghttp://en.wikipedia.org/wiki/File:Samuel_Johnson_by_Joshua_Reynolds.jpg


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DEFINITION OF PAIN

An unpleasant sensory and emotional experience

associated with actual and potential tissue

damage or described in terms of such damage

IASP Subcommitee on Taxonomy.

Pain 1980; 8:249-252


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DEFINITION OF PAIN

Pain is what the patient says,

hurts


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NOCICEPTORS

1.A-delta fibers

myelinated

2-30 m/sec

(1st pain)2. C-fibers

unmyelinated


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THE PAIN PATHWAY

FIRST ORDER NEURONS SECOND

ORDER NEURONS


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ASCENDING PAIN PATHWAY (ACUTE

PAIN)

Cerebral cortex Sensory Cortex

3rdOrder

Thalamus Spinothalamic

Midbrain Spinomesencephalic

Pons

Medulla Spinoreticular

2ndOrder

Dorsal Root

1stOrder

Nociceptors


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PAIN PATHWAY

Free nerve

endings

Aferent nerve ( A/

c)

Spinal cord

Sensorycortex

Thalamus

Descending

inhibitoryfbres

Dorsalhorn

PAG / RAS

Ascending STtracts

5thVital Sign: Doctors training mo!ule: "ain "h#siolog#

PAIN


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EFFECTS OF PAIN

I. Physiological

- Cardiovascular System

- Respiratory system

- Gastrointestinal system- Genitourinary system

- Central Nervous System

- Endocrine system

II. Psychological

III. Economic
http://en.wikipedia.org/wiki/File:OuchFlintGoodrichShot1941.jpg


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CARDIOVASCULAR SYSTEM

Increased Heart Rate

Increased Blood Pressure

increased myocardial work load

myocardial oxygen consumption

increased risk of myocardial ischaemia



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RESPIRATORY SYSTEM

Inhibition of normal respiration (unable totake deep breaths)AtelectasisHypoxia

Inability to coughRetention of secretions

Increased risk of lung infection / pneumonia



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GASTROINTESTINAL SYSTEM

Increased sympathetic and reducedparasympathetic activity

Reduced smooth muscle + sphincter tone Reduced gut motility

Ileus, nausea + vomiting

Impedes early feeding



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GENITOURINARY SYSTEM

Increased sympathetic and reduced

parasympathetic tone

reduced smooth muscle + sphincter tone

urinary retention



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MUSCULOSKELETAL SYSTEM

Prevent mobilisation & increases muscle tone

Increased risk of deep vein

thrombosis



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CENTRAL NERVOUS

SYSTEM sympathetic activity

parasympathetic activity

HyperalgesiaHyperalgesiascarring of pain pathways

Increased risk of developing

chronic pain



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ENDOCRINE SYSTEM

Stimulation of stress response Increased sympathoadrenal activation

Metabolic response to stress Hyperglycemia Catabolic state

Immunosuppression

risk of infection

m



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ECONOMIC

Delayed ambulation and feeding

Increased postoperative complications

Delayed recovery

Prolonged hospital stay

Increased cost



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SPECTRUM OF PAIN

ACUTEPAIN

C!"NICPAIN

ACUTEPAIN

Healing

N" PAIN

C!"NICPAIN

Insidious onset

postsurgical s!ndromes /cancer



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ASSESSMENT OF PAIN

Painis "ot# a p#!sical and aps!c#ological p#enomenon

T#e pain e$perience is su"%ective

&eaning'ul evaluation and success'ultreatment o' a patient it# pain

reuires uanti*cation o' t#e patient+spain


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PAIN AS THE 5TH VITAL SIGN

GUIDELINES FOR DOCTORS

(MANAGEMENT OF ADULT PATIENTS)


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PAIN AS THE 5TH VITAL SIGN

GUIDELINES FOR DOCTORS

(MANAGEMENT OF PAEDIATRIC PATIENTS)


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HOW TO ASSESS

PAIN:P: Place or site of painWhere does it hurt?

(a body chart might help describe their

pain)

A: Aggravating factorsWhat makes the pain worse?

I: IntensityHow bad is the pain?

N: Nature and neutralizing factorsWhat does it feel likeWhat makes the

pain better?

,t#-ital Sign. octors+ training module. Pain


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P Place 0#ere is !our pain1A Aggra#atin

g $actors

0#at ma2es t#e pain orse1

I Intensity I' 3 is no pain and 43 is t#e orst pain

imagina"le. %hatis !our pain score no1

0#at is t#e orst level o' pain (score) !ou

e$perience in a da!1

0#at is t#e least pain (score) !ou e$perience

in a da!1

N NatureNeutrali&in

g $actors

escri"e !our pain e5g5 ac#ing6 t#ro""ing6"urning6 s#ooting6 sta""ing6 s#arp6 dull6 deep6

pressure6 etc

0#at ma2es t#e pain "etter1

'uideline (Pain Assessment 'uide) Ta*ing a +rie$ Pain

istory

,TE-- .E A+"UT /"U! PAIN001


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PAIN MEASUREMENT TOOLS :

ADULTS

Combined NRS/ VAS Scale Combined NRS/ VAS Scale (KKM)

7RS/

7RS . 7umerical Rating Scale-AS . -isual Analog Scale


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PAIN MEASUREMENT TOOLS :

PAEDIATRICS

FLACC Scale Wong-Baker Faces

Scale


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FLOW CHART : PAIN AS THE 5TH

VITAL SIGN (NURSES)


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ANALGESICS

8 9

31

8 Non Opioids

Paracetamol

NSAIDSCOX 2 inhibitors

9 Opioids

Weak

Strong

5thVital Sign: Doctors training mo!ule: "harmacolog#


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2ormulations And Dosage "$ Commonly UsedAnalgesics


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01

203

Regular

-igher doseof wea

opioid

Or

45/S%

6orphine 70

8mg 2 hrly

OR

A9ueous

morphine80: mg

; P%6 8gm


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POST OPERATIVE PAIN

MANAGEMENT

1.Conventional Methods

i. Oral Analgesics Opioids

NSAIDS

ii. IV Injections Opioids

NSAIDS

2. Common Methods

i. Patient Controlled Analgesia

(PCA)

ii. Epidural Analgesiaiii. Patient Controlled Epidural

Analgesia (PCEA)

iv. Subcutaneous Morphine

3. Other Methods

i. Nerve & Nerve Plexus

Blocks

ii. Transcutaneous

Electrical

Nerve Stimulation

(TENS)

iii. Rectal NSAIDS

4. Multi-modal

Concepts


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PATIENT CONTROLLED ANALGESIA

(PCA)

Method of analgesic

delivery : computerised

syringe pump is set to

deliver bolus doses

whenever patient pressesbutton (patient demand)

Allows small amounts of

analgesic to be given at

frequent intervalsPatient titrates according

to individual needs


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DILUTION OF PCA DRUGS

Morphine:

Adults: 5 amp (50 mg) = 5 mls

Dilute with N/S 45 mls

Concentration : 1mg/ml (50mls)Paeds: 0.5mg/kg of morphine and make

upto 50mls with N/S.

Concentration: 1ml = 10mcg/kg


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RECOMMENDED SETTINGS

(EXAMPLE )

Drug concentration:morphine 1mg/ml

Mode:PCA

Loading dose:usually zero for postoperative patients

Bolus dose:60 years morphine 0.5mgLockoutinterval :5 minutes

4 hour limit :usually not set


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EPIDURAL ANALGESIA

Introduction of

analgesic drugs into

epidural space via an

indwelling catheter


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EPIDURAL ANALGESIA :DRUGS USED

LOCAL ANAESTHETICS ALONE

-BUPIVACAINE OPIODS ALONE

-FENTANYL - MORPHINE

MIXTURES (COCKTAIL)

- FENTANYL + BUPIVACAINE

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