PAIN MANAGEMENT IN SURGERY

Dr:Arshad M.MalikAssociate Professor Surgery

LUMHS

Introduction

• There is a wide variation in the individual perception of pain.

• Under treatment• Over treatment• General fear of

opiods

Introduction

• The optimum pain requirement have some basic requirement.

• There should be an expert team approach

• Pain may be measured regularly• Pain killers should be given before the

pain develops.• A combination of pain killers is usually

more effective.• Analgesic dose should be adequate.

Royal college of anesthetist and surgeons guidelines

• Establishment of acute pain management services comprising trained personnel to assure

• Routine recording of pain levels• Education of both staff and patients• Encourage “Multimodal” analgesia

comprising local anesthesia with simple analgesics like paracetamol or NSAIDS.

Simple analgesics

• Usually prescribed in minor surgery when the patient is orally allowed

• Paracetamol, NSAIDS and other such drugs are good enough to control minor pains.

• NSAIDS are excellent for moderate pain and can be used as an adjuct with opiods for severe pain.

NSAIDS

• These drugs cause non-specific cyclo-oxygenase inhibition. This removes gastric cyto-protection and gastritis. There are other side effects like platelet dysfunction etc.

• Patients with a tendency of peptic ulceration may need proton pump inhibitor cover.

• Rectal preparations of NSAIDS are also in use• Recently Cox-2 inhibitors are introduced with

less GIT upsets.

Stronger Analgesics.

• Morphine given intramuscular along with other analgesics can provide excellent and effective control of moderate to severe pain

Pain and Analgesics

• Pain ”an unpleasant sensory and emotional experience with actual or potential tissue damage or described in terms of such damage.

• Analgesia absence of pain

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Pain pathways

• Specialized receptors = free nerve endings• Stimulation– Mechanical damage– Extreme temperature– Chemical irritation

• Two types of neurons– A-delta: first pain, sharp– C: second pain, dull

• Four distinct processes– Transduction, transmission, modulation,

perception9

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Pain management

• Prevention: preemptive approach• Recognition of pain• Choice of substance• Drug dose and duration

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Tissue damage

• Release of chemical substances and enzymes (mediators) that alter the activity and sensitivity of sensory neurons– Prostaglandins, leukotriens: sensitization of

receptors– Bradykinin and PGs: stimulate the neurons

directly– Histamine: pain, itching

• Result– increase in nociceptor activity – Hyperalgesia– Neurogenic edema

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Principles of pain management

In order to apply the principles of effective pain management, you must first have done a pain assessment. In order to do so, you need to know the components for assessment.

Pain assessment• The components of assessment are:

– Location/s of pain– Description of pain– Type of pain– Impact on ADL– Intensity (0-10, 0-5, etc.)– Pattern:

• Continuous?• Intermittent?

– Onset– Duration– What makes pain worse?– What makes pain better?– Patient's perception of pain– Patient's goal for pain relief– Analgesics that have been used in the past– Analgesics receiving in past 24 hours

Types of pain

• There are 6 primary types of pain:1) Visceral Pain2) Muscle Pain3) Bone Pain4) Neuropathic Pain5) Pleuritic Pain6) Colic Pain

Visceral Pain

– Usually localized to the site of the injury/tumor. Pain can be referred to the somatic area supplied by the same nerve root.

– Description/clue to this kind of pain:• “I ache all the time.”

Muscle Pain

– Sometimes difficult to isolate as it may be due to an underlying disorder, a systemic or metabolic cause.

– Description/clue to this kind of pain:• “I’m sore and stiff.”

Bone Pain

– Local bone pain can range from a dull ache to deep, intense pain. Usually well localized and worse on movement and weight-bearing, it may be worse at night. Bone pain can be masked by muscle pain arising from involuntary, protective spasm of the surrounding muscles.

– Description/clue to this kind of pain:• “It hurts when I move.”• “It aches at night.”

Neuropathic Pain

– Constant, superficial burning pain is usually caused by actual damage to peripheral nerve, plexus, root, or spinal chord. When a specific nerve is involved, pain is in relatively constant are of the body surface (dermatome) but may also be referred to the somatic area supplied by the nerve. The degree of nerve pain will be effected by the degree of nerve compression or infiltration.

– Description/clue to this kind of pain:• “It feels like my skin is burning.”• “It feels like someone stabbed me.”• “It’s a shooting pain.”

Pleuritic Pain

– Patient may complain of pain on inspiration of my present with guarded, shallow breathing.

– Description/clue to this kind of pain:• “The pain is worse when I breathe in.”

Colic Pain

– Partial or complete obstruction of a hollow viscus can result in intermittent cramps.

– Description/clue to this kind of pain:• “The pain comes and goes like cramps.”

Keep it simple: The WHO “Analgesic Ladder”

"STEP 1 – - patients with mild to moderate pain should be

treated with nonopioid analgesic, which should be combined with adjuvant drugs if indication for one exists.

"STEP 2

• - patients who have limited opioid exposure and present with moderate to severe pain or who fail to achieve adequate relief after a trial of a nonopioid analgesic should be treated with an opioid conventionally used for moderate pain.

"STEP 3– - patients who present with severe pain or who

fail to achieve adequate relief following appropriate administration of drugs on the second step of the analgesic ladder should receive an opioid conventionally used for severe pain.

Critical Points for Analgesic Medication Orders

– The character (quality) of the pain has been documented on assessment (e.g.- burning/shooting pain) so that the health care provider can determine the type of pain (e.g.- neuropathic pain).

– The oral route is the first choice for analgesic orders. If a patient is unable to take PO medications, buccal, sublingual, rectal and transdermal routes are considered before intravenous or subcutaneous routes.

– Patients who report constant moderate to severe pain receive a long-acting medication and have a short acting medication ordered prn for breakthrough pain.

– Patients who report intermittent pain have medications ordered on a prn basis.

Recently introduced more sophisticated methods of pain

management• Patient Controlled

Analgesia.(PCA).• Local anesthetic blocks

Patient controlled Analgesia

• Opiods are injected intravenously or through epidural cannula.

• The patient is trained to give a bolus of dose when needed by pressing a button on the machine.

• The medical staff presets the strength and dose and frequency .

• This is a very popular method as patient can control his pain by himself.

Local anesthetic blocks

• These give excellent short-term results but require skill and have a small failure rates.

Chronic Pain

• Inadequate control of acute pain leads to chronicity. Chronic stimulation of nocioceptors produces sensitization

• Dysfunction in nerve produces neuropathic pain.

Pain control in Malignant disease.

1st- Simple analgesics (Aspirin,Paracetamol,Nsaids)

2nd Intermediate strengh. (opiods,codine,Tramadol)

3rd .Strong opiods.(Morphine,pethedine

Technique for managing chronic pain

• Oral opioids. Can lead to nasea and constipation.

• Opioid infusion. If cant take orally.• Neurolysis. Only when life expectancy is

short Subcostal injection of phenol in rib

mets percutaneous anterolateral

chordotomy to divide spinothalamic tracts

Thanks for your attention