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Jakarta
25 % of patients do not think their doctors know how to control their pain,
20% feel that their doctor does not consider their pain a problem,
and 1 in 8 state their physician never asks them about their pain. 4 of 5 patients think they must live with their pain.
1 Patients also need to feel that their pain is important and that there are many options for improving their pain and level of daily activities.
Unpleasant sensation and emotional experience accompanied with potential and actual tissue damage
PAINFUL ?
Disease
pain
disease
Pain
Doctor
Patient
1. 2. 3. 4.
1 American
Vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated
James Campbell
Disease of pain
Investigators view
MILD
MODERATE
SEVERE
10
Patients view
NO PAIN
PAIN
Muscle atrophy & weakness Weight loss/gain Negative self-talk Poor sleep Missing work
Pain
Disability
Distress
Less active Decreased motivation Increased isolation
Fear
that the patient will become addicted to opioids Inadequate perioperative pain education regarding postoperative analgesia Patients reluctance to request analgesia and/or fear of taking pain medications Lack of understanding of the wide variability in opioid requirements among patients, and the need to titrate analgesics to meet the needs of each patient Lack of recognition that age is a better predictor of opioid requirement than weight in the adult patient Prolonged dosing intervals/short-acting opioids have short elimination half-lives Lack of accountability for pain management
65%
Worst Pain: Moderate to Severe Average Pain: Moderate to Severe
45% 40%
Patients (%)
24%
26% 13%
1Beauregard
Pain as a Symphony
Complex dynamic Sensors Emotions Memory Hormones
Opiat & NSAID Powerfull drugs treating pain MANY SIDE EFFECT GI problem Dependence
Perception
Pain Transmission
Pain
Medulation
Descending modulation Ascending input Dorsal Horn Dorsal root ganglion
transmission Transduction
Spinothalamic tract
Peripheral nerve
Trauma
Peripheral nociceptors
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Type of surgery
2to 3 days
3to 4 days
Preemptive analgesia
different mechanisms via a single route for providing superior analgesic efficacy with equivalent or reduced adverse effects.
epidural opioids with epidural local anesthetics or clonidine, Intravenous opioids in combination with ketorolac or ketamine.
1Kehlet
PERCEPTION
Pain
Dorsal Horn
TRANSMISSION
LA COX-1 COX-2
TRANSDUCTION
Trauma
Spinothalamic tract
Peripheral nerve
Peripheral nociceptors
29
Pre-emptive
Preventive analgesia:
any perioperative analgesic regimen able to control pain-induced sensitization of the central nervous system to decrease both the development and the persistence of pathologic pain
introduction of an analgesic regimen before the onset of noxious stimuli prevent sensitization of the nervous system to subsequent stimuli that could amplify pain
the pain intensity and its consequences may be procedure-related Some analgesic modalities may only apply to certain surgical procedures The risk-benefit ratio of different analgesics may also vary according to the surgical procedure the risk and clinical implications of postoperative bleeding associated with certain analgesics are also procedure-specific Postoperative pain may also depend on the choice of surgical technique
Tramadol+ APAP
NSAIDS
Gastrointestinal1,2
Peptic ulceration; gastrointestinal hemorrhages Esophagitis and strictures Small and large bowel erosive disease Inhibition of platelet aggregation Increased risk of bleeding Reversible acute renal failure Fluid and electrolyte disturbance/edema Chronic renal failure and interstitial fibrosis Interstitial nephritis Nephrotic syndrome
Hematologic
Cardiorenal1
1Brooks 2Girgis
P. Am J Med. 1998;104(suppl 3a):9S-13S. L et al. Drugs Aging. 1994;4(2):101-112. 3Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50.
Pain relief requirements can vary greatly from one individual to another, and even in the same individual from one time to another. Side-effects also vary from person to person. The prescription therefore needs to be tailormade to benefit the patient
Multimodal analgesia using local anesthetic, NSAIDs and opiates provides improved pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy. (I, A [Michaloliakou et al., 1996]) Pain following upper abdominal surgery produces inspiratory muscle dysfunction. This dysfunction is reduced with analgesia. (I, A [Vassilakopoulos et al., 2000]) IV PCA morphine produces better analgesia than IM morphine, without any increase in postoperative hypoxemia. (I, A [Wheatley et al., 1992]) Patients using IV PCA morphine used more morphine and had better analgesia than patients receiving IM morphine on demand. IV PCA patients also experienced more fatigue and had less vigor than patients receiving IM morphine. (I, A [Passchier et al., 1993]) Epidural analgesia, with a combination of opiates and local anesthetic, provides better pain control during rest and activity, and is the treatment of choice. It is also associated with more rapid recovery of bowel function. (I, A [George et al., 1994; Mann et al., 2000; Liu et al., 1995]; III, A [Mulroy et al., 1996]) Epidural analgesia is associated with less postoperative myocardial ischemia (than IV PCA with morphine). (II-2, A [deLeon-Casasola et al., 1995]) For optimal analgesia, the thoracic epidural route should be used for pain relief after upper abdominal surgery. (I, A [Wiebalck et al., 1997; Chisakuta et al., 1995; George et al., 1994])
Pain control with intercostal nerve block in combination with opiates is more effective than opiates alone after subcostal incisions. Intercostal nerve blocks do not significantly improve analgesia following midline incisions. (I, B [Engberg et al., 1985]) Phenol with local anesthetic has been shown to increase the duration of intercostal block and improve analgesia following cholecystectomy. (I, B [Maidatsi et al., 1998]) Infiltration of the incision/wound with local anesthesia improved postoperative analgesia provided by epidural bupivicaine/morphine during mobilization and reduced the need for supplemental intramuscular morphine. (I, B [Bartholdy et al., 1994]) Ketorolac given before or after laparoscopic cholecystectomy reduced postoperative pain and facilitated the transition to oral pain medication. (I, A [Lane, 1996]) Pain relief promotes return of respiratory function. (I, A [Vassilakopoulos et al., 2000]) Aggressive perioperative management with epidural, NSAIDs, early feeding, and ambulation is associated with improved recovery and rapid discharge after laparoscopic colonic surgery. (II-3, B [Kehlet et al., 1999]; II-3, A [Bardram et al., 1995]) Laparoscopic cholecystectomy is associated with less pain than open cholecystectomy. (I, A [McMahon et al., 1994]) Patient-controlled epidural analgesia with a background infusion is more effective than patient-controlled epidural analgesia alone after gastrectomy. (I, A [Komatsu et al., 1998])
Multimodal analgesia using local anesthetic, NSAIDs, and opiates provides improved pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy. (I, A [Michaloliakou, 1996]) Active removal of residual pneumoperitoneum reduces postoperative pain following laparoscopic cholecystectomy. (I, A [Fredman et al., 1994]) Suprahepatic suction drains placed by the surgeon have been shown to reduce shoulder tip pain following laparoscopic cholecystectomy. (II3, B [Jorgensen et al., 1995])
Epidural analgesia produces better pain control at rest and with activity. It is also associated with earlier return to normal mental status in the elderly, better satisfaction, and more rapid recovery of bowel function. (I, A [Liu et al., 1995; Mann et al., 2000]) Aggressive perioperative management with epidural, NSAIDs, early feeding, and ambulation is associated with improved recovery and rapid discharge after laparoscopic colonic surgery. (II3, A [Bardram et al., 2000]; II-3, B [Kehlet, 1999; Bardram et al., 1995])
Epidural opiates in the postoperative period provide better analgesia with fewer side effects than IV PCA morphine. (I, A [ErikssonMjoberg et al., 1997]) Ambulation in the perioperative period is associated with a decreased risk of thromboembolic complications and more rapid recovery of bowel function. (II-3, A [Bardram et al., 2000])
Benefits of Effective Pain Management are simple and straightforward. Effective pain management can: Increase patient satisfaction. Increase the speed of recovery. Decrease hospital length of stay. Decrease overall hospital costs. Reduce the likelihood of chronic pain. Decrease the likelihood of complications. Increase productivity. Decrease suffering. Improve quality of life.
Pain is a major health problem and remains a challenge to healthcare providers Pain is subjective and must be frequently assessed on an individual patient basis. Undertreatment of pain can lead to serious negative sequelae, including:
Cardiac complications Respiratory depression Anxiety Depression
Summary
Increased speed of recovery Decreased length of hospital stay and overall hospital costs Decreased likelihood of developing chronic pain Increased patient satisfaction and productivity
Thorough documentation and patient contracts allow healthcare professionals to safely provide effective pain management to their patients.
Post operative pain is still a challenging problem, with a wide variations of treatment options
Therefore treatment of post operative pain needs a good collaboration of several disciplines to provide good post operative pain care.