Introduction

Definition of pain


Once thought to be a punishment from the gods, the word is derived from the Latin peone and the Greek poine meaning penalty or punishment An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Many clinicians define pain as whatever the patient says it is

Classification of pain


Nociceptive pain Acute pain Somatic or visceral Neuropathic pain Chronic pain Nerve damage

Characteristics of acute and chronic pain

Characteristic
Relief of pain Dependence & tolerance to medication Psychological component Organic cause Environmental contributions and family involvement Insomnia Depression Treatment goal

Acute pain
Highly desirable Unusual Usually not present Common Small Unusual Uncommon Cure

Chronic pain
Highly desirable Common Often a major problem Often not present Significant Common Common Functionality

1.2 Psychological aspects of acute pain

Preoperative anxiety, catastrophising, neuroticism and depression are associated with higher postoperative pain intensity (Level IV). Preoperative anxiety and depression are associated with an increased number of patient-controlled analgesia demands and dissatisfaction with PCA (Level IV).

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1.3 Progression of acute to chronic pain

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Some specific early analgesic interventions reduce the incidence of chronic pain after surgery (Level II). Chronic postsurgical pain is common and may lead to significant disability (Level IV). Risk factors that predispose to the development of chronic postsurgical pain include the severity of pre and postoperative pain, intraoperative nerve injury and psychological vulnerability (Level IV). Many patients suffering chronic pain relate the onset to an acute incident (Level IV).

1.4 Pre-emptive and preventive analgesia

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The timing of a single analgesic intervention (preincisional versus postincisional), defined as preemptive analgesia, does not have a clinically significant effect on postoperative pain relief (Level I). There is evidence that some analgesic interventions have an effect on postoperative pain and/or analgesic consumption that exceeds the expected duration of action of the drug, defined as preventive analgesia (Level I). NMDA (n-methyl-D-aspartate) receptor antagonist drugs in particular may show preventive analgesic effects (Level I).

Physiologic response


Cardiovascular
: HR, BP , PVR, myocardial O2 consumption MI, DVT, pulmonary embolism

Respiratory
: lung volume atelectasis : cough, sputum retention infection, hypoxemia

Gastrointestinal
: gastric & bowel motility, : risk of bacterial transgression of bowel wall

Musculoskeletal
:muscle spasm, immobility risk DVT :muscle wasting prolong recovery

Central nervous
: central sensitization chronic pain

Psychological
: anxiety, fear, sleep deprivation, leading to pain

Physiologic response


Neuroendocrine
: catabolic hormone (glucagon, growth hormone, vasopressin, aldosterone, renin angiotensin) hyperglycemia, impaired wound healing

: anabolic hormone (insulin, testosterone)

Multimodal analgesia
Opioid Anti inflammatory agents Alpha 2 agonist

Local anesthetics Opioid Anti inflammatory agents Alpha 2 agonist

Local anesthetics Opioid Anti inflammatory agents

Surgical outcome

Review Multimodal strategies to improve surgical outcome The American Journal of Surgery 183 (2002) 630641

Surgical pain
Surgical procedure
Moderate surgery Minor surgery Herniotomy Varicose vein Gynecological laparotomy Paracetamol /NSIADs +Wound infiltration Peripheral nerve block Systemic opioids PCA Hip replacement Hysterectomy maxillofacial Paracetamol /NSIADs Epidural anesthesia systemic opioids PCA Major surgery Thoracotomy Major abdominal surgery Knee surgery

Paracetamol /NSIADs / weak opiods Wound infiltration Peripheral nerve block

Treatment modality

Techniques to improve post op analgesia

      

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Local blocks (ring blocks) Nerve blocks Epidural injection Splash blocks Intraarticular injections Fentanyl patches Immobilization (bandage + cage)

Analgesics
  

1) Local 2) NSAIDs

periphery periphery

3) Opioids- periphery, spinal and central 4) Alpha 2- periphery, spinal and central 5) Dissociatives- spinal and central

Balance Analgesia Multimodal analgesia



Administration of two or more classes of analgesic drugs to create a synergistic analgesic effect. Often better analgesia than either drug used alone. Smaller doses of each drug so decrease risk of side effects. Acepromazine and Morphine (potentiate)

End of life pain and anxiety medication delivery: Options



Transmucosal (Nasal, sublingual, buccal).



     

Appropriate for baseline as well as breakthrough pain management. Titratable. Non-invasive. No infection risk. Easy for family members to manage. No needle stick risks. No need to swallow.

End of life pain and anxiety medication delivery: Options



Intravenous therapy.
 

   

Gold standard for severe pain control. Appropriate for baseline as well as breakthrough pain management. Invasive. Mild to moderate infection risk. Difficult for family members to manage. Needle stick risks.

End of life pain and anxiety medication delivery: Options



Subcutaneous/Intramuscular .


    

Suboptimal/inappropriate for baseline pain control over long periods. OK for breakthrough pain, but delivery method is painful. Slower onset than IV or Transmucosal. Invasive. Slight infection risk. Difficult for family members to manage. Needle stick risks.

End of life pain and anxiety medication delivery: Options



Oral
  

Appropriate for baseline pain control. Often too slow for breakthrough pain. Ineffective once patient cannot swallow. Appropriate for baseline pain control. Too slow for breakthrough pain. Relatively slow for breakthrough pain. Socially unacceptable to many patients and families.

Transdermal
 

Rectal
 

Persistent postsurgical pain: risk factors and prevention. Kehlet H, Jensen TS, Woolf CJ Lancet. 2006 May 13;367(9522):1618-25.
The intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention.

Peripheral Neural Blockade with Catheter Placement



Neural blockade catheter placement techniques with continuous local anesthetic infusion possible at a variety of sites
 

Upper extremity - brachial plexus Lower extremity - femoral nerve, sciatic nerve

 

Continuous analgesia for 1-5+ days Outpatient management with disposable programmable infusion pumps


Daily telephone follow-up

Regional Anesthesia Peripheral Neural Blockade



Local anesthetics are the most potent class of non-opioid analgesics to reduce or eliminate postoperative opioid analgesic requirements Multiple studies have demonstrated better analgesic efficacy and improved postoperative outcomes as compared to systemic analgesics alone Single injection or catheter placement for continuous local anesthetic infusion

Gabapentin, Pregabalin as Adjuvants in Postoperative Pain Management



Neuronal calcium channel blockers effective for neuropathic and postoperative pain relief Demonstrated analgesia and opioid sparing effect (20-60%) in several studies Additive analgesic benefit when combined with acetaminophen or NSAIDs


Gabapentin 600-1200 mg PO preoperatively, then 300-600mg PO q6h Pregabalin (LYRICA) 75-150mg PO preoperatively, then 75-150mg PO q12h

Adjuvant Analgesics and Postoperative Pain Management



Begin dosing early and around the clock (not prn) No need to withhold acetaminophen or COXIBs prior to surgery - no platelet effects, no effect on perioperative bleeding


 

Celecoxib 200 po q 12 h (avoid with renal insufficiency, sulfa allergy, hypertension/cardiac disease?) Acetaminophen 1000 mg po q 6 h Ibuprofen 600 mg q6h

Adjuvant Analgesics in Postoperative Pain Management



Numerous studies have demonstrated improved analgesic efficacy and a 30 50% reduction in opioid analgesic requirement with the use of NSAIDs or acetaminophen


 

NSAIDs have excellent analgesic efficacy for inflammatory, somatic pain (bone, muscle, joints) Opioid dose is reduced Opioid-related side effects are reduced

Pain Management for Orthopaedics



Use non-opioid analgesics as first-line therapy Use regional anesthesia peripheral neural blockade techniques whenever possible Titrate patient-specific doses of opioid analgesics as needed

Adverse Effects of Opioid (Narcotic) Analgesics



Narrow therapeutic index in individual patients Wide inter-patient variability in dose requirement and drug response Opioid (narcotic) related side effects are common


N/V, sedation, ileus, respiratory depression

There are safe and effective alternatives to opioid analgesic monotherapy

3.2 Organisational requirements

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Preoperative education improves patient or carer knowledge of pain and encourages a more positive attitude towards pain relief (Level II). Implementation of an acute pain service may improve pain relief and reduce the incidence of side-effects (Level III-3). Staff education and the use of guidelines improve patient assessment, pain relief and prescribing practices (Level III-3). Even simple methods of pain relief can be more effective if attention is given to education, documentation, patient assessment and provision of of appropriate guidelines and policies (Level III-3).

Benefits of pain relief term



Short

A patient's first request for analgesia after orthopedic surgery occurs later after operations performed with opioid premedication and intraoperative nerve blocks than after general anesthesia alone (McQuay, Carroll, and Moore, 1988) Patients who undergo cesarean section under epidural anesthesia request less postoperative pain medication in the next 3 days than patients who have general anesthesia (Hanson, Hanson, and Matousek, 1984)

Benefits of pain relief term



Short

Postoperative patients able to self-medicate with small intravenous doses of opioids such as morphine metered out by a programmable infusion pump -patient controlled analgesia or PCA (Ferrante, Ostheimer, and Covino, 1990) -- have less pain and are more satisfied with their pain relief. These patients tend to be discharged earlier from the hospital compared with those given the same drug on an "as-needed" basis

Benefits of pain relief term



Long

After elective limb amputation for vascular insufficiency, patients who receive epidural analgesia before an operation are less likely to have chronic phantom limb pain, in contrast to those conventionally treated (Bach, Noreng, and Tjellden, 1988). Aggressive pain treatment complement controlled clinical trials which indicate that postoperative morbidity and mortality decrease in high-risk populations such as the very young (Anand, Sippell, and Aynsley- Green, 1987) or very old (Egbert, Parks, Short, and Burnnett, 1990) when postoperative care includes aggressive pain relief.