Acute Pain Management Parisa Partownavid, MD Assistant Clinical

Report
Acute Pain Management
Parisa Partownavid, MD
Assistant Clinical Professor
David Geffen School of Medicine at UCLA
Department of Anesthesia
Definition of Pain
An Unpleasant Sensory and Emotional
Experience Associated with Actual or
Potential Tissue Damage, or Described
in Terms of Such Damage.
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

Acute Perioperative Pain
Pain that is Present in a Surgical
Patient Because of Preexisting
Disease, the Surgical Procedure,
or a Combination of Both
Importance of
Pain Management
Adequate Pain Control
 Reduce the Risk of Adverse Outcomes
 Maintain the Patient’s Functional Ability,
as well as Psychological Well-being
 Enhance the Quality of Life
 Shortened Hospital Stay and Reduced
Cost

Adverse Outcomes Associated
with Management of
Acute Pain
Respiratory Depression
 Circulatory Depression
 Sedation
 Nausea and Vomiting
 Pruritus
 Urinary Retention
 Impairment of Bowel Function

Adverse Outcome of
Undertreatment of Acute Pain
Thromboembolic or Pulmonary
Complications
 Needless Suffering
 Development of Chronic Pain

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.
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

Preoperative Evaluation
of the Patient
Type of Surgery
 Expected Severity of Postoperative Pain
 Underlying Medical Condition
(Respiratory or Cardiac Disease)

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

Pain Assessment Tools
Pain Assessment Tools

In Adults: Self Report Measurement
Scales, such as Numerical Scales
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)
Management of Acute Pain
Pharmacologic
Interventional
Pharmacologic Management
Alter Nerve Conduction (Local
Anesthetics)
 Modify Transmission in the Dorsal Horn
(Opioids, Antidepressants)

Routes of Administration
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PO
PR
IV
IM
Transdermal
Transmucosal
Epidural
Intrathecal
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

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, Coexisting Medical Problems, or Route of
Opioid Administered

Opioid Analgesics
Conversions: Morphine
Oral
300
Parenteral
100
Epidural
10
Intrathecal
1
Opioids
Drug
PO IV Starting
mg mg Oral Dose
Comments
Morphine
30
10
MS Contin, Release 8-12 hrs
MSIR for BTP
Hydromorphone
7.5
1.5 4-8
Meperidine
300 75
Methadone
20
mg
Fentanyl
10
0.020.05
15-30
Duration Slightly Shorter
than Morphine
Duration Slightly Shorter
than Morphine
Normeperidine Causes CNS
Toxicity
5-10 Qd
Long Half-Life, 24-36 hrs
Accumulates on Days 2-3
Fentanyl Patch, 12 hrs Delay
Onset and Offset
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
Hydrocodone
Tramodol
5-10
Vicodin or Lortab
Acetaminophen
Toxicity
50-100
Q4-6hr
Central Acting, Affinity for
Mu Receptors
Maximal Dose
400 mg/d
Patient Controlled Analgesia

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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
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
Non-Opioid Analgesics
Acetaminophen
 NSAIDs (Aspirin, Ibuprofen, Ketorolac,
COX-2 Inhibitors)
 Lidocaine Patch (Lidoderm)

NSAIDs
Relieve of Mild to Moderate Pain
 Complication:
 GI Discomfort
 GI Bleeding (Inhibition of COX-1)
 Nephrotoxicity
 Inhibition of Platelet Aggregation
 Osteogenesis

Ketorolac
Potent Analgesic
 Parenteral (IV or IM)
 15-30 mg Q 6hr
 Patients Older than 16 yrs
 Should not Exceed 5 days

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
Lidoderm
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

Interventional
Management
Epidural Analgesia (Continuous Lumbar
or Thoracic Epidural Catheter
Placement, PCEA)
 Spinal Analgesia
 Peripheral Nerve Block ( Single Shot or
Continuous)

Anatomy of
Epidural Space
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Surrounds the Dural
Sac
Anteriorly: Post.
Long. Ligament
Posteriorly:
Ligamentum Flavum
Laterally: Pedicles and
Intervertebral Foramina
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

MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE
Epidural Anesthesia

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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
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)

Advantages

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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
Contraindications
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Absolute
Patient Refusal
Coagulopathy
Increased ICP
Skin Infection
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Relative
Uncooperative
Patient
Pre-existing
Neurologic Disorder
Anatomical
Abnormalities
Factors Affecting Epidural
Dosage
Patient Factors: Age , Height, Weight,
Pregnancy
 Site of Injection

Drugs Used for Epidural
Anesthesia
Local Anesthetics
 Opioids

Local Anesthetics in Epidural
Space
Lidocaine: 1-2% , 45-90 min.
 Bupivacaine: 0.25-0.5% , 90-120 min.

Opioids in Epidural Space
Drug
Dosage
Onset
(min)
Duration
(hrs)
Morphine
2-3 mg
30-90
6-24
20-30
6-18
Hydromor- 0.4-0.8 mg
phone
Fentanyl
50-100 mcg 5-15
2-4
Hydrophilic Opioids
Morphine, Hydromorphone
Slow Onset, Long Duration, High CSF Solubility
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Advantages
Prolonged Single Dose
Analgesia
Thoracic Analgesia with
Lumbar Administration
Minimal Dose Compared
with IV Administration

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Disadvantages
Delayed Onset of
Analgesia
Unpredictable Duration
Delayed Respiratory
Depression
Lipophilic Opioids
Fentanyl
Rapid Onset, Short Duration, Low CSF Solubility
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Advantages

Rapid Analgesia
Ideal for Continuous
Infusion or PCEA

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Disadvantages
Systemic Absorption
Brief Single Dose
Analgesia
Limited Thoracic
Analgesia with Lumbar
Administration
PCEA
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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
Complications of Epidural
Analgesia
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Failure of Block (Patchy or Unilateral Block)
Injury to Nerve
Infection
Epidural Hematoma or Abscess
Dural Puncture (Total Spinal or PDPH)
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
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

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

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

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

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

Caudal Block
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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
Indications for Caudal Block
Surgeries in Sacral Segments,
(Circumcision and other Urologic
Surgeries, Rectal Dilation)
 Combined with Light General
Anesthesia Provides Adequate
Intraoperative Analgesia

Complications of Caudal Block
Infection
 Dural Puncture and Spinal Anesthesia
 Intravascular Injection of Local
Anesthetics

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

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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