pain lecture for icu club meeting
Post on 07-May-2015
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RAVINDAR BETHIAL RASS GENERAL HOSPITAL
PAIN MANAGEMENT
PAIN MANAGEMENT
• What is pain ?
• What causes pain ? • How to classify and measure the pain ?• How to treat the pain ?
PAIN MANAGEMENT
• What are the systemic effects of pain ?
• What is the cause of this pain ? • How can this pain be classified ?• How to address and treat this pain ?
Howthe treatment of pain
Is so important ?
• What is pain ?
• What causes pain ? • How to classify and measure the pain ?• How to treat the pain ?
• What are the systemic effects of pain ?
• What is the cause of this pain ? • How can this pain be classified ?• How to address and treat this pain ?
PAIN
Pain is an unpleasant
sensory and emotional experience
associated with actual or potential tissue damage
or described in terms of such
damage
The International Association for the Study of Pain
PAIN
associated with
tissue damage actual or potential
PAIN an unpleasant experience
emotionalsensory
described in terms of such
damage
Pain is an unpleasant
sensory and emotional experience
associated with actual or potential tissue damage
or described in terms of such
damage
The International Association for the Study of Pain
actual or potential
PAINPain is
an unpleasant sensory and emotional
experience associated with
actual or potential tissue damage or
described in terms of such damage
The International Association for the Study of Pain
PAINPain is
an unpleasant sensory and emotional
experience associated with
actual or potential tissue damage or
described in terms of such damage
The International Association for the Study of Pain
isU S E E
UNPLEASANTSENSORY &EMOTIONALEXPERIENCE
Anatomy and physiology
STIMULUS
Anatomy and physiology
RECEPTIONSTIMULUS
Anatomy and physiology
RECEPTION
TRANSMISSI
ON
STIMULUS
Anatomy and physiology
RECEPTION
TRANSMISSI
ON
INTERPRETATION
STIMULUS
Anatomy and physiology
PHYSICAL
PHYSICAL
EMOTIONAL
EMOTIONAL
PHYSICAL RATIONAL
PHYSICAL
EMOTIONAL
IMPORTANT• Pain can manifest without physical
component
• This type of pain too deserves the same attention, evaluation and treatment
PHYSICAL RATIONAL
• GATE CONTROL THEORY
TYPES OF PAIN
TYPES OF PAIN
ACUTE PAIN
• Usually related an identifiable event or condition• resolves in days/weeks• usually nociceptive
• Needs anxiolytics
CHRONIC PAIN
TYPES OF PAIN
ACUTE PAIN CHRONIC PAIN
• Usually related an identifiable event or condition• resolves in days/weeks• usually nociceptive
• Needs anxiolytics
• May/may not be related an identifiable event or condition• Persists for an indefinite period• usually multifactorial
• Needs antidepressants
TYPES OF PAIN
ACUTE PAIN CHRONIC PAIN
• Usually related an identifiable event or condition• resolves in days/weeks• usually nociceptive
• Needs anxiolytics
• May/may not be related an identifiable event or condition• Persists for an indefinite period• usually multifactorial
• Needs antidepressants
TYPES OF PAIN
ACUTE PAIN CHRONIC PAIN
• Usually related an identifiable event or condition• resolves in days/weeks• usually nociceptive
• Needs anxiolytics
• May/may not be related an identifiable event or condition• Persists for an indefinite period• usually multifactorial
• Needs antidepressants
NEUROPATHIC PAIN
TYPES OF PAIN
NOCICEPTIVE PAIN
SOMATIC VISCERAL
TYPES OF PAIN
NOCICEPTIVE PAIN
SOMATIC VISCERAL
TYPES OF PAIN
NOCICEPTIVE PAIN
• Involves skin, soft tissues, muscle, bone etc• stimulation of somatic nerves
• Sharp , aching, throbbing• Easily localized
SOMATIC VISCERAL
TYPES OF PAIN
NOCICEPTIVE PAIN
• Involves skin, soft tissues, muscle, bone etc• stimulation of somatic nerves
• Sharp , aching, throbbing• Easily localized
• Involves viscera-heart, lung, GIT, GUT• stimulation of autonomic nerves
• Gripping, vague aching• Difficult to localize and often referred
SOMATIC VISCERAL
TYPES OF PAIN
NOCICEPTIVE PAIN
• Involves skin, soft tissues, muscle, bone etc• stimulation of somatic nerves
• Sharp , aching, throbbing• Easily localized
• Involves viscera-heart, lung, GIT, GUT• stimulation of autonomic nerves
• Gripping, vague aching• Difficult to localize, often referred
SOMATIC VISCERAL
TYPES OF PAIN
NOCICEPTIVE PAIN
• Involves skin, soft tissues, muscle, bone etc• stimulation of somatic nerves
• Sharp , aching, throbbing• Easily localized
• Involves viscera-heart, lung, GIT, GUT• stimulation of autonomic nerves
• Gripping, vague aching• Difficult to localize, often referred
NEUROPATHIC PAIN
TYPES OF PAIN
• Burning, Shooting• Tingling, Numbing• Electrical shock like
Intensity exceeding the observable injury
NEUROPATHIC PAIN
TYPES OF PAIN
Cancer in vicinity of nerves
• Compression• Traction• Infiltration• Ischemia
NEUROPATHIC PAIN
TYPES OF PAIN
Cancer infiltration of nerves
Post herpeticneuralgia
• Compression• Traction• Infiltration• Ischemia
NEUROPATHIC PAIN
TYPES OF PAIN
Cancer infiltration of nerves
• Compression• Traction• Infiltration• Ischemia
Post herpeticneuralgia
Phantom limb
NEUROPATHIC PAIN
TYPES OF PAIN • Opioids + Analgesics
• Antidepressants• Anticonvulsants• Anti arrhythmics
• Nerve blocks, • Neurolysis, resections
NEUROPATHIC PAIN
TYPES OF PAIN • Opioids + Analgesics
• Antidepressants• Anticonvulsants• Anti arrhythmics
• Nerve blocks, • Neurolysis, resections
PAIN ASSESSMENT - RGH• Frequency• Intensity• Location• Exclusive Quality• Since when ?
NEUROPATHIC PAIN
TYPES OF PAIN • Opioids + Analgesics
• Antidepressants• Anticonvulsants• Anti arrhythmics
• Nerve blocks, • Neurolysis, resections
PAIN ASSESSMENT - RGH• Frequency• Intensity• Location• Exclusive Quality• Since when ?
MEASURING THE PAIN INTENSITYPAIN CAN NOT BE SEEN
BUT CAN BE SHOWN
MEASURING THE PAIN INTENSITYPAIN CAN NOT BE SEEN
BUT CAN BE SHOWN
MEASURING THE PAIN INTENSITYPAIN CAN NOT BE SEEN
BUT CAN BE SHOWN
• Hospital reception areas• Nursing stations
VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE
5/10
3/10
9/10
VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE
5/10
3/10
9/10
HOW OFTEN ?• On admission• On change of every shift• After every procedure• After analgesic medication
VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE
5/10
3/10
9/10
HOW MUCH TIME AFTER ANALGESIC ?• 15 min after iv• 30 minutes after IM/SC• 60 minutes after oral • according to manufacturer’s recommendations
VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE
5/10
3/10
9/10
HOW OFTEN ?• ON ADMISSION• ON CHANGE OF EVERY SHIFT• AT EVERY PROCEDURE• AFTER MEDICATION
VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE
5/10
3/10
9/10
Signs of inadequate pain relief• Continuing pain > 4/10• Inability to concentrate• Inability to perform the activities of daily living• Tachycardia/HTN• Tachypnea /inadequate respiration
VITAL SIGNS CHARTTIME PULSE BP TEMP 0C SpO2 PAIN SCORE
5/10
3/10
9/10
Signs of analgesic overdosing• Decreased LOC unresponsiveness• Bradycardia• Decreased rate of respiration• Shallow respiration• Pinpoint pupils
RELIEF OF PAIN
What first ?TO DIAGNOSE THE CONDITION
VS TREATMENT OF PAIN
SYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN• Neuro-endocrine stress
response
• Respiratory restriction in abdomino-thoracic surgeries
• Moderate to severe pain, regardless of the site, can affect every organ function and may adversely affect th post operative morbidity and mortality
SYSTEMIC EFFECTS OF PAIN
SYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN• Neuro-endocrine stress
response
• Respiratory restriction in abdomino-thoracic surgeries
• Moderate to severe pain, regardless of the site, can affect every organ function and may adversely affect th post operative morbidity and mortality
CHRONIC PAIN• CARDIO-VASCULAR
• Tachycardia, HTN• Myocardial irritability• Increased SVR• O2 demand/supply
imbalance MI• RESPIRATORY
• Oxygen demand• CO2 production• Atelectasis due to
prolonged bed rest• GIT & URINARY SYSTEM
• Ileus• Urinary retention
SYSTEMIC EFFECTS OF PAIN
SYSTEMIC EFFECTS OF PAINACUTE PAIN eg. POST OP PAIN• Neuro-endocrine stress
response
• Respiratory restriction in abdomino-thoracic surgeries
• Moderate to severe pain, regardless of the site, can affect every organ function and may adversely affect th post operative morbidity and mortality
CHRONIC PAIN• ENDOCRINE
• Catecholamines • Neg N2 balance• Carbohydrate intolerance
• Renin-angiotensin, aldosterone• Sodium & water retention
• HEMATOLOGICAL• Platelet adhesiveness• Reduced0fibrinolysis hypercoagulability
• IMMUNE SYSTEM• Lymphopenia depressed
RE systeminfection
SYSTEMIC EFFECTS OF PAIN
RELIEF OF PAIN
ACETAMINOPHEN AND NSAIDS
CEILING EFFECTHEPATO AND RENAL TOXICITY
RELIEF OF PAIN
OPIOIDS• ACT ON IOPIATE RECEPTORS
• FEARS AND MYTHS ABOUT DEPENDANCE AND ADDITION
• HEPATIC – RENAL CLEARANCE
• ORAL• PARENTERAL• SKIN PATCHES
RELIEF OF PAIN HOW OFTEN ?
• Duration of action• Formulation
• What is PRN ?• What is break though pain ?
RELIEF OF PAIN HOW OFTEN ?
• Duration of action• Formulation
• What is PRN ?• What is break though pain ?
RELIEF OF PAIN HOW OFTEN ?
PCA
• Duration of action• Formulation
• What is PRN ?• What is break though pain ?
RELIEF OF PAIN
ADJUVANTS• Anxiolytics• Antidepressants• Anticonvulsants• Anti-arrhythmics
Adjuvants for local anesthetic interventions
• Narcotics• Clonidine
RELIEF OF PAIN
PHYSICAL THERAPY
RELIEF OF PAIN
PHYSICAL THERAPY
RELIEF OF PAIN
PHYSICAL THERAPY
RELIEF OF PAIN
ACUPUNCTURE
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
INTERVENTIONAL PROCEDURES
RELIEF OF PAIN
• All related medical specialists
• Nurses• Social workers• Pharmacists• Religious affairs• Physiotherapists• Occupational
therapists• Child life specialists
PAIN TEAM
WHO PAIN RELIEF LADDER
1
2
3
MILD
MODERATE
SEVERE
WHO PAIN RELIEF LADDER
1
2
3
MILD
MODERATE
SEVERE
WHO PAIN RELIEF LADDER
NON-OPIOD + ADJUVANT
1
2
3
MILD
MODERATE
SEVERE
NON-OPIOD + ADJUVANT
NON-OPIOD + ADJUVANT
OPIOD
1
2
3
MILD
MODERATE
SEVERE
WHO PAIN RELIEF LADDER
NON-OPIOD + ADJUVANT
NON-OPIOD + ADJUVANT
OPIOD
NON-OPIOD + ADJUVANT
OPIOD
1
2
3
MILD
MODERATE
SEVERE
WHO PAIN RELIEF LADDER
NON-OPIOD + ADJUVANT
NON-OPIOD + ADJUVANT
OPIOD
NON-OPIOD + ADJUVANT
OPIOD
1
2
3
MILD
MODERATE
SEVERE
WHO PAIN RELIEF LADDER
FREEDOM FROM CANCER PAIN
NON-OPIOD + ADJUVANT
NON-OPIOD + ADJUVANT
OPIOD
NON-OPIOD + ADJUVANT
OPIOD
1
2
3
MILD
MODERATE
SEVERE
WHO PAIN RELIEF LADDER
FREEDOM FROM CANCER PAIN
PAIN IS VERY OFTEN POORLY TREATED
PAIN IS VERY OFTEN POORLY TREATED
BARRIERS• Lack of knowledge and
commitment• Myths about addiction • Other barriers• Patient related• System related• Profession related
TAKE HOME MESSAGE
• Pain is one of the vital signs
• Pain by itself needs to be addressed
• Pain is a team approach
• Commit yourself for giving pain relief
day to day
THANK YOU
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