Acute pain service , clinical application in ICU

By Sahar Elkaradawy

Professor in Anaesthesia MRI, Alexandria University 2012

ObjectivesAcute pain serviceWhy pain service should be built in our

hospitals?And how?What pain service team has to do?The pain management protocols in peri-

operative field.Multimodal analgesia and multidisciplinary

approach for pain relief.

Acute pain serviceIt is peri-

operative good quality service introduced by physicians and well trained nurse to educate patient about post operative pain and choose the best methods available to relieve his /her pain and speed up recovery.

Physicians

Patient Nurse

Documentations

PaperworkSheets

Why pain service should be built in our hospitals?

Aims of APS are to: Reduce pain

intensity and increases patient’s wellbeing.

Decrease morbidity and mortality

Speed up recoveryDecrease patient's

short-and long-term use of healthcare facilities, and subsequent costs to society.

How can we build acute pain service?

Multidisciplinary approach:Patient’s education ( audio- visual aids)Personnel training (Physicians and nurses)Protocols for management of pain. ( Sheets)Concept of multimodal analgesia and

perioperative rehabilitation

Patients’ educationDiscuss pain issue with your patient. Patient

can help if he understood methods to measure his pain

Patient’s education decreases anxiety and makes patient involved in postoperative pain management plans so his pain becomes easier to treat.

Booklet for education: postoperative pain, medicines for pain relief, analgesia and addition non-drug methods for pain relief ( appendix 1)

Personnel trainingPhysician and nurse should to know:

Definition and pathophysiology of pain and

understand consequences of unrelieved pain

Pain scales ( to measure pain)

Be familiar with the pharmacologic therapy

( drugs, side effects, how to manage)

Protocols of acute pain management

Multimodal analgesia

Physician and nurse should to know:

Definition. Pathophysiology of pain.

Understand consequences of unrelieved pain.

Definition of painUnpleasant

sensation associated with actual

or potential tissue damage.

Neurotransimission of sharp pain

Neurotransimission of sharp pain

Reducing their activation Threshold and enhancing their Response to the other stimuli

ProstaglandinsSympathetic efferent neurones

NeuropeptidesPrimary afferentneurones

NOKininsVasculature

Cell injuryKininsH+

K+

Prostaglandins

Immune cellsCytokines NeurotrophinsCannabinoids Histamine

Opiods 5HT Adenosin

Neurotransimission of sharp pain

Spinal cord transmission of pain

SP and excitatory amino-acids prostanoids nitric oxid calcitonin gene related peptide are excitatory peptides that produce long lasting depolarization of DH neurons and facilitates transmission of impulses leading to production of central hypersensitization. Central hypersensitization can augment responses of DH neurons by up to 20 fold in amplitude and prolong responses even after cessation of peripheral impulse.

C polymodal nociceptors synapse exclusivelyin lamina I and IIo of the dorsal horn. Aδnociceptors terminate in lamina I and IIo butalso penetrate deeper to end in lamina V.

The activation of CPNs duringinflammation produces slow synapticpotentials, which summate temporally on lowrepetition rates leading to a non-linearlyincreasing cumulative depolarization.

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5

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Spinal cord Accentuation of pain

Accentuation of pain.

Neurotransmission of nociceptive pain

On

Multimodal analgesiaThe concept of

multimodal analgesia involves the use of different classes of analgesics(NSAID,

Opioids, local anaesthetics and adjuvants e.g. alpha 2 agonist, neurontin)

Or different sites of analgesic administration

e.g. PNB or neuroaxial with iv PCA

Aiming to provide superior dynamic pain relief with reduced analgesic-related side effects.

I.V PCA

Neurotransimission of sharp pain

Inadequately controlled pain can :

• Prolong recovery time

• Delay return to normal living

• Decrease satisfaction with care.

• Increase the use of health care resources,

thereby increasing total healthcare costs.

• Lead to chronic pain specially after breast

surgery, thoracotomy, and inguinal

hernia

CONSEQUENCES OF POSTOPERATIVE PAIN

What Physician and nurse should to do:?Help in patients’ educationDecide with his patient a protocol for post

operative pain relief.Assess painIntraoperative and post operative pain

managementMake sure that APS modality is working and

patient is OK Make sure that patient is stable before

discharging home.

Patient’s education

Multimodal analgesiaThe concept of

multimodal analgesia involves the use of different classes of analgesics(NSAID,

Opioids, local anaesthetics and adjuvants e.g. alpha 2 agonist, neurontin)

Or different sites of analgesic administration

e.g. PNB or neuroaxial with iv PCA

Aiming to provide superior dynamic pain relief with reduced analgesic-related side effects.

I.V PCA

Multimodal analgesia sheet

Assessment of pain ( pain scales)

Assessment of painPain Intensity

This is an actual patient in the recovery room, minutes after surgery on her hand. She is smiling because she doesn't hurt, and she doesn't hurt because of post-operative pain programme application.

Thank you