international pain school. type in your name using low technology methods management of...

International Pain School

type in your name

using low technology methodsManagement of Post-Operative Pain

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Topics to be discussed in this talk

• Why should acute pain be treated?

• How to assess acute pain?

• How can you manage acute pain?

• How can you organize management of acute pain

within your hospital?

Why should acute pain be treated?


• Pain is a natural, inevitable, acceptable and

harmless consequence of surgery and trauma.

• Under-treatment of severe pain has no adverse

consequences.

True or false?


1. For ethical and humanitarian reasons

2. To reduce the severity of associated adverse

physiological & psychological factors

3. It might decrease the risk of developing

chronic pain.

Each of these issues will be addressed in the

following slides.


• Relief of suffering, caused by pain, is the chief and un-

disputed benefit of pain treatment.

• Providing effective pain management is a professional

responsibility, the duty of healthcare professionals.

– Under-treatment of pain is poor medical practice.

• Organizations such as the International Association for the

Study of Pain, European Federation of IASP Chapters and

Human Rights Watch, have issued statements identifying

access to pain management as a fundamental human right.

1. For ethical and humanitarian reasons


2. To reduce severity of adverse physiological effects

Major body systems are negatively affected by acute pain


Untreated pain can lead to

or increase:

• patient anxiety or fear

• sleeplessness leading to fatigue

When these psychological

factors are lessened, they might

lead to decreased sensation of

pain.

3. To reduce the severity of adverse psychological factors


Although in most patients the pain resolves with time, some patients

(~1 in 10 - 20) will develop chronic pain after surgery

or injury

•treatment will be necessary in about 50% of these patients.

The risk of developing chronic pain might be higher in those patients

who had severe pain after surgery.

• Chronic pain is difficult to treat.

• Don‘t withhold strong opioids from patients after surgery, the risk of

developing addiction in these patients is negligible.

4. It might increase the risk of developing chronic pain.

How to assess acute pain?


• The experience of pain is too complex to be assessed.

• It‘s a waste of time & the information is useless - one

patient‘s ‘5‘ is not the same as another patient‘s ‘5.‘

• Health professional can appreciate the level of pain of the

patient because of their experience

Cons for measuring pain


• Provides information whether there is a problem

• Determines its severity

• Guides treatment options

• Assesses the effectiveness of therapy & if there is a need

to change it

• Is reliable when carried out using standardized methods

Pros for measuring pain

Does this patient feel pain?


• Pain is always subjective.

• Behavior does not necessarily reflect if a patient is

experiencing or not pain

–people can sleep, laugh, talk and yet experience

pain

–Discrepancy between pain vs extent of injury is

common

–Inter-individual variations are common.

Ask the patient: make pain visible


• There is no test or equipment for measuring pain.

• As pain is a multi-dimensional experience

–there is often a poor correlation between the staff‘s

estimate and that of the patient.

–BUT clinicians must accept a patient‘s report of pain.

Believe the patient! There are no biological markers for

pain.



• Unless asked specifically, patients tend to tolerate

unrelieved pain silently

• As pain is recognized predominantly through

a patient‘s report:

–patients who have difficulty communicating are at risk

for under-treatment

–groups at risk: patient who speak a different language,

elderly, cognitively impaired, children.


… Recognize pain

•No biological markers

•Discrepancy pain / injury

•Inter-individual variations

… Adapt treatment

•Choice of treatment and dose

•Efficacy

… Improve communication

•Patients communicate pain intensity

Summary: Pain scales are useful tools that help to …



Most children over 7 years old & communicating

adults can use a numerical scale.

When acute pain is evaluated - the dimension

of ‚intensity‘ is assessed.

Numerical scale


1. no pain 0

2. mild pain +

3. moderate pain ++

4. severe pain +++

Simple Verbal pain scale


• When in pain, patients tend to refrain from moving /

taking a deep breath / coughing.

• Asking only ‚how much pain do you have?‘ refers to

pain during rest, that is typically low.

Assess pain at rest AND movement


Ask:

(1) How much pain do you have when you are at rest?

AND

(2) How much pain do you have when you move in

bed / sit up / get out of bed (= orthopedic patients)

How much pain do you have when you take a deep

breath OR cough (= general surgery patients).

OR to swallow (= patients after tonsillectomy)-

i.e. ask the patient to carry out an activity which is

related to the surgery.

Assess pain at rest & movement


• If the cause of acute pain is unknown – establishing

the cause of the pain is a priority but symptomatic

treatment of the pain should be initiated.

• It is rarely justified to defer treatment until the

cause of the pain is known.

• A comfortable patient will be able to cooperate with

the diagnostic procedures.

please remember …

How to assess & record acute pain?Recording : make pain

visible

No evaluation =

No treatment of pain


How to treatpost-surgical pain?

Mild pain 1 – 3

Paracetamol

+NSAID (if no CI)

+

infiltration with LA

Moderate pain 4 – 6

Paracetamol

+NSAID (if no CI)

+

Codeine or Tramadol

+infiltration with LA

Severe pain7 – 10

Paracetamol

+NSAID (if no CI)

+Morphine

+infiltration with LA

Increasing severity of pain CI= contraindication; LA = local anaesthetic

How to treat post-surgical pain?


• Pre-operatively

–Discuss options with patients

–Teach about assessment, treatment options

–Pre medication with paracetamol

• Intra-operatively

–Wound infiltration with local anaesthetic (surgeon)

–Administer analgesics (IV or rectally)

When to start pain management?


• Post-operatively – recovery room AND ward

–Give analgesics at regular intervals – not as

needed

–Combine opioids with non-opioids

–Titrate according to needs of individual patients –

one dose does not fit all!

–Duration of treatment will depend on the type of

surgery and the patient’s individual

requirements.

When to start pain management?


• Oral (PO)

–route of choice: simple, effective, well tolerated.

–Suitable as soon as the patient is able to tolerate oral

fluids.

• Intra-muscular (IM)

–Injection painful and absorbtion un-reliable.

–Should be not be used as a route for giving analgesics.

Which route?


• Sub-cutaneous (SC)

–Route of choice if oral route is not possible

–Avoid for long term, repetitive dosing

• Intra-venous (IV)

–Allows for rapid titration.

–Allows for continuous OR bolus administration

–requires monitoring!

Which route?

Drug Dose Route FrequencyParacetamol 1 g p.o., i.v., rectal q.i.d

NSAID’sibuprofendiclofenacketorolac

Opioids

50-100 mg

75 mg 50-100 mg

p.o.i.m.i.m. or i.v.

q.i.db.i.d or t.i.d

(codeine) * 30 mg p.o. q.i.d

tramadol(pethidine) *

50-100 mg 25-150 mg

p.o. or i.v.i.m.

t.i.d or q.i.dt.i.d or q.i.d)

morphine 10 (IR), 30mg (SR)

p.o. Every 4 hours

10 mg sc Every 4 hours

bupivacaine 1mg/kg Wound infiltration

End of surgery


Analgesics for post-operative use

b.i.d. –X2 daily; t.i.d. X 3 daily; q.i.d. – X4 daily

Caution !

•C

odeine – Its metabolism is highly variable and might result in

severe overdosing. – Use only when no other opioid is available.

•P

ethidine – Accumulation may cause CNS-related side effects.– Use only when no other opioid is available.


• Provides a mild analgesic effect

• Low toxicity

• No difference in quality of analgesia when given IV vs PO

–but is more expensive

• For short surgical procedures possible to give 1gr PO with

a little water 1/2 hour before the surgery.

• After minor surgery:

–if given as sole analgesic and pain is not relieved – after

30 – 45 minutes - combine with another non-opioid or

opioid.

Paracetamol


• NSAIDs can be effective on their own for mild

or moderate pain OR combined with an opioid

for severe pain

• Mechanisms of action different from paracetamol

• Effective for treatment of inflammatory and bone

pain.

• Administer a dose before the end of a procedure

• Synergistic effect with paracetamol and/or opioid.

• Asses patient for contraindications or precautions.

Non Steroidal Anti Inflammatory Drugs (NSAIDs)


• Hypersensitivity to NSAID (NSAID induced asthma,

rhinitis, nasal polyps, allergic or anaphylactic

reactions)

• Peptic ulcer

• Renal impairment

• Clotting disorders

• Congestive heart failure and other cardiovascular

diseases.

NSAIDs

Contra-indications


Hypertension, hypovolemia, dehydration, severe

malnutrition

• Sepsis

• During pregnancy particularly 3rd trimester

Side effects are linked to the dose and the duration of

the treatment

Do not exceed 7 consecutive days of treatment.

NSAIDs caution in patients with


• Opioids offer the most effective analgesia for

moderate to severe pain.

• Morphine is the opioid of choice for peri-operative

analgesia

• When administered correctly - opioids used for

treatment of pain do not induce addiction.

• Opioid should be combined with non-opioids

• There is no ceiling effect for opioids and dose should be

tailored to patient / pain response however, if large

doses are being administered, consult a pain specialist

for alternatives.

Opioids (overview)


• Respiratory depression can occur in overdose. It is

preceded by sedation which should be detected

• Frequent side effects are nausea vomiting

• Opioid induced bowel dysfunction (constipation /

ileus) may become a problem.

– Less typical after short term treatment, as is

common after surgery.

• Availability is problematic in some countries

Opioids (overview)


• Step 2 analgesic

• Analgesic (opioid and monoaminergic)

• 5 to 10 times less potent than morphine

• Risk of respiratory depression negligible

• Easier to import than morphine

• Not in the WHO list of essential medicines

Tramadol


• Do not administer in patients at risk of seizures.

• May cause dizziness, nausea, vomiting, sweating, dry mouth

• Do not combine with other level 2 analgesics.

• IV : infuse over 20-30 min rather than bolus injection

• Pregnancy and breast-feeding:

– risk of adverse effects at the end of 3° trimester and during breast

feeding.

– Administer with caution for a short period at the lowest effective

dose and monitor the child

Tramadol – Contra–indications , precautions


• Step 2 analgesic

• weak opioid: 5 – 10 times less effective than

morphine

• No injectable formulations

• Remember – Codeine’s metabolism is highly variable

and might result in severe overdosing. – Use only when no other opioid is available.

Codeine


• Do not administer to patients with asthma, COPD,

emphysema

• May cause constipation, dizziness, nausea, vomiting,

dry mouth, rarely respiratory depression

• Reduce dose in patients with renal or hepatic

impairment and elderly.

Codeine – Contra-indications, precautions


• Pregnancy : No CI but possible newborn withdrawal syndrome

when administered in large doses in 3° trimester

• Breast feeding: Administer with caution for a short period at

the lowest effective dose and monitor the child

Codeine – Contra-indications, precautions


• Used correctly, opioids do not induce addiction in

patients after surgery.

• Pseudo addiction may appear when pain is not

adequately treated

Morphine and addiction


Nausea & vomiting

• give an anti-emetic

– E.g. metoclopramide: Adult : p.o. 15 - 30 mg / day in 3

divided doses

– Child ondansetron : p.o. 50-100 mcg/kg

Constipation / ileus

– Normally not a problem in the first 48 hours of use;

– After 48 hours: give agents such as bisacodyl (child 5

mg at night, adult 5-10 mg) OR an osmotic laxative

such as lactulose and hydration.

Common opioid-related side effects


Neurologic

• abnormal drowsiness = warning sign of early respiratory depression

Respiratory

• respiratory depression (bradypnea, apnea)

Onset of excessive drowsiness indicates an overdose and often precedes the onset of

bradypnoea (abnormally slow irregular breathing rate of less than 8 respirations per

minute).

Oxygen saturation may be an un-reliable indicator, especially if the patient is

receiving supplemental oxygen.

Less frequent opioid related side effects

• Monitor sedation regularly to avoid development of

respiratory depression

• Use a ‘sedation score‘.


Assess sedation & respiratory depression


Assess sedation & respiratory depression

Observe

Intervene


• Sedation can occur even with the first dose

of an opioid.

• A sedation score of 2 is an early sign of respiratory

depression and should be taken seriously.

Management of Sedation


• Administer oxygen by face mask

• Monitor pain & sedation score

• Withhold next dose of opioid

• When the patient is alert, opioids can be resumed

for pain relief, at a lower dose and at longer

intervals

• Assess for hepatic and / or renal impairment

Management of Sedation

• Call for help

• Administer oxygen by face mask at 10 L / min

• Stimulate the patient and encourage him to breath if he can be

aroused.

• Dilute naloxone 0.4 mg in 4 ml of water or normal saline.

• Administer naloxone 0.1 mg (1 ml) every 1 – 2 minutes until the

patient wakes up or the respiratory rate is greater than 10 / min

Continue to monitor the sedation score and respiratory rate every half

hour for at least another 4 hours

• An infusion of low dose naloxone may be used

– This will reverse the analgesia.


Management of respiratory depression (1)

Naloxone

•The half-life of naloxone is ~30 – 81 minutes;

•This is shorter than the half life of some opioids, e.g.

morphine for morphine ~ 2 -3 hours.

• When using naloxone to antagonize the respiratory

depression of morphine patients should be

monitored for at least 4 hours.


Management of respiratory depression (2)


Titrate for rapid control of pain

•Give e.g. IV morphine 2 – 3 mgs every 5-10 minutes

until relief is obtained

•Maintain analgesic plasma levels by regularly timed

doses of morphine subcutaneous or p.o.

Severe pain (8 – 10 / 10) requires emergency

treatment


Prerequisite conditions for IV treatment

• Healthcare providers trained in emergency

airway/respiratory care• Resuscitation equipment (Ambu bag, masks,

suction)• Naloxone

Severe pain (8 – 10 / 10) requires emergency

treatment


• Treatment is more effective when given before the

pain starts or becomes severe.

• Prescription of analgesic drugs should be systematic

– give medication at fixed times but also option for

additional doses in the event of breakthrough pain.

• Oral form should be used as soon as patients can

drink.

• Aim to provide multimodal analgesia.

Key points to remember

How to organize postoperative

pain management within your hospital

How to organize postoperative pain management within your hospital?

„It is being increasingly recognized that the solution

to the problem of inadequate postoperative pain

relief lies not so much in development of new

techniques but in development of a formal

organization for better use of existing techniques.“

Rawal N, Berggren L. Pain. 1994 Apr;57(1):117-23.

How to organize postoperative pain management within your hospital?

• Ensure the hospital has WHO essential

medications, as a minimum

• Provide education for medical & nursing staff &

patients

• Standardize treatment by preparing local protocols

& get staff to follow them

• Implement routine quality assessment

How to organize pain management within your hospital

Opioids are a necessity to provide

adequate management of

post-operative pain

• Find out regulations about prescription of opioids in

your country.

• If necessary, get a licence to prescribe opioids.

1. Ensure hospital has essential medications


One of the best recognized barriers for providing

good management of pain is inadequate knowledge about

pain and its management and misconceptions on behalf

of medical & nursing staff, patients & their families.

2. Education


Staff•Participate in a course like prepared here.

PatientsTeach them: • How to assess pain• That they should inform the staff when they are in pain and when they experience side effects.

• That dependence or tolerance to medications are rare when treating acute pain.

2. Education - possible solutions


How to teach? •Verbal & written (e.g. pamphlet or poster).

– ~ 30% of patients forget the information given to them.•Remind staff to repeat the information - patients remember only a small part at any one time.

2. Education - possible solutions


• Consider preparing standard order sheets or local

protocols for surgical units AND recovery

3. Standardization

How to organize pain management …

• Medication orders & patient assessment:

–Analgesics & treatment of side-effects

• e. g. unless contraindicated, all patients after

surgery receive 1 gr paracetamol X 4 daily.

–Monitoring

• e.g. pain is assessed once every shift & after

provision of an analgesic.

3. Standardization – examples

How to organize pain management …

• Quality improvement = evaluation of what you do to

improve what is not so good

• Different aspects of care can be evaluated

–Processes: is pain assessed routinely? Is

multimodal analgesia provided?

–Patient‘s outcomes: pain intensity, side effects,

satisfaction

–Organization: protocols, drug availability

• Choose important criteria for you

• Choose criteria that you can measure

• Compare your ward over time and with other wards.

4. Quality assessment

How to organize pain management …4. Quality assessment

example of an audit

Summary 1

• Pain after surgery and trauma can be harmful.

• Under-treatment of pain can have adverse

consequences.

• Providing effective pain management is a

professional responsibility of clinicians.

Summary 2

• Assessing pain using standard tools is important

–It makes pain visible and guides treatment.

–If the patient is communicative – rely on his

report.

–If non–communicative initiate treatment & carry

out regular follow-up yourself.

–If the patient reports pain (e.g. >= 4/10) –

provide treatment !

Summary 3

• Aim that your hospital has the essential analgesics

to provide treatment.

• Use the WHO Essential Medicine list as a guide.

• Morphine is an essential medicine for treating

severe pain.

This talk was originally prepared by:

Dominique Fletcher, M.D, Garches & Xavier Lassalle, RN, MSF

Paris, France

Talks in the International Pain School include the following:


Physiology and pathophysiology of pain Nilesh Patel, PhD, Kenya

Assessment of pain & taking a pain historyYohannes Woubished, M.D, Addis Ababa, Ethiopia

Clinical pharmacology of analgesicsand non-pharmacological treatments

Ramani Vijayan, M.D. Kuala Lumpur, Malaysia

Postoperative – low technology treatment methodsDominique Fletcher, M.D, Garches & Xavier Lassalle, RN, MSF, Paris, France

Postoperative– high treatment technology methodsNarinder Rawal, M.D. PhD, FRCA(Hon), Orebro, Sweden

Cancer pain– low technology treatment methods Barbara Kleinmann, MD, Freiburg, Germany

Cancer pain– high technology treatment methodsJamie Laubisch MD, Justin Baker MD, Doralina Anghelescu MD, Memphis, USA

Palliative CareJamie Laubisch MD, Justin Baker MD, Memphis, USA

Neuropathic pain - low technology treatment methodsMaija Haanpää, MD, Helsinki & Aki Hietaharju, Tampere, Finland

Neuropathic pain – high technology treatment methodsMaija Haanpää, M.D., Helsinki & Aki Hietaharju, M.D., Tampere, Finland

Psychological aspects of managing pain Etleva Gjoni, Germany

Special Management Challenges Debra Gordon, RN, DNP, FAAN, Seattle, USA


The project is supported by these organizations:

international pain school. type in your name using low technology methods management of...

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