pain relief in sickle cell disese
TRANSCRIPT
Pain relief; A basic human right
Yousf M. Tak Consultant of Anesthesia
Security Forces Hospital Dammam KSA
Regards from Kashmir; a paradise on earth
Pain relief; A basic human right
Pain is leading cause of ER visits and hospitalizations
Pain is a common mode of presentation in patients with sickle cell disease (SCD) but there is considerable variability in the way SCD pain is managed
Pain relief; A basic human right
Pain is common undertreated entity
One of the factors contributing to poor pain management is
conflicting perceptions between patients, their families and
healthcare professionals about pain that is reported and
analgesia that is required (Stinson & Naser, 2003).
Pain relief; A basic human right
The most reliable indicator of the existence pain and its intensity is the patient’s description
Pain relief; A basic human right
The aim of the wise is not to secure pleasure, but to avoid pain. Aristotle
Pain is a worst lord of mankind than death itself.
Pain relief; A basic human right
.
Tachycardia And elevated blood pressure
Decreased Limb movement; increased risk of DVT
Respiratory effects; shallow breathing , tachypnea, cough suppression
due to increased risk of pneumonia & atelectasis
Decreased GI Motility
Increased catabolic demands
Pain relief; A basic human right
Psychological effects of Pain
Negative emotions: anxiety, depression
Sleep deprivation
Existential suffering: may lead to patients seeking active end of life
Immunologic Effects of pain Decrease natural killer cell counts Effects on other lymphocytes not yet defined
Pain relief; A basic human right
5TH Vital Sign
Basic human Right; Human rights watch
Pain relief; A basic human right
Effective control of pain
Lack of awareness among public
Minimal knowledge among health providers
Pain relief; A basic human right
Pain Clinic
Pain
Step 1Nonopioid
Adjuvant
Pain persisting or increasing
Step 2Opioid for mild to moderate pain
Nonopioid Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3Opioid for moderate to severe pain
Nonopioid Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
Modified WHO Analgesic Ladder
Proposed 4th Step
The WHO
Ladder
Deer, et al., 1999
Pain relief; A basic human right
Pain relief; A basic human right
Pain relief; A basic human right
Pain relief; A basic human right
Pain relief; A basic human right
Pain relief; A basic human right
Paediatric Scales
Pain relief; A basic human right
0
Mafee alam No Pain
1
Shoa alam Mild Pain
2
Nus nus alam Moderate pain
3
Kateer alam) Severe Pain
Table: Severity of pain (Using a simple pain score).
Acute Pain in Sickle Cell Disease
Somatic pain
– Deep structures
– Focal or referred
Visceral pain
– Spleen, liver, lungs
– Vague, poorly localized, referred, diffuse, dull-aching in character
– Nausea, vomiting, sweating
– Associated with muscle spasms, tenderness, hyperaesthesia
Comprehensive Regimen for the sickle cell disease pain
Maintenance therapy with opioid analgesic
Non opioid analgesic
Rescue therapy for breakthrough pain
Adjuvant therapy
Anxiolytics/muscle relaxants
Laxatives
Non-pharmacologic therapy
Incentive spirometry
Hydration (1-1.5x maintenance)
Physical: Heating pads, massage, TENS, acupuncture, physical therapy
Behavioral: Relaxation, deep breathing, behavior modification, biofeedback
•Psychological: cognitive therapies, distraction, social support, hypnotherapy
Pain relief; A basic human right
WHO Pain Ladder
Meperidine
Shorter duration of action (1-2 hours only )
Seizures on repeated administration
Dermal and sub dermal fibrosis on I.M injection
Pethidine
Narrow therapeutic index
Norpethidine > Antagonistic
Seizures on repeated administration
Pain relief; A basic human right
Pain relief; A basic human rightS.No Severity of pain Regimen
1 Mild Paracetomol 0.5g to 1g every 8H /
Lornoxicam4-8 mg Every 12-24 H
2 Moderate Paracetomol 0.5g to 1g every 8H /
Lornoxicam4-8 mg Every 12-24 H
+
Tramadol50-100mgs Q 8H
3 Severe Paracetomol 0.5g to 1g every 8H /
Lornoxicam4-8 mg Every 12-24 H
+
Morphine 5-mgs Q 8 H
Pain relief; A basic human right
PRN Schedule Illogical
Pain Cycle (Basal + Incident + Breakthrough Pain
Start (1Hr)} Asses} Reassess} Adjust
Tapering and not abrupt withdrawl
Pain relief; A basic human right
NSAIDS
Bone Pain
Opiod Sparing
Ceiling Effect
Opiods
Potent analgesics
Safety Profile
Pain relief; A basic human right
Addiction
Nightmare for physician
Curse for the patient
Pain relief; A basic human right
When asked, 59% of the patients desired that oral non-opioid analgesics be prescribed while 31% were not bothered about what analgesic was given. Only 8% requested opioids.
A total of 65% of the patients did not require hospital admission but were observed in the day-care unit and allowed home within 24 h. Only 17% required hospital admission for more than a week.
Pain relief; A basic human right
Prevention of Pain
Triggers of pain: viral illness,
infection/sepsis, stress, extreme exercise,
change in temperature, change in altitude
Fluids (2 glasses of water q 2 hours)
Avoiding extreme temperatures, activities (e.g. swimming in cold
water)
Regular moderate exercise
Penicillin prophylaxis to prevent infection
STAY PAINFREE