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Pain Management Pain management Preeyaphan Arunakul MD FRCAT Department of Anesthesia Faculty of Medicine, Thammasat University Definition “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Classification of pain by time • Acute pain - Pain less than 12 weeks • Chronic pain - Pain longer than 12 weeks Nociceptive Nonnociceptive Somatic Visceral Neuropathic Psychogenic sharp, dull Poorly localized, Burning, electrical -Rarely pure aching deep squeezing, (lancinating), -No nociceptive or crampy numbing, neuropathic mechanism allodynia, can be identified -Myofascial hyperalgesia -With sufficient -Metastatic -Small bowel psychogenic symptoms bone pain obstruction -Postsurgical -Carcinomatosis -Trigeminal neuralgia -Arthritis peritonii -Postherpetic neuralgia -Painful peripheral neuropathy NSAIDs -CRPS I,II Opioids TCA/SSRI -Phantom limb pain Muscle relaxants Gabapentin Aniline deriv. Opioids Anticonvulsants Antidepressants Multimodalities Interventions Antidepressants Psychological therapy Psychotherapy Interventions Multimodalities Acute Postoperative Pain ผู้ป่วยมีอาการปวดเฉียบพลัน “5th Vital sign” มีสาเหตุที่ท าให้เกิดอาการปวด รักษาสาเหตุ ประเมินระดับความปวด ไม่ต้องการ อาการปวดต้องการการรักษาหรือไม่ ประเมินซ ้าและบันทึก ต้องการ (PS ≥ 4 หรือปวดปานกลางขึ้นไป) เครื่องมือที่ใช้ประเมินความปวด รักษาโดยใช้ยา - VAS/VRS/NRS รักษาโดยไม่ใช้ยา - FACE/FLACCs รักษาแบบผสมผสาน - CHEOPS ไม่ได้ผล การรักษาได้ผลดีหรือไม่ ปรึกษาผู้เชี่ยวชาญ ได้ผลดี เกิด เกิดภาวะแทรกซ้อนจากการรักษาหรือไม่ รักษาภาวะแทรกซ้อน ไม่เกิด ประเมินซ ้าและบันทึก Postoperative pain • Acute pain • Choices: - iv bolus/iv PCA/oral opioids - neuraxial opioids (spinal & epidural) - peripheral nerve blocks with LAs - NSAIDs and other medications • Effects of pain on systems CNS & Neuroendocrine 1. Secretes enkephalins, endorphins 2. Reflex escape response “Fight or Flight” - stimulated sympathetic nervous system - increased E and NE - inhibit peristalsis and secretion of digestive enzymes 3. Increasing CRH, ACTH, Cortisol from hypothalamus 4. Increasing glucagon and reduce insulin level CNS & Neuroendocrine 5. Increasing E & NE from adrenal medulla 6. Decreasing ADH = Na & water retention 7. Increasing renin & AT II secretion from adrenal gland 8. Increasing protein breakdown = reduce wound healing 9. Increasing IL-1 level = increase inflammatory effect Cardiovascular system Increasing sympathetic activity Hypertension increase myocardial Tachycardia O2 consumption Myocardial ischemia GI and Immune system • Depress immune system • Impaired GI function - delayed gastric emptying - reduce bowel motility, potential paralytic ileus - nausea & vomiting (also from CTZ) Respiratory system Limiting movement of thoracic & abdominal muscles Respiratory dysfunction Retained sputum and secretion (reluctant to cough) Reduction in vital capacity Hypoxia Cardiac complication, disorientation, confusion, and delayed wound healing KUB system Increasing CAs, aldosterone, ADH, cortisol, AT-II, and PGs (regulate urinary output, fluid & electrolyte balance, blood volume, and BP) Na & water retention Increase K+ excretion Fluid overload Increase cardiac workload Hypertension Musculoskeletal system Reflex muscle spasm, impaired muscle function Muscle fatigue Immobility Venous stasis Increase coagulability Increase risk of developing DVT Psychological & Cognitive function Acute stress-induced hormonal changes 1. Anxiety interrupt sleep pattern (insomnia) Depression interfere daily activity 2. Distressing cognitive impairment - disorientation - mental confusion - reduce ability to concentrate 3. Poorly-controlled acute pain --> chronic pain Neuropathic pain Definition • “Pain caused by a lesion or disease of the somato- sensory nervous system” • Clinical description (not a diagnosis) ; requires demonstrable lesion or disease that satisfies established neurological diagnostic criteria • Central and peripheral neuropathic pain Management • Pharmacotherapy • Physical and Psychotherapy • Interventions • Surgery • Lifestyle modifications • Alternatives • Neurostimulation (SCS) Pharmacotherapy • Gabapentin/Pregabalin (Neurontin®/Lyrica®) • Amitriptyline/Nortriptyline • Carbamazepine/Oxcarbazepine (Tegretol®/Trileptal®) • Duloxetine/Venlafaxine (Cymbalta®/Effexor®) • Tramadol (for acute exacerbation only) Cancer pain Medications • Opioids • Gabapentin and pregabalin • NSAIDs (for bone metastasis) • Antidepressants/antianxiety Nociceptive Neuropathic Cancer- Tumor- Visceral pain ยา pain cancer pain induced induced MBO* bone pain headache ดีมากสาหรับอาการ Opioids ดีมาก ปานกลาง ดีมาก ดี ปวดตลอดเวลา NSAIDs ดีมาก ไม่ดี ดีมาก ดี ไม่แนะนา Antidepressants น้อย ดีมาก ปานกลาง ไม่แนะนา ไม่แนะนา TCAsและSNRIs ดีสาหรับ visceral Gabapentinoids น้อย ดีมาก ดี ไม่แนะนา hyperalgesia ดีสาหรับ paroxysmal น้อย ยกเว้นใช้เป็นยา Carbamazepine ไม่ดี น้อย ไม่ดี sharp shooting pain กนั ชกั Bisphosphonates ไม่ดี ไม่ดี ดีเมื่อให้ระยะยาว ไม่ดี ไม่ดี ดีมากสาหรับ ดีสาหรับ liver capsule Corticosteroids ไม่แนะนา nerve/cord ปานกลาง ดีมาก distension compression Strong opioids • Morphine (Morphine, MST, Kapanol) • Meperidine (Pethidine) • Fentanyl (Fentanyl, Duragesic, Durogesic) • Methadone • Oxycodone Visceral Pain Visceral pain Clinical features : • Diffuse localization, deep, squeezing, crampy • Unreliable association with pathology • Referred sensation to cutaneous structures • Cutaneous or deep tissue hyperalgesia • Strong autonomic and emotional response may be evoked with minimal sensation Referred pain • Pain referred from a deep somatic or visceral structure to a distant region within the same segment • With/without hyperalgesia and hyperesthesia, deep tenderness, muscle spasm, and autonomic disturbances. • No changes in reflexes, no weakness or atrophy • Segments involved are identified (all somatic and visceral structures innervated are carefully examined for a pathologic process) • Ex: Shoulder pain in subphrenic abscess Visceral pain etiologies • Inflammation (acute and chronic), including inflammation caused by mechanical irritants (kidney stone) • Infection • Disruption of normal mechanical process (GI dysmotility) • Neoplasms (benign or malignant) • Alterations in nerves carrying sensations from the viscera • Ischemia Medications & Interventions • Opioid for cancer in origin • Antidepressants • Gabapentin/pregabalin • Sympathetic plexus block/neurolysis Musculoskeletal pain Pharmacotherapy . NSAIDs . Muscle relaxants Medications Oral medications - Acetaminophen (paracetamol) - NSAIDs - opioids = tramadol, codeine - tramadol + paracetamol (Ultracet®) - antidepressants/anticonvulsants IV medications - Opioids = morphine, pethidine, tramadol, fentanyl - NSAIDs = Parecoxib (Dynastat®), Ketorolac WHO step ladder modified by TASP Patient-controlled analgesia (PCA) Patient-controlled epidural analgesia (PCEA) 1. Improved pain control 2. Receive immediate delivery of pain med. 3. Patient control 4. Frequent but smaller dose, less side effects PCA variables • Bolus dose or PCA dose or demand dose (self-administered intermittently) • Lock out interval (time between dose) • Loading dose • Background infusion • Dose limit in 1 or 4 hour Using PCA - Patient education - Monitor O2 saturation (in high risk patient) 1. Pain scores at rest/movement 2. Side effects Sedation, N/V, pruritus, respiratory depression, urinary retention 3. Total amount of opioids delivered Neuraxial Opioids Spinal/epidural morphine - duration 18-24 hours/it depends - no sedatives or sleeping pills (except for order from anesthesiologist) - side effects : respiratory depression nausea and vomiting pruritus urinary retention Local anesthetic for epidural . 0.0625% - 0.15% Bupivacaine/Levobupivacaine . 1-2% Lidocaine with or without adrenaline Opioids • Morphine 1-5 mg bolus or epidural infusion at 0.005-0.02 mg/ml • Fentanyl 1-2 mcg/ml epidural infusion Peripheral nerve blocks - Local anesthetics only - Single shot or catheter - US-guided and/or peripheral nerve stimulator - 18-24 hours - Side effects : motor weakness catheter migration Acetaminophen Acetaminophen (paracetamol) • tablet 500 mg 1 tab oral prn/every 4-6 hrs • tablet 650 mg 1 tab oral prn/every 8 hrs • FDA Liver warning: Severe liver damage may occur if you take - more than 4,000 mg of acetaminophen in 24 hours - with other drugs containing acetaminophen - 3 or more alcoholic drinks everyday while using this product • FDA reminds health care professionals to stop dispensing prescription combination drug products with more than 325 mg of acetaminophen (4/28/2014) • Acetaminophen in both OTC and prescription products and the risk of attention deficit hyperactivity disorder (ADHD) in children born to women who took this medicine at any time during pregnancy. Liew Z, Ritz B, Rebordosa C, Lee PC, Olsen J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr 2014;168:313-20. NSAIDs Role of NSAIDs • Acute postoperative pain • Chronic musculoskeletal pain • Cancer-induced bone pain Evidence-based practice • Prevent and treat postoperative pain in ambulatory surgery • Decrease: opioid consumption early return of bowel function early recovery of physical activity increase patient satisfaction • No difference if given before or after surgery Maximum Drug mg Frequency dose/day Parecoxib (dynastat®) 40 IV q 12 h 80 Ketorolac 15, 30 IV q 8 h 90 Ibuprofen 200,400,600 q 4-6 h 2400 25,50 q 8 h Diclofenac 150 SR75,100 q 12-24 h Indomethacin 25 q 8-12 h 200 Naproxen 250 q 12 h 1000 Piroxicam 10,20 q 24 h 20 Meloxicam
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