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AIN MANAGEMENT SHATADRU INTHE SURGICAL ATIENTACUTE PAIN • Most common acute clinical presentation encountered by a surgical team • ‘an unpleasant sensory or emotional experience associated with actual or potential tissue damage,or describe in the terms of such damage’* • It is estimated that up to 50% of surgical inpatients and 54% of medical inpatients were in significant pain,at any given time despite the availability of various analgesics and pain management techniques** • Concept of pain assessment as the ‘fifth vital sign’*** *International Society for the Study of Pain – 2011 **Tong Et al 2014 ***Rockett MP,et al 2013WHYTREA T PAINAGGRESSIVEL Y? • Humanitarian reasons: • It is a basic human right • Preserves dignity of the patient • Improves mental health • Improves speed of recovery = reduces hospital stay • Improves Quality of Life after surgery • Reduces likelihood of development of chronic pain syndromesWHYTREA T PAINAGGRESSIVEL Y? • Medical reasons – directly reduces burden on the following systems: • Cardiovascular –ACS, Arrhythmias • Respiratory –Atelectasis,HAP • Gastro-intestinal – Ileus, Anastomotic Failure* • Endocrine – release of stress hormones – accelerated catabolism • Circulation – hypercoagulability = DVT,PE • Immunology –Anergy = infection,delayed wound healing • Psychology – anxiety,depression,panic attacksPAINASSESSMENT • S-O-C-R-A-T -E-S • Site • Onset • Character • Radiation • Associated Symptoms • Time / Duration • Exacerbating factors • SeverityPAIN SCORING • Numeric Rating Scale (NRS) – time-efficient,patient-dependent,extremely subjective • Wong and Baker Faces Scale – time-efficient,observer-dependent,subjective • Abbey Pain Scale – time-consuming,standardised,fairly objectiveABBEY PAIN SCALECLASSIFICA TION OFTYPICALANALGESICS • Acetaminophen: • PARACETAMOL – oral / IV / IM / PR • NSAIDs: • IBUPROFEN – oral • NAPROXEN – oral • DICLOFENAC – oral / IV / IM / PR • PARECOXIB – IV / IMCLASSIFICA TION OFTYPICALANALGESICS • Weak Opioids: • DIHYDROCODEINE – oral • TRAMADOL – oral / IV / IM • Strong Opioids: • MORPHINE – oral / IV / IM • OXYCODONE – oral • FENTANYL – oral / transdermal / IV • BUPRENORPHINE – IV / IMMISCELLANEOUSANALGESICS • Anti-spasmodics • Hyoscine Butylbromide – BUSCOPAN! • Drotaverine • Dicyclomine • Regional acting • Lidocaine patches • Nerve BlockW .H.O. ANALGESIA LADDER • Mild pain • Paracetamol + NSAID/adjuvant • Moderate pain • Paracetamol + oral weak opioid + NSAID/adjuvant, • Paracetamol + NSAID + codeine or • Paracetamol + NSAID + dihydrocodeine or • Paracetamol + NSAID + oral tramadol or • Paracetamol + NSAID + oral opioid • Severe pain • Parenteral opioid (IV/IM/SC) + NSAIDMANAGEMENT OF – MILD P AIN (KHFT GUIDELINES) • Pain score 1-3 • ORAL / RECTAL PARACETAMOL • 500mg – 1000mg every 4-6hours (4g per day max) • IV PARACETAMOL (if oral route contra-indicated) • Same as above (>50kg) • If <50kg = 15mg/kg every 4-6 hours (60mg/kg per day max)MANAGEMENT OF – MILD P AIN (KHFT GUIDELINES) • NSAID adjuvant • 1 Line – oral IBUPROFEN - 200 to 400 mg 3-4 times a day • 2 Line – oral NAPROXEN - 250mg 6-8 hourly • Special Considerations: • If oral administration is contra-indicated – DICLOFENAC would be the NSAID of choice (IM / IV / PR) • If allergic to first line NSAIDs – consider PARECOXIB – to consult PainTeam priorMANAGEMENT OF – MODERA TE P AIN (KHFT GUIDELINES) • Pain score 4-6 • PARACETAMOL +/- NSAID as before • In addition (one of the following): • Oral DIHYDROCODEINE - 30mg 4 - 6 hourly (240mg per day MAX) • Oral TRAMADOL - 50 to 100 mg 6 hourly (400mg per day MAX) • Oral MORPHINE – 2.5 to 10mg 4 hourly (MAX dose _____)MANAGEMENT OF – MODERA TE P AIN (KHFT GUIDELINES) • Options if oral route is contra-indicated: • Deep subcutaneous / IM DIHYDROCODEINE – 50mg every 4-6 h • IM / IVTRAMADOL – 50 – 100 mg every 4-6h • If allergic to opioids – consider PARECOXIB – but bleep pain team first! • 100mg ofTramadol approximately equals 10-20mg of MorphineMANAGEMENT OF – SEVERE P AIN (KHFT GUIDELINES) • Pain score 7-10 • Involve PainTeam • Bleep - #627 • Extension - #2076 • OOH - #040 • Stronger oral opioids should be considered on PRN basis in addition to Step 2 analgesia first. • If this is insufficient,Step 2 analgesia should be stopped and Step 3 analgesia prescribed regularlyMANAGEMENT OF – SEVERE P AIN (KHFT GUIDELINES) • MORPHINE • Modified Sustained Release tablets – BD • PRN Oral solution – 2.5 to 5 mg 4-6 hourly • OXYCODONE • Oral solution – 2.5 to 5 mg 4 hourly • Modified Sustained Release tablets – BD • 2.5mg of OXYCODONE = 5mg of MORPHINEMANAGEMENT OF – SEVERE P AIN (KHFT GUIDELINES) • FENTANYL • Transdermal Patch – 12 to 25mcg every 72 hours • 25mcg of FENTANYL = 90mg of MORPHINE • IV MORPHINE • Stat doses,not in a ward setting • <70years – 1 to 2mg • >70years – 0.5 to 1mgPA TIENT CONTROLLEDANALGESIA (PCA) (KHFT GUIDELINES) • Set up and dose titrated by PainTeam • When to consider weaning a patient off PCA? • The pain score is none or mild on movement. • The patient is able to tolerate oral analgesia. • The patient has used 5-10mg morphine (100-200micrograms fentanyl),or less,in the previous 24 hours.ADVERSE EFFECTS • PARACETAMOL • Toxicity • NSAIDs • GI ulcers / bleed / perforations • Thrombo-embolic events • Nephrotoxity • Sodium RetentionADVERSE EFFECTS • Opioids • Constipation • Nausea &Vomiting • Pruritus • Dependence • Respiratory Depression • Hallucinations and Nightmares • SpasmodicActionSOME FREQUENT FEA TURES RENAL COLIC • IV Paracetamol +/- NSAID +/- Morphine to stabilise patient at presentation • Maintenance: • Regular ORAL PARACETAMOL • PRN DIHYDROCODEINE • PRN DICLOFENACE (suppository) – SOS only – Max 100mg per daySOME FREQUENT FEA TURES RIB FRACTURE(S) • IV Paracetamol +/- NSAID +/- Morphine to stabilise patient at presentation • Maintenance: • LIDOCAINE Transdermal patch • Nerve Block – Serratus anterior plane / Intercostal nerve / both • PCA • Avoid Opioids in elderly,delirious or frequent fallersSOME FREQUENT FEA TURES ACUTE PANCREATITIS • IV Paracetamol +/- Morphine to stabilise patient at presentation • Maintenance: • OMEPRAZOLE to reduce gastric irritation • Oral MORPHINE • PCA when needed • Fentanyl Patch when need • Chronic Pancreatitis – Splanchnic Nerve BlockSOME FREQUENT FEA TURES TESTICULARTORSION • Morphine to stabilise patient at presentation • Maintenance: • ToTheatres stat!CASE DISCUSSION • 45 year old lady presents toA&E with severe epigastric pain following a weekend BBQ lunch.She is known to have gall stones and is on the waitlist for an elective surgery.Her blood profile is fairly unremarkable in ED and her LFTs are routine. • She was administered routine analgesia – Paracetamol + Dihydrocodeine in ED – with the plan of being ambulated.However,she shortly reported a sharp spike of abdominal pain and now has had her maiden episode of vomiting. • ED team is concerned and has sought your input about the same...CASE DISCUSSION • 35 year old gentleman presents toA&E with difficult in passing urine and moderate lower abdominal pain.He underwent an elective repair of left inguinal hernia 24 hours back. • You have access to the operative notes and can see that the procedure was unremarkable.The patient was discharged with some PRN analgesics which he has been taking regularly,as he claims to have a low threshold for pain. • ED team is concerned about a Urological pathology and has asked you to assess...QUESTIONS? • Please contact Paeam!THANK OU