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For people to join. Okay. Okay. All right. Uh Yeah. Okay. Um Oh, praise. You're welcome. I want to Towler Aji bad. You're welcome. Good evening. You want to give five minutes so that people will join us for us to start. There will be in a proper, please. Um Hold on an excess patient. Thank you. Okay. Uh Prints and Towler, please. If you can hear my voice loud and clear and you can see the screen, please. Can you make a comment on the find live kind? Leave a message on the comment box. Thank you. Ok, tell a lot of the screen. Can you see the slide presentation? John, you are welcome to Lou One. You are welcome. Uh Merely you're welcome, please. Um I want to guys to confirm if you can see him advice because in the next one minute to restart. Thank you. Leave a comment on on the comment boss. Yes, sir. Just give me two minutes. Okay. So hello. Can you hear me? Yes, I can hear you. Let me quickly set up where my Children will not interfere with their movement, will not interfere with your presentation. Okay, no problem. So So we're working for you, sir. Thank you. Okay, thank you. Um Please let's hold on this pick up with some journals they want to do some set up. So please let's hold on. Thank you. Give you some start. You're welcome. Um Please let's excised some patient. The speaker will soon be with us. Thank you. Yeah. Um let's access some patient. The speaker will soon be with those. Thank you. Uh uh huh 21. Yeah, serving his fun. Hello, Mr Collins. Yeah, I'm here. I just noticed now my laptop, I don't know, the NATO just went off. Maybe I'll think without a laptop. Can you share from there? Okay. Yes, I can share from here. So it's better. You just share. So that uh uh huh. Okay. Let me share from here. Uh so that we don't waste any more time. Okay. Maker, I put up this game. We will start immediately. Hello. Yeah. Um is a very well okay. Um Good evening everybody. Welcome to our first webinar of the year. This is um see graph anesthesiology and my name is Okay Collins. Um The team lead and our speaker is Doctor Rafael Ocella, is a consultant anesthesiologist at FMC local JAH and is currently the Population Officer of the Nigerian Association of Anesthesiologist. So we are pleased to have, you know, Army's. Thank you very much. Thank you. Good evening everyone. My name is Doctor Cecilia Rafael Taiwo, a consultant anaesthetist which FMC low Khoja, uh the current publicity secretary with the Public Relations Officer of the Nigerian Society of Anesthetist. Thank you. Okay. Um Well, staff in a few moments, but if you have a question, please, um you can, you know, drop them in the chat box as the webinar is going out and the at the end of the weapon now you can't attend to your questions. Thank you very much. Have you? Yeah. Can you let me know when I can start? Okay. So, so I can see this life. Yes, I can. OK. Can start okay. Good evening. Once again, everyone um to talk on anesthesia and pain management. And let me start by saying it will be absolutely impossible to make you are paying experts within this just one hour. But I would try as much as possible to stimulate your interest in the management of pain. And so I intend to look at this presentation using the following outlines. That's right. Introduction. The water is pain, the definition of anesthesia, history of pain management types of pain. We look at pastor physiology of pain assessment of pain. Do you have a view of pain management? And we'll summarize and conclude next slide, next slide please. By way of introduction pain, it's said to be the most common symptom of a disease and it's very often the first pointer to in deviation from the normal functioning of different parts of human body as well from seed in a hospital, more than 70 to 80% of patient have come to clinic out that comes to hospital comes because of one pain in one part of the body or the other. So, management of pain constitutes a significant body anywhere in the world. And this is not too different in our own country as it has been a recording challenge across the country. In Nigeria hospital, several reports on postoperative pain management have demonstrated infrequent assessment, poor diagnosis, I need adequate treatment among patient's and one of the factors that has been identified to be responsible for this poor pain management is the poor knowledge of healthcare professionals in the comprehensive management of pain ness slide. So what is pain according to International Association for the study of pain, which gave up with a definition in 1979 and defined pain as an unpleasant sensory or emotional experience that is associated with actual or potential tissue damage or that is described in terms of such damage. But this definition has been around for like over 40 years and it was reviewed in 2018 and by 2020 this definition was updated to the current one in 2020 by the same internationalization of the study of pain. As so, pain is now being defined as an unpleasant sensory and emotional experience that is associated with all resembling that associated with. Now, you can see that a clause has been included, which is all resembling that associated with. So even if it's not associated with it, but is resembling it, the actual or potential tissue damage. Now, the pain is always a personal experience and it is influenced revealing degrees by biological, psychological and social factors. What are we saying that his pain is subjective, it is whatever the person who's experiencing it says it is that is spain a person's report of experience as pain should be respected. Hence, pain is always subjective nurse slide. So what is the correlation between anesthesia and ST etiology and pain? What is the definition of anesthesia according to our own baba? That's so Gin Commando. Huh. Oh Ladakh. Oh He defined anesthesia as a specialization of medicine that deals with reversible controllable and predictable methods of pain relief for operative surgery with or without loss of consciousness. Now, you can see in this definition that everything is geared towards pain relief for patient that are to undergo surgery either pre operatively, post inter operatively and post operatively. So it is the medical specialty that is concerned with the total perioperative care of patient's that is before during and after surgery. It m purposes anesthesia, critical care medicine and emergency care meeting and even pain medicine. So in the next slide, I'm going to show us the versatility of an anesthetize next slide. Now this slide talks about how go treated IV from Adam. Yeah, by making go the first anaesthetist. Next line for those of us who are Christian, you know that if was sticking from the rim of a dumb when he fell asleep, when go put him to sleep. So what was the first anesthetize by putting Adam to sleep? Let's slide. Okay. Now we want to look at who is an an S status or how or weirdos and an estate is function on anesthesiologist. By the way, it is the Americans there cause anesthesiologist that is the physician anesthetist. Why the British the Britain or Britain called anesthetist. So you can use the two words interchangeably anaesthetist. But because we commonly also find people using nose anesthetize, you can differentiate it by saying you're a physician anaesthetist. But in the US, once you say you're an anesthesiologist, everybody knows that you're a doctor who are specialized in anesthesia. So an anesthesiologist is a superman doctor. It's not just in the operating room like most people will believe or you can see that an anesthesiologist work in the operating room as a perioperative physician. You also work in the labor world and delivery suits where we offer paying services to patient's in labor. There are other places like in the procedural areas like intensive care unit, post operative care units. Even in MRI, there are some patient to, they want to undergo such procedure. I may not be able to, may not cooperate and then you have to call for necessities to put the patient to sleep. So the patient can cooperate for MRI Cities can when you have a small child, then top Mas's pain management, either acute pain or chronic pain and in emergency medicine. Cold blue team respiratory therapy accusation in operating room, hospital, medical school education, health professional were also involved in research and we're also managers. So you can see that an anesthetist is a superman doctor. Uh I wasn't able to show you one particular picture that shows the versatility of um an anaesthetist. Anaesthetist is so on who must have a very big bladder that can store urine. So that while you are a protein patient, you don't need to be running up and down because you want to urinate and you must also have a very small stomach so that you don't usually get hungry and then you must have eyes everywhere. You must be very, very vigilant and observe erred because vigilant is our own internal safety. Next life. Next slide. Now, what is the history of pain management? The struggle to manage pain in patient's effectively. And Sibley has long been an issue in medicine. And tracing back this history of pain management therapy is often complicated by the fact that historically speaking, many of the past pain treatment options can be credited to multiple nationalities. And one of the aliens forms of therapy came from a compound called salicylic acid. However, the 20 point for this type of pain management, according the 18th century and 19th centuries, Rafael period, and you say Bogner and other scientists work on lowering the formula slightly into what we now know today as what as a spring to our spring is actually the that we can call the first energetic and the use of opiate trees back to the 16 0 zeros. And uh where morphine and heroin became commonplace in 19 0 zeros because of the addictive tendencies of morphine. This led to development of pain management as medical field in 19 sixties. That's life okay. Next slide. So this is just to show us picture of some foreigner in this uh pain management. Next one, next slide, Steven Waldman was the fourth anesthesiologist who practice pain management in the US and he's the founder of the Society for Pain Practice Management and was one of the leader of interventional pain management. Next slide. Now, types of pain, how do you classify pain? Now, pain can be classified or categorized in several ways. You can classified pains based on the duration of that pain. Commonly we say acute and chronic pain. When we talk about acute pain, it means pains that the duration is less than one month. It's between one month. When has this patient be having this pain? You say within one month and if the pain is more than three months, you say this is chronic pain. Some other persons also say six months, but generally what is accepted is acute pain is any pain, less than one month becomes chronic when it is more than three months. So in between the uh one month and three months is sub acute pain. Then you can classify pain based on the part of physiological mechanism. Is it a nociceptive or neuropathic pain? Nociceptive pain are usually from tissue damage? Why neuropathic pain as a result of organ damage? And you can talk about neuropathic pain like in the case of diabetic pain and nociceptive pain. Like if you just enjoy your hand, like putting your hand in a hot object. So notice ft pain are usually acute pain. While neuropathic pain are usually chronic pain, then you can also classify pain based on what part of the body or the anatomical location. People having chest pain, low back pain, abdominal pain, etcetera, etcetera. Then what or you can also classify pain based on the cost of this pain. We have new plastic and non new plastic pain. Of course, when you talk about new plastic pain, these are pains caused by all that are cancer related and no new plastic pains are not cancer related. There could also be psychogenic pain and there could be also we also classify pain as refer pain. Now we go to the pathophysiology of pain. Basically, when we talk about the pathophysiology of pain, we look at it from the signal transduction in the transmission, then the perception or we call it integration and then the modulation of this. So pain, usually when there is tissue injury, it immediately leads to inflammation. This is what we know from our pathology. And once there is inflammation, there will be release of medical, of mediators of chemical mediators. For example, substance P. Kristen gland is serotonin is an acetylcholine. And when we are going to be talking about the management of of this pain, these are some of the mediators that some of these pain um treatment try to modulate or try to block. So you have nociceptive or peripheral uh receptive receptor, which this peripheral enough peak once there's injury and there will be signal transduction in through the peripheral. Now, they're actually about to type of. Now we have the a data now and the C fiber. Now uh the day data carry the fast uh pain receptor uh receptor. Why the C fiber carry the slow pain receptor. And this goes into the spinal cord deposition uh information to the other side of the spinal code and this is not transmitted that is transmission through the spinal Kalanick track. This also carry temperature to through the uh spinal column extract to the to Alamos. So we have the first order neuron from this peripheral. Now, getting to the dose, a root ganglion from those a root ganglion through the in the spinal cord, we have the second order neuron stopping in the thalamus and the total than your own from the thalamus to the higher cerebral cortices where this pain will be interpreted. And then there is this is this is what we call the ascending pathway of the uh paying uh part of physiology. Why did descending pathway through this cerebral uh the higher centers there will be a mutilation of this chemicals and it will lead to generation of inhibitory mediators like opioid peptides, non of refereeing, lysine and gaba, that's return it Aminobutyric acid. So through the descending part way through the brain stem, it now goes back to the spinal cord and then this pain of the patient is reduced. Let's slide next slide. Okay. Now this is exactly what I just explained. Trans ductions. Transmission is the relay in the spinal code, then goes to the thalamus from thalamus. It send it to the hire center where there will be interpretation and uh the the integration and interpretation of this um uh stimulus that is perception and then through the descendant pathway, it will be modulated. Thank you. Next slide. Next slide. Now, how do we assess pain pain assessment is the cornerstone of a successful patient pain management. Effective clinical management of pain, ultimately depends on it's accurate assessments which entails comprehensive evaluation of the patient's pain symptoms, clinical history and functional status. Now, the critical elements of the assessment of pain include one normal what we do in medical school, you take patient history, physical examination and then you do pain measurements. Now this is pain intensity skill. We have different types. Here, I have the visual analog skill, the numeric rating scale, the Vibe A rating scale and one beca faces Spain Written scale. Let me say that the one BECA faces re pain rating scale is for Children, for Children that may not be able to vocalize, that may not be able to talk, that may not be able to carry out the instruction we will give to them. In the case, like in the case of vibe a rating scale, numeric rating scale and the visual analog scale. So you look at the expression of the face of the patient and then use call from 0 to 10, 0 is usually no pain and 10 is the worst pain. So when we talk about vibrating skill envi berating scale, you draw a line from 0 to 10 or you tell the patient zero represent no pain. 10 means your worst possible pain. And then you ask the patient to choose that's how you assess pain. And then in the America creating speak scale, you ask the patient to draw on a scale of 1 to 10. It's just mark. Where is he? Well, we'll work form of pain. Is it no pain, more dripping or worse pain? And then in vibe aerating a visual analog scale, there's a chat you give to the patient. So all these things are semantics. The good thing is that you're able to communicate with the patient education is able to communicate back to you. Well, let me see that in pain assessment don't forget that you must talk about the what are detains that provoke this patient pain when you are taking your history? What are detains that palettes, this patient pain? Where does this pain radiate to in this patient? What is the severity of this pain? And how long has this pain been there? So we have any money for it? We call it P Q R S team how to assess pain. When you go to clark your patient, next slide, next slide. So I'm gradually rounding up since it's just to stimulate our appetite's so to speak or our interest in pain management. Now, when we talk about treatment methods in managing pain, you must understand that the management of any pain will depend on. What type of pain. How long has this pain been there? So you have to individualize your patient's, there is no one straitjacket, one size fits all or for everyone, you must individualize your patient. And this treatment method could be pharmacologic or non pharmacologic. It could be that you want to marry the two together at this point. Let me also state that there are consequences if pain is not adequately managed or effectively and simply manage. And when we do not manage pain well or when we allow pain to linger for too long, there are psychological and physiological consequences. For example, one of the physiological consequence is that you see the patient will develop tachycardia, high BP and then hyperventilates, going into alkalosis, respiratory ankylosis, they can even have depressed immunity. And then you talk about the psychological effects. Pain can actually teach a patient to depression to even having suicidal ideation and say, okay, let me just leave. And maybe by the time I die, this pain will be off my neck. So you see why it is very, very important to manage pain. Well, so like I said, it can be non pharmacological or pharmacological. So when we talk about the non pharmacological method, that's when we're talking about the physical method and psychological method like physiotherapy manipulation, transcutaneous, electrical nerve stimulation, acupuncture, ice bags, they will talk about relaxation, realization cycle, prophylaxis and hypnosis. All these can be used to manage pain. But when we now talk about the pharmacological uh treatment, now these can be non opioids or opioids. Our non opioids, we include paracetamol and that's what we call the acetaminophen things. And then the non steroidal anti inflammatory drugs like a spring. And then this would want to can be classified into the nonselective and selective uh non steroidal anti inflammatory drugs. Then you can also have opioid like morphine, fentaNYL, mean pethidine. So for Antonin a fan tinning, etcetera, etcetera, then as anaesthetist, we also have some form of intervention for procedure that we do in taking care of pain. For example, if someone is having low back pain, you can actually inject what we call a epidural steroid injection. That means you put a look at an aesthetic agent into the epidural space to help elevate that pain. And over the years people have founded that this work very fine for patient. We can also do what is called nerve blocks. There are different kinds of nerve block. Do we need to elevate pain? And we also have spinal anesthesia. So these are all the various modalities, various ways by which pain can be elevated. Let's slide next slide, please. So I just want to talk briefly and this will be the last one on the W H O L three step and our Jesic ladder and this was actually developed in 1986. W you came up with how to manage patient's who have cancer, who develop cancer pain, patient with cancer, who also have pain. But over the years, people have adapted this to any other kind of pain. So when you are seeing the patient for the first time, coming to complain of pain, you start from a myd energetic until you gradually increase two, a more complex one depending on the severity of patient's pain. Now, we use, we usually start with non opioid energetics. That is our usual non steroidal anti inflammatory drugs. And as a Tamil a pain that is paracetamol. A spring people profane. Um um Pirro's Aecom diclofenac, etcetera, etcetera. We have ketorolac, we have a diagnostic um all of them like that. So plus or minus and adjuvants. And when you talk about adjuvants. These are older drugs or intervention that we're not primarily developed for pain abin issue, but you can actually use them when you combine them with our regular and a Jesse, the help and pain management. I give you an example like I'm a trip to learn. I mean, trip to learn is a tricycle e antidepressant was actually developed to manage depression. However, is the notice we noted that in Europe attic pain, patient with diabetic neuro party. When you add, I'm a Triptolin to whatever you're giving them as pain management, it helps because don't forget that pain is not only sensory, it is also the emotional part of the experience. So that's an example of of an adjuvant. Look, an aesthetic injection of local anesthetic agent or nerve block can also serve as an adjuvant. We also have some other drugs like pregabalin, gabapentin can also serve as adjuvant. We also have alpha agonist, olfactory agonist, like cloNIDine can also serve as adjuvant. So you start your pain management from a made an urgency like acetaminophen or non surrendered inflammatory drug plus or minus. Some of these are given to confirmation if this pain still persists and it's increasing, you move up to what is called, he might open, it might opioid plus or minus and adjuvants. And when this pain steeper seeds or increasing, then you have no choice but to use, oh puree plus or minus, non opioid and plus or minus a juvenile. So in X sense, the management of pain, actually, you need to combine medications or terra you can combine psychotherapy, physical therapy and even um pharmacologic and non pharmacologic method. And I must say that Money Gate of Pain should be a multidisciplinary approach. If a patient has cancer, of course, you know, if you don't remove the, the cancer, the pay will not go. So you need the intervention of the surgeon to take out the, the the the cancer and oncologist, which they are also drug to. You may not be true. Surgical means it may be by chemotherapy. So you need everybody to be involved. So, so if you have patient suffering from leukemia, you need hematologists, you need to join hands together. But what we are saying is that as anaesthetist who daily practice and make use of some of these drugs regularly, routinely in the theater and even outside the theater, they are the best manager of pain. Thank you. Next like next slide. Okay. Next slide. Okay. Thank you. Now, the or what I have said, some of the drugs have mentioned, if you, if you remember when we're talking about the path of physiology, how this would be trans ducted, transmitted and then it will be integrated and then there will be perception from the brain and then there'll be modulation. If you look at all at all, all this point at transactions level, we use non steroidal anti inflammatory drug antihistamine, opioids and Luca anaesthetics. If you remember when we're talking about that part, uh artificial that some chemical mediators were released. So that is what this N C it's antihistamine were one block. Remember prostate gland is process, I get all the stuff like that. Then at the transmission level, that's where our local anesthetics, you can actually block them there and opioids. Then when we talk about perception, we'll have opioids uh two ago knees uh and general anesthetics. Then when we talk about modulation, we talk about opioid alpha two ago knees, then NMDA receptor blocker example is ketamine, which is a drug that we anaesthetics are very, very familiar with. So, anesthetize um ketamine is a very, very, a good drug that we can use in several ways. You can patient, you can, you can give patient's through virtually all the roots and you can use it if you know what you're doing um to manage pain effectively. That's right. That's light. So in summary, a pain physician is a specialist who assesses and evaluates pain classifies and graduates and then treat it effectively. And I must say civilly to the specialist must have a detailed knowledge of the part of physiology of pain, the pharmacology of pain medications and must also be skilled in interventional procedures to relieve pain. He or she treats pain with drugs, different types of nap blocks, spinal epidural radio frequency ablation, viscosupplementation, implantation of traffic. A pumps, spinal cord stimulator dose and the world is going to stem cell treatment. Now, that's the future of pain management's. Thank you. The last light next slide, next slide. So in conclusion, based on the daily routine of anesthetize, these are these working with some of the drugs that I've mentioned earlier on. They are best equipped to manage any kind of pain. Thank you. Thank you. OK, thank you very much. Uh for the wonderful presentation, please. Um If you have a question, please, um can you indicate or drop your question or comment? Uh If you have any question, please, can you indicate? So I'll invite you to the state to ask the question or you can drop your question on the comment box? Okay. Do you have any questions? It's in that none of them have questions for you, sir? Okay. Thank you very much. Thank you very much for accepting the invitation to tell us about pain management. Um The a lecture was actually interesting. I really learned a lot and uh I don't, uh initially, I don't know that pain have um buses like some can be based on anatomy. Um In, in Europe. I know I always know of neuropathic pain and no math thing that somebody or feel, but I don't know that there's not a skeptic in and uh I really appreciate the lecture. Thank you very much, sir. You're most welcome. Thank you. It's a pleasure. Okay. I'll be ending the meeting um, later there will be, there will be a feedback from to I will be sent to all of us. Please do well to fill our feedback from. So I'll be able to get a certificate. Thank you and have a lovely day. A lot of the evening. Bye bye. All right.