Acute pain services ppt.pptx. for pg ug and medical students

for all taking care of post op patients

1. ACUTE PAIN SERVICES Uma G Kims&Rc

2. “Pain is all in the mind” “Surgery will be associated with pain” Does it have to???

3. ROLE OF PAIN 1. Focus attention and empathy 2. Protect body from further damage 3. Gives rest to the part - helps healing 4. Immediate benefit to patient/caregiver 5. Disposition to care for people in pain

4. IASP definition of PAIN “Unpleasant sensory or emotional experience associated with actual or potential damage or described in terms of such damage!”

5. PAIN Most common annoying complaint Most inadequately assessed & treated symptom Most difficult sensation to define - protopathic Subjective, but not personal & is of vital importance Most important person is the observer - hears beyond the words - sees behind the picture

6. WHAT IS ACUTE PAIN? Post - operative Trauma Burns Medical procedures Signals organic disease,easy to diagnose Disappears with Rx Opioids are specifically effective

7. “ It is important to realise that not all patients are lovable – many do not care about themselves and are seen responsible for many of the difficulties for which they seek our care. But all patients are entitled to relief of suffering even if they themselves are the cause of much of their suffering”.

8. WHY IS ACUTE PAIN BADLY MANAGED? Lack of awareness - surgery is assoc. with pain “Pain not visible”- not assessed Understaffed anaesthesia dept.( freelancing) Myths & fears assoc. with opiates/ underprescription, Unavailability of opiates and preservative free drugs Patient expenditure when using sophisticated equip

9. More sympathy for palliative care & cancer pain Multidisciplinary services easier to organise Clinical freedom within the department Difficult to change old concepts and managements Anesthesia - Service unit –not income generating Unwillingness – nursing services, pharmacy More costs to the hospital ( personnel, equipment)

10. WHY TREAT ACUTE PAIN? Surgery--> tissue damage/ release of mediators CNS stimulation and pain perception CVS - Increase BP, HR, Workload RS - Increase work of breathing Renal /GIT - decreased function Inadequate --- cause of 30% chronic pain

11. NEURO – ENDOCRINE RESPONSES Stress hormone release, catabolism, lipolysis Hyperglycaemia & glucose intolerance Retention of Na+ & H2O, excretion of K+ Impaired wound healing–reflex vasoconstriction Reflex skeletal muscle spasm-hypoventilation Recovery & Rehabilitation delayed

12. ACUTE PHASE RESPONSE (APR) Stimulated by cytokines - interleukins (IL6) Max conc: in 24 hrs , remain elevated 48-72hrs Stimulates a/c phase proteins -CRP, ACTH , Cortisol Negative feedback --- to depress IL6 conc: Stress responses from visceral, peritoneal, abd wall,muscle Anaesthesia – no effect on cytokine response or APR Modification of APR - opioids, X2 agonist, regionals (best)

13. CHRONIC PAIN AFTER SURGERY Pain atleast 2 months duration after surgery Other causes excluded - malignancy, c/c inf Mastectomy, cholecystectomy, thoracotomy Inguinal hernia, laminectomy, amputations Phantom sensations with / without pain Neuroplasticity / continuation of pre-op pain

14. “Patient is the best sensor of his pain, Believe his pain”

15. PAIN MECHANISMS Pain receptors – free nerve endings Nerve fibres - A delta (a/c) & C fibres(c/c) Neurotransmitters – excitatory / inhibitory Algogenic substances -leucotrienes -serotonin -substance P -histamine -Prostaglandins

16. PAIN PATHWAY Pain receptors Spinal cord - dorsal horn cells Spinal cord tracts Reticular formation - HR, BP, resp changes Thalamus, Cortex- conscious awareness WIND–UP of pain, PRE-EMPTING pain

17. CLINICAL PHENOMENA Nociceptors – activated by tissue damage Pain – perception of noxious stimulus Suffering - negative affective response Pain behaviours - linked to suffering Subjective - emotional, psychological

18. Medical Reasons: Improved respiratory function Earlier ambulation --> DVT Shorter post - op hospitalisation Cost to patient and hospital less Comfortable and pain- free patient NEED FOR ADEQUATE PAIN RELIEF

19. NURSING POINT OF VIEW Better nurse - patient relationship Increased sense of responsibility Lesser nursing time (PCA, infusions,S/C) High acceptance and popular FIFTH VITAL SIGN

20. MEAN EFFECTIVE ANALGESIC CONCENTRATION (MEAC) Variability in MEAC levels Increase beyond MEAC --> will not increase analgesia Alternative methods required Inverse relationship -- endogenous opiate conc & peri-op exogenous requirement

21. NEED FOR NEWER METHODS Traditional I/M route disliked by all Big prn doses ---> sedation, analgesia, pain Underprescription due to myths & fears Relies on another person for pain relief Multiple needle sticks --> infection Variability in absorption ---- peak time & conc:

22. ANY PAIN THERAPY not “One size fits all or Set and forget therapy. Is essentially a maintenance therapy”

23. GOALS OF ACUTE PAIN SERVICES “ NO MAGIC BULLETS” Ensure all patients pain-free at rest, on movt. Discourage IM analgesics and prn orders Switch to S/C routes wherever possible STD protocols to avoid confusion Prevent pain – round the clock drugs

24. Posters Make “PAIN” visible APS Sheets Free services initially and contactable any time Equipment technician-maintenance/record of equip. Anaesthesia technician –adequate supply of epi.cocktail IMMEDIATE back up and advice whenever required. Encouragement / acknowledgement in plenty

25. “Any drug in valueless if if remains in the ampoule, bottle on infusion pump.” It has to be give in adequate doses at adequate time intervals to be effective, whatever technique you use.

26. MODALITIES AVAILABLE 1.Intravenous 8. Oral 2. Subcutaneous 9. Rectal 3. Intrathecal 10. Transmucosal 4. Epidural 11. Transdermal 5. Via peripheral nerves 12. Sublingual 6. Direct wound infiltration 13. Intranasal 7. Interpleural 14. Intra- articular

27. EMPHASISE AND STRESS Every patient different, Multimodal therapy All pain protocols not suitable for all patients If one protocol fails, choose another Rescue analgesics mandatory No IM opiates when already on other opiates Discuss with the surgeons / assure safety

28. “And I always thought that Pain Perception was the end results of nociceptive inputs, passing through dorsal horn modification, then entering and activating the mid brain autonomic regulation area, before affecting the emotional, reflex, endocrine areas before finally being interpreted as 'PAIN' by the cerebral cortical areas by a comparison of the afferent messages to the Brain's many stored past memory of similar experiences.” Acutally, this is where most clinician's theories of pain go wrong. Pain is not a serial process, but a parallel process. Nociceptive inputs go almost directly to all of the areas you mention simultaneously. Pain is not the result of a one way pathway, but the combination of simultaneous activation of all of the pathways. Knock out one of the pathways, and you still have pain, minus the attributes of that particular pathway. Knockout enough of the pathways and it probably cannot be called pain anymore, but could still be bothersome, or not, depending on the system knocked out. I suspect if you evaluate your clinical experience from this point of view, many seemingly weird observations will make more sense. The end result for treatment will probably be the same as you have already figured out. ‘’Treatment must be of the whole person, not a single symptom. ‘’ Al Light

29. Multimodal pain therapy NSAIDs, Opiods Spinal & Systemic Opiods Regional

30. WHAT WE DO IN APS Subcutaneous opiates Continuous opiate infusions - I/V, S/c Epidural / intrathecal LA + opiates / infusion PCA via I/V, S/C, epidural routes Nerve blocks /Interpleural / intra-articular/ PV Oral / rectal / parenteral NSAIDs

31. SUBCUTANEOUS ROUTE Cheap, good even with intermittent dosing multiple needle sticks can be avoided same as I/V kinetics / no surge effect depot with continuous release variable absorption - slower than I/M Modified by pain, hypotension, hypothermia

32. 22’ Butterfly scalp vein or cannula inserted anywhere / below the clavicle Morphine: 5-10mg 4 - 6 hrly (0.5ml) Tramadol/ pethidine: 50-100mg 4-6 hrly flush tubing with 0.5ml saline can be given as bolus, infusions or PCA SUBCUTANEOUS ROUTE

33. . Improves controllability thru any route Prevents fluctuating analgesic concs: Does not have to rely on others Rate adjustments may be required Post-op pain intensity not the same thru CONTINUOUS INFUSIONS

34. Continuous I/V, S/C, epidurally Morphine-1mg/ml: pethidine10mg/ml: Initially 1 ml/hr with naloxone I/V or S/C Ensure pumps functioning well Most common causes of patient mishaps - pump dysfunction - errors in programming OPIATE INFUSIONS

35. Infusions set at 5-10 ml / hr for 72 hrs 0.1%bupivacaine + 2-5ug/ml fentanyl Monitor pulse, BP, respiration closely PCEA - bolus 5-8ml: LOI-15-20 mins Catheter migration - I/V or dural space Premixed syringes - LA + opioids EPIDURAL INFUSIONS

36. Fig.2. ELECTRONIC PCA PUMP MEAC

37. Analgesia on demand Patients can regulate analgesic to MEAC Sense of control over his pain High acceptance and popular Decreased drug usage via any route Trained staff, back up, education PATIENT - CONTROLLED ANALGESIA (PCA)

38. THE PATIENT IN PCA Must understand the concept of PCA Must be willing to use it Must be able to perceive pain intensity Must be able to respond Must be relieved of all doubts Must not be an `Opiate-abuser ’

39. PCA PUMPS Pumps with patient demand button Ensure pump is locked, key kept safe Set 1 ml boluses, no background infusion Lockout interval - 5-10 mins 1/V, S/C Disposable PCA pumps available Note total dose consumed by the patients

40. SAFETY ASPECTS OF PCA Demand made only by the patient Lock- out interval for full effect of drug Negative feed- back and dose limits Demand/infusion modes/computer integrated PCEA Fail-proof designing of pumps (max.dose limits) Lockable, monitor incorporated pumps (O2,BP)

41. “It is important what you have, What is more important is what you do With what you have”

42. Fig.1.DISPOSABLE PCA PUMPS

43. “Patient is the best sensor of his pain, Believe his pain”

44. COMPLICATIONS WITH OPIATES Resp depression/ sedation/ pruritis Hypotension/ bradycardia/ urine retention Have mephentine & naloxone in the ward Call the ward doctor & APS doctor (pager 448) Meanwhile treat with O2,vasopressors & fluids Instructions on the pink APS sheets

45. “ It is better not to monitor than to monitor and ignore it, or be ignorant of what to do with the data obtained”

46. “ACUTE PAIN SERVICES Looks good from far, Actually Far from good!” RAWAL

47. APS IS TO ENSURE All patients pain-free entire post-op period STD protocols to avoid confusion Discourage IM analgesics/ use other techniques Switch to other routes whenever one fails Routine patient observation charts/ audits Create Awareness among Surgeons/ Nurses Better relationship between Nursing staff & pts

48. COST ANALYSIS OF ACUTE PAIN SERVICES Impeded by lack of baselines & outcome measures No valid method to assign costs to diff levels of analgesia No actual studies involving APS APS not decision makers as to type of analgesia rendered Cost issues & benefits not in their control Low cost – nurse-based models or traditional analgesia??

49. ECONOMIC OUTCOMES IN PAIN MANAGEMENT Pain relief, satisfaction, complications validated Role of APS to decrease side effects not established Economic outcomes of regional analgesia not examined APS-a/c emergencies & high risk patients not established Workload, training, education costs not considered

50. PATIENT OUTCOME STUDIES Pain relief per se did not affect patient outcome Post op morbidity / hospital stay depends on multiple factors Pre-op informn, post-op rehabilitation, nutrition, mobilisation APS along with Critical care improved patient outcome Decreased adverse effects & events, & Cost effective Considerable workload & non-sustainable .

51. FACTORS IN COST- EFFICIENCY ANALYSIS Cost of analgesics, Devices, Equipment, Oxygen therapy Side effects of analgesics, Techniques & Drugs for Rx Nursing time, Monitoring equipment in wards Duration of stay in Recovery, ICU, Wards Education of Patients, Nurses, Physicians, Technicians

52. VARIABILITY IN COSTS AMONG APSs Whether Nurse-based, Physician-based, Anesthesia-based Full multidisciplinary team of trained personnel Nurses, Pharmacists, Physiotherapists, Technical Staff Low-cost or high-cost models? Evidence-based studies not available/ relevant in our country

53. FUTURE OF APS APS threatened by economic constraints & need for cost-effective therapeutic interventions A/c pain management integrated into an enforced multimodal rehabilitation programme to decrease costs?? Once pain awareness & education becomes universal, ARE ACUTE PAIN SERVICES REALLY NECESSARY??

54. Pain is perfect miserie, The worst of all Evils, And if excessive, Overturns all patience! Milton

55. “If I can keep one heart from breaking, I shall not live in vain, If I can ease one life the aching, I shall not live in vain.”