paininflammationandfever-200404171818 (1).pptx

long life learning

1. Pain, Inflammation AND FEVER Faraza Javed Ph.d pharmacology

2. Pain Pain  is a distressing feeling often caused by intense or damaging stimuli . In medical diagnosis, pain is regarded as a symptom of an underlying condition.

3. The International Association for the Study of Pain widely used definition defines pain as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”  

4. Classification of pain

5. Based on duration Acute Pain Chronic Pain a) Chronic Non Cancer Pain b) Chronic Cancer Pain c) Chronic Episodic Pain

6. Based on Location Headache Back Pain Joint Pain Stomach Pain Cardiac Pain

7. Based on intensity Mild Pain (1 to 3) Moderate Pain (4 to 6) Severe Pain (7 to 10)

8. Pain scale

9. Based on etioloy 1. Nociceptive Pain a) Somatic b) Visceral 2. Neuropathic Pain a) Peripheral Neuropathic Pain b) Central Neuropathic Pain

10. Pain is usually transitory, lasting only until the noxious stimulus is removed or the underlying damage or pathology has healed, but some painful conditions, such as  rheumatoid arthritis ,  peripheral neuropathy ,  cancer  and  idiopathic  pain, may persist for years. Pain that lasts a long time is called  chronic  or persistent, and pain that resolves quickly is called  acute .  

11. Traditionally, the distinction between  acute  and  chronic  pain has relied upon an arbitrary interval of time between onset and resolution; the two most commonly used markers being 3 months and 6 months since the onset of pain, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. A popular alternative definition of  chronic pain , involving no arbitrarily fixed durations, is "pain that extends beyond the expected period of healing".

12. Psychogenic pain Psychogenic pain  is physical pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors . Researchers refer psychogenic pain or psychalgia as a form of  chronic pain . Causes may be linked to  stress ,  unexpressed emotional conflicts ,  psychosocial problems , or various  mental disorders . Some specialists believe that psychogenic chronic pain exists as a protective distraction to keep dangerous repressed emotions such as anger or rage unconscious.

13. Headache, back pain, or stomach pain are some of the most common types of psychogenic pain .  It may occur in persons with a  mental disorder , but more commonly it accompanies or is induced by social rejection or other such emotional events . It remains controversial that chronic pain might arise from emotional causes .  Treatment may include  psychotherapy ,  antidepressants ,  analgesics , and other remedies that are used for chronic pain in general.

14. Management of pain Pain van be managed through: Pharmacological Intervention Non Pharmacological Intervention

15. Pharmacological intervention Pharmacological therapy is given by analgesics. Analgesics may be Opioids or Non Opioids (NSAID) or Adjuvants. Adjuvants are drugs originally developed to treat conditions other than pain but also have analgesic properties.

16. Adjuvants: Used for analgesic reasons and for sedation and reducing anxiety. 1. Tricyclic Antidepressants 2. Antiepileptics 3. Corticosteriods 4. Local Anesthetics

17. WHO Pain Management Ladder

18. WHO Pain Management Ladder Pain Scale Reading WHO Steps 1-3 Step 1 4-6 Step 2 7-10 Step 3

19. NON PHARMACOLOGICAL therapies Heat and Cold Application Meditation Distraction Imagery TENS Application

20. Music Therapy Massage Yoga Acupuncture Herbal Therapy e.g. Ginseng

21. Inflammation

22. INFLAMMATION Inflammation   is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants ,  and is a protective response involving immune cells, blood vessels, and molecular mediators. 

23. The function of inflammation is to eliminate the initial cause of cell injury, clear out necrotic cells and tissues damaged from the original insult and the inflammatory process, and initiate tissue repair.

24. SIGNS OF INFLAMMATION Cardinal signs are: Heat ( Calor ) Redness ( Rubor ) Swelling (Tumor) Pain (Dolor) Loss of Function ( Functio Laesa )

25. Types of inflammation Acute Chronic

26. ACUTE INFLAMMATION Acute inflammation is a short-term process occurring in response to tissue injury, usually appearing within minutes or hours.

27. Acute inflammation has two major components: Vascular Changes Cellular Events

28. VASCULAR CHANGES The process of acute inflammation is initiated by resident immune cells already present in the involved tissue, mainly   macrophages ,   histocytes and   mast cells . These cells possess surface receptors known as  pattern recognition receptors  (PRRs), which recognize (i.e., bind) two subclasses of molecules:  pathogen-associated molecular patterns  (PAMPs) and  damage-associated molecular patterns  (DAMPs). PAMPs are compounds that are associated with various pathogens, but which are distinguishable from host molecules. DAMPs are compounds that are associated with host-related injury and cell damage.

29. At the onset of an infection, burn, or other injuries, these cells undergo activation (one of the PRRs recognize a PAMP or DAMP) and release inflammatory mediators responsible for the clinical signs of inflammation. Vasodilation and its resulting increased blood flow causes the redness ( rubor ) and increased heat ( calor ). Increased permeability of the blood vessels results in an exudation (leakage) of plasma proteins and fluid into the tissue (edema), which manifests itself as swelling ( tumor ). Some of the released mediators such as bradykinin increase the sensitivity to pain ( dolor ).

30. Cellular Events The  cellular component  involves  leukocytes , which normally reside in blood and must move into the inflamed tissue via  extravasation  to aid in inflammation. Some act as  phagocytes , ingesting bacteria, viruses, and cellular debris. Others release enzymatic granules  that damage pathogenic invaders. Leukocytes also release inflammatory mediators that develop and maintain the inflammatory response.

31. Acute inflammation may be regarded as the first line of defense against injury. Acute inflammatory response requires constant stimulation to be sustained. Inflammatory mediators are short-lived and are quickly degraded in the tissue. Hence, acute inflammation begins to cease once the stimulus has been removed.

32. Inflammatory Mediators Histamine is the main mediator of inflammation. Released from mast cells and basophils and is the primary cause of increased vascular permeability. Prostaglandins are derived by arachidonic acid which can cause vasodilation, fever, and pain. Leukotriene is able to mediate leukocyte adhesion and activation, allowing them to bind to the endothelium and migrate across it and is able to induce the formation of reactive oxygen species and the release of lysosome enzymes by the cells.

33. Cytokines are polypeptide products of activated lymphocytes and monocytes. The main cytokines participating in acute inflammation are interleukin-1 (IL-1 ), interleukin-8 (IL-8) , and tumor necrosis factor alpha (TNFα ). The clotting pathway is responsible for coagulation of blood by formation of fibrin from fibrinogen.

34. CHRONIC INFLAMMATION Chronic inflammation is also referred to as slow, long-term inflammation lasting for prolonged periods of several months to years. Generally, the extent and effects of chronic inflammation vary with the cause of the injury and the ability of the body to repair and overcome the damage. 

35. Chronic inflammation is characterized by less swelling but presence of more lymphocytes and fibroblasts, which macrophage have been unable to clear the area of foreign substances.

36. Chronic inflammation can result from the following : Failure of eliminating the agent causing an acute inflammation such as infectious organisms including  Mycobacterium tuberculosis that can resist host defenses and remain in the tissue for an extended period . An autoimmune disorder in which the immune system is sensitized to the normal component of the body and attacks healthy tissue giving rise to diseases such as rheumatoid arthritis.

37. Recurrent episodes of acute inflammation. However, in some cases, chronic inflammation is an independent response and not a sequel to acute inflammation for example diseases such as tuberculosis and rheumatoid arthritis . Exposure to a low level of a particular irritant or foreign materials that cannot be eliminated by enzymatic breakdown or phagocytosis in the body including substances or industrial chemical that can be inhaled over a long period, for example, silica dust.

38. Management of inflammation Nonsteroidal anti-inflammatory drugs (NSAIDs ) Steroids Antihistamines

39. FEVER/ PYREXIA

40. Pyrexia Pyrexia or fever is a physiologic response triggered by aseptic stimuli or infections which result in elevation of body temperature due to increased concentration of PGE2 within certain areas of the brain.

41. A fever can be caused by many medical conditions ranging from non-serious to life-threatening .  This includes viral, bacterial and parasitic infections such as the common cold,  urinary tract infections , meningitis, malaria and appendicitis among others. Non-infectious causes include vasculitis, deep vein thrombosis, side effects of medication, and cancer among others.

42. Temperature is ultimately regulated in the hypothalamus. A trigger of the fever, called a pyrogen , causes release of prostaglandin E2 (PGE2). PGE2 in turn acts on the hypothalamus, which creates a systemic response in the body, causing heat-generating effects to match a new higher temperature set point . H ypothalamus works like a  thermostat .  When the set point is raised, the body increases its temperature through both active generation of heat and retention of heat.

43. Peripheral vasoconstriction both reduces heat loss through the skin and causes the person to feel cold.  Norepinephrine  increases thermogenesis in brown adipose tissue, and muscle contraction through shivering raises the metabolic rate .  If these measures are insufficient to make the blood temperature in the brain match the new set point in the hypothalamus, then shivering begins in order to use muscle movements to produce more heat. When the hypothalamic set point moves back to baseline either spontaneously or with medication, the reverse of these processes ( vasodilation) and sweating are used to cool the body to the new, lower setting.

44. MANAGEMENT OF PYREXIA 1. Conservative Measures (Sponging, Cooling and Proper Hydration) 2. Medication NSAIDs (PCM, Ibuprofen, Aspirin)

45. Thankyou