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GREY BOOK 57th Edition Aug2012

GREY BOOK 57th Edition Aug2012

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Published by Ram Babu Doradla

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Published by: Ram Babu Doradla on Jun 02, 2013
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01/16/2014

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Link consultant: Dr Jeremy Cashman

Note that for some conditions, such as acute coronary syndromes, acute painful joints, and
sickle cell crises, analgesic approaches differ.

Acute pain, whether due to a medical or surgical condition, should be relieved as soon as
possible. Simultaneously investigate and treat the underlying cause – it is rare for
analgesia to mask a diagnosis. Pain may be classified as mild, moderate, severe or very
severe and treated accordingly. In general it is more realistic to strive for comfort rather
than complete abolition of pain.

TheAnalgesic Ladder

Mild pain

paracetamol or an NSAID

Mild-to-moderate

combination analgesic + an NSAID

Moderate

oral opioid or combination analgesic + an NSAID

Moderate-to-severe

oral opioid + paracetamol + an NSAID

Severe

parenteral opioid (IM, SC or IV) + paracetamol + an NSAID

TREATMENT DETAILS
Simple Analgesic

Paracetamol: 1g PO/NG/PR 4-6 hourly (maximum 4g/day).

Note: For adult patients <50kg especially those who are malnourished, we advise dosing
at 15mg/kg PO/NG/IV 4-6 hourly.

Non-Steroidal Anti Inflammatory Drugs (NSAIDs)

Diclofenac: 50mg PO 8-hourly or 12.5mg, 25mg, 50mg, 100mg PR/day (max
150mg/day)
Ibuprofen: 200-400mg PO 4-6 hourly (maximum 2.4g /day).
Contraindications: Bleeding diathesis, peptic ulceration, renal dysfunction, allergy to
NSAIDs (care in asthma), congestive cardiac failure.

Combination Analgesic

Co-dydramol (10mg dihydrocodeine + 500mg paracetamol/tablet): 1-2 tablets PO 4-6
hourly (maximum 8 tablets/day).

Initial pain
assessment

Significant pain
requiring intervention

Pain consistent with
surgical/medical condition

Initiate analgesic regimen or
adjust dose/interval of pre-existing analgesic regimen
*according to the analgesic ladder*

Surgical/medical
evaulation

Re-assess at
regular intervals

Satisfactory
response

Inadequate
analgesic/unacceptable
side-effects

Discharge Planning

Refer to Specialist Services

Yes

Yes

Yes

No

No

No

Re-assess at
regular intervals

37

Opioids – Oral

Dihydrocodeine: 30mg PO 4-6 hourly (maximum 240mg/day)
Codeine Phosphate:

30mg PO 4-6 hourly

Tramadol:

50-100mg PO 4-6 hourly

Opioids – Parenteral

Morphine is the preferred opioid. It may be given on the wards IM, SC or IV-Patient-
Controlled Analgesia (PCA). In A&E, ICUs and Theatres, morphine is also
administered as an IV bolus or infusion. If the patient is hypotensive or has signs of
shock, treat these before starting as it may reduce blood pressure further.
Injection: Severe acute pain often requires morphine to be given by injection to give
adequate control. Use the dosage regimens given in the following tables.

*IV morphine

IM morphine

Age (yrs)

Dose

Age (yrs) Dose

Pain severe

Less severe 20-39

7.5-12.5mg

70

2mg

1mg

40-59

5-10mg

> 70

1mg

0.5mg

60-69

2.5-7.5mg

*A&E, ICU and Theatres Only

70-85

2.5-5mg

>85

2-3mg

Assess the patient 60min after IM, and 5min after IV, injection.
Assuming there is no evidence of opiate overdose (see section below for diagnosis and
treatment), then if:
pain relieved, repeat same dose up to 2-4 hourly PRN after IM injection. Check for
overdose post injection as below.

pain persists, for IM administration immediately repeat injection but at a dose
no more than 50% of the original dose; for IV administration (only in A&E, ICUs and
Theatres
) immediately repeat same or at a dose no more than 50% of the original dose.
Check for analgesia or overdose post-injection as above.
Infusion: Infusions (morphine 1-6 mg/hour IV) should only be given where there is
close supervision with adequate patient monitoring. O2 should be administered
continuously and O2 saturation monitored. Monitor patient closely. A subcutaneous
infusion may be used in patients without IV access.

PCA: Patient Controlled Analgesia allows titration of the opioid to the patient‟s need

with a higher degree of safety than a continuous infusion. Contact the Acute Pain Team
for help with this regimen.

OPIOID OVERDOSE

If the opioid causes features of overdose such as drowsiness or respiratory depression
(respiratory rate of less than 8 per minute) then:
1. stop the opioid,
2. administer oxygen by face mask,
3. give naloxone by IV injection 100micrograms every 2-3 minutes until patient is
rousable and respiratory drive returns,
4. consider giving doxapram (1mg/kg) IV. This is a respiratory stimulant and does not
reverse analgesia.
Both naloxone and doxapram are shorter-acting than morphine so observe the patient to
ensure that the signs of overdose do not recur.
Communications: Acute Pain Team (bleep 6477/6159); On-call anaesthetist (bleep
6111); Palliative Care team (bleep 6796/6508 or ext 3313).

38

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