(Clinical Guidance for Acute Pain Management)

1 .. 2552 ( 1)
ISBN: 978-974-8285-72-6

ACUTEPAIN
Thai Association for the Study of Pain (TASP)

1 .. 2552 ( 1)
ISBN: 978-974-8285-72-6


*** ***

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(Clinical Guidance)
20

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(Clinical Guidance:
) The American Society of Anesthesiologists (ASA:2004)1, The
American Pain Society (2005)2, Australian and New Zealand College of Anaesthetists (2005)3,
British Pain Society (2007)4, Institute for Clinical Systems Improvement (ICSI:2008)5

20

5 246
>7 28.77
228

(acute pain)
(chronic pain)

6

*** *** 1

epidural block patient-controlled analge-
sia (PCA)

3

4 :

5
()


6
7

2 *** ***
 1
1. 1:
:
2. 2: (pain assessment)
: 1)
2)
3)
3. 3:
:

4. 4: (acute pain treatment)
4.1 (pharmacological therapy)
: 1)

2)

3) (multimodal pain therapy)
4) (opioid) IM IV
4.2 (non-pharmacological therapy)
: 1)

5. 5:
:

6. 6:
:

7. 7:
: 1)
2)
8. 8:
:
( 2, 3 2)

*** *** 3


1. ( 1)
:

2. ( 2)9
: 1)
2)

3)




1

3. ( 3)
:

4 *** ***
 Numerical
rating scale
(NRS)
0 1 2 3 4 5 6 7 8 9 10
Verbal
rating scale
(VRS)


Visual
analog scale
(VAS)

Face pain
assessment
scale
0 2 4 6 8 10

1
( European society of regional anaesthesia and pain therapy Newman CJ10)

4. ( 4)

*** *** 5





( ) ( )
( )


( 1)
( 2)
/ /
(multimodal analgesia)

(Pharmacological therapy)
paracetamol, nonsteroidal anti-inflammatory drugs, opioids,
local anesthetic adjuvants

1. ( 2)

2 3

6 *** ***
 2.
3.

4.

Opioid
opioid (IV) (IM/SC)
2, 3 4

(Non-pharmacological therapy)
psychological therapy physical therapy
Psychological therapy
1. (Provision of information)
2. (Relaxation and attention strategies)
3. (Hypnosis)
4. (Cognitive-behavioral therapy)
psychological therapy

Physical therapy
1. (Applications of heat and cold)
2. (Manual and massage therapy)
3. Transcutaneous electrical nerve stimulation (TENS)
4. (Acupuncture)
physical therapy
-

non-pharmacological therapy

1.
2.
3.
4.

*** *** 7

2 opioid (IV titration)3

Morphine 1 mg/ml
Pethidine 10 mg/ml

Sedation score < 2
Sedation score < 2 RR > 10/min
RR > 10/min1 naloxone

hypotension 0.1 mg IV

< 3
TASP
15
( 1)


< 70
pain score 7
~ 5
1 . 0.5 .
pain score 7

1 . 2 .

1. RR = respiratory rate 10 /
Sedation score 0-3
(0 = , 1 = , 2 = , 3 = , S = )

8 *** ***
 3 opioid (IV around the clock)3

Sedation score < 2, RR > 10/min1
hypotension Morphine IV
()
(
2 )
1-2 mg iv 2 hr
2-3 mg iv 3 hr
5-10 3-4 mg iv 4 hr

Sedation score < 2

RR > 10/min



Sedation score < 2
RR > 10/min
Sedation score < 2
naloxone
RR > 10/min
0.1 mg IV



2

BTP 25%

3
50%

1. RR = respiratory rate 10 /
2. opioid IV
3. BTP = breakthrough pain ( 25-50% )
Sedation score 0-3 (0 = , 1 = , 2 = , 3 = , S = )

*** *** 9

4 opioid (IM/SC PRN)3

Sedation score < 2 IM prn q 2 hr

RR > 10 /min1 () Morphine (mg) Pethidine (mg)
20-59 5.0-10.0 50-100
60-85 2.5-5.0 25-50
2 > 85 2.0-3.0 20-30

30

Sedation score < 2

RR > 10 /min


Sedation score < 2
RR > 10 /min
Sedation score < 2 naloxone
RR > 10 /min 0.1 mg IV

2 2 2 .

50% 25%

1. RR = respiratory rate 10 /
2. opioid IM prn q 2 hr ()
Sedation score 0-3
(0 = , 1 = , 2 = , 3 = , S = )

10 *** ***
 (Multimodal analgesia)


11 12


11 NSAIDs
opioids opioids peripheral, spinal
supraspinal NSAIDs peripheral NSAIDs
spinal cord

5. ( 5)
:

5 : none (0), slight (1), moderate (2), good or
lots (3) complete (4) numeric rating scale (0-10): 0
10 visual
analogue scale

4 13

6. ( 6)
:
( 7)

7. ( 7)
: 1)
2)
opioid

*** *** 11

opioids
1. seda-
tive naloxone 0.001-0.004 mg/kg 2-3
0.003-0.005 mg/kg/hr
opioids sedation scores ()
2.
2.1 sedation scores (0-3) 0 = , 1 = ,
2 = , 3 =
2.2 opioids

1 ondansetron metoclopramide
opioids
2.3

8. ( 8)
:
( 2, 3 2)

opioid (IV) 5-10 opioid
(IM/SC) 30
60

12 *** ***

14

( prostaglandin, substance-P,
histamine, H+ )
C fiber A fiber
dorsal horn 2
spinothalamic tract
thalamus cerebral cortex ( 3)

3
(NSAIDs = Nonsteroidal anti-inflammatory drugs, COXIBs = COX-II specific inhibitors)

*** *** 13



peripheral sensitization dorsal horn

central sensitization
peripheral central sensitization

( 1)
1. Numerical rating scale (NRS)
0 1-9
10
2. Verbal rating scale (VRS)
5 0 , 1-3 , 4-6
, 7-9 10
3. Visual analog scale (VAS) 10 0
10 (X)

4. Face pain scale visual pain analogue
5-8

*
0, 2, 4, 6, 8, 10
*
()

*
5.
5.1 The FLACC behavioral pain scale ( 1)
5
(activity) (consolability) 0-2
10
5.2 The CHEOPS behavioral pain scale15 ( 2)
4-13

14 *** ***
 1 The FLACC behavioral pain scale15
Categories Definition Scoring
0
1

2
0
1
2
0
1
2
( ) 0
1
2
0
1

2

2 The CHEOPS behavioral pain scale15

()
1= 0= 0= 1= 1= 1=
2=/ 1= 2=/ 2= //
3= 2= 1= 2= // / //
, // / /
2= +

06.00
10.00
14.00

6.

*** *** 15

(Pharmacological therapy)

1. Paracetamol Acetaminophen Paracetamol
()
paracetamol

Paracetamol descending
serotonergic pathways16 prostaglandins AM404
( COX ) fatty acid amide hydrolase (FAAH)
AM404 TRPV1 receptor ligand CB1 receptor
anadamide ( endogenous canabinoid) endoge-
nous canabinoid
Paracetamol

paracetamol 2
: 500-1,000 . 4-6
4 / 8 ( 500 .)/ 10-20 .
1 . 4-6 3 paracetamol
codeine, NSAIDs tramadol
325 . 500 .
120 125 ./ 5 . 60 ./0.6 .

7

3 paracetamol 17

(.) (.)
0 - 3 40 6 - 8 320
4 - 11 80 9 - 10 400
1 - 2 120 11 480
2 - 3 160 12 - 14 640
4 - 5 240 > 14 650

16 *** ***



2. Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs

NSAIDs
prostaglandins cyclooxygenase

cyclooxygenase 2 isoenzymes cyclooxygenase-1 (COX-1) cyclooxy-
genase-2 (COX-2) COX-1
COX-1 COX-2

NSAIDs COX-1 COX-2
COX-1 COX-2
NSAIDs conventional NSAIDs diclofenac,
aspirin, ibuprofen, ketoprofen, naproxen, mefenamic, piroxicam meloxicam COX-2
specific inhibitors18 celecoxib, valdecoxib, parecoxib, etoricoxib conventional
NSAIDs COX-1 COX-2
COX-2 specific inhibitors
COX-2 COX-1 conventional NSAIDs
COX-2 specific
inhibitors conventional NSAIDs

NSAIDs
NSAIDs
3-7

NSAIDs

*** *** 17




diclofenac, ketoprofen, ketorolac, piroxicam,
tenoxicam parecoxib
NSAIDs


()

NSAIDs


COX-2 specific inhibitors
conventional NSAIDs19
conventional NSAIDs COX-2 specific inhibitors

20

conventional NSAIDs
COX-1
conventional
NSAIDs 21 COX-2 specific inhibitors
thrombosis COX-2 specific inhibitors
22
conventional NSAIDs
aspirin-exacerbated respiratory disease
conventional NSAIDs COX-2 specific inhibitors 23
NSAIDs 2 opioid
opioid opioid 24,25
NSAIDs 2

18 *** ***
 3. Opioids ( 7)
opioid 2 opioid
A. Opioids
A1. Codeine
Codeine opioid 5
1/10 morphine26 10 codeine morphine27
30-120 . 4 26 codeine 60 . paracetamol
600-1,000 . paracetamol 28
codeine 28

A2. Tramadol
Tramadol 2 -opioid receptor
2 serotonin norepinephrine 29,30
tramadol 2 tramadol 1/20-1/5 mor-
phine tramadol 26
26,31 50-100 . 4 26 400 .
200 .
B. Opioids
Opioids morphine, pethidine fentanyl
equianalgesic dose ( 4) opioids

20 morphine 3
morphine ( 10 )
morphine
morphine

4 Equianalgesic doses of opioids5

Opioids (Parenteral)
Morphine 10 mg
Pethidine 100 mg
Fentanyl 100 microgram
Tramadol 100 mg

*** *** 19

opioids
opioids 3
opioids 2, 3 4
B1. Morphine
Morphine opioid morphine
5-20 , 20-60
20-60 morphine 2-4 .
Morphine morphine-3-glucuronide (M3G) morphine-6-glu-
curonide (M6G) M6G morphine morphine

morphine metabolites (M6G) 32
B2. Pethidine
opioid anticholinergic
pethidine 2-2.5 . 2-4 . pethidine meta-
bolite norpethidine
pethidine
32
B3. Fentanyl
opioid 2-3
30-60 fentanyl norfentanyl
( 7) 32
4. Local anesthetics ()
sodium channels
depolarization

spinal epidural
33,34
1.
lignocaine (lidocaine) prilocaine
(prilocaine methemoglobinemia 600 .)
Lidocaine
lidocaine (infusion)
(tachyphylaxis)

20 *** ***
 2.
bupivacaine, levobupivacaine ropivacaine bupivacaine
racemic S-enantiomer R-enantiomer levobupivacaine
ropivacaine S-enantiomer bupivacaine
S-enantiomer R-enantio-
mer racemic
bupivacaine
ventricular fibrillation bupivacaine
sodium channel bupivacaine levobupivacaine
ropivacaine35

1. ester para aminobenzoic acid

2.



1. (topical anesthesia)
EMLA cream (eutectic mixture of local anesthetics)
2.5% lidocaine 2.5% prilocaine
1-2 10 .. 45-60 1-2 .
2-4% lidocaine, 4-10% cocaine

2. (local infiltration)
0.5-1% lidocaine, 0.25% bupivacaine, 0.2-0.5% ropivacaine

3. (peripheral nerve block)

brachial plexus block, intercostal nerve
block, femoral nerve block
1-1.5% lidocaine, 0.25-0.5% bupivacaine 0.5-1% ropivacaine
4. (intravenous regional anesthesia)
spinal epidural epidural analgesia

*** *** 21

5. (Adjuvants)

N-methyl-D-aspartate (NMDA)
receptor antagonists ( ketamine36,37 dextromethorphan37,38), antidepressant, anticonvul-
sant (gabapentin)39, membrane stabilizers (lidocaine), alpha-2 agonists (clonidine dexme-
detomidine)38,40

5
6

22 *** ***
 5 ()
/
Bupivacaine amide, - cardiotoxicity Toxicity: - Infiltration/Epidural: - Infiltration/Epidural:
local infiltration, 2 mg/kg, 4-hourly
epidural block - IV regional 2 mg/kg, 4-hourly - Max dose
spinal anesthesia analgesia - Max dose
duration 200-400 - adrenaline -
0.25-0.5%
Celecoxib NSAIDs - sulfonamide - - PO: 400 mg initially
Cyclooxygenase-II (COX-II) aspirin 200 mg od bid
-
-
-

- CABG/Stent
-
Codeine Opioid - PO: 1 mg/kg, - PO: 30-60 mg, 4-hourly
6-hourly - Max dose 240 mg/day
- Max dose 3 mg/kg/
day

*** ***
Codeine paracetamol paracetamol - paracetamol
15/30 mg + codeine codeine codeine
Paracetamol
300 mg

23
24
5 () ()
/
Diclofenac NSAIDs - aspirin - PO: ( > 1 ) - PO: 25-50 mg, 8-hourly
- 1 mg/kg, 8-hourly - deep IM: 75 mg od
- Max dose 3 mg/kg/ - IV infusion:
- day :
75 mg IV infusion
- bronchospasm 15-30
- 75 mg
2-3
: 25-50
mg IV infusion 15-30
5 mg/hour

- Max dose 150 mg/day

- IV/IM 2
PO
EMLA 2.5% lidocaine + - Methe- 1-2 .
(Eutectic 2.5% prilocaine moglobinemia 1
Mixture of -
Local Anes- mucous mem- G6PD deficiency
thetic) brane

*** ***
 5 () ()
/
Etoricoxib NSAIDs - aspirin - - PO: 60-120 mg od
cyclooxygenase-II (COX-II) - ( 120 mg
-
- 8 )

-

- CABG/Stent
-
Fentanyl Opioid - - IV bolus: - IV bolus:0.001-0.005 mg/
- on venti- kg (up to 0.05 mg/kg)
cardiostability Epidural/spinal: lator : - Epidural: 0.025-0.1 mg
duration 30-60 delayed respiratory muscle rigidity ( saline)
depression 0.0003 - Spinal: 0.005-0.02 mg
mg/kg p.r.n. q 2 hr


0.0003-0.0005 mg/

*** ***
kg p.r.n. q 2 hr
>1
0.0005-
0.001 mg/kg p.r.n.

25
q 2 hr
26
5 () ()
/
Fentanyl on ventilator


- IV Infusion:
on
ventilator :


0.0003 mg/kg/hr

0.0003-

0.0005 mg/kg/hr
>1
0.0005-
0.001 mg/kg/hr
on ventilator

*** ***
 5 () ()
/
Ibuprofen NSAIDs - aspirin - - PO: 6-10 mg/kg tid - PO: 400 mg qid
- 5 mg/kg qid
- (BW >7 kg)
NSAIDs -
- bronchospasm
-
Indometha- NSAIDs - aspirin - - - PO: 50-100 mg bid
cin -
-
-
- bronchospasm
-
Ketamine Phencyclidine derivative - - - -
dissociative - 0.05-0.1 mg/kg/hr
anesthesia - opioid
( )

-

*** ***
-

Levobupiva- Levorotatory (S) enan- bupivacaine - bupivacaine
caine tiomer of bupivacaine bupivacaine bupivacaine Max dose 150 mg,

27
cardiotoxicity Max dose 400 mg/day
CNS toxicity
 5 () ()

28
/
Lidocaine amide, adrenaline Toxicity: - 0.5-2% - 0.5-2%
duration 30-90 preservative - Max dose - Max dose
adrenaline
- 3 mg/kg, 4-hourly - 3 mg/kg, 4-hourly
(with adrenaline: (with adrenaline: 6 mg/
6 mg/kg, 4-hourly) kg, 4-hourly)
Morphine Opioid analgesic 1. epidural/spi- - histamine - PO: 0.3-0.5 mg/kg, - IV: 2-5 mg p.r.n. q 2 hr
nal - 4-hourly - IM/SC: 5-10 mg, 4-hourly
- bronchospasm p.r.n. q 2 hr
- - IV bolus:
2. biliary colic - > 1 : 0.03-
morphine 0.05 mg/kg p.r.n. q
spasm sphincter of 2-4 hr
Oddi pethidine - IV infusion - PO: 10-30 mg, 4-hourly
3. renal colic pain > 1 : 0.01-

morphine 0.03 mg/kg/hr - Epidural: 2-4 mg*

spasm ureter - Spinal: 0.1-0.3 mg*
NSAIDs pethidine (* preservative free)
Naloxone Pure opioid antagonist Duration of action 30 - IV bolus:-0.005-0.01 - IV bolus: 0.1-0.4 mg
opioid mg/kg titrated to desired effect
opioid renarcotisa- - Infusion: 0.005-0.02 - epidural opioid:
tion acute withdrawal mg/kg/hr 0.1 mg bolus + 0.3 mg
epidural opioid - IM in Newborn: 0.2 IV fluid
opioid IM mg
opioid - epidural

*** ***
opioid: 0.005 mg/kg
 5 ()
/
Naproxen NSAIDs - aspirin - - PO: 5 mg/kg bid - PO: 500 mg bid
- (>5 yr)
-
-
- bronchospasm
-
Paracetamol - PO: 10-20 mg/kg, - PO: 0.5-1 g , 4-6 hourly
G-6-PD deficiency 4-6 hourly - Slow IV: 0.5-1 g qid
- PR: loading dose - Max dose 6 gm/day
30-40 mg/kg
(>44 wk post
conception)
Paracetamol paracetamol paracetamol paracetamol
300 mg codeine codeine dose codeine codeine
+ codeine
15 /30 mg
Paracetamol paracetamol paracetamol - paracetamol

*** ***
325 mg + tramadol tramadol tramadol
tramadol
37.5 mg

29
 5 () ()

30
/
Parecoxib - Pro-drug valdecoxib - sulfonamide - - - IV/IM: 40 mg, then
NSAIDs aspirin 20-40 mg, 12-hourly
Cyclooxygenase- - CABG/Stent - Max dose 80 mg/day
II (COX-II) -
-
-
-
- -
3 -
Pethidine Opioid - - IV/IM/SC: - IV: 20-50 mg p.r.n.
1. - Max dose 1g/day (20 mg/ - 0.5-1 mg/kg q 2 hr
2. kg/day) - - Infusion: : 10-25 mg
3. Biliary colic MAOI 5 mg/kg in 50 ml - IM/SC: 25-100 mg,

4. Renal colic NSS 3-hourly p.r.n. q 2

rate 1-3 ml/hr hr
(0.1-0.3 mg/kg/hr)


Piroxicam NSAID - aspirin - - PO: 10-30 mg od
-
-
-

*** ***
- porphyria bronchospasm

 5 () ()
/
Tenoxicam NSAIDs - aspirin - PO: 20 mg od
-
-
-
- bronchospasm
-
Tramadol - Opioid - naloxone - PO: 1-2 mg/kg, - PO: 50-100 mg, 4-hourly
30% 6-hourly - Slow IV/IM: 50-100 mg
euphoria - epilepsy 4-hourly
opioid - - Max dose 400 mg/day
- MAOI
opioid non-opioid
Tramadol paracetamol paracetamol - paracetamol
37.5 mg + tramadol tramadol tramadol
paracetamol
325 mg
:

*** ***
od = once daily, bid = twice daily, tid = three times daily, qid = four times daily
Max = maximum, MAOI = monoamine oxidase inhibitors, NSS = normal saline
PO = per oral, PR = per rectal, SC = subcutaneous, SL = sublingual, IM = intramuscular, IV = intravenous
PR

31
 6 5

32
Non-pharmacological

therapy
A: Psychological Procedural information Combined sensory-procedural information
therapy (Sensory-proce-
1. dural informa-
(Provision of Sensory information tion)
information)

procedural sensory

2.

(Relaxation
and Attention
Strategies)

Attention techniques

*** ***

 6 5 ()
Non-pharmacological

therapy
3.
(Hypnosis)









4.

(coping skills)
(Cognitive-
Behavioral therapy)
,

*** ***

33

34
6 5 ()
Non-pharmacological

therapy
B: Physical therapy -
1. -
(Applications of
heat and cold)




physical modalities

2.
(Manual
and massage (chiropractic)
therapy)

*** ***
 6 5 ()
Non-pharmacological

therapy
3. Transcutaneous TENS noninvasive TENS
electrical nerve (amplitude) 15 mA
stimulation (TENS)
TENS TENS (frequency) 50 Hz
100 Hz
TENS PCA morphine
neu- morphine
ropathic pain PCA morphine
TENS

TENS 3 TENS


4.
(Acupuncture)

*** ***

35


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(Evidence-based resources)
1. Bandolier evidence based thinking about health care. Available from http://www.medicine.ox.ac.uk/bandolier/booth/
painpag/acute.html
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Evidence. 2nd ed. Melbourne: Australian and New Zealand College of Anaesthetists, Available from http://www.anzca.edu.au/
publications/acutepain.htm.
3. Institute for clinical systems improvement 6th edition; Available from http://www.icsi.org/pain_acute/
pain__acute__assessment_and_management_of__3.html
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therapy. Available from http://www.postoppain.org/frameset.htm
5. European society of regional anaesthesia and pain therapy. www.anaesthesia-az.com

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ACUTEPAIN

Thai Association for the Study of Pain

ISBN: 978-974-8285-72-6