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PAIN & ITS MANAGEMENT

Based On Anaesthetic House Officer


Training Module

Kementerian Kesihatan
Malaysia
Edited by Dr Alif Ramli

Those who do not feel pain


seldom think that it is felt.
Dr. Samuel Johnson
(1709-1784)

DEFINITION OF PAIN
An unpleasant sensory and emotional experience
associated with actual and potential tissue
damage or described in terms of such damage

IASP Subcommitee on Taxonomy.


Pain 1980; 8:249-252

DEFINITION OF PAIN

Pain is what the patient says,


hurts

NOCICEPTORS
1.

2.

A-delta fibers
myelinated
2-30 m/sec
(1st pain)
C-fibers
unmyelinated
<2 m/sec
(2nd pain)

THE PAIN PATHWAY


FIRST ORDER NEURONS
ORDER NEURONS

SECOND

ASCENDING PAIN PATHWAY (ACUTE


PAIN)
Cerebral cortex

Sensory Cortex

3rd Order

Thalamus

Spinothalamic

Midbrain

Spinomesencephalic

Pons

Medulla

Spinoreticular
2nd Order

Dorsal Root

Nociceptors

1st Order

PAI
N

PAIN PATHWAY

Sensory
cortex
Thalamu
s

PAG / RAS
Descendin
g
inhibitory
fibres

Ascending ST
tracts

Free nerve
endings

Spinal cord

Afferent nerve ( A /
c)
5th Vital Sign: Doctors training module: Pain Physiology

Dorsal
horn

EFFECTS OF PAIN
I. Physiological
- Cardiovascular System
- Respiratory system
- Gastrointestinal system
- Genitourinary system
- Central Nervous System
- Endocrine system
II. Psychological
III. Economic

CARDIOVASCULAR SYSTEM
Increased Heart Rate
Increased Blood Pressure
increased myocardial work load
myocardial oxygen consumption
increased risk of myocardial ischaemia

5th Vital Sign: Doctors training module: Pain Physiology

RESPIRATORY SYSTEM
Inhibition of normal respiration (unable to
take deep breaths)
Atelectasis
Hypoxia

Inability to cough
Retention

of secretions
Increased risk of lung infection / pneumonia

5th Vital Sign: Doctors training module: Pain Physiology

GASTROINTESTINAL SYSTEM
Increased sympathetic and reduced
parasympathetic activity
Reduced smooth muscle + sphincter tone
Reduced gut motility
Ileus, nausea + vomiting
Impedes early feeding

5th Vital Sign: Doctors training module: Pain Physiology

GENITOURINARY SYSTEM

Increased sympathetic and reduced


parasympathetic tone
reduced smooth muscle + sphincter tone
urinary retention

5th Vital Sign: Doctors training module: Pain Physiology

MUSCULOSKELETAL SYSTEM

Prevent mobilisation & increases muscle tone

Increased risk of deep vein


thrombosis

5th Vital Sign: Doctors training module: Pain Physiology

CENTRAL NERVOUS
SYSTEM

sympathetic activity

parasympathetic activity
Hyperalgesia

scarring of pain pathways

Increased risk of developing


chronic pain

5th Vital Sign: Doctors training module: Pain Physiology

ENDOCRINE SYSTEM
Stimulation of stress response

Increased sympathoadrenal activation


Metabolic response to stress
Hyperglycemia
Catabolic state

Immunosuppression

risk of infection

5th Vital Sign: Doctors training module: Pain Physiology

PSYCHOLOGICAL
Anxiety
Agitation
poor sleep
uncooperative patient

5th Vital Sign: Doctors training module: Pain Physiology

ECONOMIC

Delayed ambulation and feeding


Increased postoperative complications
Delayed recovery
Prolonged hospital stay
Increased cost

5th Vital Sign: Doctors training module: Pain Physiology

SPECTRUM OF PAIN
ACUTE
PAIN

Healing

NO PAIN

Insidious onset

CHRONIC
PAIN

ACUTE
PAIN

post-surgical syndromes /
cancer

5th Vital Sign: Doctors training module: Pain Physiology

CHRONIC
PAIN

ACUTE VS CHRONIC PAIN


Acute Pain

Chronic Pain

Onset and
timing

Sudden onset, short duration.


Resolves/disappears when
tissues heal.

Onset may be insiduous.


Pain persists despite tissue
healing.

Signal

A warning sign of actual or


potential tissue damage

Not a warning signal of


damage : a false alarm

Severity

Severity is correlates with


amount of damage.

Severity not correlated with


damage.Good days and
Bad days.

CNS
involvement

CNS intact acute pain is a


symptom

CNS may be dysfunctional


chronic pain is a disease

Psychological
effects

Less, but unrelieved pain


anxiety & sleeplessness (which
improves when pain is relieved)

Often associated with


depression, anger, fear,
social withdrawal, etc

Common
causes /
examples

Surgery, fracture, burns,


myocardial infarct, labour and
childbirth, inflammatory
conditions e.g. abscess

Chronic headache, back


pain, chronic pelvic / abd
pain, cancer pain,
neuropathic pain PHN,
DPN, post stroke pain, etc

5th Vital Sign: Doctors training module: Pain Physiology

ASSESSMENT OF PAIN

Pain is both a physical and a

psychological phenomenon
The

pain experience is subjective

Meaningful

evaluation and successful


treatment of a patient with pain
requires quantification of the patients
pain

PAIN AS THE 5TH VITAL SIGN


GUIDELINES FOR DOCTORS
(MANAGEMENT OF ADULT PATIENTS)

PAIN AS THE 5TH VITAL SIGN


GUIDELINES FOR DOCTORS
(MANAGEMENT OF PAEDIATRIC PATIENTS)

HOW TO ASSESS
PAIN:

P : Place or site of pain

A : Aggravating factors

What makes the pain worse?

I : Intensity

Where does it hurt?


(a body chart might help describe their
pain)

How bad is the pain?

N : Nature and neutralizing factors

What does it feel like What makes the


pain better?

5th Vital Sign: Doctors training module: Pain

Guideline 1
Pain Assessment Guide: Taking a Brief Pain
History
TELL ME ABOUT YOUR PAIN
P Place
A Aggravatin
g factors
I Intensity

N Nature
Neutralizin
g factors

Where is your pain?


What makes the pain worse?
If 0 is no pain and 10 is the worst pain
imaginable: What is your pain score now?
What is the worst level of pain (score) you
experience in a day?
What is the least pain (score) you experience
in a day?
Describe your pain e.g. aching, throbbing,
burning, shooting, stabbing, sharp, dull, deep,
pressure, etc
What makes the pain better?

PAIN MEASUREMENT TOOLS :


ADULTS
Combined NRS/ VAS Scale

Combined NRS/ VAS Scale (KKM)

NRS/

NRS : Numerical Rating Scale


VAS : Visual Analog Scale

PAIN MEASUREMENT TOOLS :


PAEDIATRICS

FLACC Scale

Wong-Baker Faces
Scale

WHICH TOOL TO USE


TO MEASURE PAIN?

Use the standard tool for pain assessment as


recommended by Ministry of Health, Malaysia
adult

patients : combined NRS / VAS scale


paediatric patients 1 month to 3 years old :
FLACC
paediatric patients > 3-7 years : Wong-Baker
FACES scale
paediatric patients >7 years : combined
NRS/VAS scale (same as for adults)

*Always use the same tool for the same patient


5th Vital Sign: Doctors training module: Pain

FLOW CHART : PAIN AS THE 5TH


VITAL SIGN (NURSES)

FLOW CHART FOR PAIN


MANAGEMENT IN ADULT
PATIENT: (DOCTORS)

ANALGESICS

Non Opioids

Paracetamol
NSAIDS
COX

Opioids

Weak

Strong

2 inhibitors

31

5th Vital Sign: Doctors training module: Pharmacology

Formulations And Dosage Of Commonly Used


Analgesics

Guideline 4
Drugs in Acute Pain Management: The Analgesic Ladder
Analgesic Ladder for Acute
Pain Management

SEVERE
7-10

MODERATE
4-6

MILD
0-3
Regular
No
medicati
on or
PCM
1gm
6hrly

PRN
PCM
&/or
NSAID /
COX2
inhibitor

Regular
Weak
Opioid
PCM 1gm
QID oral
NSAID /
COX2
inhibitor

PRN
Additional
weak
opioid

Regular
Higher dose
of weak
opioid
Or
IV/SC
Morphine 510mg 4 hrly
OR
Aqueous
morphine
10-20 mg
PCM 1gm
QID oral /
rectal
NSAID /
COX2
inhibitor

PRN
IV/SC
Morphine
5-10mg
OR
Aqueous
morphine
*Oral or
SC
Morphine
may be
safely
given at
hourly
intervals

UNCONTROLLED

To refer to APS
for:
PCA or Epidural
or other form of
analgesia

POST OPERATIVE PAIN


MANAGEMENT
1.Conventional Methods

i. Oral Analgesics Opioids


NSAIDS
ii. IV Injections Opioids
NSAIDS
2. Common Methods

i. Patient Controlled Analgesia


(PCA)
ii. Epidural Analgesia
iii. Patient Controlled Epidural
Analgesia (PCEA)
iv. Subcutaneous Morphine

3. Other Methods
i. Nerve & Nerve Plexus
Blocks
ii. Transcutaneous
Electrical
Nerve Stimulation
(TENS)
iii. Rectal NSAIDS
4. Multi-modal
Concepts

PATIENT CONTROLLED ANALGESIA


(PCA)
Method of analgesic
delivery : computerised
syringe pump is set to
deliver bolus doses
whenever patient presses
button (patient demand)
Allows small amounts of
analgesic to be given at
frequent intervals
Patient titrates according
to individual needs

DILUTION OF PCA DRUGS


Morphine:
Adults: 5 amp (50 mg) = 5 mls
Dilute with N/S 45 mls
Concentration : 1mg/ml (50mls)
Paeds: 0.5mg/kg of morphine and make
upto 50mls with N/S.
Concentration: 1ml = 10mcg/kg

RECOMMENDED SETTINGS
(EXAMPLE )
Drug

concentration: morphine 1mg/ml

Mode:

PCA

Loading
Bolus

dose:

Lockout
4

dose: usually zero for post


operative patients
<60 years morphine 1mg
>60 years morphine 0.5mg

interval :5 minutes

hour limit : usually not set

EPIDURAL ANALGESIA

Introduction of
analgesic drugs into
epidural space via an
indwelling catheter

EPIDURAL ANALGESIA :
DRUGS USED

LOCAL ANAESTHETICS ALONE

- BUPIVACAINE

OPIODS ALONE

- FENTANYL
- MORPHINE

MIXTURES (COCKTAIL)
- FENTANYL + BUPIVACAINE