ACUTE PAIN

MANAGMENT
MODERATOR: DR SANJAY BANAKAL
SPEAKER: DR TAHIR

INTRODUCTION

• The relief of pain has been one of the

primary reasons for development of health care
• Pain derived from Latin word Poena means
punishment
• John J. Bonica (Father of Pain Medicine)

DEFINITION OF PAIN

• The International Association for the Study of

Pain defines pain as:
• “An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage”.

CLASSIFICATION OF PAIN
•Nociceptive
• Somatic
• Visceral
•Neuropathic
•Complex Regional Pain Syndromes

PHYSIOLOGY

NERVE FBERS
Afibres

Afibres

C fibres

Diameter

Large

Small 2-5m

Smallest <2m

Myelination

Highly

Thinly

Unmyelinated

Conduction
velocity

> 40 ms-1

5-15ms-1

< 2ms-1

Receptor
activation
thresholds

Low

High and low

High

Sensation on
stimulation

Light touch,
non-noxious

Rapid, sharp,
localised pain

Slow, diffuse,
dull pain

• The nociceptive pathway is an afferent

three-neuron dual ascending (example:
anterolateral and dorsal column medial
lemniscal pathways) system, with
descending modulation from the cortex,
thalamus and brainstem.
• The four elements of pain processing
include: (1) transduction, (2) transmission,
(3) modulation and (4) perception

TRANSDUCTION &
TRANSMISSION

Transduction is the event whereby noxious thermal
mechanical stimuli are converted into an action pote

Transmission occurs when the action potential is conduc
through the nervous system via the first-, second-, and thi
order neurons, which have cell bodies located in the dorsa
root ganglion, dorsal horn and thalamus, respectively.

MODULATION

Altering afferent neural transmission along the pain pa

nhibition or Augmentation of pain signal

Dorsal horn most common site

• Inhibitory Spinal Modulation
• Release of inhibitory neurotransmitters (GABA and
glycine )

• Endogenous pain suppression pathway
• Augmentory Spinal Modulation

central sensitization, which is a consequence of neuronal plasti

• Perception of pain is the final

common pathway, which results from the
integration of painful input into the
somatosensory and limbic cortices.
Generally speaking, traditional analgesic
therapies have only targeted pain
perception.
• A multimodal approach to pain therapy
should target all four elements of the
pain processing pathway.

ACUTE EFFECTS OF POSTOPERATIVE PAIN

nociceptive stimuli from the periphery to the CNS results
in the neuroendocrine stress response
involve hypothalamic-pituitary-adrenocortical and
sympathoadrenal interactions

-The increased secretion of the
catabolic hormones; cortisol, glucagon, growth hormo
and catecholamines
Decreased secretion of the
anabolic hormones; insulin and testosterone
Result in hyperglycemia and a negative nitrogen balance
the consequences of which include poor wound healing,
Muscle wasting, fatigue and impaired immunocompetenc
The sympathoadrenal response has detrimental effects
numerous organ systems

Cardiovascul Tachycardia, hypertension and increase in cardiac
ar
work load,MI
Respiratory muscle spasm [splinting], decrease in
vital capacity, atelectasis, hypoxia and risk of
Pulmonary pulmonary function
Gastrointesti
nal
Postoperative ileus
Renal
Increased risk of oliguria an urinary retention
 
 
Hypercoagulability, Increased risk of
Coagulation thromboemboli
 
 
Immunologic Impaired immune function
Muscle weakness and fatigue. Limited mobility
Muscular
can increase the risk of thromboembolism
Psychologica Anxiety, fear and frustration results in poor

Chronic Effects

• Presence of postop pain >3month
• common in - limb amputation, thoracotomy,
sternotomy, breast surgery, and gallbladder surgery
• Poorly controlled acute postoperative pain is an
important predictive factor in the development of CP

Pain the fifth vital sign
Number of scales developed

Numerical Rating Scale

Visual Analog Scale

Verbal Descriptor Scale

Wong Baker Facial Grimace Scale

FLACC scale

Numeric Rating Scale (NRS): Here patients are asked to indica
how strong their pain is on a scale from 0 to 10 on which “0”
represents "no pain at all" and 10 "the worst pain imaginable".

Visual Analogue Scale (VAS): The VAS consists of 10 cm horizo
or vertical line with the two ends labelled as “no pain” and “worst
pain ever”. Patient will be required to mark the 10 cm line at a po
that corresponds to the level of pain intensity he or she feels-

Verbal Descriptor Scales: Melzack and Torgerson introduced t
following scale for pain intensity “Mild, Discomforting, Distressin
Horrible, Excruciating."

Wong-Baker Faces Pain Rating Scale
Explain to the child that each face is for a person who fee
Face
Face
Face
Face
Face
Face

0 is very happy because he doesn't hurt at all
2 hurts just a little bit.
4 hurts a little more.
6 hurts even more.
8 hurts a lot.
10 hurts as much as you can imagine

FLACC SCALE University of Michigan Health System
Face

0
No particular
expression or smile

1 Occasional
grimace or frown,
withdrawn,
disinterested

2
Frequent to constant frown,
clenched jaw, quivering chin

Legs

0 Normal position or
relaxed

1 Uneasy,
restless, tense

2 Kicking, or legs drawn up

Activity

0
Lying quietly, normal
position, moves easily

1 Squirming,
shifting back and
forth, tense

2 Arched, rigid, or jerking

0
No cry (awake or
asleep)

1
Moans or
whimpers,
occasional
complaints

2
Crying steadily, screams or
sobs, frequent complaints

Cry

Consolabili
0 Content, relaxed
ty

1 Reassured by
occasional
2
touching, hugging Difficult to console or
or “talking to”.
comfort
Distractable

TREATMENT

PREVENTIVE ANALGESIA (preemptive)

• based on the inhibition of the development of central sensitizat

• an analgesic intervention that preceded a surgical injury and w
more effective in relieving acute postoperative pain than the s
treatment following surgery.
• When the block of nociceptive affrents diminishes, the surgical
injury is able to reinitiate central sensitization.
• Maximal clinical benefit is observed when complete multisegme
blockade of noxious stimuli occurs, with extension of this effec
the postoperative period.

“ MULTIMODAL ANALGESIA”
Combination of 2 or more analgesic techniques
1. Systemic Analgesic Techniques
2. Regional Analgesic Techniques
3. Non Pharmacological Measures
Aim :improve analgesia and decrease side
effects

SYSTEMIC ANALGESIA

ROUTES OF DRUG
ADMINISTRATION

• Intravenous – most preferred route
• Intramuscular
• Oral
• Subcutaneous
• Per Rectal
• Transdermal / Transmucosal

Drugs

NSAIDs

Opioids

Gabapentin/ Pregabalin

NMDA antagonists

Alpha-2 agonist

Antiepileptics/ Antidepressants

OPIODS
• Opioid analgesics are one of the cornerstone
options for the treatment of postoperative pain
• They generally exert their analgesic effects
through μ-receptors in the CNS, although
opioids may also act at peripheral opioid
receptors.
• Theoretical - No analgesic ceiling

ADVANTAGES
• Standard for treatment of moderate to severe
postoperative pain

• Acts at multiple sites
• Can be administered via multiple routes
• Reduction in anesthetic requirements and part
of balanced anesthesia

ADVERSE EFFECTS

Nausea / Vomiting

Dependence

Sedation

Addiction


Respiratory Depression
Pruritus

Constipation

Urinary Retention

Ileus

Tolerance

MORPHINE
• Hydrophilic phenantherene
derivative
• Delayed onset of action due
to hydrophilic nature.
• Metabolites: Morphine-3glucuronide(M3G) and
Morphine-6-glucuronide.
• Metabolism: Liver and renal,
extrahepatic( gastric and
intestinal mucosa)

DOSAGE
• Intravenous: 0.05—
0.2 mg/kg
• Infusion: 10--200
mcg/kg/hr
• IM/SC : 0.05—0.2
mg/kg
• Induction: 1mg/ kg
• Spinal: 4—20 mcg/kg
• Epidural
• Bolus: 40– 100
mcg/kg

• PCA
• MORPHINE IV(1mg/ml)
• Adult
• BOLUS : 10—60 mcg/kg
• INFUSION : 15—200 mcg/
kg/ hr
• LOCKOUT : 5—10min

• Pediatric
• BOLUS : 10--30
mcg/kg/hr(max
150mcg/kg/hr)
• INFUSION : 10--30mcg/ kg/

MORPHINE--Considerations
• Reduce dose in elderly, hypovolemic and
high risk patients
• Antagonised with Naloxone IV/IM/SC--0.2 to
0.4 mg, Infusion 5 to 10 mcg/kg/hr)
• Morphine crosses the placental barrier.
• Incidence of reactivation of herpes simplex
have occurred with epidural or spinal
morphine.

FENTANYL
• Highly lipophilic, phenylperidine derivative.
• High affinity for mu receptors
• 75-125 times more potent than morphine.
• Transdermal patches


Cancer pain
Alternative for patients with GI issues.
Fewer side effects.

• Transmucosal oralets

FENTANYL--Dosage
• IV/IM: 0.7—2 mcg/kg

 PCA
▪ FENTANYLIV(10mg/ml)
• Infusion: 0.3--3 mcg/kg/hr • Adult

• Oral transmucosal:
5mcg/kg

• Induction: 5--40mcg/ kg
• Spinal: 0.1—0.4 mcg/kg
• Epidural

Bolus: 1– 2 mcg/kg
Infusion: 2—0.7mcg/kg/hr

▪ BOLUS : 0.3—1.5 mcg/kg
▪ INFUSION : 0.3—2 mcg/ kg/ hr
▪ LOCKOUT : 4—10 min

• Pediatric
• BOLUS : 0.5-1mcg/kg(max
4mcg/kg/hr)
• INFUSION : 0.5--1mcg/ kg/ hr
• LOCKOUT : 5--10 min

FENTANYL--Dosage

• IV regiona lblock : 1 mcg/ kg (Max: 50 mcg)
1 --added to local anaesthetic

• Brachial Plexus block:

1—2mcg/ kg

• Trandermal
• Intial: 25—50 mcg/hr
• Maintanence: 25 to 100 mcg/hr

FENTANYL-- Consideration
• Reduce dose in elderly, hypovolemic and high risk
patient with concomitant use of sedatives.

• Crosses placental barrier and cause sedation and
respiratory depression in neonate.

• Side effects of epidural, caudal or intrathecal
• Delayed respiratory depression(Naloxone
IV/IM/SC-0.2 to 0.4 mg, Infusion 5 to 10 mcg/kg/hr)
• Prurits (Diphenhydramine IV/IM 12.5 to 25mg
Q6H)
• Nausea and vominting (Metoclopramide 10mg
slow IV Q6H)
• Urinary retention( Catheterization)

MEPERIDINE / PETHIDINE
• Phenylpiperidine synthetic opioid agonist
• Local anesthetic and atropine like action
• Well absorbed from GIT
• Preferable for pain control in diverticulitis,
as it decreases intestinal intraluminal
pressure

• Normeperidine - serotonin syndrome,
seizures, delirium, dysphoria, tremor

• Negative inotropic effects and orthostatic
hypotension

OPIOD—SIDE EFFECTS

TRAMADOL

• Classified as weak synthetic opioid with mild
serotonin and nor epinephrine reuptake
inhibition.
• MOA
• Weak mu opioid receptor agonist
• Local anaesthetic effect
• Anti-inflammatory effect
• Reduction in substance P in synovial fluid
• Site : Peri aqueductal gray matter in
midbrain

Formulations
 Sustained release(SR)– Q12H –
(50,100,150,200)
 Extended Release (ER)—Q24H—
100,200,300
 S/c, IV, IM, Intra spinal
Uses
 Osteoarthritis, post amputation
phantom limb
 Post operative pain
 Cancer related pain
 Side effects reduced with combination

IV DOSAGE OF COMMON OPIOIDS AND
PRECAUTIONS
DRUG
DOSAGE
PRECAUTION
S
MORPHINE
FENTANYL

0.01-0.2
mg/kg
1-5 μgm/kg

TRAMADOL

0.5-1 mg/kg

PETHIDINE

0.1-1 mg/kg

PENTAZOCINE

30-40 mg

Careful in
renal failure
Prolonged
infusions
careful of
delayed
elimination
Seizure
nausea
CNS
stimulation
Increase in

Drug

Intrathecal or
Epidural Continuous
Subarachnoid Single Epidural Single Dose
Infusion
Dose

Fentanyl

5-25 µg

50-100 µg

25-100 µg/hr

Sufentanil

2-10 µg

10-50 µg

10-20 µg/hr

Alfentanil

0.5-1 mg

0.2 mg/hr

Morphine

0.1-0.3 mg

1-5 mg

0.1-1 mg/hr

Diamorphine

1-2 mg

4-6 mg

Hydromorphone

0.5-1 mg

0.1-0.2 mg/hr

Meperidine

10-30 mg

20-60 mg

10-60 mg/hr

Methadone

4-8 mg

0.3-0.5 mg/hr

Extended-release
morphine

Not recommended

5-15 mg

Not recommended

NONSTEROIDAL ANTI-INFLAMMATORY AGENT

Analgesia has “ceiling effect”(Higher doses do not provide any
additional pain relief)

Block cyclooxygenase (COX) enzyme → ↓ prostaglandin synt
COX-2 → Prostaglandins → pain, inflammation, fever
COX-1 → Prostaglandins → gastric protection, hemostasis

CLASSIFICATION
Non Specific Inhibitors (Various chemical
classes)
• Diclofenac
• Acetaminophen
• Ibuprofen
• Naproxen
• Aspirin
• Ketorolac
COX 2 specific Inhibitors
• Celecoxib
• Rofecoxib
• Valdecoxib
• Parecoxib

ADVANTAGES
• Effective for mild to moderate pain
• Useful adjuncts to opioids for moderate to severe pain
• Helps to reduce peripheral sensitization-Pre emptive
analgesia

• Reduces opioid consumption

ADVERSE EFFECTS

Renal dysfunction

GI ulceration

Bleeding disorders / Coagulopathy

High cardiac risk – COXII inhibitors

Asthma and Allergy (avoid celecoxib in
sulpha allergy)

Deleterious effects on bone healing
and osteogenesis

ACETAMINOPHEN
 Analgesic and antipyretic properties
 Devoid of anti inflammatory properties
Centrally acting inhibitor of COX enzyme (COX
II>COXI) and other central actions

 Oral/Rectal/Intravenous
 IV dosage 15-30mg/kg Q4H/Q6H
 Warning : Hepatic Impairment

Celecoxib, rofecoxib, valdecoxib
ADVANTAGES
▪ Less gastric mucosal

damage
▪ No platelet effects
▪ Long acting- 12-18 hours
▪ IV preparation available

• Therapeutic anticoagulation &
coagulopathy
• Renal failure & renal transplantation
• Hepatic Failure
• Coagulopathy
• Reduced platelet function
• GI ulceration or bleeding
• Pre- eclampsia, eclampsia & uncontrolled
HTN

OTHER ANALGESIC
DRUGS
• NMDA Antagonists•

Ketamine

Dextromethorphan

• Alpha 2 adrenergic agonists•

Clonidine,

Dexmedetomidine

• Gabapentinoids
Gabapentin
• Pregabalin

• Anticonvulsants
• Lignocaine and Glucocorticoids
• Capsaicin
• Tapentadol

KETAMINE
• Low dose ketamine
• 0.2-0.8 mg/kg IV
• Actions NMDA antagonistic properties
μ opiod agonistic activity

• rescue analgesic need & pain intensity
• Does not appear to cause hallucinations &
cognitive impairment

• attenuates central sensitization & opioid
tolerance

TAPENTADOL
• Moderate to severe pain
• Centrally acting analgesic
• μ opioid receptor agonistic activity
• Norepinephrine reuptake inhibition

• 50 – 100 mg q4h/ q6h IV
• Side effects incidence less than other
opioids

REGIONAL ANALGESIC TECHNIQUES

• Superior to that with systemic opioids
• Limitation in the presence of various anticoagulants.
• Types
• Single-Dose
• Continuous
• clinical pharmacology for a particular opioid is its degree
of lipophilicity (versus hydrophilicity)
• hydrophilic opioid - longer duration of analgesia
• lipophilic opioid - rapid analgesic onset (minutes) combined
with a moderate duration of action (<4 hours)

DOSING OF NEURAXIAL OPIOIDS*
Drug

Intrathecal or
Subarachnoid
Single Dose

Epidural
Single
Dose

Epidural
Continuou
s Infusion

Fentanyl

5-25 μg

50-100mcg

25-100 μg
/hr

Sufentanil

2-10 μg

10-50mcg

10-20
μg /hr

Alfentanil

----

0.5-1mg

0.2 mg/hr

morphine

0.1-0.3mg

1-5mg

0.1-1
mg/hr

Hydromorphone

-----

0.5-1mg

0.1-0.2
mg/hr

MExtended-release
morphine†

Not
recommended

5-15mg

Not
recommen

PEDIATRIC PATIENTS
Important barriers to pain control

incorrect assumptions

assessment of pain
pain management
• should be discussed with the family and
patient before surgery
• mild to moderate pain -oral route preferred
• moderate to severe -Intravenous or regional
• intramuscular injections is strongly
discouraged

PCA device
• Children as young as 4 years
• morphine is the standard drug
• unable to use intravenous PCA, continuous
infusions or intermittent intravenous
administration of opioids is effective
• Unlike adults, pediatric patients do not appear
to exhibit multiple episodes of clinically
significant oxygen desaturation with opioids

other analgesics

• NSAIDs or acetaminophen
• ketamine and
• tramadol
Along with opiods decrease some opioid-related side
effects such as postoperative nausea and vomiting and
may improve over- all analgesia

Peripheral and neuraxial regional analgesics
techniques are commonly used and effective
Epidural analgesia:
Single dose or by using a continuous-infusion
caudal approach seems to be the most common
Local anesthetics or opioids, or both, can be administered
Adjuvant-may enhance postoperative analgesia

Neonates--dose is probably smaller than that in older chil
relatively immature liver
lower levels of α1-acid glycoprotein

Regional analgesic techniques may be useful in providing
analgesia for wound incision (e.g., herniorrhaphy or
orchiopexy), thoracotomy, and orthopedic procedures.

OBESITY AND OBSTRUCTIVE SLEEP APNEA

obese patients do not necessarily have OSA (5% of morbi
obese patients have OSA )
obesity is the most important physical characteristic asso
with OSA (60% to 90% of OSA patients are obese )
OSA: defined as more than five episodes per hour of cess
of airflow for more than 10 seconds despite continued ve
tory effort
pathophysiology ; to upper airway pharyngeal collapse,
including the retropalatal, retroglossal, and retroepiglottic
pharynx, during sleep, especially during REM sleep

• OSA, morbidly obese subjects (with or without OSA) mo
likely will experience frequent desaturation and may h
risk for respiratory arrest in the postop
• respiratory depression and arrest may be attenuated b
the use of
• NSAIDs
• nonopioid adjuvants (clonidine, ketamine, dexmed
• regional analgesia with a local anesthetic