‫بسم هللا الرحمن الرحيم‬

Lecture Title: Acute Pain Management

Lecturer name: Dr.Salah N EL-Tallawy

Prof. of Anesthesia and Pain Management
 Lecture Objectives..

Students at the end of the lecture will be able to:

1. Learn a common approach to emergency medical problems encountered in the
postoperative period.
2. Study post-operative respiratory and hemodynamic problems and understand how
to manage these problems.
3. Learn about the predisposing factors, differential diagnosis and management of
PONV.
4. Understand the causes and treatments of post-operative agitation and delirium.
5. Learn about the causes of delayed emergence and know how to deal with this
problem.
6. Learn about different approaches of post-Operative pain management
 Postoperative care
-
Post Anesthesia Care Unit

“PACU”
 PACU
• Design should match function

• Location:
– Close to the OR.
– Access to x-ray, blood bank & clinical labs.

• Monitoring equipment

• Emergency equipment

• Personnel
 Admission to PACU

Steps:
• Coordinate prior to arrival,
• Assess airway,
• Administer oxygen,
• Apply monitors,
• Obtain vital signs,
• Receive report from anesthesia personnel.
 PACU - ASA Standards
1. Standard I
All patients should receive appropriate care
2. Standard II
All patients will be accompanied by one of anesthesia team
3. Standard III
The patient will be reevaluated & report given to the nurse
4. Standard IV
The patient shall be continually monitored in the PACU
5. Standard V
A physician will signing for the patient out of the PACU
 Patient Care in the PACU
• Admission
– Apply oxygen and monitor
– Receive report

• Monitor & Observe & Manage

 To Achieve
• Cardiovascular stability
• Respiratory stability
• Pain control

• Discharge from PACU

 Monitoring in the PACU
• Baseline vital signs.
• Respiration
– RR/min, Rythm
– Pulse oximetry
• Circulation
– PR/min & Blood pressure
– ECG
• Level of consciousness
• Pain scores
 Initial Assessment

1. Color

2. Respiration

3. Circulation

4. Consciousness

5. Activity
 Aldrete Score

Score Activity Respiration Circulation Consciousness Oxygen

Saturation

Breaths BP + 20 mm
Moves all deeply and of Fully awake Spo2 > 92%
2 extremities coughs preanesth.
on room air
level
freely.
Dyspneic, or BP + 20-50
Moves 2 shallow mm of Arousable on Spo2 >90%
1 extremities breathing preanesth. calling With suppl. O2
level

BP + 50
Unable to Apneic mm of Not responding Spo2 <92%
0 move
preanesth.
level
With suppl. O2
 Common PACU Problems
• Airway obstruction • Bleeding

• Hypoxemia • Agitation

• Hypoventilation • Delayed recovery

• Hypotension • “PONV”

• Hypertension • Pain

• Cardiac dysrhythmias • Oliguria

• Hypothermia
 1. Airway Obstruction

• Most common: tongue fall back

 posterior pharynx

• May be foreign body

• Inadequate relaxant reversal

• Residual anesthesia
 Management of Airway Obstruction
• Patient’s stimulation,
• Suction,
• Oral Airway,
• Nasal Airway,
• Others:
– Tracheal intubation
– Cricothyroidotomy
– Tracheotomy
 2. Hypoventilation

• Residual anesthesia
– Narcotics

– Inhalation agent

– Muscle Relaxant

• Post oper - Analgesia

– Intravenous

– Epidural
 Treatment of Hypoventilation

• Close observation,

• Assess the problem,

• Treatment of the cause:

– Reverse (or Antidote):
• Muscle relaxant  Neostigmine

• Opioids  Naloxone

• Midazolam  Anexate
 3. Hypertension

• Common causes: e.g.

– Pain
– Full Bladder

• Hypertensive patients

• Fluid overload

• Excessive use of vasopressors

 Treatment of Hypertension

• Effective pain control

• Sedation

• Anti-hypertensives:
– Beta blockers
– Alpha blockers
– Hydralazine (Apresoline)
– Calcium channel blockers
 4. Hypotension

• Decreased venous return

– Hypovolemia,
•  fluid intake
•  losses
• Bleeding

– Sympathectomy,

– 3rd space loss,

– Left ventricular dysfunction

 Treatment of Hypotension

• Initially treat with fluid bolus,

• + Vasopressors,

• + Correction of the cause

 5. Dysrhythmias
• Secondary to
– Hypoxemia

– Hypercarbia

– Hypothermia

– Acidosis

– Catecholamines

– Electrolyte abnormalities.
 Treatment of Dysrhythmia

• Identify and treat the cause,

• Assure oxygenation,

• Pharmacological
 6. Urine Output
• Oliguria
– Hypovolemia,
– Surgical trauma,
– Impaired renal function,
– Mechanical blocking of catheter.

• Treatment:
– Assess catheter patency
– Fluid bolus
– Diuretics e.g. Lasix
 7. Post op Bleeding
Causes:
• Usually Surgical
Problem,

• Coagulopathy,

• Drug induced
 Treatment of Post op Bleeding

Treatment:
• Start i.v. lines  push fluids
• Blood sample,
- CBC,
- Cross matching,
- Coagulopathy

• Notify the surgeon,

• Correction of the cause
 8. Hypothermia
• Most of patients will arrive cold

• Treatment:
– Get baseline temperature

– Actively rewarm

– Administer oxygen if shivering

– Take care for:

• Pediatric,
• Geriatric.
 9. Altered Mental Status

• Reaction to drugs?
– Drugs e.g. sedatives, anticholinergics
– Intoxication / Drug abusers
• Pain
• Full bladder
• Hypoventilation
• Low COP
• CVA
 Treatment of Altered Mental Status

• Reassurances,

• Always protect the patient,

• Evaluate the cause,

• Treatment of symptoms,

• Sedatives / Opioids if necessary.

 10. Delayed Recovery

• Systematic evaluation
– Pre-op status

– Intraoperative events

– Ventilation

– Response to Stimulation

– Cardiovascular status
 Delayed Recovery

• The most common cause:

– Residual anesthesia  Consider reversal

• Hypothermia,

• Metabolic e.g. diabetic coma,

• Underlying psychiatric problem

• CVA
 11. Postoperative Nausea & Vomiting
“PONV”
• Risk factors
– Type & duration of surgery,

– Type of anesthesia,

– Drugs,

– Hormone levels,

– Medical problems,

– Autonomic involvement.
 Prevention of PONV

• NPO status

• Dexamothasone,

• Droperidol,

• Metoclopramide,

• H2 blockers,

• Ondansetron,

• Acupuncture
 12. Postoperative Pain
 Causes:
 Incisional Skin and subcutaneous tissue
 Laparoscopy Insuflation of Co2
 Others:
 Deep cutting, coagulation, trauma
 Positional nerve compression, traction & bed sore.
 IV site needle trauma, extravasation, venous irritation
 Tubes drains, nasogastric tube, ETT
 Surgical complication of surgery
 Others cast, dressing too tight, urinary retention
 PAIN MEASUREMENTS

Subjective Objective

Uni-Dimensional Multidimentional  Behavioral.

 VRS, VAS & NRS.  McGill P Q,  Physiological.

 Pain Inventory.  Neuro-endocrinal.

 Facial expression.

 Algometry.

 ACUTE PAIN  Chronic Pain  Both

 Pain Scores

Visual Analogue Scale (VAS)

0 10

Numeric Rating Scale (NRS)

 Verbal scale

No Severe
Mild Moderate
Pain Pain

Wong-Baker “Faces Scale”

 ACUTE POSTOPERATIVE MANAGEMENT TOOLS
Pharmaco - Therapy Regional Techniques
1. Non Opioid Analgesics 1. Local infiltration
 NSAADs 2. Wound perfusion
 Analgesic /Antipyretic
 Analgesic/Anti-inflam/Antipyretic 3. Intra-abdominal inj. of LA/Analg.
 NSAIDs
 Non-selective COX inhibitors 4. Intercostal & Interpleural
 Selective COX-2 inhibitors
5. Paravertebral
2. Opioids
 Weak Opioids. 6. USG-RA: e.g. TAP
 Strong Opioids.
 Mixed agonist-antagonists 7. Neuraxial:
3. Adjuvants  Epidural:
 -2 Agonists  Thoracic
 LA
 SP inhibitors  Lumbar
 NMDA inhibitors  Spinal
 Anticonvulsant / Antidepressants
 Calcitonin  Single shot
 Relaxants  CSA
 Cannabinoids
 Others  CSE
 WHO IV Interventional
WHO Ladder
Updated Severe pain (7-10)

WHO III Strong opioids

± Adjuvant

Moderate pain (4-6)

WHO class II Weak opioids

± Adjuvant

Mild pain (0-3) By the mouth

WHO class I NSAIDs By the clock

± Adjuvant By the ladder

1. Non Opioid Analgesics
 NSAADs
 Analgesic / Anti-inflam / Antipyretic / Anticoagulant
 ASA
 Analgesic /Antipyretic
 Paracetamol Severe pain (7-10)
WHO III Strong opioids

± Adjuvant

 NSAIDs
Moderate pain (4-6)
 Non-selective COX inhibitors: WHO class II Weak opioids

 Diclofenac & Ketoprofen ± Adjuvant

 Selective COX-2 inhibitors Mild pain (0-3)

 Celecoxib & Rofecoxib WHO class I NSAIDs

± Adjuvant
 Scientific Evidence – NON OPIOID ANALGESICS

1. Paracetamol:
1. is an effective analgesic for acute pain; the incidence of adverse effects comparable to
placebo (Level I [Cochrane Review]).
2. Paracetamol / NSAIDs given in addition to PCA Opioids   Opioid consumption (Level
I).

2. NSAIDs:
1. are effective in the treatment of acute postoperative (Level I ).
2. With careful patient selection and monitoring, the incidence of renal impairment is low
(Level I [Cochrane Review]).

3. NSAIDs + Paracetamol improve analgesia compared with paracetamol alone (Level I).

Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

 WHO Ladder II - Weak Opioids:

1. Tramadol:
– Tramadol : Morphine:
• Parenteral = 1 : 10 & Oral = 1 : 5
• Dose: 200 – 400 mg/d

Severe pain (7-10)

2. Codeine: WHO III Strong opioids

± Adjuvant
– Metabolized to morphine.
– Codeine : Morphine = 1 : 10
Moderate pain (4-6)
WHO class II Weak opioids

3. Dextro-propoxyphene: ± Adjuvant

Mild pain (0-3)

– Methadone Derivative
WHO class I NSAIDs
– Prolongation of Q-T interval.
± Adjuvant
 Scientific Evidence – WEAK OPIOIDS

1. Tramadol:
 has a lower risk of respiratory depression & impairs GIT motor function <
other opioids
(Level II).

 is an effective treatment for neuropathic pain

(Level I [Cochrane Review]).

2. Dextropropoxyphene:
 has low analgesic efficacy
(Level I [Cochrane Review]).

Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

 WHO Ladder III - Strong Opioids
1. Morphine:
1. Sedation
2. PONV
3. Respiratory Depression

2. Fentanyl
1. Rapid action, Short duration.
2. Fentanyl : Mophine = (1:10)
Severe pain (7-10)

3. Pethidene: WHO III Strong opioids

± Adjuvant
1. Active metabolite:  t½ .
2. Prolongs Q-T interval.
Moderate pain (4-6)
3. Pethidine : Mophine = (1:10)
WHO class II Weak opioids

4. Hydromorphone: ± Adjuvant

1. Powerful, rapidly acting. Mild pain (0-3)

2. Release is in distal gut. WHO class I NSAIDs
3. Hydromorphone : Morphine = 1 : 5 ± Adjuvant
 WHO Ladder IV – Regional Anesthetic Techniques
1. Local infiltration
2. Wound perfusion
3. Intra-abdominal LA
4. Intercostal
5. Interpleural
WHO IV Interventional
6. Paravertebral
7. USG - RA: e.g. TAP Severe pain (7-10)

8. Neuraxial: WHO III Strong opioids

± Adjuvant
 Epidural:
 Thoracic Moderate pain (4-6)

 Lumbar WHO class II Weak opioids

 Spinal ± Adjuvant

 Single shot
Mild pain (0-3)
 CSA WHO class I NSAIDs
 CSE ± Adjuvant
 Neuraxial (Spinal / Epidural)
(LA / Opioids / others)

• Advantages:
– Provide prolonged & effective analgesia

• Side effects
– Respiratory depression.
– N/V.
– Pruritis.
– Urinary retention.
 WHO Algorithm for Management of Pain

+ Multidisciplinary: Neuraxial LA
• Adjuvant therapy. Opioids
WHO III Strong opioids
• Psychotherapy.
• Physioltherapy.
• Causal diag. & ttt.
Plexus block
Paravertebral / PNB

WHO class II Weak opioids

Non-pharmacological

LA infiltration
WHO class I NSAIDs
 Management Algorithm for Postoperative Pain

Diagnosis
Procedure Specific Preventive /
Pain manag. Pain Assessment Preemptive

ttt of Pain and Co morbidities

1ry Treatment Supportive Treatment

Pharmacotherapy Psychological ttt.

Interventional Physical / Rehab.

 PACU Discharge Criteria
• Fully Awake,
• Patent airway,
• Good respiratory function,
• Stable vital signs,
• Patency of tubes, catheters, IV’s
• Pain free,
• Reassurance of surgical site.
 Postanesthesia Discharge Scoring System
Vital Signs Activity PONV Pain Surgical
(PR & ABP) Bleeding

2: Within 20% 2: Steady gait, 2: Minimal: treat 2: Acceptable 2: Minimal: no

of preoperative no dizziness with PO meds control per the dressing
baseline patient; changes
controlled with required
PO meds
1: 20-40% of 1: Requires 1: Moderate: 1: Not 1: Moderate:
preoperative assistance treat with IM acceptable to up to 2 dressing
baseline medications the patient; changes
not controlled
with PO meds
0: >40% of 0: Unable to 0: Continues: 0: Severe 0: Severe:
preoperative ambulate repeated Uncontrolled more than 3
baseline treatment pain dressing
changes
Reference book and the
relevant page numbers..
 Thank You 
Dr.

Date: