PAIN MANAGEMENT

ACUTE POSTOPERATIVE PAIN

• Method of relief:
 Opioids: given i.v., i.m., epidural, intrathecal and oral routs. The problem is with opioids in respiratory
depression especially in children and old age. Mixed agonist-antagonists like pentazocine produce less
respiratory depression. Epidural opioids (especially fentanyl) with bupivacaine (0.125%) is an excellent
method of controlling postoperative pain. Morphine, tramadol, pentazocine, alfentanyl, sufentanyl have
been successfully used through epidural route for relieving pain.
 Non steroidal anti inflammatory drugs (NSAIDs): whatever the method of analgesia is used, NSAIDs
must always be given because of their anti inflammatory property as well as they reduce the dose of opioids.
 Regional analgesic blocks.
 ACUTE POSTOPERATIVE PAIN

• Method of relief:
 Patient controlled analgesia (PCA): it is an automatic system in which the patient himself
presses a button which delivers a fix amount of opioid (usually morphine). This system is
connected to either i.v. line or epidural catheter. A lockout interval (during which drug will not be
delivered) is set to avoid overdosage. If the side effect of drug is explained to patient it is seen
that the drug taken by the patient is less than given by i.m. route by nursing staff.
 Transcutaneous electric nerve stimulation (TENS): special TENS machines deliver electric
current at pain points to relieve the pain.
 ACUTE POSTOPERATIVE PAIN

• Method of relief:
 Cryoanalgesia: it is produced by cryoprobes which uses compressed carbon dioxide to nitrous
oxide. They cool the peripheral nerves to -5 to -20˚C to produce analgesia.
 Inhalational: nitrous oxide is used.
 Ketamine infusion: in analgesic doses.
 CHRONIC PAIN

• Drugs used for neurolysis (permanently damaging nerve) are: phenol 5% in glycerine; absolute alcohol.
Neuropathic pain:
 Trigeminal neuralgia: most often the pain is in maxillary division. There is no sensory loss except in post herpetic trigeminal neuralgia.
 Treatment: drug of choice is carbamazepine 100 to 1000 mg/day. Radiofrequency ablation of trigeminal ganglion. Neurolytic block.
 Post herpetic neuralgia:
 Treatment:
o Drugs: Fluphenazine (drug of choice), amitryptiline, desimipramine.
o Transcutaneous nerve stimulation (TENS).
o Intercostal nerve blocks/interpleural nerve block.
o Topical aspirin in ether.
o Extradural block
 CHRONIC PAIN

Neuropathic pain:
 Phantom limb:
 Drug of choice is Mexiletine.
 Pre-emptive analgesia (analgesia before pain occurs) is the best treatment.
 Other modalities of treatment are:
o Local analgesic blocks.
o Transcutaneous electric nerve stimulation (TENS).
o Sympathectomy.
o Cordotomy (spinal cord portion is damaged by needles).
 CHRONIC PAIN

Reflex sympathetic dystrophy (RSD, chronic regional pain syndromes):

 Commonly encountered dystrophies are:
 Raynaoud’s phenomen.
 Trombophelbitis obliterans.
 Erythromelalgia.
 Buerger’s disease.
 Arteriosclerosis.
 Causalgia (reflex sympathetic dystrophy after direct nerve injury is causalgia).
 Amputation stump neuralgia.
 Sudeck’s dystrophy.
 CHRONIC PAIN

Reflex sympathetic dystrophy (RSD, chronic regional pain syndromes):

 The hallmark of RSD is extremely painful limb. The limb becomes extremely sensitive to pain
(hyperesthesia); even a light touch can produce pain (allodynia).
Treatment:
 Sympathetic block: for upper limb dystrophies stellate ganglion block is performed and for lower
limb dystrophies lumbar sympathetic block is performed.
 Intravenous regional sympathetic block (chemical sympathectomy): Guanethedine 10 to 20 mg
with 500 units of heparin is injected in the same way as xylocaine for Beir’s block.
 CANCER PAIN

• Treatment of cancer pain required multifaceted approach.

 Pharmacologic therapy:
 NSAIDs: NSAIDs are often the first line drugs.
 Opioids:
 Oral opioids.
 Transdermal fentanyl patch: it is a very good alternative to oral route. One patch provides analgesia for 48 to 72
hours.
 I.v./i.m./s.c.: used when oral medication fails or oral route is not accessible.
 In rare circumstances rectal and sublingual route can be chosen for opioid delivery.
 CANCER PAIN

 Opioids:
 Neuroaxial opioids: preservative free morphine is used through epidural catheter. Addition of
low concentration local anesthetic decreases the dose of morphine. If this is effective in relieving
pain the epidural catheter may be surgically implanted for long term use.
 Regional blocks like celiac plexus block for pancreatic and stomach malignancy.
 Neurolythic blocks: only if block with local anesthetic is successful then only neurolythic block
should be considered.
 For intractable case surgical intervention (cordotomy) should be sought.
 CHRONIC PAIN

Low backache
 Before treating low backache neurosurgical and orthopedic consultation should be always sought
to rule out any surgical intervention.
 Analgesics.
 Epidural steroids: usual indication for epidural steroid is disc prolapse and post laminectomy
syndrome.
 Paravertebral spinal nerve root block.
 Facet joint (sacroiliac) injections.
 CHRONIC PAIN

Myofascial pain:
 If the organic cause has been ruled out, then trigger points are found and injected with local
anesthetic and steroid. Transcutaneous electrical nerve stimulation (TENS) and acupuncture is
also effective in myofascial pains.
Anesthesia dolorosa:
 Pain is desensitized areas as seen in thalamic lesions.
 Treatment: deafferntation drugs like carbamazepine, clonazepam, sodium valproate.
 ACUPUNCTURE

• Mediated by endogenous opioids (endorphins) through epsilon receptors.

• Needle stimulation may be electrical, manual or thermal.