ACUTE PAIN

SERVICE
Dr Mohamad Isa Hj Bikin
Department Anaesthesiology
2nd April 2009
INTRODUCTION
 Severe post op pain cause increase mortality and
morbidity
CVS - tachycardia,HPT, increase PVR,increase heart
O2 consumption.
RS - diaphragmatic splinting –atelectasis,lungs
infection,hypoxemia
GI - delayed gastric emptying-pain,opioid, surgery
GU - urinary retention
Endocrine – cathecholamines,etc
Psychology – anxiety, sleeplessness, fatigue,distress
Chronic Pain – pt suffer acute pain likely to develop
chronic pain.
MEASUREMENT OF PAIN
 Verbal
 Numeric
 Visual analog
 Observation
 Vital signs
ANALGESIC DRUGS
 Paracetamol – orally/rectally/ IV?
 NSAIDs – diclofenac,ketorolac,ibuprofen
- celecoxib, valdecoxib , parecoxib
orally, IM, IV, rectally
 Opioids – morphine,pethidine,fentanyl
- codein,tramadol
METHOD USE IN APS
 Continuous infusion
 Intermittent IV
 Intermittent IM/SC
 Transdermal
 Oral
 PCA
 Epidural/PCEA
 Spinal(intrathecal)
 Rectal
 Transmucosal/intranasal
PCA(PATIENT CONTROLLED
ANALGESIA)
 Self administration of IV opioids-prevent
variability -patient titrate the dose to
MEAC.prevent MTC
 Safety of PCA –more dose make patient more
sedated-no one but the patient is allowed to
operated the PCA
 Commonly used opioids
(morphine,fentanyl,
pethidine,tramadol)
 Patient should be comfortable before starting PCA
-bolus dose
Complications
 Equipment malfunction is rare
 Operator error is much more common
 Side effect related to opioids

nausea , vomiting, pruritus, resp. depression, urinary

retention, confusion, constipation, hypotension etc
 Pain

Troubleshooting
- antiemetic/anti histamine
- combine with NSAIDs
-MONITOR (sedation score, pain score, vital signs)
EPIDURAL ANALGESIA
 Goal standard for major surgery
 Incidence of pulmonary Cx is lower
 Reduced DVT
 Improves intestinal motility

C/I –patient refusal

-contraindication of epidural(local and general
sepsis,hypovol,coagulopathy,anticoagulant)
-untrained staff-able to recognise and treat Cx
Troubleshooting
 Pain –adding regular NSAIDs,opioids,PCM

- bolus dose/increase infusion

- check connections and insertion site
- check block level
 Pruritus –anti-histamine

- naloxone
 Hypotension – give fluids

- reduce rate
- vasoconstriction
 Motor block –reduce infusion and concentration
Other complications
 Headache
 Nerve and spinal cord injury
 Epidural hematoma/abscess
 Catheter migration

Drugs use for epidural

Bupivacaine
Levo-bupivacaine
Ropivacaine
Opioids
INTRATHECAL
 Opioid can be administered intrathecally in
combination with local anaesthetic
 Drugs use – morphine,pethidine,fentanyl
 Delayed or late resp depression can occur
 Can last up to 24 hrs post operatively
IVI AND INTERMITTENT OPIOIDS
 Suitable for recovery and ICU
 Morphine, pethidine, fentanyl
 NSAIDs
INTERMITTENT SC OR IM
OPIOIDS
 Traditional route
 Must be regular-4 hourly/PRN
 SC port can be set-prevent intermittent injection
Injection into the fatty layer just beneath the skin
(subcutaneous tissue)
Rate of uptake is almost equal to IM
(about ½ hour)
Indwelling small gauze cannula
- deltoid, infraclavicular
Intramuscular Subcutaneous
 Advantages
- less pain on injection compared to IM ?
- patient can be mobile
- avoid first pass metabolism
- slow release and maintain plasma level
 Disadvantages

- onset delayed
- may have burning sensation on the injection site
- risk of opioid overdose and resp. depression
INSERTION OF THE NEEDLE

 Anaesthetist usually does this in the theatre

 Swab the chosen area with alcohol
 Insert the cannula into the subcutaneous by
pinching up the skin then insert the cannula
about 30’ below the skin
 Cover the cannula with the sterile transparent
dressing
 Label the dressing with (S/C Morphine)
 For injection - do not dilute the drugs
- max.2 mls
- not to mix up the drugs
MONITORING

 Respiratory rate
 Sedation score
 Pain score
 Vital signs
 Record the dose of drug given at each dosing
interval
 No other opioid or sedatives to be given to the
patient other than order by the doctor
ORAL
 Oral bioavailability is limited due to first-pass
metabolism
 NSAIDs/PCM/Opioids
TRANSDERMAL
 Very lipid soluble opioids are absorbed through
skin
 Fentanyl (25ug-50ug)
 Not suitable for acute pain-no study yet
TRANSMUCOSAL
 Fentanyl lollilops
 Premedication for children
 Can be use in opioid-tolerant patients with
cancer
INTRA-NASAL
 Diamorphine
 Very effective in children
CONCLUSION
 All method of pain relief need
monitoring/trained staff
Why?
 NO PROCEDURE WITHOUT RISK