A Review of Pain Management Choices, Resources, and Information Access

Patients consider pain as one of the worst

postoperative experiences Severe postoperative pain is detrimental to

recovery

Acute Pain management improves patient outcomes!

If severe pain is not controlled, it may:

negatively affect patient recovery

lead to development of chronic pain

Acute pain services have been developed as anesthesiologists working with nursing have been found to have the most interest in pain management Nursing education encouraging development

of critical thinking skills is central to optimizing individualized patient care

Nurse clinicians/nurse practitioners are being trained to support clinical pain management

Post surgical pain Trauma pain

Pain control (e.g. labour and delivery) Acute exacerbations of chronic conditions

e.g. acute on chronic pain

Past medical history Pre-injury/preoperative pain report and

medical management Patient response both past and present to

pain medications Type of injury/surgery Present pain assessment including patient

pain report and response to meds ordered Goals of therapy

The body reacts to external stimuli and has the ability to distinguish between minor

and substantial injury After tissue injury and the resulting

inflammatory response, a patient’s threshold to and perception of pain is altered

Desborough J. (2000). The Stress Response to Trauma and Surgery. British Journal of Anaesthesia, 85(1), 109-117.

This response promotes maximum chances

for survival because it: • Increases cardiovascular functions • Preserves body fluid • Supplies the body with increased energy generating molecules

Desborough J. (2000). The Stress Response to Trauma and Surgery. British Journal of Anaesthesia, 85(1), 109-117.

Prolonged response can lead to: exhaustion weight loss decreased immune response less enthusiasm and ability to perform

rehabilitation needed for recovery

Desborough J. (2000). The Stress Response to Trauma and Surgery. British Journal of Anaesthesia, 85(1), 109-117.

Pain affects: ventilation immune system (increasing infection) GI tract (decreased gastric emptying) endocrine system (altered hormone release causing

metabolic disturbances) The stress/inflammatory response to pain puts the

body into a prothrombotic (hypercoagulable) state increasing blood clotting risks

Joint Commission on Accreditation of Healthcare Organization (December 2001, p.14). Pain: Current Understanding of Assessment, Management, and Treatments. P.14

Anesthesiologists’ goals in managing pain is

to reduce this response with planned trauma and minimize the response after traumatic injury

An anesthesiologist is assigned to Acute Pain

Service at each site (UH and VH)

Nurse Clinician acute pain management – one for each site

• PAIN Consultant is listed at the top of the OR record

• Monday to Friday, excluding holidays there is an anesthesiologist assigned to the acute pain service

Communication Algorithm for Acute Pain Service, UH Daytime weekdays 0800 – 1600 hours

1st call - Anesthesiologist Pain Consultant – 13351 2nd call - Nurse Clinician Pain Management – 14227

After hours and on weekends Anesthesiologist on call for pain covers weekend clinical rounds

First call - Anesthesia Resident on call – 19855 Second call – Anesthesiologist on call – 13830

Third call – for difficult pain management issues only – Anesthesiologist Pain Consultant -

(e.g. epidural hematoma, acute on chronic pain management) – pager 13351 – contact should be made through anesthesia on call

Communication Algorithm for Acute Pain Service, VH.

Daytime weekdays (0800-1600 hours) APS Nurse Clinician: 14691

Anesthesia pain Consultant: 18954 For all pre-op consults during the day, please contact the APS consultant at –

pager #18954 For any pain issues or pain consults during the day 7:30 am - 15:30hrs, please

contact APS nurse Clinician at pager # 14691

After hours 1st Call Anesthesia Resident on Call: 13305 2nd Anesthesia Consultant on Call: 14206

Available on the APS website http://www.lhsc.on.ca/priv/pain/algorith.htm • UH anesthesia resident

on call carries a text pager

Helps you to remember essential pain assessment criteria: • P – provoking or precipitating factors • Q – quality of pain (what words does the person use to describe pain?) • R – radiation of pain (does the pain extend from the site?) • S – severity of pain (intensity, 0-10 scale) • T – timing (occassional, intermittent, constant)

Registered Nurses Association of Ontario (November 2002). Nursing Best Practice Guideline: assessment and management of pain. Toronto.

Nociceptive pain Innate, protective response to trauma. Injury activates pain sensing nerve fibers

sending communication of such pain to the CNS

Neuropathic pain Response to damage to the nervous system

related to disease or trauma

Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 890.

Nociceptive pain responds well to

opioids

Neuropathic pain opioids are third line after:

1. Tricyclic antidepressants (e.g. Amitriptyline) and anticonvulsants (e.g.,Gabapentin)

2. Topical Lidocaine and SNRIs (serotonin/norepinephrine reuptake inhibitors)

(e.g. Duloxetine) Moulin D., et al. (2007). Pharmacological Management of Chronic Neuropathic Pain –

Consensus Statement and Guidelines from the Canadian Pain Society. Pain Res Manag., 12(1), 13-21.

Nociceptive Pain Quality descriptors might include achy, throbbing pain Neuropathic Pain Quality descriptors sound like electricity such

as stabbing, burning, shooting pain

Pain standards of the Joint Commission on Accreditation of Healthcare Organizations Recommendation: make pain assessment/management a

priority in daily practice

PQRST: Consider pain intensity or severity the fifth vital sign along the temperature, pulse, respiration, BP

Patient’s rights: full pain workup when pain is not easily characterized or treated

JCAHO 1999-2000.

From Key

From flow sheet

Documentation: revised generic LHSC Adult Graphic Record

Everything you want to know about acute pain management baseline knowledge base is an expectation

for practice See the APS website under pain management

strategies, education: http://www.lhsc.on.ca/priv/pain/slpacm.htm

All new nurses will review:

Acute Pain Management Self Directed Learning Package (SDLP) http://www.lhsc.on.ca/priv/pain/slpacm.htm

Intravenous PCA pump and website http://www.lhsc.on.ca/priv/pain/ivpca/index.htm

All new nurses who will be working with these modalities will also review: Neuraxial Pain Management SDLP

(epidural/intrathecal opioid analgesia) http://www.lhsc.on.ca/priv/pain/epidural/epstrat.htm

Regional Anesthesia/Analgesia SDLP (on line soon)

This site has been produced to help clinical staff with easy access to: Clinical reference

Clinical staff education material

Patient education material

Technology quick reference

Click intranet explorer icon on your desktop or under start menu

Select “Programs/Departments/Resources” located

near the top of the home page Select “Acute Pain Services”

Menu located on the left side of the page

Welcome

APS Communication Algorithm

Pain Management Strategies

Opioid Choices and Conversions

Order Forms

Monograph Index

IV PCA

Intrathecal Opioid Analgesic

Epidural

Regional Block

Technology

Duragesic

Methadone

Complementary Strategies

Links

Click on epidural

Staff education on the site

Patient safety assessment reviewed

Basic assessment information

Common concerns regarding the use of opioids include:

the potential for detrimental side effects

physical dependence

Addiction

opioid-induced hyperalgesia

Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp.

291-300.

Located in the CNS, pituitary gland and the GI

tract

Especially abundant in the dorsal horn of the spinal cord

Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 284

Opioid pain management decision making is influenced by:

Efficacy

Potency

Responsiveness

Resistance Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp.290-291.

Efficacy optimal dose for each patient (considering

side effect profile and reported pain relief) Potency equivalent dosing of different opioids using a

conversion chart (see APS website)

Responsiveness is influenced by:

patient characteristics

the particular type of pain the patient is having e.g. opioid responsiveness is reduced when managing neuropathic pain

Resistance (tolerance)

is the body’s adjustment to constant dosing of opioid decreasing the effect. Patients , over time, will need higher dose of drug to maintain an effect

Opioid Conversion Chart

http://www.lhsc.on.ca/priv/pain/conversi/narcotic.pdf

Morphine

Codeine

Oxycodone

Hydromorphone

Methadone

Fentanyl

10 mg

100 mg

NA

2 mg

1 mg

25 mg/hr

X 24 hr

Parenteral Oral

30 mg

200 mg

15 mg

6 mg

2 mg

Conversion of any opioid using morphine as our standard, helps clinician as he/she

considers safe dose range for his/her patient

Neuroplasticity: “the ability of the peripheral and central nervous systems to change both structure and function as a result of noxious stimuli.”

If patient’s opioid receptors are “flooded” with high dose opioid, the body will reroute signals through other receptors (e.g. NMDA receptors) Opioids will be less effective in this

situation Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 860.

Key points in management:

Consider opioid tolerance

Management of baseline pain

Be cognizant that the patient will have tolerance to most of the opioid induced adverse effects

Balanced analgesia strategy use is important Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 293-294; 624.

Pain management administration choices:

1. IV Opioid Patient Controlled Analgesia (PCA)

2. Intrathecal Opioid one-shot

3. Epidural Analgesia

4. Regional Block Analgesia

Safety is our first priority in caring for our

patients

With our patient safe, excellent analgesia is our ultimate goal

PCA is associated with greater patient satisfaction compared with intermittent opioid injections.

The reasons for this include:

Patient driven small and frequent intravenous bolus doses of opioid

Flexibility in dosing

The intensity of acute pain is rarely constant Patients are able to titrate the amount of opioid

delivered against dose-related side effects

• Shaded area represents targeted analgesia concentration

• The aim to achieve analgesia

• When below targeted conc., the patient is likely to experience more pain

Advantage of this opioid administration route:

Quick access to opioid prior to team knowing opioid requirements of patient

Disadvantage

Drug is metabolized more quickly than parenteral or oral routes which sometimes affects patient sleep/effective pain control

Minimum IV rate may preclude use of PCA for patients with a fluid restriction (e.g. minimum is 50 ml/hr)

Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 410.

Safety: Assess for and identify early opioid - induced

respiratory depression (apply this strategy to all routes)

Monitor for sedation as an early sign of respiratory depression

Learn to assess unstimulated respiratory rate and pattern on patients who are sedated

Omnifuse PCA syringe pump http://www.lhsc.on.ca/priv/pain/ivpca/tech.htm

Given close to site of action – the Dorsal Horn of the Spinal Cord

Close proximity of injection avoids loss of drug as it travels to the receptors and thus means smaller doses are required to achieve analgesia

Morphine can be given in much smaller doses

(about 5 % of injectable dose) and will last 12-24 hours

Dose is given by an anesthesiologist in the Operating Room

Safety assessment is required related to

duration of action

Assessment of respiratory rate, sedation, oxygen saturation q1h x 24 hours

Horlocker et al (2009). Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration. Anesthesiology, 110(2), 218-230. Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 418-419.

Intrathecal, spinal, and subarachnoid are interchangeable terms. Epidural remains outside or on the dura

Intrathecal/spinal anesthesiologists insert a needle through the dura into the cerebrospinal fluid

Epidural analgesia (Neuraxial Pain Management Self Directed Learning Package)

http://www.lhsc.on.ca/priv/pain/epidural/index.htm

Regional block analgesia catheters (Peripheral Nerve Blocks) http://www.lhsc.on.ca/priv/pain/regional.htm

Postoperative pain management

As a sole technique for surgical procedures (e.g. cesarean section)

Analgesia alone (e.g. childbirth, knee manipulations)

Trauma pain

Chronic pain management

Reduced doses of local and opioid are used in combined dosing

Better activity pain control

Decreased incidence of ileus promoting early feeding

Preservation of pulmonary function

Provides cardiac protection = by reducing oxygen requirements and increasing blood supply

Taken from: http://www.webmm.ahrq.gov/case.aspx?caseID=90

Use low concentrations of local anesthetic drug in an attempt to block sensory fibers only (motor fibers unaffected)

This means that the patient will be able to move and walk normally while still receiving good pain relief

NOTE: dense motor blockade is not an expected effect of low dose epidural local infusions and indicates serious complications

Failure or poor analgesia Hypotension Post Dural puncture headache Epidural can slow labour Rare but potentially catastrophic catheter related

issues which include:

- Nerve root/spinal cord damage - Infection (epidural abscess) - Epidural hematoma - Catheter migration to blood vessel or CSF Pasero, C, McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. Mosby, pp. 433, 437, 439.

Causes of hypovolemia after major surgery include: blood loss, bowel prep, 3rd spacing Heart conditions e.g.MI, valve disease, CHF Anemia Sepsis Anastomotic leak Cowling G, Haas R. (2002). Hypotension in the PACU: An Algorithmic Approach. Journal of PeriAnesthesia Nursing, 17(3), 159-163.

In the low concentrations used in combination with opioids for pain relief, significant hypotension is unlikely unless the patient is also hypovolemic.

Called “regional” block because:

the goal is to numb a specific area of the body

named after the anatomical location/nerve plexus targeted.

E.g. Femoral block = femoral nerve

Lower limb regional blocks are the most frequently done block at UH (e.g. femoral/sciatic)

Knowledge of anatomy helps you to trouble shoot potential catheter- related issues http://www.lhsc.on.ca/priv/pain/regional/femoral.pdf

Needle/catheter is placed in tissue in close proximity to targeted nerve/nerve plexus.

Dose/concentration of local anesthetic agent used determine the density of the block

anesthesia = full block analgesia = block to pain

Ultrasound and/or nerve stimulator is used to ensure safe and precise catheter placement

NOTE: pump number Quick reference and pump education material available at: http://www.lhsc.on.ca/priv/pain/epidural/tech.htm

Block assessment columns for local anesthetic infusions only >catheter site for epidural only

Opioid safety assessment columns

Pain Scores: Rest and activity

Pump number from previous slide charted here

APS Bedside Record

This is an example of assessment of IVPCA opioid

• Note columns used for

IV PCA documentation

• Columns looking for block assessment are not used for opioid assessment

• Direction on how to use bedside record for IV PCA assessment @

http://www.lhsc.on.ca/priv/pain/ivpca/monitor.htm

This record tells a story

APS Bedside Record

Back of the bedside record (previous example continued) • Contains scales

for pain assessment

• an area to do narrative charting

Vital signs: Respiratory Rate (RR) Level of sedation

(sedation is an early sign of respiratory depression)

Oxygen saturation (SpO2)

NRS or appropriate pain score tool

Side effect profile

Assess respiratory pattern: Adult ⇒ q1h x 12 hours ⇒ q2h x 12 hours ⇒ q4h for remainder of therapy

Pediatrics ⇒q1h x 24 hours ⇒ q2h x 24 hours ⇒q4h for remainder of therapy Pain score q4h at rest and

with activity while patient is receiving analgesia

Side effect profile q4h See APS website

APS Bedside Record

This is an example of the bedside record used to assess epidural analgesia Remember that

the dermatome chart is located on the back of this record

Direction on how to use the monitoring record for epidural assessment

http://www.lhsc.on.ca/priv/pain/epidural/secg.pdf

What does this charting tell you??

Vital Signs: Respiratory rate Sedation score Oxygen saturation Blood pressure Pain score Sensory blockade Motor blockade Catheter monitoring Side effects

Assess respiratory pattern: the same as with IV PCA

Blood pressure q4h while on infusion

Pain score q4h(rest and activity) Sensory and motor blockade

q4h x 24 hours then q12h at the beginning of each shift

Infusion system – hub q1h Site with dressing checks Side effects q4h

Acute pain service now uses electronic

charting

APS power chart notes can be reviewed by all staff

Go to start menu and select information systems

Open power chart Prod Domain

Enter user name and password

Open the patient that you are caring for (you are in

the flow sheet view)

• Go to “All results flow

sheet”

• Click the down arrow

to reveal

selections there

• Scroll to the Acute

Pain Service View

• Pain service

documentation

including

procedure

records entered

will appear in this

view

Power chart view:

Procedure record for

epidural insertions

Nice concise

summary of

insertion which

includes location of

catheter at skin on

insertion

If not entered in power chart, documentation of the

procedure may be recorded on:

The anesthesia record (under the title Regional) or

Paper anesthesia procedure record located in the

OR section of the chart

Go to LHSC intranet;

Programs/Departments/Resources; Nursing; Nursing Grand Rounds; Videos

See presentations by Heather Fisher and Cindy Carnegie on Pain Management and Epidural Analgesia

http://www.lhsc.on.ca/priv/nursing/rounds/videos.htm