what’s pain got to do with it? pad launch day march 30 th, 2015 donald griesdale md mph frcpc...

What’s Pain Got to Do With It?

PAD Launch DayMarch 30th, 2015

Donald Griesdale MD MPH FRCPCAssistant ProfessorDepartment of Anesthesiology, Pharmacology & Therapeutics Division of Critical Care MedicineUniversity of British Columbiadonald.griesdale@vch.ca

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1. Objectives

2. Disclosure

52 year old female, previously healthy

Immediate onset of pain and weakness in both hands

Immobilized at scene and transferred to hospital

CC licence: Ludovic Peron

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Neurology: Grade 1 – 2 motor strength in bilateral upper

extremities 4 – 5/5 strength in her legs Decreased sensation in her hands

Conservative management Transferred to spine ICU Current pain management:

Acetaminophen 975 mg PO q6h regularly Hydromorphone 2 – 4 mg q4h prn (used 16 mg in

24 hours)

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Describes 2 types of pain Neck pain (NRS 2 – 3 / 10) “Burning, electrical shocks” in both arms and

hands

NRS 8 – 10 / 10 Opioids dull the pain slightly, but don’t help much

Unable to sleep Even the sheets touching her arms cause excruciating pain

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Nociceptive

Neuropathic

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“Pain caused by a lesion or disease of the

somatosensory nervous system”

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Other

Ketamine IV Other AED

2nd LineStrong opioids Tramadol

Topical AgentsAmitrip / Ketamine CR Lidocaine

1st LINEGabapentin or Pregabalin Nortriptyline

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Gabapentin Start at 300 mg / day

Titrate up to 4800 mg / day

tid SE: dizziness, somnolence, nausea, rash, blurred vision

Pregabalin Start at 150 mg / day

Titrate up to 600 mg / day

bid Similar SE to gabapentin

Better bioavailability

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Initially started on: Pregabalin 150 mg / day Nortriptyline 10 mg in AM and 25 mg qHS Topical amitriptyline – ketamine cream Oxycodone prn

Despite increasing her pregabalin, her neuropathic pain worsened

Repeat MRI to ensure no obvious worsening pathology

Started on ketamine IV Topiramate 25 mg BID Methadone 1 mg PO TID

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Recognize and consider neuropathic pain What is the etiology of neuropathic pain? Pharmacologic management is different than with nociceptive pain

Early use of gabapentin / pregabalin and TCA’s Use of topical agents for allodynia

Referral to a pain specialist for refractory neuropathic pain

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27 year old male, belted driver in high speed MVC

Intubated at the scene for respiratory distress

Isolated flail chest with pulmonary contusion

Rib 4 – 9# on right

Initially managed on IV morphine and regular acetaminophen

Damnsoft 09 at en.wikipedia

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"Pulmonary contusion" by Karim - http://www.trauma.org/index.php/main/image/32/

Complications: Pneumonia & empyema

Respiratory failure

Chronic pain & long term disability

Primary goals: Excellent pain control

Pulmonary volume expansion

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8 am the next day:

Currently on PSV 5, PEEP 5 with FiO2 0.40

You are now wanted to extubate this patient

Try to wean his propofol infusion! Tachypneic, fighting ventilator

Hypertensive, tachycardic

RASS +2 to +3

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Behavioural Pain Scale

BPS 7

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ICDSC Score

Altered LOC 1

Inattention 1

Disorientation 1

Hallucinations – delusions 0

Psychomotor agitation or retardation 1

Sleep/wake cycle disturbances 0

Symptom fluctuation 1

TOTAL 5

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Overnight pain management: Morphine total of 40 mg IV total Tylenol 975 mg NG q6h Methyltrimeprazine 20 mg IV total

Propofol infusion for sedation and ventilator synchrony

Report: “Either awake, agitated and confused or too sedated”

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Agitation

Pain Delirium

N Engl J Med 2010;362:1503

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Infusion of local anesthetic & opioid

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Pro’s

Better pain control than PCA

Improve respiratory function

Minimizes complications of systemic opioids

Con’s

Technically difficult

Complications Local Hemodynamic

Inadequate block

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Contraindications to epidural anesthesia:

Coagulopathy Antiplatelet agents (e.g. Clopidogrel) LMW heparin

Elevated ICP

Local or systemic infection

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Epidural analgesia is a level1

recommendation for the management

of severe blunt chest injury

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Pain scales may not be specific

Consider the interactive effect of pain & delirium

Alternates to opioid analgesia where appropriate

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