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TRANSCRIPT
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using low technology methodsManagement of Post-Operative Pain
type in name of your institution
Topics to be discussed in this talk
• Why should acute pain be treated?
• How to assess acute pain?
• How can you manage acute pain?
• How can you organize management of acute pain
within your hospital?
Why should acute pain be treated?
• Pain is a natural, inevitable, acceptable and
harmless consequence of surgery and trauma.
• Under-treatment of severe pain has no adverse
consequences.
True or false?
Why should acute pain be treated?
1. For ethical and humanitarian reasons
2. To reduce the severity of associated adverse
physiological & psychological factors
3. It might decrease the risk of developing
chronic pain.
Each of these issues will be addressed in the
following slides.
Why should acute pain be treated?
• Relief of suffering, caused by pain, is the chief and un-
disputed benefit of pain treatment.
• Providing effective pain management is a professional
responsibility, the duty of healthcare professionals.
– Under-treatment of pain is poor medical practice.
• Organizations such as the International Association for the
Study of Pain, European Federation of IASP Chapters and
Human Rights Watch, have issued statements identifying
access to pain management as a fundamental human right.
1. For ethical and humanitarian reasons
Why should acute pain be treated?
2. To reduce severity of adverse physiological effects
Major body systems are negatively affected by acute pain
Why should acute pain be treated?
Untreated pain can lead to
or increase:
• patient anxiety or fear
• sleeplessness leading to fatigue
When these psychological
factors are lessened, they might
lead to decreased sensation of
pain.
3. To reduce the severity of adverse psychological factors
Why should acute pain be treated?
Although in most patients the pain resolves with time, some patients
(~1 in 10 - 20) will develop chronic pain after surgery
or injury
•treatment will be necessary in about 50% of these patients.
The risk of developing chronic pain might be higher in those patients
who had severe pain after surgery.
• Chronic pain is difficult to treat.
• Don‘t withhold strong opioids from patients after surgery, the risk of
developing addiction in these patients is negligible.
4. It might increase the risk of developing chronic pain.
How to assess acute pain?
• The experience of pain is too complex to be assessed.
• It‘s a waste of time & the information is useless - one
patient‘s ‘5‘ is not the same as another patient‘s ‘5.‘
• Health professional can appreciate the level of pain of the
patient because of their experience
Cons for measuring pain
How to assess acute pain?
• Provides information whether there is a problem
• Determines its severity
• Guides treatment options
• Assesses the effectiveness of therapy & if there is a need
to change it
• Is reliable when carried out using standardized methods
Pros for measuring pain
How to assess acute pain?
• Pain is always subjective.
• Behavior does not necessarily reflect if a patient is
experiencing or not pain
–people can sleep, laugh, talk and yet experience
pain
–Discrepancy between pain vs extent of injury is
common
–Inter-individual variations are common.
Ask the patient: make pain visible
How to assess acute pain?
• There is no test or equipment for measuring pain.
• As pain is a multi-dimensional experience
–there is often a poor correlation between the staff‘s
estimate and that of the patient.
–BUT clinicians must accept a patient‘s report of pain.
Believe the patient! There are no biological markers for
pain.
Ask the patient: make pain visible
How to assess acute pain?
• Unless asked specifically, patients tend to tolerate
unrelieved pain silently
• As pain is recognized predominantly through
a patient‘s report:
–patients who have difficulty communicating are at risk
for under-treatment
–groups at risk: patient who speak a different language,
elderly, cognitively impaired, children.
Ask the patient: make pain visible
… Recognize pain
•No biological markers
•Discrepancy pain / injury
•Inter-individual variations
… Adapt treatment
•Choice of treatment and dose
•Efficacy
… Improve communication
•Patients communicate pain intensity
Summary: Pain scales are useful tools that help to …
How to assess acute pain?
How to assess acute pain?
Most children over 7 years old & communicating
adults can use a numerical scale.
When acute pain is evaluated - the dimension
of ‚intensity‘ is assessed.
Numerical scale
How to assess acute pain?
1. no pain 0
2. mild pain +
3. moderate pain ++
4. severe pain +++
Simple Verbal pain scale
How to assess acute pain?
• When in pain, patients tend to refrain from moving /
taking a deep breath / coughing.
• Asking only ‚how much pain do you have?‘ refers to
pain during rest, that is typically low.
Assess pain at rest AND movement
How to assess acute pain?
Ask:
(1) How much pain do you have when you are at rest?
AND
(2) How much pain do you have when you move in
bed / sit up / get out of bed (= orthopedic patients)
How much pain do you have when you take a deep
breath OR cough (= general surgery patients).
OR to swallow (= patients after tonsillectomy)-
i.e. ask the patient to carry out an activity which is
related to the surgery.
Assess pain at rest & movement
How to assess acute pain?
• If the cause of acute pain is unknown – establishing
the cause of the pain is a priority but symptomatic
treatment of the pain should be initiated.
• It is rarely justified to defer treatment until the
cause of the pain is known.
• A comfortable patient will be able to cooperate with
the diagnostic procedures.
please remember …
Mild pain 1 – 3
Paracetamol
+NSAID (if no CI)
+
infiltration with LA
Moderate pain 4 – 6
Paracetamol
+NSAID (if no CI)
+
Codeine or Tramadol
+infiltration with LA
Severe pain7 – 10
Paracetamol
+NSAID (if no CI)
+Morphine
+infiltration with LA
Increasing severity of pain CI= contraindication; LA = local anaesthetic
How to treat post-surgical pain?
How to treat post-surgical pain?
• Pre-operatively
–Discuss options with patients
–Teach about assessment, treatment options
–Pre medication with paracetamol
• Intra-operatively
–Wound infiltration with local anaesthetic (surgeon)
–Administer analgesics (IV or rectally)
When to start pain management?
How to treat post-surgical pain?
• Post-operatively – recovery room AND ward
–Give analgesics at regular intervals – not as
needed
–Combine opioids with non-opioids
–Titrate according to needs of individual patients –
one dose does not fit all!
–Duration of treatment will depend on the type of
surgery and the patient’s individual
requirements.
When to start pain management?
How to treat post-surgical pain?
• Oral (PO)
–route of choice: simple, effective, well tolerated.
–Suitable as soon as the patient is able to tolerate oral
fluids.
• Intra-muscular (IM)
–Injection painful and absorbtion un-reliable.
–Should be not be used as a route for giving analgesics.
Which route?
How to treat post-surgical pain?
• Sub-cutaneous (SC)
–Route of choice if oral route is not possible
–Avoid for long term, repetitive dosing
• Intra-venous (IV)
–Allows for rapid titration.
–Allows for continuous OR bolus administration
–requires monitoring!
Which route?
Drug Dose Route FrequencyParacetamol 1 g p.o., i.v., rectal q.i.d
NSAID’sibuprofendiclofenacketorolac
Opioids
50-100 mg
75 mg 50-100 mg
p.o.i.m.i.m. or i.v.
q.i.db.i.d or t.i.d
(codeine) * 30 mg p.o. q.i.d
tramadol(pethidine) *
50-100 mg 25-150 mg
p.o. or i.v.i.m.
t.i.d or q.i.dt.i.d or q.i.d)
morphine 10 (IR), 30mg (SR)
p.o. Every 4 hours
10 mg sc Every 4 hours
bupivacaine 1mg/kg Wound infiltration
End of surgery
How to treat post-surgical pain?
Analgesics for post-operative use
b.i.d. –X2 daily; t.i.d. X 3 daily; q.i.d. – X4 daily
Caution !
•C
odeine – Its metabolism is highly variable and might result in
severe overdosing. – Use only when no other opioid is available.
•P
ethidine – Accumulation may cause CNS-related side effects.– Use only when no other opioid is available.
How to treat post-surgical pain?
• Provides a mild analgesic effect
• Low toxicity
• No difference in quality of analgesia when given IV vs PO
–but is more expensive
• For short surgical procedures possible to give 1gr PO with
a little water 1/2 hour before the surgery.
• After minor surgery:
–if given as sole analgesic and pain is not relieved – after
30 – 45 minutes - combine with another non-opioid or
opioid.
Paracetamol
How to treat post-surgical pain?
• NSAIDs can be effective on their own for mild
or moderate pain OR combined with an opioid
for severe pain
• Mechanisms of action different from paracetamol
• Effective for treatment of inflammatory and bone
pain.
• Administer a dose before the end of a procedure
• Synergistic effect with paracetamol and/or opioid.
• Asses patient for contraindications or precautions.
Non Steroidal Anti Inflammatory Drugs (NSAIDs)
How to treat post-surgical pain?
• Hypersensitivity to NSAID (NSAID induced asthma,
rhinitis, nasal polyps, allergic or anaphylactic
reactions)
• Peptic ulcer
• Renal impairment
• Clotting disorders
• Congestive heart failure and other cardiovascular
diseases.
NSAIDs
Contra-indications
How to treat post-surgical pain?
Hypertension, hypovolemia, dehydration, severe
malnutrition
• Sepsis
• During pregnancy particularly 3rd trimester
Side effects are linked to the dose and the duration of
the treatment
Do not exceed 7 consecutive days of treatment.
NSAIDs caution in patients with
How to treat post-surgical pain?
• Opioids offer the most effective analgesia for
moderate to severe pain.
• Morphine is the opioid of choice for peri-operative
analgesia
• When administered correctly - opioids used for
treatment of pain do not induce addiction.
• Opioid should be combined with non-opioids
• There is no ceiling effect for opioids and dose should be
tailored to patient / pain response however, if large
doses are being administered, consult a pain specialist
for alternatives.
Opioids (overview)
How to treat post-surgical pain?
• Respiratory depression can occur in overdose. It is
preceded by sedation which should be detected
• Frequent side effects are nausea vomiting
• Opioid induced bowel dysfunction (constipation /
ileus) may become a problem.
– Less typical after short term treatment, as is
common after surgery.
• Availability is problematic in some countries
Opioids (overview)
How to treat post-surgical pain?
• Step 2 analgesic
• Analgesic (opioid and monoaminergic)
• 5 to 10 times less potent than morphine
• Risk of respiratory depression negligible
• Easier to import than morphine
• Not in the WHO list of essential medicines
Tramadol
How to treat post-surgical pain?
• Do not administer in patients at risk of seizures.
• May cause dizziness, nausea, vomiting, sweating, dry mouth
• Do not combine with other level 2 analgesics.
• IV : infuse over 20-30 min rather than bolus injection
• Pregnancy and breast-feeding:
– risk of adverse effects at the end of 3° trimester and during breast
feeding.
– Administer with caution for a short period at the lowest effective
dose and monitor the child
Tramadol – Contra–indications , precautions
How to treat post-surgical pain?
• Step 2 analgesic
• weak opioid: 5 – 10 times less effective than
morphine
• No injectable formulations
• Remember – Codeine’s metabolism is highly variable
and might result in severe overdosing. – Use only when no other opioid is available.
Codeine
How to treat post-surgical pain?
• Do not administer to patients with asthma, COPD,
emphysema
• May cause constipation, dizziness, nausea, vomiting,
dry mouth, rarely respiratory depression
• Reduce dose in patients with renal or hepatic
impairment and elderly.
Codeine – Contra-indications, precautions
How to treat post-surgical pain?
• Pregnancy : No CI but possible newborn withdrawal syndrome
when administered in large doses in 3° trimester
• Breast feeding: Administer with caution for a short period at
the lowest effective dose and monitor the child
Codeine – Contra-indications, precautions
How to treat post-surgical pain?
• Used correctly, opioids do not induce addiction in
patients after surgery.
• Pseudo addiction may appear when pain is not
adequately treated
Morphine and addiction
How to treat post-surgical pain?
Nausea & vomiting
• give an anti-emetic
– E.g. metoclopramide: Adult : p.o. 15 - 30 mg / day in 3
divided doses
– Child ondansetron : p.o. 50-100 mcg/kg
Constipation / ileus
– Normally not a problem in the first 48 hours of use;
– After 48 hours: give agents such as bisacodyl (child 5
mg at night, adult 5-10 mg) OR an osmotic laxative
such as lactulose and hydration.
Common opioid-related side effects
How to treat post-surgical pain?
Neurologic
• abnormal drowsiness = warning sign of early respiratory depression
Respiratory
• respiratory depression (bradypnea, apnea)
Onset of excessive drowsiness indicates an overdose and often precedes the onset of
bradypnoea (abnormally slow irregular breathing rate of less than 8 respirations per
minute).
Oxygen saturation may be an un-reliable indicator, especially if the patient is
receiving supplemental oxygen.
Less frequent opioid related side effects
• Monitor sedation regularly to avoid development of
respiratory depression
• Use a ‘sedation score‘.
How to treat post-surgical pain?
Assess sedation & respiratory depression
How to treat post-surgical pain?
• Sedation can occur even with the first dose
of an opioid.
• A sedation score of 2 is an early sign of respiratory
depression and should be taken seriously.
Management of Sedation
How to treat post-surgical pain?
• Administer oxygen by face mask
• Monitor pain & sedation score
• Withhold next dose of opioid
• When the patient is alert, opioids can be resumed
for pain relief, at a lower dose and at longer
intervals
• Assess for hepatic and / or renal impairment
Management of Sedation
• Call for help
• Administer oxygen by face mask at 10 L / min
• Stimulate the patient and encourage him to breath if he can be
aroused.
• Dilute naloxone 0.4 mg in 4 ml of water or normal saline.
• Administer naloxone 0.1 mg (1 ml) every 1 – 2 minutes until the
patient wakes up or the respiratory rate is greater than 10 / min
Continue to monitor the sedation score and respiratory rate every half
hour for at least another 4 hours
• An infusion of low dose naloxone may be used
– This will reverse the analgesia.
How to treat post-surgical pain?
Management of respiratory depression (1)
Naloxone
•The half-life of naloxone is ~30 – 81 minutes;
•This is shorter than the half life of some opioids, e.g.
morphine for morphine ~ 2 -3 hours.
• When using naloxone to antagonize the respiratory
depression of morphine patients should be
monitored for at least 4 hours.
How to treat post-surgical pain?
Management of respiratory depression (2)
How to treat post-surgical pain?
Titrate for rapid control of pain
•Give e.g. IV morphine 2 – 3 mgs every 5-10 minutes
until relief is obtained
•Maintain analgesic plasma levels by regularly timed
doses of morphine subcutaneous or p.o.
Severe pain (8 – 10 / 10) requires emergency
treatment
How to treat post-surgical pain?
Prerequisite conditions for IV treatment
• Healthcare providers trained in emergency
airway/respiratory care• Resuscitation equipment (Ambu bag, masks,
suction)• Naloxone
Severe pain (8 – 10 / 10) requires emergency
treatment
How to treat post-surgical pain?
• Treatment is more effective when given before the
pain starts or becomes severe.
• Prescription of analgesic drugs should be systematic
– give medication at fixed times but also option for
additional doses in the event of breakthrough pain.
• Oral form should be used as soon as patients can
drink.
• Aim to provide multimodal analgesia.
Key points to remember
How to organize postoperative pain management within your hospital?
„It is being increasingly recognized that the solution
to the problem of inadequate postoperative pain
relief lies not so much in development of new
techniques but in development of a formal
organization for better use of existing techniques.“
Rawal N, Berggren L. Pain. 1994 Apr;57(1):117-23.
How to organize postoperative pain management within your hospital?
• Ensure the hospital has WHO essential
medications, as a minimum
• Provide education for medical & nursing staff &
patients
• Standardize treatment by preparing local protocols
& get staff to follow them
• Implement routine quality assessment
How to organize pain management within your hospital
Opioids are a necessity to provide
adequate management of
post-operative pain
• Find out regulations about prescription of opioids in
your country.
• If necessary, get a licence to prescribe opioids.
1. Ensure hospital has essential medications
How to organize pain management within your hospital
One of the best recognized barriers for providing
good management of pain is inadequate knowledge about
pain and its management and misconceptions on behalf
of medical & nursing staff, patients & their families.
2. Education
How to organize pain management within your hospital
Staff•Participate in a course like prepared here.
PatientsTeach them: • How to assess pain• That they should inform the staff when they are in pain and when they experience side effects.
• That dependence or tolerance to medications are rare when treating acute pain.
2. Education - possible solutions
How to organize pain management within your hospital
How to teach? •Verbal & written (e.g. pamphlet or poster).
– ~ 30% of patients forget the information given to them.•Remind staff to repeat the information - patients remember only a small part at any one time.
2. Education - possible solutions
How to organize pain management within your hospital
• Consider preparing standard order sheets or local
protocols for surgical units AND recovery
3. Standardization
How to organize pain management …
• Medication orders & patient assessment:
–Analgesics & treatment of side-effects
• e. g. unless contraindicated, all patients after
surgery receive 1 gr paracetamol X 4 daily.
–Monitoring
• e.g. pain is assessed once every shift & after
provision of an analgesic.
3. Standardization – examples
How to organize pain management …
• Quality improvement = evaluation of what you do to
improve what is not so good
• Different aspects of care can be evaluated
–Processes: is pain assessed routinely? Is
multimodal analgesia provided?
–Patient‘s outcomes: pain intensity, side effects,
satisfaction
–Organization: protocols, drug availability
• Choose important criteria for you
• Choose criteria that you can measure
• Compare your ward over time and with other wards.
4. Quality assessment
Summary 1
• Pain after surgery and trauma can be harmful.
• Under-treatment of pain can have adverse
consequences.
• Providing effective pain management is a
professional responsibility of clinicians.
Summary 2
• Assessing pain using standard tools is important
–It makes pain visible and guides treatment.
–If the patient is communicative – rely on his
report.
–If non–communicative initiate treatment & carry
out regular follow-up yourself.
–If the patient reports pain (e.g. >= 4/10) –
provide treatment !
Summary 3
• Aim that your hospital has the essential analgesics
to provide treatment.
• Use the WHO Essential Medicine list as a guide.
• Morphine is an essential medicine for treating
severe pain.
This talk was originally prepared by:
Dominique Fletcher, M.D, Garches & Xavier Lassalle, RN, MSF
Paris, France
Talks in the International Pain School include the following:
International Pain School
Physiology and pathophysiology of pain Nilesh Patel, PhD, Kenya
Assessment of pain & taking a pain historyYohannes Woubished, M.D, Addis Ababa, Ethiopia
Clinical pharmacology of analgesicsand non-pharmacological treatments
Ramani Vijayan, M.D. Kuala Lumpur, Malaysia
Postoperative – low technology treatment methodsDominique Fletcher, M.D, Garches & Xavier Lassalle, RN, MSF, Paris, France
Postoperative– high treatment technology methodsNarinder Rawal, M.D. PhD, FRCA(Hon), Orebro, Sweden
Cancer pain– low technology treatment methods Barbara Kleinmann, MD, Freiburg, Germany
Cancer pain– high technology treatment methodsJamie Laubisch MD, Justin Baker MD, Doralina Anghelescu MD, Memphis, USA
Palliative CareJamie Laubisch MD, Justin Baker MD, Memphis, USA
Neuropathic pain - low technology treatment methodsMaija Haanpää, MD, Helsinki & Aki Hietaharju, Tampere, Finland
Neuropathic pain – high technology treatment methodsMaija Haanpää, M.D., Helsinki & Aki Hietaharju, M.D., Tampere, Finland
Psychological aspects of managing pain Etleva Gjoni, Germany
Special Management Challenges Debra Gordon, RN, DNP, FAAN, Seattle, USA