1. Dr Rajeev HarsheMD (Anesthesiology)Pain ConsultantApollo Hospitals, Ahmadabad(Hon. Pain consultant to H.E.Govorner of Gujarat)Private clinicRelief Pain Clinic35/1, sector 2 AGandhinagarGujarat, India.

2. Contents Golden rules in acute pain management. Various chronic pains-methods of prevention-goldenrules of treatment-recent developments 3. The Pain PathwayPeripheralnociceptorsDescendingmodulationDorsalhornAscendinginputSpinothalamictractDorsal rootganglionPeripheralnerveActivation of CNS atspinal cordPainActivation of theperipheral nervoussystemTraumaTransmission of thepain signal to thebrain 4. (Acute Pain Management)Why ???? Hyper sensitization issue Healing and recovery issue Human issue Medico legal issue JCI and NABH issue 5. Pain pathway and modulation1Descending inhibitory controls /Diffuse noxious inhibitory controlsInterpretation incerebral cortex:painStimulation of nociceptors(A and C fibers) /Release ofneurotransmitters andneuromodulators (i.e. PG)1. Adapted from: Bonica JJ. Postoperative pain. In Bonica JJ, ed. The management of pain. Philadelphia: Leaand Febiger;1990:461-80.Release of serotonin,noradrenalin and enkephalinsat spinal levelActivation of serotoninergicand noradrenergic pathwaysInjuryAscending nociceptive pathways 6. Modes of action of analgesics1,2,3,41. DAmours RH et al. JOSPT 1996;24(4):227-36.2. Piguet V et al. Eur J Clin Pharmacol 1998;53:321-4.3. Pini LA et al. JPET 1997;280(2):934-40.4. Chandrasekharan NV et al. PNAS 2002;99(21):13926-31.OpioidsActivation ofopioid receptorsParacetamolInhibition of central Cox-3 (?)(Inhibition of PG synthesis)ParacetamolInteraction withserotoninergic descendinginhibitory pathwayNSAIDs / CoxibsInhibition of peripheral andcentral Cox-1 / Cox-2(Inhibition of PG synthesis) 7. The concept and benefits ofbalanced analgesiaThe rationale for multimodal analgesia isachievement of sufficient analgesia due toadditive or synergistic effects betweendifferent analgesics, with concomitantreduction of side effects, due to resultinglower doses of analgesics and differences inside -effect profiles1. Kehlet H et al. Anesth Analg 1993;77:1048-56. 8. Case number 1 60 years old man vehicular accident Multiple fractures Semi conscious brought in emergency 9. Issues CNS status Hemodynamics No knowledge of co morbid conditions 10. Analgesia Best-----Nerve/Plexus Blocks / Infusions Paracetamol next if LFT normal NSAID difficult choice even in normal RFT No Opioids Tramadol safe No Epidural please 11. Case number 2 40 years fat female Planned Cholecystectomy LFT borderline RFT normal 12. AnalgesiaInfiltration of wound with LA.Infiltration of chole bed with LA.Tramadol /fentanyl IV infusionNSAID round the clock. Disposable infusion pumps are of great helpMULTI MODAL AND CONTINUOUS ANALGESIATo avoid analgesic gaps 13. Case 3 30 year old female In active labor In severe pain asking pain relief Otherwise normal 14. Analgesia Epidural analgesia Walking epidural (0.125% Bupivacaine + fentanyl low dose) Infusion better than shots.Preserve pelvic muscle tone and ensure fetal head rotation 15. Golden Rules Suspecting liver dysfunction Avoid Paracetamol / Use NSAID,Tramadol,LA Suspecting Renal dysfunction Avoid NSAID / Use Paracetamol,Tramadol,LA In compromised hemodynamics Avoid opioids,NSAID. LA is safer(not centralneuraxial) 16. Case number 4 55 years diabetic lady Severe right shoulder pain and stiffness Not responding to nsaid, physiotherapy What to do ? 17. Analgesia Consider Pregabalin, Consider Tramadol and paracetamol Consider Amytryptilin low dose Consider MRI shoulder and Cervical spineLatest OptionsSupra Scapular nerve block / RF ablationCervical Facet joint denervation by RF Ablation 18. Case number 5 60 years old male Severe right knee pain Mild changes of Osteoarthritis in knee No ligament/meniscus injury Analgesics a regular need Physiotherapy not working Not yet a case for Surgery 19. analgesia Options for pain management Old Methods Intraarticular steroid Intraarticular Prolo therapy Periarticular myofascial blocks Intraarticular RF ablation 20. Analgesia Options for pain management Latest: USG guided Saphenous nerve block 21. Case number 6 Young man of 30 years Severe back pain non radiating Increased on prolonged sitting/standing MRI: black disc L 4-5 Otherwise everything normal Not responding to medicines,physio. Examination midline tenderness in low backincreasing on flexion 22. Analgesia This could be discogenic pain. (Pain from inter vertebral disc) Options are Transforaminal DRG Block(bilateral) With bilateral Gray Rami Block Or Per cutaneous disc procedures like1. Radio Frequency ablation2. Ozone nucleolysis3. Decompressor4. Nucleotomy 23. Case number 7 70 year old lady Severe back pain since three weeks Tender vertebra in mid back X ray shows L1 vertebra comression #. Cant bend either way due to pain NSAID not enough,not tolerating opioids What to do ???? 24. Analgesia Consider Percutanous vertebroplasty OR Bilateral DRG Pulsed RF Ablation at that levelOne procedure and pain / requirement of analgesics drastically goes down 25. Case number 8 65 year old retired govt. employee back pain since few months-off and on Increased on prolonged sitting and standing Radiates to thigh Paraspinal Tenderness MRI shows multiple black discs. Needing analgesics very often 26. Analgesia This could be lumbar facet joint pain due to lumbar spondylitis Consider Radiofrequency ablation of the nerves to thesefacet jointsSame rule applies for cervical spondylitis 27. Case number 9 Lady of 52 years Severe pain in back and leg Increased on walking with tingling in legs Can not stand or sit longer SLR on left side restricted MRI-L4-5 PID Not happy with analgesics and physiotherapy 28. Analgesia This is case for surgery. But if patient does not prefer surgery Consider Trans foraminal epidural steroid/Ozone treatment indisc. This may /may not need repetition. 29. Case number 10 Young boy of 28 years foot ball player Develops buttock pain radiating to thigh Mild tingling MRI normal Analgesics give temporary relief Examination: tenderness in buttock 30. Analgesia This could be muscular pain MOST likely PIRIFORMIS syndrome Consider USG guided PIRIFORMIS Injection. 31. Case number 11 Lady of 59 years Severe pain one side of face-episodic-current like-increased on chewing On medication for trigeminal neuralgia since long side effects of medicines a trouble Not ready for surgery. What to do ??? 32. Analgesia Consider Radiofrequency ablation of Trigeminal ganglionSAME WAY Pulsed RF Ablation of nerve rootscan be used for Post herpetic neuralgia 33. Case number 12 Case of CA PANCREAS with multiple metastasis SEVERE ABDOMINAL PAIN Already on fentanyl patch, morphine and still in pain What more to offer ? 34. Analgesia Consider Celiac plexus block or Radiofrequency ablation of splanchnic nervesOne procedure and pain / requirement of analgesics drastically goes down 35. Case number 13 A Chronic smoker with severe left leg pain Discoloured two fingers Pulsations in left leg less Otherwise normal Normal MRI No response to medicines What to do till vascular surgery is done ? 36. Analgesia Consider Percutaneous Lumbar sympathectomy byRadiofrequencyThis can prevent rest pain and gangrene but notclaudication. 37. Case number 14 A male of 58 years L4-5 laminectomy done before six months. Burning pain in legs and back Can not walk longer. Medicines do not work Physiotherapy done but not working. What to do?????????? 38. AnalgesiaConsider1. Epiduroscopy, epidurography and adhesinolysis2. Transforaminal Injections3. Spinal Cord stimulation implantation4. At times acupuncture and medicines help. 39. Other latest interventions Peripheral nerve stimulator implantation For conditions like Occipital neuralgia Spinal infusion pump implantation For patients on high morphine and side effects 40. NeuropathyGolden Rules1. Early use of anticonvulsants like Pregabalin2. Use of tramadol & Paracetamol as they work atspinal and central level to reduce hypersensitivity3. Amitryptelin works at spinal level in low doses4. Nerve/plexus blocks/infusions help a lot5. Pulsed Radiofrequency ablation LATESTHypersensitivity of nerves,dorsal horn and CNS is the key factor 41. Acute Pain ManagementGolden Rules1. Early and effective analgesia2. Multilodal analgesia3. NSAID + LA Blocks/Infusions+ weak/strong opioids4. Infusion is best but careful about respiratorydepression.5. PCA/PCEA alone can also be inadequate.Putinfusion in background.This will avoid hypersensitivity of nerves,dorsal horn and CNS 42. Take home message Start pain management early in acute pain. Use multimodal analgesia. Dont ignore muscular pain. There are noninvasive options of surgery which arevery effective. Use Tramadol -paracetamol combination frequently toprevent chronicity of pain. Infusions are better than SOS analgesics. Patch is better option in multiple mets patient. 43. Bottom line Never give up There is always an option available Need is to try further in spite of failures in some steps. Science is progressing fast. It offers new things always soBE OPEN to new ideas andembrace them. 44. THANKSDr Rajeev Harshe MDPhone: 9825252100Website: www.reliefpainclinic.comPain consultantApollo HospitalAhmedabad,Gujarat,India.OPD time:11 am to 5 pmRelief pain clinicGandhinagarGujarat,India.9 am to 11 am5 pm to 8 pm