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 Line

Strong opioids Tramadol

Topical Agents

Amitrip / Ketamine CR Lidocaine

1st LINE

Gabapentin 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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