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Acute Pain Management PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Acute Pain Management" to learn appropriate assessment of acute pain, concept of multi-modal analgesia (indications and side effects of analgesics), how to rationally prescribe opioids (side effects and complications of opioids), special populations, i.e., elderly, opioid tolerant and Neuraxial/regional analgesia.

Tags : Acute Pain Management, multi-modal analgesia, opioids, opioid tolerant, Neuraxial, regional analgesia

Published on : Mar 14, 2023 | Views : 1885 | Downloads : 3

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Slide 1-

Acute Pain Management
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Objectives/Discussion Topics Appropriate assessment of acute pain Concept of multi-modal analgesia Indications and side effects of analgesics How to rationally prescribe opioids side effects and complications of opioids Special populations ie elderly, opioid tolerant Neuraxial/regional analgesia side effects and complications of neuraxial analgesia interaction of various anticoagulant medications and neuraxial analgesia
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Goal To provide patients with a level of pain control that allows them to actively participate in recovery This level will be individual to each patient To minimize nausea and vomiting To minimize other side effects of analgesics Sedation Ileus Weakness Hypotension
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Why all the fuss? Pain is a miserable experience Pain increases sympathetic output Increases myocardial oxygen demand Increases BP, HR Pain limits mobility Increases risk for DVT/PE Increases risk for pneumonia, atelectasis secondary to splinting
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Assessment Intensity Location Onset Duration Radiation Exacerbation Alleviation
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How do we do it? Multimodal analgesia: Several analgesics with different mechanisms of action, each working at different sites in the nervous system Acetaminophen Non-steroidal anti-inflammatory drugs (NSAIDs) Opioids Anticonvulsants Antidepressants Local anaesthetics NMDA Antagonists Non-pharmacologic methods
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OPIOIDS Efficacy is limited by Side-Effects The harder we “push” with single mode analgesia, the greater the degree of side-effects Analgesia Side-effects
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Multimodal Analgesia Lower doses of each drug can be used therefore minimizing side effects With the multimodal analgesic approach there is additive or even synergistic analgesia, while the side-effects profiles are different and of small degree (Pasero & Stannard, 2012). Analgesia Side-effects
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Systemic Analgesia Opioids Potent analgesics Drug of choice for moderate to severe pain Unfortunately, they are often the only drug ordered Side effects:
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Opioids 10 fold variability between patients All opioids have same side effects but efficacy:side effect ratio is different for everyone Stick with what works and keep it simple Always by mouth if possible Avoid pro-drugs ie. codeine Avoid combo preparations
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Equianalgesia
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NALOXONE (Narcan) Mu opioid antagonist Dilute 1 mL of naloxone 0.4 mg/mL (ie. one vial) with 9 mL of NS for a total of 10 mL of solution and a final concentration of 0.04 mg/mL Administer 0.04 mg at a time until reversal of respiratory depression has been achieved, ie. when they’re sitting up awake and talking to you!
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NALOXONE (Narcan) REMEMBER: the half-life of naloxone is only 30 minutes, while the half-life of opioid is 2-3 hr so you may have to repeat dosing OR place pt on naloxone infusion until all opioid has been metabolized to prevent further respiratory depression
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Elderly Patient Pronounced effect therefore, lower doses Cognitive dysfunction is a major issue Organ dysfunction/insufficiency affects metabolism Interaction with other medications, increased incidence of polypharmacy
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Addiction Primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Characterized by behaviors that include one or more of the following: impaired control over drug use compulsive use continued use despite harm craving Definitions Related to the Use of Opioids for the Treatment of Pain. American Academy of Pain Medicine; American Pain Society; American Society of Addiction Medicine. 2001.
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Physical Dependence State of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
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Tolerance The body's physical adaptation to a drug: Greater amounts of the drug are required over time to achieve the initial effect as the body adapts to the intake
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Pseudo Addiction Term used to describe patient behaviors that may occur when pain is undertreated May become focused on obtaining medications, "clock watch," seem inappropriately "drug seeking." Illicit drug use and deception can occur in the patient's efforts to obtain relief Distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
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NSAIDS Work at site of tissue injury to prevent the formation of the nociceptive mediators Prostaglandins Can decrease opioid use ~30% therefore decreasing opioid-related side effects Minor surgeries can use NSAIDs instead of opioids to completely eliminate opioid-associated side effects Side effects:
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NSAIDS Newer NSAIDS selectively (primarily) inhibit cyclooxygenase-2 (COX-2) which is induced by surgical trauma with minimal effect on COX-1 which is responsible for GI and platelet side effects Celecoxib (Celebrex)
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Neuraxial TechniquesWho Gets Them? Patient factors: Low pain tolerance, opioid tolerance Sleep apnea Narcolepsy Obesity COPD Cardiac disease Elderly – those at risk for post-operative cognitive dysfunction
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Epidural Infusions Used for major surgery ie. oncologic TAH BSO, thoracotomy Ideally placed pre-operatively and used in combination with a GA for surgery and continued ~ 2 days Usually patient is tolerating diet and ambulation to chair when epidural is D/C
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Ideal Epidural Infusions When placed at the level of the incision and with a constant infusion of LA and opioid: Minimal or no pain at all, particularly with movement No motor block Can ambulate Speedier return of bowel function With more LA and less opioid –Cochrane review 2003 Less nausea Less sedation Less delerium Do not require supplemental IV opioids and associated side effects Less pulmonary complications Quicker extubation, better oxygen saturation, less pneumonia
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Side Effects of Epidural Infusions Hypotension LA causes a sympathectomy which leads to vasodilatation Mild volume depletion, which can normally be compensated for with vasoconstriction, will be unmasked with an epidural Pts require adequate volume status with an epidural
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Side Effects Hypotension Pts will initially c/o dizzyness, lightheadedness and nausea when sitting up or standing Can document orthostatic hypotension Will then progress to supine hypotension if not corrected Major problem POD #1 when 3rd spacing still occurring, minimal IV fluids infusing and pt NPO
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Side Effects Leg weakness or numbness Can occur if catheter is too low (low thoracic or lumbar) or if it is one-sided Inhibits ambulation and distressing to pt therefore must be fixed Infusion can be adjusted or catheter pulled back Must be addressed as this is the first sign of epidural hematoma leading to permanent paralysis
Slide 30-

Complications Post dural puncture headache 1:100 Only if dura is unintentionally punctured More likely in younger people Infection Some reports of epidural abscess as high as 1:1900 Usually just superficial skin infections Increased risk in immunosuppressed
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Complications Epidural hematoma Most feared complication Incidence of 1:180 000 – 1:220 000 Increased with heparin, age, gender, ASA, NSAIDs, traumatic placement, spinal stenosis Leg weakness, numbness and bladder/bowel disturbance are first signs If not evacuated within 8-12 hours, usually leads to permanent paralysis
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Complications Epidural Hematoma Risks Abnormal coagulation Elderly Female Debilitated patients Traumatic insertion Unknown spinal pathology
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Complications Anticoagulation and Epidurals: ASA – OK NSAIDS – OK UFH 5000 sc bid – OK if no other antiplatelets UFH 5000 sc tid – sort of OK, but not really (according to ASRA) LMWH (Dalteparin)– increased risk – not really OK IV heparin – not OK Clopidigrel, ticlodipine – not OK Coumadin – not OK
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Ideal Patient Care Surgeons, APMS, nursing all working for same goal Pre-operative optimization Intra-operative care Post-operative Ambulation, pain, bowels, voiding Improved patient recovery
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Addiction – proposed mechanisms Incentive sensitization Casual use sensitizes reward system high motivation to repeat rewarding behaviour for pleasurable experience Hedonic allostasis Chronic exposure and production of stress factors and negative emotional state, withdrawal and anxiety Use to avoid negative-affect state Mesocorticolimbic dopamine system Wand, G. (2010). The influence of stress on the transition from drug use to addiction. National institute on alcohol abuse and alcoholism: National Institute of Health.
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Addiction – proposed mechanisms Positive reward Reward system responds – corticotropic releasing factors and stress factors reduced End of drug salience Dopamine reward threshold increases, pleasure decreases Drug use based on negative affect and stress Modulation of withdrawal, stress and anxiety Wand, G. (2010). The influence of stress on the transition from drug use to addiction. National institute on alcohol abuse and alcoholism: National Institute of Health.
Slide 37-

Dependence and Tolerance Opioids bind to Mu receptor [all are Mu agonists] Dopamine release into Nucleus Accumbens
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Dependence and Tolerance Repeated use – Mu receptors become downregulated Same mechanism as end of drug salience – tolerance
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Dependence and Tolerance More receptors created to accommodate chronic use = more that become unbound when brain/blood levels decrease Excessive norepinephrine release & low dopamine levels Withdrawal occurs Kosten, T., George T. (2001). The neurobiology of opioid dependence: implications for treatment. Science & Practice Perspectives, 1, 13-20.
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Acute Pain Management Service (APMS) Consulting service, mostly post-op patients PCAs, non-labour epidurals, regional techiques Don’t need to co-sign our orders Can’t order any analgesics, anti-emetics, antihistamines, neuropathic pain agents, or sedatives while patient being followed by APMS “Suggest Orders” once APMS signs off DO need to be co-signed