Transcript Milestones of Acute Pain Medicine at

Prof. Krishna Boddu
.
MBBS, MD, DNB, FANZCA, MMEd
University of Texas Health Sciences at Houston, Texas, USA
University of Western Australia, Perth, Australia
Director, Regional Anaesthesia, Royal Perth Hospital, Perth, Australia
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Patient’s
Friends
Our staff
Patient’s
Colleagues
Our
Patients
Patient’s
Family
All the people who are concerned about this patient 2
Pain Control With an aim to Improve Functionality
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•
•
•
•
No pain/suffering during and after intervention
– welcomes you without fear and
anxiety of pain
Minimal/ no side effects from pain meds
Functionality maintained during and after
intervention
Cheerful and happy
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Acute Post-op Pain or
Pain after Injury
Interventional ± Opioid
± Non-Opioid
Strong Opioid + Non-Opioid
Weak Opioid + Non-Opioid
Non-opioid
Pain Rx in the
Community
&
Clinics
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Biological
•DVT, PE
•Pneumonia
•Poor wound healing
•Chronic Pain
•Angina & MI
Social
•Delayed Rehab
•Prolonged Hosp Stay
•Increased Readmission
•Increased Cost
Psychological
•Anxiety
•Dissatisfaction
•Depression
•Lack of motivation
•Effects of Family
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Ask Every Patient:
1. PPG (Personalized
Pain Goal) is
Important
2. Pain at Rest
(Static Pain)
Not of much value
3. Pain on Activity
Dynamic Pain
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
Background pain

Procedural pain

Breakthrough pain

Post procedural pain
Background Pain
Procedural Pain
Breakthrough Pain
POST INTERVENTIONAL PAIN IS OFTEN NEGLECTED
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1. Four grams of Paracetamol / Acetaminophen (IV/PO)/day
2. NSAIDs (Parecoxib, Celecoxib, Diclofenac Na etc.)
3. Pregabalin 75-600mg/day
4. Lidoderm Patch
5. Ketamine
6. Clonidine
7. NERVE BLOCKS
BENZODIAZEPINES ARE NOT ANALGESICS
????. Tramadol along with antiemetic (SR or IR 400mg/day)
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Suffering
Activity
Medication
Activity
ORDER
ONLY ONE PRN
MEDICATION PER
INDICATION
Relief
Activity
Activity
Activity
Activity
Regular/ Scheduled Medication
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No Background Pain
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Baseline Pain Medication
No Background Pain
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Biggest Fears In Treating Pain
Respiratory Depression
Nausea & Vomiting
Addiction
Under Treated Pain
Leads To
“Pseudo Addiction”
Behavior
Most of the fears related to “Opioids”
Severity of Side Effects are dose related
Physical dependency is not addiction
Most Side Effects can be effectively
minimized by “Multimodal approach”
• And by Educating Patients & Providers
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PCA Dose
Lockout Interval
(LOI)
Pain down to
patient’s
satisfaction?
Is the pain
relief lasting
till next dose?
Basal Rate
• Needing to press
button many times
• LOI <8min
• Waking up with pain
Encourage
Increase
PCA Dose
by 50 or
100%
Encourage
Decrease
LOI
• >7 day use of opioids
prior to surgery
• Opioid abuse
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PRN Dose
Dose Interval
Pain down to
patient’s
satisfaction?
Is the pain
relief lasting
till next dose?
ATC, ER or
Patches
• Needing to take all
PRN doses
• PRN dose interval
needing <3 hours
• Waking up with pain
Encourage
Increase
PRN Dose
Encourage
Decrease
Dose
Interval
• >7 day use of opioids
prior to surgery
• Opioid abuse
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Look for
Over dose
50-60 % of 24 h
consumption as
basal/ ER in
divided doses
60-70% of 24 h
consumption as
PRN doses
In Next Visit
Continue the
same PRN
doses
Increase Basal
/ER by 40-50%
of 24hr PRN
Consumption
Calculate 24 hr
PRN Opioid
Consumption
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Dose, Frequency, Peak levels &
Steady State
Plasma Concentration of drug
Toxic Level
Respiratory Depression
Plasma Level Required
For Pain Relief
Time in hours
Half Life 3 hours
Avoid Toxic Levels With
Multimodal Approach
Toxic Level
Respiratory Depression
Plasma Level Required
For Pain Relief
First Optimize
Non Opioids:
Local Anesthetic
Acetaminophen
NSAIDs
+
Neuropathic Pain
Medication
Serious
Adverse
Effects
Opioid Dose
Pain Free: Trust the Patient
Pain
Intensity
Time
What if Patient Getting Sedated with
Poor Pain Control: ? Look at other systems
? Neuropathic Pain
? Drug Interaction
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OurOur
Pledge
Pledge
to Primary
to Patients
Team
We are available
24/7
canbebe
•• Everything
Possible
will
reached
instantaneously
Done
to Provide
Pain Relief
Safely to Your Satisfaction
• We Accept Shared
with You and
•Accountability
We focus on “Improving
YourFunctionality”
Team
your
We Educate
Primary Nurses
•• Our
team is available
24/7
& be
Team
rather
to
reached
bythan
yourjust help
them byNurse
treating
patient
Primary
or Primary
Team
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Thank You
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