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Pain Management in the
Acute Setting
2012 MN Affiliate of NACNS
Conference
Debra Drew, MS, RN-BC, ACNS-BC
Sara Hall, MS, RN-BC, ACNS-BC
University of MN Medical Center, Fairview
Objectives
• Compare and contrast characteristics
of acute and chronic pain.
• Identify multimodal analgesics in
acute pain management.
Acute
vs
• Acute pain due to
surgery, trauma, injury,
medical process (MI,
kidney stone, ischemic,
etc)
• Usually known cause
• Expected timeline with
beginning, middle and
end (less than 3 months)
• Decreases with healing
Chronic Pain
• May be elicited by injury or
disease but sometimes cause is
unknown
• Environmental, emotional, and
cognitive factors will contribute
to persistence of pain and
associated illness behaviors
• Persists for a long period of
time : months, years…
• Low level of underlying
pathology that does not explain
presence or extent of pain
•
Fishman et al, 2010.
Pathophysiology of Acute Pain
• Sources: Nociceptive, neuropathic, muscle, bone
• Basic Process of Normal Pain Transmission
 Transduction: Damaged cells release sensitizing
substances to initiate action potential
 Transmission: Action potential from injury site ascends to
brain
 Perception: Conscious experience pain
 Modulation: Inhibition of nociceptive impulses
• Different than chronic pain
McCaffery & Pasero, 1999
Importance of treating acute pain?
• Uncontrolled acute pain triggers a physiologic stress
response involving multiple systems
• Adequate control leads to earlier mobilization and less
complications from surgery
• Prevent persistent postsurgical chronic pain-incidence
between 20-50% following major surgery
• May lead to shorter hospital LOS=reduced health care
costs
• Increase patient satisfaction
Kahlet, 2006
UMMC Preoperative Pain Consult (POPC)
• Identification of complex patients with a high risk for a
poor response to traditional post-operative pain
management protocols.
• Provision of a pain management assessment 1-2 weeks
prior to surgery.
Population Studied
Elective Lower Extremity Inpatient
Procedures: March 2011-March 2012
Average Length of Stay in Days
Severity of Illness
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
6.00
6%
40%
4.88
5.00
77%
75%
4.00
60%
4.38
3.53
3.00
Test
Minor
19%
23%
Control Similar
Control Dissimilar
Moderate
Major
2.00
1.00
0.00
Treatment
Control A
Control B
Financial Analysis
POTENTIAL SYSTEM
SAVINGS:
20% of approximately 3500
patients
x(Test-Similar Control) Case Cost
$5.83 Million savings*
*while preserving the same contribution
margin as the healthier 80% of the
population!
Central Sensitization
After long-lasting nociceptive stimulation:
• Primary afferents terminating in spinal cord sprout new
connections between neurons
• Inhibitory interneurons die from excessive activation of
NMDA receptors
• Clinically, one sees hyperalgesia +/- allodynia
Van Wilgen & Keizer, 2012
Hierarchy of Pain Assessment
In Order of Most Reliable to Least Reliable Measures
1.
2.
3.
4.
5.
Patient’s self-report is the most valid and reliable
measure of pain existence and intensity.
Pathologic conditions or procedures that usually
cause pain
Observe Behaviors (e.g. facial expression, body
movements, crying)
Proxy ratings. Report of pain from
parent/family/others close to patient.
Physiologic measures: Least sensitive measure of
pain existence and intensity. Conclusion: inappropriate
to rely solely on physiologic data to measure pain.
Herr et al, 2011
Self Reported
Elements of a Pain Assessment
Location: where, more than one
location?
Duration: when did it start?
Intensity: how much does it hurt?
Description: what does it feel like?
Aggravating/relieving factors : what
helps/or doesn’t help?
Selected Pain Assessment Tools
Numerical Rating Scale (NRS)
 0 – 10 where 0 is no pain and 10 is the worst pain imaginable
Word Scale: “no pain, mild, moderate, severe”
Faces Scale
 Visual depiction of pain severity
 Used with younger children
FLACC
 Behavioral assessment based on facial expression, leg and arm
movements, cry, and consolability
 Preverbal children and infants
 Unable to self-report
FLACC Scale
Functional Assessment
Evaluate impact of pain on physical function, quality
of life and ability to perform ADLs
• Self care abilities
• Rehab activities
• Physical therapy
• Occupational therapy
• ADLs
Comorbidities of Substance Abuse
or Mental Illness
• Acute care setting is not the environment to successfully
treat substance abuse or mental illness
• Patients with acute pain and disease of addiction should
be given appropriate multimodal analgesics which may
include opioids.
• Severe depression and anxiety must be treated for
successful pain management.
Drew & St. Marie, 2011
Preemptive Analgesia for Post op Pain
• Use of medications prior to surgery to reduce post op
pain
• Help reduce central sensitization
• NSAIDs, gabapentinoids, NMDA receptor antagonists,
opioids
• Literature is non-conclusive, however clinically see a
difference
Moiniche, 2002
Perioperative Medications
• Use Multi-modal Analgesia-using two or more analgesic
agents with different mechanisms of action
• Have a synergistic effect leading to better analgesia
•
•
•
•
Opioids-multiple formulations
Nonopioid analgesics (NSAIDs, acetaminophen)
Coanalgesics/adjuvant analgesics
Need to adjust for age (neonate to elderly), renal and
hepatic impairment, individual responses, other
comorbidities, potential drug interactions
Pasero, 2012
Opioids
• MUST use an equianalgesic conversion guide that is
trustworthy
• American Pain Society-Principles of Analgesic Use in
Treatment of Acute Pain and Cancer Pain (6’th edition)
• Account for prior to admission doses of opioids in post op
requirements
• Pt was taking 12 tablets of oxycodone/acetaminophen
(5/325) on a daily basis prior to admission. This would be
converted into hydromorphone basal rate of 0.2 mg/hr.
Equianalgesic Conversions
Opioid-Induced Hyperalgesia
• Opioids can cause an increase in sensitivity to painful
stimuli
• Seems paradoxical
• Hallmarks: Increased pain intensity and spread of pain
beyond initial area
• Treatment: Reduction of opioid by tapering down or
rotating, NMDA-Receptor Antagonists, alpha-2 agonists
• Use of dexmedetomidine to “reboot” opioid tolerance
• Seen with intraoperative administration of remifentanil in
humans
Koppert, 2007
Nonopioid Analgesics
• New: Intravenous acetaminophen –approved in Nov 2011
by FDA for both adults and pediatrics (Ofirmev®)
 Useful when pt is NPO or nauseated from surgery
 Quicker onset of action compared to oral
• NSAIDs (ketorolac, ibuprofen, naproxen, celecoxib)
• Have an opioid dose-sparing effect
• Do not produce respiratory depression
• Do not impair GI motility
Pasero, 2012
Coanalgesics
• Anticonvulsants
• Antidepressants
• Steroids
• Muscle Relaxants
• NMDA receptor antagonists-Ketamine
• Dexmedetomidine-Opioid-Induced Hyperalgesia
• Antihistamines
• IV Lidocaine-start intraop and infuse for 24 hours
following. Most effective for abdominal surgery.
McCarthy, 2010
Methadone:
used in two different ways
1. Methadone-maintenance: used to maintain
sobriety from other opioid-like drugs (eg
heroin, opioids). Dosed once daily by
methadone maintenance clinic. Continue
during hospitalization. PO or IV.
2. Analgesia: pain management. Dosed BID to
QID.
Buprenorphine
• May be used for substance dependency, similar to
methadone maintenance therapy
• Need a special certification to prescribe for dependency
• Suboxone® (buprenorphine/naloxone) or Subutex®
(buprenorphine)
• Mixed opiate receptor agonist-antagonist: Partial µ
agonist and ĸ-receptor antagonist
• High affinity for the µ receptor
• Less respiratory depression than regular opioids
Buprenorphine
• Can last 48-72 hours, ceiling effect, 32 mg/day
• Restarting maintenance therapy, need to be off all pure µ
agonists for 1-2 days, have mild withdrawal before
restarting. If start too soon, will have severe opioid
withdrawal symptoms.
• Routes: sublingual, intravenous, transdermal, others in
Europe
• What does that mean for clinicians?
• Need to have a solid plan in place for pt on discharge
Alford, 2006
Spinal and Local Analgesia
• Regional Analgesia:
– Neuraxial (Intraspinal) Infusions
• Epidural
• Intrathecal
• Single injections
– Continuous Nerve Infusions
• Paravertebral, Intrascalene, Transabdominus Plane (TAP)
• Local Analgesia:
– Continuous infusions into subcutaneous tissue (wound or
incisional bed)
Anatomy of Epidural and Intrathecal Spaces
Topicals
• Morphine 0.1% weight to weight in Intrasite® gel. Used
in open painful wounds.
• Gabapentin 8% in PLO® gel.
• NSAIDS:
 Ketoprofen 10% in PLO® gel.
 Diclofenac (Flector® patch)
• Lidocaine patch (Lidoderm®)
Nonpharmacological Measures
Cognitive Behavioral Therapies:
 Hypnosis, distraction, imagery, humor
 Music Therapy
Cutaneous Stimulation
 TENS
 Massage
Energy Therapies
 Acupuncture, acupressure
 Healing Touch, Reiki therapy
Aromatherapy
Summary
“The problems within pain management care in our health
care system can no longer be viewed as problems to be
solved. Instead, they must be viewed as opportunities to
change perspectives and further understanding of
humanity, the environment, and the world.”
St.Marie,2010
References
• Alford, D.P., Compton, P., & Samet, J.H. (2006). Acute Pain Management for
Patients Receiving Maintenance Methadone or Buprenorphine Therapy.
Annals of Internal Medicine, 144, 127-134.
• American Pain Society (APS) (2008). Principles of analgesic use in the
treatment of acute pain and cancer pain, (6’th ed.) Glenview, IL: APS.
• Drew, D.J. & St. Marie, B.J. (2011) Pain in critically ill patients with substance
use disorder or long-term opioid use for chronic pain. Advanced Critical
Care, 22(3), 238-254.
• Fishman, S.M., Ballantyne, J.C., & Rathmell, J.P. (2009). Bonica’s
Management of Pain. (4th ed.) Lippincott Williams & Wilkins.
• Herr, K., Coyne P.J., McCaffery, M., Manworren, R., & Merkel, S. (2011) Pain
assessment in the patient unable to self-report: Position statement with
clinical practice recommendations. Pain Management Nursing,12(4),230250.
References
• Kehlet, H., Jensen T.S., & Woolf, C. (2006). Persistent postsurgical pain:
Risk factors and prevention. The Lancet, 367(9522), 1618-1625.
• Koppert, W. & Schmelz, M. (2007). The impact of opioid-induced
hyperalgesia for postoperative pain. Best Practice & Research Clinical
Anesthesiology, 21(1), 65-83.
• McCaffery,M., & Pasero, C. (1999). Pain: Clinical Manual.(2nd ed.) Mosby:
St. Louis, MO.
• McCarthy, G.C., Megalla, S.A., & Habib, A.S. (2010). Impact of Intravenous
Lidocaine Infusion on Postoperative Analgesia and Recovery from Surgery.
Drugs , 70(9), 1149-1163.
• Moiniche, S., Kahlet, H., & Dahl, J.B. (2002). A Qualitative and Quantitative
Systematic Review of Preemptive Analgesia for Postoperative Pain Relief.
Anesthesiology, 96, 725-741.
• Pasero, C. & Stannard, D. (2012). The Role of Intravenous Acetaminophen
in Acute Pain Management: A Case-Illustrated Review. Pain Management
Nursing, 13(2), 107-124.
References
• St.Marie, B. (2010) Core Curriculum for Pain Management Nursing. 2nd ed.
Kendall Hunt Professional.
• Van Wilgen, C.P., & Keizer, D. (2012). The sensitization model to explain
how chronic pain exists without tissue damage. Pain Management Nursing,
13, (1), 60-65.