Transcript Post-op pain management - International Pain School

International Pain School
Management of Post-Operative Pain
using low technology methods
type in your name
type in name of your institution
Topics to be discussed in this talk
• Why should acute pain be treated?
• How to assess acute pain?
• How can you manage acute pain?
• How can you organize management of acute pain within
your hospital?
Why should
acute pain be treated?
Why should acute pain be treated?
True or false?
• Pain is a natural, inevitable, acceptable and harmless
consequence of surgery and trauma.
• Under-treatment of severe pain has no adverse
consequences.
Why should acute pain be treated?
1. For ethical and humanitarian reasons
2. To reduce the severity of associated adverse
physiological & psychological factors
3. It might decrease the risk of developing
chronic pain.
Each of these issues will be addressed in the following
slides.
Why should acute pain be treated?
1. For ethical and humanitarian reasons
• Relief of suffering, caused by pain, is the chief and un-disputed
benefit of pain treatment.
• Providing effective pain management is a professional
responsibility, the duty of healthcare professionals.
– Under-treatment of pain is poor medical practice.
• Organizations such as the International Association for the Study
of Pain, European Federation of IASP Chapters and Human
Rights Watch, have issued statements identifying access to pain
management as a fundamental human right.
Why should acute pain be treated?
2. To reduce severity of adverse physiological effects
Major body
systems are
negatively
affected by
acute pain
Why should acute pain be treated?
3. To reduce the severity of adverse psychological factors
Untreated pain can lead to
or increase:
•
patient anxiety or fear
•
sleeplessness leading to fatigue
When these psychological factors
are lessened, they might lead to
decreased sensation of pain.
Why should acute pain be treated?
4. It might increase the risk of developing chronic pain.
Although in most patients the pain resolves with time, some patients
(~1 in 10 - 20) will develop chronic pain after surgery
or injury
•treatment will be necessary in about 50% of these patients.
The risk of developing chronic pain might be higher in those patients
who had severe pain after surgery.
• Chronic pain is difficult to treat.
• Don‘t withhold strong opioids from patients after surgery, the risk of
developing addiction in these patients is negligible.
How to assess acute pain?
How to assess acute pain?
Cons for measuring pain
• The experience of pain is too complex to be assessed.
• It‘s a waste of time & the information is useless - one patient‘s ‘5‘ is
not the same as another patient‘s ‘5.‘
• Health professional can appreciate the level of pain of the patient
because of their experience
How to assess acute pain?
Pros for measuring pain
• Provides information whether there is a problem
• Determines its severity
• Guides treatment options
• Assesses the effectiveness of therapy & if there is a need
to change it
• Is reliable when carried out using standardized methods
Does this patient feel pain?
How to assess acute pain?
Ask the patient: make pain visible
• Pain is always subjective.
• Behavior does not necessarily reflect if a patient is
experiencing or not pain
– people can sleep, laugh, talk and yet experience pain
– Discrepancy between pain vs extent of injury is common
– Inter-individual variations are common.
How to assess acute pain?
Ask the patient: make pain visible
• There is no test or equipment for measuring pain.
• As pain is a multi-dimensional experience
– there is often a poor correlation between the staff‘s
estimate and that of the patient.
– BUT clinicians must accept a patient‘s report of pain.
Believe the patient! There are no biological markers for pain.
How to assess acute pain?
Ask the patient: make pain visible
• Unless asked specifically, patients tend to tolerate
unrelieved pain silently
• As pain is recognized predominantly through
a patient‘s report:
– patients who have difficulty communicating are at risk
for under-treatment
– groups at risk: patient who speak a different language,
elderly, cognitively impaired, children.
How to assess acute pain?
Summary: Pain scales are useful tools that help to …
… Recognize pain
• No biological markers
• Discrepancy pain / injury
• Inter-individual variations
… Adapt treatment
• Choice of treatment and dose
• Efficacy
… Improve communication
• Patients communicate pain intensity
How to assess acute pain?
Numerical scale
Most children over 7 years old & communicating adults can
use a numerical scale.
When acute pain is evaluated - the dimension of
‚intensity‘ is assessed.
How to assess acute pain?
Simple Verbal pain scale
1. no pain
0
2. mild pain
+
3. moderate pain
++
4. severe pain
+++
How to assess acute pain?
Assess pain at rest AND movement
• When in pain, patients tend to refrain from moving / taking
a deep breath / coughing.
• Asking only ‚how much pain do you have?‘ refers to pain
during rest, that is typically low.
How to assess acute pain?
Assess pain at rest & movement
Ask:
(1) How much pain do you have when you are at rest?
AND
(2) How much pain do you have when you move in bed / sit
up / get out of bed (= orthopedic patients)
How much pain do you have when you take a deep breath
OR cough (= general surgery patients).
OR to swallow (= patients after tonsillectomy)-
i.e. ask the patient to carry out an activity which is related to
the surgery.
How to assess acute pain?
please remember …
• If the cause of acute pain is unknown – establishing the
cause of the pain is a priority but symptomatic treatment of
the pain should be initiated.
• It is rarely justified to defer treatment until the cause of the
pain is known.
• A comfortable patient will be able to cooperate with the
diagnostic procedures.
How to assess & record acute pain?
Recording : make pain visible
How to assess acute pain?
No evaluation
=
No treatment of pain
How to assess acute pain?
How to treat
post-surgical pain?
How to treat post-surgical pain?
Mild pain
1–3
Moderate pain
4–6
Severe pain
7 – 10
Paracetamol
Paracetamol
Paracetamol
+
NSAID (if no CI)
+
NSAID (if no CI)
+
NSAID (if no CI)
+
+
infiltration with LA
Codeine or Tramadol
+
Morphine
+
infiltration with LA
CI= contraindication; LA = local anaesthetic
+
infiltration with LA
How to treat post-surgical pain?
When to start pain management?
• Pre-operatively
– Discuss options with patients
– Teach about assessment, treatment options
– Pre medication with paracetamol
• Intra-operatively
– Wound infiltration with local anaesthetic (surgeon)
– Administer analgesics (IV or rectally)
How to treat post-surgical pain?
When to start pain management?
• Post-operatively – recovery room AND ward
– Give analgesics at regular intervals – not as needed
– Combine opioids with non-opioids
– Titrate according to needs of individual patients – one
dose does not fit all!
– Duration of treatment will depend on the type of
surgery and the patient’s individual requirements.
How to treat post-surgical pain?
Which route?
• Oral (PO)
– route of choice: simple, effective, well tolerated.
– Suitable as soon as the patient is able to tolerate oral
fluids.
• Intra-muscular (IM)
– Injection painful and absorbtion un-reliable.
– Should be not be used as a route for giving analgesics.
How to treat post-surgical pain?
Which route?
• Sub-cutaneous (SC)
– Route of choice if oral route is not possible
– Avoid for long term, repetitive dosing
• Intra-venous (IV)
– Allows for rapid titration.
– Allows for continuous OR bolus administration
– requires monitoring!
How to treat post-surgical pain?
Analgesics for post-operative use
Drug
Dose
Route
Frequency
Paracetamol
1g
p.o., i.v., rectal
q.i.d
50-100 mg
q.i.d
b.i.d or t.i.d
50-100 mg
p.o.
i.m.
i.m. or i.v.
(codeine) *
30 mg
p.o.
q.i.d
tramadol
(pethidine) *
50-100 mg
25-150 mg
p.o. or i.v.
i.m.
t.i.d or q.i.d
t.i.d or q.i.d)
morphine
10 (IR), 30mg (SR)
p.o.
Every 4 hours
10 mg
sc
Every 4 hours
1mg/kg
Wound infiltration
End of surgery
NSAID’s
ibuprofen
diclofenac
ketorolac
75 mg
Opioids
bupivacaine
b.i.d. –X2 daily; t.i.d. X 3 daily; q.i.d. – X4 daily
Caution !
• Codeine
– Its metabolism is highly variable and might result in
severe overdosing.
– Use only when no other opioid is available.
• Pethidine
– Accumulation may cause CNS-related side effects.
– Use only when no other opioid is available.
How to treat post-surgical pain?
Paracetamol
• Provides a mild analgesic effect
• Low toxicity
• No difference in quality of analgesia when given IV vs PO
– but is more expensive
• For short surgical procedures possible to give 1gr PO with
a little water 1/2 hour before the surgery.
• After minor surgery:
– if given as sole analgesic and pain is not relieved –
after 30 – 45 minutes - combine with another nonopioid or opioid.
How to treat post-surgical pain?
Non Steroidal Anti Inflammatory Drugs (NSAIDs)
• NSAIDs can be effective on their own for mild
or moderate pain OR combined with an opioid
for severe pain
• Mechanisms of action different from paracetamol
• Effective for treatment of inflammatory and bone pain.
• Administer a dose before the end of a procedure
• Synergistic effect with paracetamol and/or opioid.
• Asses patient for contraindications or precautions.
How to treat post-surgical pain?
NSAIDs
Contra-indications
• Hypersensitivity to NSAID (NSAID induced asthma, rhinitis,
nasal polyps, allergic or anaphylactic reactions)
• Peptic ulcer
• Renal impairment
• Clotting disorders
• Congestive heart failure and other cardiovascular
diseases.
How to treat post-surgical pain?
NSAIDs caution in patients with
Hypertension, hypovolemia, dehydration, severe malnutrition
• Sepsis
• During pregnancy particularly 3rd trimester
Side effects are linked to the dose and the duration of
the treatment
Do not exceed 7 consecutive days of treatment.
How to treat post-surgical pain?
Opioids (overview)
• Opioids offer the most effective analgesia for
moderate to severe pain.
• Morphine is the opioid of choice for peri-operative analgesia
• When administered correctly - opioids used for treatment of
pain do not induce addiction.
• Opioid should be combined with non-opioids
• There is no ceiling effect for opioids and dose should be
tailored to patient / pain response however, if large doses are
being administered, consult a pain specialist for alternatives.
How to treat post-surgical pain?
Opioids (overview)
• Respiratory depression can occur in overdose. It is preceded
by sedation which should be detected
• Frequent side effects are nausea vomiting
• Opioid induced bowel dysfunction (constipation / ileus) may
become a problem.
– Less typical after short term treatment, as is common
after surgery.
• Availability is problematic in some countries
How to treat post-surgical pain?
Tramadol
• Step 2 analgesic
• Analgesic (opioid and monoaminergic)
• 5 to 10 times less potent than morphine
• Risk of respiratory depression negligible
• Easier to import than morphine
• Not in the WHO list of essential medicines
How to treat post-surgical pain?
Tramadol – Contra–indications , precautions
• Do not administer in patients at risk of seizures.
• May cause dizziness, nausea, vomiting, sweating, dry mouth
• Do not combine with other level 2 analgesics.
• IV : infuse over 20-30 min rather than bolus injection
• Pregnancy and breast-feeding:
– risk of adverse effects at the end of 3° trimester and during breast
feeding.
– Administer with caution for a short period at the lowest effective dose
and monitor the child
How to treat post-surgical pain?
Codeine
• Step 2 analgesic
• weak opioid: 5 – 10 times less effective than morphine
• No injectable formulations
• Remember
– Codeine’s metabolism is highly variable and
might result in severe overdosing.
– Use only when no other opioid is available.
How to treat post-surgical pain?
Codeine – Contra-indications, precautions
• Do not administer to patients with asthma, COPD, emphysema
• May cause constipation, dizziness, nausea, vomiting, dry
mouth, rarely respiratory depression
• Reduce dose in patients with renal or hepatic impairment and
elderly.
How to treat post-surgical pain?
Codeine – Contra-indications, precautions
• Pregnancy : No CI but possible newborn withdrawal syndrome
when administered in large doses in 3° trimester
• Breast feeding: Administer with caution for a short period at
the lowest effective dose and monitor the child
How to treat post-surgical pain?
Morphine and addiction
• Used correctly, opioids do not induce addiction in patients
after surgery.
• Pseudo addiction may appear when pain is not adequately
treated
How to treat post-surgical pain?
Common opioid-related side effects
Nausea & vomiting
• give an anti-emetic
– E.g. metoclopramide: Adult : p.o. 15 - 30 mg / day in 3
divided doses
– Child ondansetron : p.o. 50-100 mcg/kg
Constipation / ileus
– Normally not a problem in the first 48 hours of use;
– After 48 hours: give agents such as bisacodyl (child 5
mg at night, adult 5-10 mg) OR an osmotic laxative
such as lactulose and hydration.
How to treat post-surgical pain?
Less frequent opioid related side effects
Neurologic
• abnormal drowsiness = warning sign of early respiratory
depression
Respiratory
• respiratory depression (bradypnea, apnea)
Onset of excessive drowsiness indicates an overdose and often precedes the
onset of bradypnoea (abnormally slow irregular breathing rate of less than 8
respirations per minute).
Oxygen saturation may be an un-reliable indicator, especially if the patient is
receiving supplemental oxygen.
How to treat post-surgical pain?
Assess sedation & respiratory depression
• Monitor sedation regularly to avoid development of
respiratory depression
• Use a ‘sedation score‘.
How to treat post-surgical pain?
Assess sedation & respiratory depression
Intervene
Observe
Sedation score
Respiratory score
S0
Awake
R0
Regular respiration, no
breathing difficulty and
RR ≥ 10/min
S1
Intermittently drowsy, easily
awakened
R1
Snoring and RR ≥ 10/min
S2
Drowsy most of the time,
responds to voice
R2
Irregular respiration,
obstruction, chest indrawing,
RR < 10/min
S3
Drowsy most of the time,
responds only to physical
stimulation
R3
Respiratory pauses,
apnoeas
How to treat post-surgical pain?
Management of Sedation
• Sedation can occur even with the first dose
of an opioid.
• A sedation score of 2 is an early sign of respiratory
depression and should be taken seriously.
How to treat post-surgical pain?
Management of Sedation
• Administer oxygen by face mask
• Monitor pain & sedation score
• Withhold next dose of opioid
• When the patient is alert, opioids can be resumed for pain
relief, at a lower dose and at longer intervals
• Assess for hepatic and / or renal impairment
How to treat post-surgical pain?
Management of respiratory depression (1)
• Call for help
• Administer oxygen by face mask at 10 L / min
• Stimulate the patient and encourage him to breath if he can be aroused.
• Dilute naloxone 0.4 mg in 4 ml of water or normal saline.
• Administer naloxone 0.1 mg (1 ml) every 1 – 2 minutes until the patient
wakes up or the respiratory rate is greater than 10 / min
Continue to monitor the sedation score and respiratory rate every half
hour for at least another 4 hours
• An infusion of low dose naloxone may be used
– This will reverse the analgesia.
How to treat post-surgical pain?
Management of respiratory depression (2)
Naloxone
•The half-life of naloxone is ~30 – 81 minutes;
•This is shorter than the half life of some opioids, e.g.
morphine for morphine ~ 2 -3 hours.
• When using naloxone to antagonize the respiratory
depression of morphine patients should be monitored for
at least 4 hours.
How to treat post-surgical pain?
Severe pain (8 – 10 / 10) requires emergency treatment
Titrate for rapid control of pain
•Give e.g. IV morphine 2 – 3 mgs every 5-10 minutes
until relief is obtained
•Maintain analgesic plasma levels by regularly timed doses
of morphine subcutaneous or p.o.
How to treat post-surgical pain?
Severe pain (8 – 10 / 10) requires emergency treatment
Prerequisite conditions for IV treatment
• Healthcare providers trained in emergency
airway/respiratory care
• Resuscitation equipment (Ambu bag, masks, suction)
• Naloxone
How to treat post-surgical pain?
Key points to remember
• Treatment is more effective when given before the
pain starts or becomes severe.
• Prescription of analgesic drugs should be systematic –
give medication at fixed times but also option for additional
doses in the event of breakthrough pain.
• Oral form should be used as soon as patients can drink.
• Aim to provide multimodal analgesia.
How to organize postoperative
pain management
within your hospital
How to organize postoperative pain
management within your hospital?
„It is being increasingly recognized that the solution to the
problem of inadequate postoperative pain relief lies not so
much in development of new techniques but in development
of a formal organization for better use of existing
techniques.“
Rawal N, Berggren L. Pain. 1994 Apr;57(1):117-23.
How to organize postoperative pain
management within your hospital?
• Ensure the hospital has WHO essential medications,
as a minimum
• Provide education for medical & nursing staff & patients
• Standardize treatment by preparing local protocols & get
staff to follow them
• Implement routine quality assessment
How to organize pain management within
your hospital
1. Ensure hospital has essential medications
Opioids are a necessity to provide
adequate management of
post-operative pain
• Find out regulations about prescription of opioids in your
country.
• If necessary, get a licence to prescribe opioids.
How to organize pain management within
your hospital
2. Education
One of the best recognized barriers for providing
good management of pain is inadequate knowledge about
pain and its management and misconceptions on behalf
of medical & nursing staff, patients & their families.
How to organize pain management within
your hospital
2. Education - possible solutions
Staff
•Participate in a course like prepared here.
Patients
Teach them:
• How to assess pain
• That they should inform the staff when they are in pain and
when they experience side effects.
• That dependence or tolerance to medications are rare when
treating acute pain.
How to organize pain management within
your hospital
2. Education - possible solutions
How to teach?
•Verbal & written (e.g. pamphlet or poster).
– ~ 30% of patients forget the information given to them.
•Remind staff to repeat the information - patients remember
only a small part at any one time.
How to organize pain management within
your hospital
3. Standardization
• Consider preparing standard order sheets or local
protocols for surgical units AND recovery
How to organize pain management …
3. Standardization – examples
• Medication orders & patient assessment:
– Analgesics & treatment of side-effects
• e. g. unless contraindicated, all patients after
surgery receive 1 gr paracetamol X 4 daily.
– Monitoring
• e.g. pain is assessed once every shift & after
provision of an analgesic.
How to organize pain management …
4. Quality assessment
• Quality improvement = evaluation of what you do to improve
what is not so good
• Different aspects of care can be evaluated
– Processes: is pain assessed routinely? Is multimodal
analgesia provided?
– Patient‘s outcomes: pain intensity, side effects,
satisfaction
– Organization: protocols, drug availability
• Choose important criteria for you
• Choose criteria that you can measure
• Compare your ward over time and with other wards.
How to organize pain management …
4. Quality assessment
example of
an audit
Summary 1
• Pain after surgery and trauma can be harmful.
• Under-treatment of pain can have adverse consequences.
• Providing effective pain management is a professional
responsibility of clinicians.
Summary 2
• Assessing pain using standard tools is important
– It makes pain visible and guides treatment.
– If the patient is communicative – rely on his report.
– If non–communicative initiate treatment & carry out
regular follow-up yourself.
– If the patient reports pain (e.g. >= 4/10) – provide
treatment !
Summary 3
• Aim that your hospital has the essential analgesics
to provide treatment.
• Use the WHO Essential Medicine list as a guide.
• Morphine is an essential medicine for treating
severe pain.
This talk was originally prepared by:
Dominique Fletcher, M.D, Garches &
Xavier Lassalle, RN, MSF
Paris, France
International Pain School
Talks in the International Pain School include the following:
Physiology and pathophysiology of pain
Nilesh Patel, PhD, Kenya
Assessment of pain & taking a pain history
Yohannes Woubished, M.D, Addis Ababa,
Ethiopia
Clinical pharmacology of analgesics
and non-pharmacological treatments
Ramani Vijayan, M.D. Kuala Lumpur, Malaysia
Postoperative – low technology treatment methods
Dominique Fletcher, M.D, Garches & Xavier
Lassalle, RN, MSF, Paris, France
Postoperative– high treatment technology methods
Narinder Rawal, M.D. PhD, FRCA(Hon),
Orebro, Sweden
Cancer pain– low technology treatment methods
Barbara Kleinmann, MD, Freiburg, Germany
Cancer pain– high technology treatment methods
Jamie Laubisch MD, Justin Baker MD, Doralina
Anghelescu MD, Memphis, USA
Palliative Care
Jamie Laubisch MD, Justin Baker MD,
Memphis, USA
Neuropathic pain - low technology treatment methods
Maija Haanpää, MD, Helsinki & Aki Hietaharju,
Tampere, Finland
Neuropathic pain – high technology treatment methods
Maija Haanpää, M.D., Helsinki & Aki Hietaharju,
M.D., Tampere, Finland
Psychological aspects of managing pain
Etleva Gjoni, Germany
Special Management Challenges
Debra Gordon, RN, DNP, FAAN, Seattle, USA
International Pain School
The project is supported by these organizations: