Pain Control: Acute and Chronic Conditions

صفحه 1:
Frank C. Nacario MD DPBA Associate Professor Anesthesiology & Pain Medicin Palliative Care UERMMMCI 

صفحه 2:
117001211 0 the first duty of medicine is to heal- if it car to relieve often, to comfort always” 

صفحه 3:
Definition of pain Acute vs Chronic pain Physiology of pain Effects of pain Pain scores in different surgical procedures Pain assessment Pain control in the postoperative period خبربا ا لع ۳ ۳۲ ‎iS]‏ 

صفحه 4:
Pain “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” International Association for the Study of Pain, 1979 

صفحه 5:
“Pain is whatever the experiencing person says it is; existing whenever he or she says it does.” McCaffrey, 1980 “Pain is now recognized as a complex experience with at least four main components © nociception © sensation © suffering or distress © behaviour Champagne and Weisse,1994 

صفحه 6:
Pain threshold refers to the point when stimulation is felt as painful. Pain tolerance refers to “how much” one can bear the pain experience; varies between individuals and cultures. i.e. females vs males pain as a form of punishment pain as a vital experience 

صفحه 7:
Two categories of pain Acute: primarily due to nociception | short-lived and reversible;less than six months | organic disease or injury is present Chronic: may be due to nociception but in which psychological and behavioral factors often play a major role ‏لا‎ behavior state, initiated by a real injury ‘ six months or longer; that it has itself become the disease 

صفحه 8:
Acute Pain 

صفحه 9:
ACUTE PAIN 

صفحه 10:
Chronic Pain 7 

صفحه 11:
Chronic Pain 

صفحه 12:
Two Types of Pain 1. Physiologic or nociceptive pain 1 Includes acute, subacute, chronic, and _ inflammatory pain J Results from noxious stimuli and inflammation in an otherwise intact tissue ‘Pain system is functioning as nature intends it to 1. Pathologic or neuropathic pain | Associated with frank injury to neural tissue ‘Reflects abnormal functioning of the pain system 

صفحه 13:
Nociceptors: special sense receptors in the skin or internal organs ‏0ه‎ receptors receive noxious (painful) stimuli produced by intense heat, extreme pressure, pricks and cuts, surgery or ischemia Noxious sensation: two components First pain Fast, sharp, well-localized | A6 fibers Second Slower onset, duller, C fibers pain poorly localized 

صفحه 14:
Peripheral Nociceptor System 1. Somatic structures = Cutaneous nociceptors: pain receptors at the termination of free-nerve endings in the skin (1) A-6 high- threshold mechanoreceptors (HTM) activated by mechanical noxious stimuli (2) A-6 myelinated mechanothermal nociceptors activated by noxious mechanical stimuli and noxious heat (3) C polymodal nociceptors activated by mechanical, thermal, and chemical noxious stimuli (4) miscellaneous C mechanical nociceptors and cold nociceptors 

صفحه 15:
3 Deep nociceptors: also supplied by A-5 and C fibers | Less sensitive to noxious stimuli than _ cutaneous nociceptors ‘ Easily sensitized by inflammation; dull and poorly-localized | Muscle, fascia, tendons, and other deeper somatic structures 

صفحه 16:
2. Visceral structures ™ Supplied by C afferents and some A-6 fibers ®™ Activated by disease, inflammation, contraction under isometric conditions, ischemia, rapid distention, and other adequate visceral nociceptive stimuli and endogenous algogenic substances 

صفحه 17:
Sensitization following Tissue Injury Peripheral Sensitization direct effect: injury > release of algogens - (activate and sensitize nociceptors); indirect effect: (release of a complex soup of inflammatory substances further sensitizing injured tissue and surrounding tissues) - make the nociceptors more sensitive to the painful stimulus, more prone to activation by: - weak touch - thermal stimuli - during movement lowered threshold to stimulation, and prolonged and enhanced response 

صفحه 18:
OPrimary hyperalgesia ‘ Sensitization at the site of injury “ Characterized by lowered pain threshold, increased sensitivity to suprathreshold stimuli, and spontaneous pain - peripheral sensitization oSecondary hyperalgesia ‘ Refers to the pain and tenderness felt at the area adjacent to the site of the initial injury including the area without inflammation - central sensitization 

صفحه 19:
35337 سس ‎Central Sensitization‏ - abnormal degree of amplification of the incoming sensory signal in the CNS - amplifies the signal of nociceptors, and amplifies the signal of low-threshold A-B sensory fibers (touch-sensitive & vibration) which previously are subliminal - A-B touch input is perceived as painful - key involvement of glutamate neurotransmitter and its NMDA receptor 

صفحه 20:
° Burn - produce tenderness in the burnt area (primary hyperalgesia); due to ized nociceptors (peripheral ization) also produce tenderness in a substantial me of intact skin (secondary hyperalgesia) - due to spinal amplification of otherwise normal touch input (central sensitization) 

صفحه 21:
Lloyd/ | Diamete [Letter ] Conduc Receptor /Ending Types Hunt |r System | tion _ (um) Pe [es ‏ا‎ 

صفحه 22:
Pain Pathways 

صفحه 23:
Descending Ascending modulation. Dorsal Dorsal root ganglion Spinothalamic ۳ tract Peripheral _\ nerve Peripheral nociceptors 

صفحه 24:
Ascending input Dorsal root ganglion Peripheral ‏اه‎ ‎nerve 

صفحه 25:
Endogenous Opiate System ¢ Enkephalins o Opiate-binding sites in the dorsal horn, periaqueductal gray (PAG), nucleus raphe magnus, globus pallidus and other areas involved with the pain pathway o Neurons containing serotonin (5HT) also contain enkephalins ۰ Dynorphins ‏مه‎ Hypothalamus, PAG, reticular formation, medulla, dorsal horn of the SC in laminae I, V ¢ B-endorphins © Basal hypothalamus, limbic system, 3" ventricle, midbrain, locus ceruleus 

صفحه 26:
LE Opioid Receptors & Ligands Receptor Natural Ligand yu (mu) Enkephalins K (kappa) Dynorphin 5 (delta) Enkephalins E (epsilon) B-endorphins 

صفحه 27:
Non-opiate Descending Inhibitory System ° Serotonin oThe cell bodies of SHT originate in the nucleus raphe, medulla and pons OTheir axons terminate in laminae I, Ho, IV and V of the spinal dorsal horn and near the central canal; others in the ventral horn O the analgesic action of systemic opiates can be blocked by depletion of 5HT 

صفحه 28:
Non-opiate Descending Inhibitory System ° NE (norepinephrine) descending system oAxons descend in all of the laminae of the spinal cord Mediates analgesia and dorsal horn inhibition oAppears to be critical for opiate-induced analgesia oHyperpolarizes 1* order neuron, internuncial neurons , and wide-dynamic range neurons in the STT 

صفحه 29:
سس ‎Peripheral Nociceptor System‏ 1. Somatic structures 6 Cutaneous nociceptors: on free-nerve endings 1) A-6 high- threshold mechanoreceptors (HTM) activated by mechanical noxious stimuli (2) A-6 myelinated mechanothermal nociceptors activated 1 noxious mechanical stimuli and noxious heat (3) C polymodal nociceptors activated by mechanical, thermal, and chemical noxious stimuli (4) miscellaneous C mechanical nociceptors and cold nociceptors a Deep nociceptors: supplied by A-6 and C fibers Less sensitive to noxious stimuli than cutaneous nociceptors Easily sensitized by inflammation; dull and poorly- localized ‘Muscle, fascia, tendons, and other deeper somatic structures 

صفحه 30:
2. Visceral structures Oo Supplied by C afferents and some A-6 fibers 0 Activated by disease, inflammation, contraction under isometric conditions, ischemia, rapid distention, and other adequate visceral nociceptive stimuli and endogenous algogenic substances 

صفحه 31:
Peripheral Nociceptor system 

صفحه 32:


صفحه 33:
Gate Control Theory اه ی لا مان عم ماوت ‎vowpettey port‏ © 8, (C _ 1 Ortivatiog oF forge oPPeneot epiontic Pibers tohibits OOR vewvd unl GPP ‏بشفعه‎ ‎8 ‏ون و مو۳)‎ port oP the body iohibits pois ic ‏اه‎ ته نا " Rubbiog the toured red wakes tt beter” ‏مه‎ electicd ‏له بسا ,موجه سوه‎ cold therapies ced other shir ‏شاه سا ما لمع مس ملد‎ 

صفحه 34:
!ات ‎Effects of Pain‏ Components of the Str a) Neuro-endocrine b) Cardiovascular c) Respiratory d) Gastrointestinal e) Genitourinary f) Immunologic/ Coagulation g) General Well Being 

صفحه 35:
Pain Scores: Common procedures ° Appendectomy:5-7 * Cholecystectomy: 7 * Cesarian section: 4-7 ° Thoracic surgery: 7-8 ۰ Bowel surgery: 7-9 * Gynecologic surgery:7-8 * Hemorrhoidectomy: 9 * Opthalmologic procedures: 1-6 ° Liposuction: 4-6 ° Nephrectomy: 10 

صفحه 36:
Pain Assessment Self-Report: Visual Analog Scale Numeric Rating Scale 

صفحه 37:
Visual Analogue Scale (VAS): 0 10 No pain Worst imaginable pain 

صفحه 38:
Numeric Rating Scale HHH 0 1 2 3 4 5 6 7 8 9 10 No pain Woret nain 

صفحه 39:
OUCHER! 99 ‏هت‎ ان سح اب 9 

صفحه 40:
The Okdey & Oven Paces Rater Grate فم ( ‎(OS) (eS)‏ )5( )روه ‎te) Noe righ TER 025‏ 5 4 3 2 0 

صفحه 41:
Pain Rating Scales 

صفحه 42:
Pu Paces Grote 260668 

صفحه 43:
LE “Pain as the Fifth Vital Sign” “We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated” James Campbell, MD Presidential Address, American Pain November 11, 1996 

صفحه 44:
Pain Interventions 1. Non-opioid and Opioid drug therapy via the Oral Transdermal Transmucosal Parenteral Intramuscular Intravenous intermittent 0 Intravenous continuous 

صفحه 45:
Cyclooxygenase pathway Phospholipids | تست Arachidonic acid ‏یس‎ ۱ ١ Leukotrienes TXA2 Pl. aggr, vasoconstric PGI2 Vasodilator, hyperalgesic,inhib ‏وود .ام‎ PGF2 PGE2 PGD2 Bronchoconstr, myomet contrac Vasodil,hyperalg ۱۳۳۰ Pit aggreg, vasodil 

صفحه 46:
Involvement of COX ۱ COX 1( constitutive) COX 2 (inducible) Inflammation Inflammation Nociception Nociception GI mucosal integrity GI mucosal integrity Gl adaptive cytoprotection Renal sodium balance GF Kidney development Angiogenesis Angiogenesis PI. TXA 2 synthesis Endothelial PGI2 synthesis Endothelial PGI2 synthesis Protection myocardial damage 

صفحه 47:
Non-opioid drugs Aspirin: non-selective COX inhibitor 1 COX 1 & 3 inhibitor Acetaminophen: COX 3 inhibitor NSAIDs: Non selective COX inhibitor Ketorolac (Toradol): IV | Ketoprofen (Orudis): IV, IM Mefenamic acid (Ponstan): oral Diclofenac (Voltaren, Diclowal): IM, oral, topical Ibuprofen (Alaxan, Advil): oral COX2 inhibitors Etoricoxib, Celecoxib - oral Parecoxib- IV (Rofecoxib, Valdecoxib, Nimesulide) 

صفحه 48:
Non opioid drugs Mechanism of Action o Inhibition of PG-mediated amplification of chemical and mechanical irritants on the sensory pathway. d Inhibits COX (prostaglandin synthetase) « Blocks response to inflammatory substances, bradykinins, acetylcholine, serotonin = mediation of peripheral inflammatory response 

صفحه 49:
Opioids Agonist on the opioid receptors oPeriaqueductal grey oPeriventricular gray ONucleus reticularis oGigantocellularis oMedial thalamus oOReticular formation oLateral hypothalamus oSpinal cord 

صفحه 50:
Opioid Receptors Mul Supraspinal analg nv Mu2 Resp depression, dependence Spinal analgesia nv Delta Kappa Spinal analgesia, sedation Sigma Dysphoria 

صفحه 51:
Opioids Agonists: Mu receptor © Morphine: oral, IV, IM, intrathecal, epidural o Fentanyl: transdermal, transmucosal, IV 5 Oxycodone: oral © Hydromorphone: oral Weak Agonists :Mu " Tramadol: oral, IV, transmucosal ‘Meperidine: IV, IM, epidural Agonist-antagonists: kappa, sigma/ no activity on Mu; potential to reverse effect of agonist Oo Nalbuphine: IM, IV o Butorphanol: IM, IV 

صفحه 52:
2. Central neuraxial analgesia © Intrathecal: spinal opioid receptors (SG) "addresses the shortcomings of IV and IM single dose 12 to 24hours pain relief potential for both acute and delayed respiratory depression (rostral spread) o Bbidural reduced incidence of side effects: pruritus, respiratory depression ‘catheter may be inserted for intermittent 12 to 24 hour interval doses or continuous infusion ‘PCA with background infusion achieves better analgesia 

صفحه 53:
LE Undesirable Effects of Opioids Sedation - k Nausea and Vomiting - m Suppression of cough reflex - m Psychological and Physical dependence Tolerance Constipation - most common - k Respiratory depression - m 

صفحه 54:
PCA - Patient-controlled Analgesia Background infusion with PCA boluses @ IV or epidural ™ Better maintenance of therapeutic levels ™ Better patient satisfaction O Not dependent on care giver (no delay in meds) O Patient has control over own pain concerns O Usually, patients gives only to maintain tolerable pain level - less drug use 

صفحه 55:
Other interventions 3. Transcutaneous Electrical Nerve Stimulation 4. Psychological Intervention for Post op Analgesia 

صفحه 56:
Administration Round the clock vs prn RTC : maintain blood level decreases total opioid requirement prn: intermittent, peaks and troughs PCA - patient-controlled analgesia 0 IV or epidural oO Better maintenance of therapeutic levels © Better patient satisfaction {Not dependent on care giver (no delay in meds) ‏ا‎ Patient has control over own pain control needs "Usually, patients demand only to maintain tolerable pain level - less drug use 

صفحه 57:
Ideal pain management 

صفحه 58:
Adjuvant drugs: Antidepressant Anxiolytic Steroids Antiemetic Management of drug related side effects Antacids Laxatives/stool softeners 

صفحه 59:
ص--< . ۵۷ عط بره | ‎x‏ with WHO Guidelines 8ythe attention 3 clock todetal for Pain Relief 2 ۱۱6۱۵006۲ For the individual (WHO 1996) 

صفحه 60:
WHO Analgesic Ladder Three step sequence for pain control 

صفحه 61:
Multimodal Pain Control ¢ Inflammation & Analgesia ONSAID ° Analgesia oOpioid ° Adjuvants ° Non-pharmacologic therapy oPsychological support OoTENS 

صفحه 62:
Pharmacotherapy Opies Alphas agonists 

صفحه 63:
Triad of Pain Pain / \ Depression —_—— | Mpaired sleep Anxiety Impaired ADL 

صفحه 64:
Control pain 24/7 

صفحه 65:
Medicines for severe pain 

صفحه 66:
“Pain is perfect misery, the worst of evils, and excessive overturns all patience.” John Milton, Paradise Lost 

صفحه 67:


صفحه 68:
Pain free Day!!!