INTRO TO ANESTHESIOLOGY

EXIMIUS
ACUTE PAIN
Cabaro, Catabay, Suguitan MD February 2019 2021

I. DEFINITION OF TERMS
• Pain – caused by actual or potential damage that can results in
unpleasant physical and/or emotional experience
• Nociceptive pain - results from stimulation of mechanical,
thermal or chemical nociceptors. Can be somatic or visceral.
• Neuropathic pain – results from a lesion in the nervous system
or a dysfunction of the nervous system
• Allodynia – perception of an ordinarily non-noxious stimulus
as pain
• Anesthesia dolorosa – pain in an area without sensation
• Analgesia – absence of pain perception
• Anesthesia – absence of all sensations
• Dysesthesia – unpleasant sensation
• Paresthesia – abnormal sensation perceived without
stimulation
• Hyperesthesia - INCREASE response to stimulation.
• Hypoesthesia - DECREASE sensation to stimulation
• Hyperalgesia - INCREASE sensation to noxious stimulation
• Hypoalgesia - DECREASE sensation to noxious stimulation
• Neuralgia – pain in the distribution of a nerve
• Radiculopathy – functional abnormality of nerve roots (pain
associated with numbness) B. EFFERENT MODULATING PATHWAY

II. ACUTE PAIN

• “normal, predicted, physiological response to an adverse
chemical, thermal, or mechanical stimulus”
• Generally: resolves within 1 month BUT poorly managed acute
pain have the potential to produce chronicity
• neuronal plasticity: Acute pain-induced change in the CNS
result in sensitization of CNS

C. PAIN PROCESSING
• Tissue injury tends fuel neuroplastic changes in NS= both PNs
and CNS sensitization
• four elements of pain processing
o Transduction
o Transmission
A. ANATOMY AND PHYSIOLOGY OF ACUTE PAIN o Modulation
• detected by nociceptors o perception
• Aẟ and C fibers
• main ascending pathway: spinothalamic tract Transduction  noxious thermal, chemical, or mechanical stimuli are
• first-order neuron: cell body is located in (DRG) bipolar converted into an action potential
neuron Transmission when the action potential is conducted through the
• Second-order neuron: nervous system via the first-, second-, and third-order neurons
o nociceptive specific neurons (lamina I) Modulation of pain transmission altering afferent neural transmission
o wide dynamic range (WDR) neurons (laminae IV, V, along the pain pathway either inhibition or augmentation of the pain
and VI) which receive both noxious and non-noxious signals.
input Perception final common pathway, integration of painful input into the
• Third-order neuron: VPL nucleus of thalamus somatosensory and limbic cortices

TRANSCRIBERS Group 10 EDITOR Rachel Lei Augustine P. Vite, RMT 1 of 7

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directly produce pain transduction via. Peripheral sensitization of

D. CHEMICAL MEDIATORS OF TRANSDUCTION VIA NOCICEPTOR polymodal C fibers and high-threshold mechanoreceptors by these
STIMULATION AND INCREASING EXCITABILITY OF NOCICEPTORS chemicals leads to primary hyperalgesia, which by definition is an
exaggerated response to pain at the site of injury.

E. CHEMICAL MEDIATORS OF TRANSMISSION

Antidromic release of substance P and glutamate from small nociceptive

afferents results in vasodilation, extravasation of plasma proteins, and
stimulation of inflammatory cells to release numerous algogenic
substances .
Primary nociceptive transmission in the spinal cord. Primary afferent
nociceptive input is transmitted via α-amino-3-hydroxy-5-methyl-4-
isoxazole propionic acid (AMPA), neurokinin-1 (NK1), and calcitonin
gene–related peptide (CGRP) synapses, whose signals work their way to
the thalamus. Glutaminergic (N-methyl-Daspartate [NMDA]) synapses
do not participate significantly in primary nociceptive transmission, but
instead play a crucial role in spinal sensitization. Accordingly, even after
complete NMDA blockade in the spinal cord, primary afferent nociceptive
information is transmitted to the thalamus. NMDA antagonists thus have
an antihyperalgesic rather than an analgesic effect in the spinal cord. Glu,
glutamate; SP, substance P. (Adapted with permission from the
International Association for the Study of Pain. Pain control updates. IASP
Newlett. 2005;13[2]:3.)

TRANSCRIBERS Group 10 EDITOR Rachel Lei Augustine P. Vite, RMT 2 of 7

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F. PERIPHERAL MODULATION I. SURGICAL STRESS RESPONSE

• Primary hyperalgesia:
o nociceptors are activated by excitatory amino acids
(eg, glutamate) and neuropeptides (eg, substance P)
o The release of potasium, bradykinins, or
protaglandins, from damaged tissues sensitizes
nociceptors= greater excitability and frequency of
firing
• Secondary hyperalgesia:
o mediated by substance P to nociceptive field such
that noninjured tissues are involved as well.

G. CENTRAL ENHANCEMENT VIA THREE MECHANISMS

• Wind-up phenomenon- persistence of action potential due to
prolonged depolarization of the neuron despite the
discontinuation of the stimulus.
• Spinal reflexes act as efferents back to the peripheral
nociceptive field, which generate more nociceptive afferents.
• Expansion of receptive fields in dorsal horn. • hyperglycemia and a
• negative nitrogen balance poor wound
augmentation of pain pathways central sensitization: consequence of • healing, muscle wasting, fatigue, and impaired
neuronal plasticity immunocompetency.
“wind-up” results from repetitive C-fiber stimulation of WDR neurons
in the dorsal horn.
III. PREVENTIVE ANALGESIA
• antinociceptive regimen given perioperative period
H. CENTRAL ATTENUATION VIA TWO MECHANISMS attenuate pain-induced sensitization.
• Gate theory: stimulation of non pain fibers peripherally inhibits • Goal: to block the development of sustained pain by
WDR neurons. preventing NMDA receptor activation in dorsal horn
• Descending antinociceptive pathways: these neurons originate (associated with windup, facilitation, central sensitization
from periaquedutal gray, reticular formation and nucleus raphe expansion of receptive fields, and long-term potentiation)
magnus and travel down to synapse in the dorsal horn to • three critical principles:
inhibit pain. o The depth of analgesia must be adequate enough to
block all nociceptive input during
7 inhibitory spinal modulation surgery
o the analgesic technique must be extensive enough to
(1) release of inhibitory neurotransmitters such as γ-amino butyric acid include the entire surgical field
(GABA) and glycine by intrinsic spinal neurons o the duration of analgesia must include both the
surgical and postsurgical periods.
(2) activation of descending efferent neuronal pathways from the motor
cortex, hypothalamus, periaqueductal gray matter, and the nucleus raphe
Patients with pre-existing chronic pain may not respond as well to these
magnus, = release of norepinephrine, serotonin, and endorphins in the techniques because of pre-existing sensitization of the nervous system.
dorsal horn.

TRANSCRIBERS Group 10 EDITOR Rachel Lei Augustine P. Vite, RMT 3 of 7

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IV. ASSESSMENT OF ACUTE PAIN • Neuropathic pain, on the other hand, may benefit from the
• transduction- initial contact with pain addition of the nonopioid analgesic adjuvants such as:
• trasmission-  NMDA receptor antagonists
• modulation  α2-agonists
• perception  α2–δ subunit calcium channel ligands
• pain- most common cause of HTN

VII. OPIOD ANALGESICS

Central acting start with high dose
peripheral- start with low dose
do not start with high dose sa acute pain

• Opioid analgesics are the mainstay for the treatment of acute

postoperative pain
• Morphine is the “gold standard”
• Tramadol is a synthetic opioid-like drug

“weak” opioids because their side effects become significant before

reaching good analgesic effects
tramadol- that blocks reuptake of norepinephrine (NE) and 5-
hydroxytryphytamine (5-HT)

WEAK STRONG
A. FEATURES OF PAIN COMMONLY ADDRESSED DURING Codeine Morphine
ASSESSMENT Oxycodone Hydromorphone
• Onset of pain Hydrocodone Fentanyl
• Temporal pattern of pain Propoxyphene Methadone
• Site of pain Pentazocine Levorphanol
• Radiation of pain • Hydromorphone: is a semisynthetic opioid that has four to six
• Quality of pain times the potency of morphine, making it the ideal drug for
• Intensity of pain long-term subcutaneous administration in opioidtolerant
• Exacerbating factors patients.
• Relieving factors • Fentanyl: is available for intravenous (IV), subcutaneous,
• Response to analgesics transdermal, transmucosal, and neuraxial administration.
• Response to other interventions • Sufentanil: The high intrinsic potency of sufentanil makes it an
• Associated physical symptoms excellent choice for epidural analgesia in opioiddependent
• Associated psychological symptoms patients.
• Interference with activities of daily living • Methadone: is well absorbed from the gastrointestinal (GI)
tract. Opioid rotation is a useful technique to restore analgesic
Quality (character) of pain sensitivity in highly tolerant patients, and methadone is a
Intensity (severity) of pain common choice for opioid rotation.
Exacerbating factors (what makes the pain start or get worse?)
Relieving factors (what prevents the pain or makes it better?)
Response to analgesics (including attitudes and concerns about opioids) VIII. NON-OPIOD ANALGESICS
can significantly decrease the incidence of opioid-related side effects such
as postoperative nausea and vomiting and sedation.
V. ASSESSMENT OF ACUTE PAIN
• Breakthrough: Pain that escalates above a persistent this includes (NSAIDs) which have been proven effective in the treatment
background pain. of postoperative pain
• Transitory and Intermittent: Pain that is episodic in the
absence of background pain. A. NSAIDS
• Background: Pain that is persistent but may vary over time. CYCLOOXYGENASE-1 (COX-1) COX-2 INHIBITORS
INHIBITORS
1. Including pripionic acid, anthranilic 1. Have anti-inflammatory
VI. STRATEGIES FOR ACUTE PAIN MANAGEMENT acid, and salicylates properties
• The majority of postoperative pain is nociceptive in character, 2. They have analgesic, antipyretic, and 2. They do not disrupt
but there are a small percentage of patients who can anti-inflammatory properties platelet function
experience neuropathic pain postoperatively. 3. The block prostaglandin synthesis 3. Cause fewer GI side effects
• Nociceptive pain responds best to: that sensitizes nociceptors 4. They do not have an
o opioids 4. They disrupt platelet function incidence of cardiovascular
o nonsteroidal anti-inflammatory drugs (NSAIDs) 5. May exacerbate bronchospasm complications
o para-aminophenol agents 6. Cause GI mucosal irritation
o regional anesthesia techniques.10
TRANSCRIBERS Group 10 EDITOR Rachel Lei Augustine P. Vite, RMT 4 of 7
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• NMDA receptor antagonists: may be analgesic adjuncts. C. PERIPHERAL NERVE BLOCKADE

• a2- Adrenergic agonists: may be administered perioperatively 1. BRACHIAL PLEXUS
to provide analgesia, sedation, and anxiolysis.
• Gabapentin and pregabalin: neuropathic pain syndromes INTERSCALENE BLOCK SUPRACLAVICULAR INFRACLAVICULAR
• postoperative pain. When these drugs are combined with an - painful orthopedic - provides - surgical
NSAID, the combination has been shown to be synergistic in - vascular procedures anesthesia to the procedures below
attenuating the hyperalgesia associated with peripheral on shoulder and entire upper the midhumerus:
inflammation. upper arm extremity - hand, wrist,
• Lidocaine: analgesic, antihyperalgesic, and anti-inflammatory - Ulnar nerve is spared forearm, or elbow
after IV administration.
• Glucocorticoids: analgesic, anti-inflammatory, and antiemetic
effects.

IX. METHODS OF ANALGESIA

A. PATENT-CONTROLLED ANALGESIA (PCA)
• is any technique of pain management that allows patients to
administer their own analgesia on demand.
• a method of continuous fusion that gives the patient some
control titrating the medication to the desired analgesic level • The interscalene block is the ideal peripheral nerve block
The five variables associated with all modes of PCA include: for:…….but is a poor choice for forearm and hand surgery
 bolus dose • The supraclavicular The safety of this approach has improved
 incremental (demand) dose dramatically with the use of ultrasonography.
 lockout interval • c. The infraclavicular The block targets the brachial plexus at
 background infusion rate the level of the cords, where it is in close proximity to the
 1- and 4-hour limits axillary artery. Ultrasound guidance has dramatically improved
the safety and success of the infraclavicular approach.
Advantages include good analgesia efficacy and greater patient
satisfaction. 2. LUMBAR PLEXUS
There is a lower frequency of side effects such as sedation and
POSTERIOR ANTERIOR SAPHENOUS
respiratory depression of the extreme plasma trough and peak
concentration seen in IM or IV routes are avoided. - major surgeries of the - site-specific - frequently
hip and knee analgesia and is an combined with a
• Risk Factors for Use of Opioid Patient-controlled Analgesia integral part of lateral popliteal
✴ Pulmonary disease any multimodal block or sciatic
✴ Obstructive sleep apnea analgesic regimen block for
✴ Renal or hepatic dysfunction after major knee procedures
or hip surgery involving the
✴ Congestive heart failure
lower leg
✴ Closed head injury
✴ Altered mental status
✴ Lactating mothers

B. NEURAXIAL ANALGESIA
• Since the discovery of the opioid receptor, the intrathecal
administration of opioids and the epidural administration of
opioids plus a local anesthetic have produced significant pain
control.
• Posterior approach (psoas compartment block) is indicated for
• Provide good postoperative pain control, which results in
major surgeries of the hip and knee. When combined with
earlier ambulation and participation in physical theraphy,
resulting in fewer postop complications. sciatic nerve blockade, virtually any surgical procedure can be
• Epidural analgesia is a critical component of multimodal performed on the lower extremity.
perioperative pain management and improved patient • Anterior approach (femoral nerve block).
outcome. • Saphenous nerve blockade is frequently combined with a lateral
• Intrathecal analgesia is provided with a variety of opioid popliteal block or sciatic block for procedures involving the
analgesics (morphine, hydromorphone, meperidine, lower leg.
methadone, fentanyl, sufentanil)

TRANSCRIBERS Group 10 EDITOR Rachel Lei Augustine P. Vite, RMT 5 of 7

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3. SACRAL PLEXUS XII. PERIPHERAL NERVE BLOCK

• Single injection of peripheral nerve blockade may provide pain
PARAVERTEBRAL BLOCKADE SCIATIC NERVE BLOCKADE control that is superior to opioids with fewer side effects.
- segmental analgesia for numerous - effective, and long-lasting Single-injection techniques are limited in duration, but
surgical procedures (thoracotomy, postoperative analgesia continuous peripheral nerve block techniques may extend the
mastectomy, nephrectomy, benefits of peripheral nerve blockade well into the
cholecystectomy, rib fractures, postoperative period.
video-assisted thorascopic • Duration of block depends on the local anesthetic used.
surgery, and inguinal and Continuous catheters allow for continuous infusions of
abdominal procedures). medications to bring longer period of relief

A. CONTINUOUS PERIPHERAL NERVE BLOCKADE CAVEATS

• Hemorrhagic complications, rather than neurologic deficits,
appear to be the predominant risk associated with the
performance of peripheral nerve blockade in anticoagulated
patients.
• Major hemorrhage can occur following performance of psoas
compartment blockade (e.g., LPB) and lumbar sympathetic
blockade.

• Sciatic nerve blockade provides safe, effective, and long-lasting

XIII. COMPLICATIONS FROM REGIONAL ANESTHESIA
postoperative analgesia.
• Serious complications associated with the performance of
• Paravertebral blockade may provide segmental analgesia for
regional anesthesia include:
numerous surgical procedures (thoracotomy, mastectomy,
nephrectomy, cholecystectomy, rib fractures, video-assisted
thorascopic surgery, and inguinal and abdominal procedures).

X. TRIGEMINAL NERVE BLOCK

• an adjunct to pharmacologic treatment of trigeminal neuralgia.
• Complications include intravascular injection and hematoma.
• used to treat :
 facial pain
 acute zoster

The incidences of cardiac arrest and neurologic

complications are higher after spinal anesthesia
than after all other types of regional procedures

XI. INTERCOSTAL NERVE BLOCK

• indications include rib and chest wall pain. Complications
include pneumothorax
PARAPLEGIA

• Ultrasound-
guided regional
anesthesia has
several advantages but does not completely eliminate all of the
risks associated with the performance of peripheral nerve
blockade (nerve injury, local anesthetic toxicity,
pneumothorax).

TRANSCRIBERS Group 10 EDITOR Rachel Lei Augustine P. Vite, RMT 6 of 7


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XIV. PERIOPERATIVE PAIN MANAGEMENT OF OPIOD DEPENDENT
PATIENTS
A. PERIOPERATIVE MANAGEMENT
• involves determining the patient’s “baseline” opioid
requirement and instruction to the patient to take his or her
normal opioid dose on the day of surgery.
• Patients maintained on methadone should continue their
“baseline” dose throughout the perioperative period. Patients
receiving >200 mg/day of methadone may develop a prolonged
QT interval, which places them at risk for torsades de pointes.
• Full antagonists: Naloxone, Naltrexone
• Partial agonists antagonists: Nalbuphine, Pentazocine,
Butorphanol
• “should be avoided because they precipitate withdrawal
symptoms in opioid-dependent patients”
B. INTRAOPERATIVE MANAGEMENT
• Intraoperative management of opioid-dependent patients
requires the prudent use of fentanyl, morphine, or
hydromorphone to provide effective intraoperative anesthesia
and postoperative analgesia and to prevent opioid withdrawal
• This requires the administration of the patient’s
• “baseline” opioid requirement plus his or her intraoperative
requirements secondary to surgical stimulation.
C. POSTOPERATIVE MANAGEMENT
• 1. Upon arrival to the recovery room, IV opioids may be
administered on an “as needed” basis; however, initiation
of an IV PCA opioid with both a basal and incremental
(bolus) dose minimizes the risk of breakthrough pain.
• 2. Nonopioid coanalgesics (low-dose ketamine) are opioid
sparing and should be part of any multimodal
perioperative pain management regimen in opioid-
dependent patients.
• 3. Regional anesthesia is highly recommended in this patient
population.
• 4. Monitor patient for excessive sedation and respiratory
depression.
IV PCA – Intravenous patient controlled analgesia – fewer analgesic gaps
and maintains analgesia with less total opiods consumption and less side
effects.
TRANSCRIBERS Group 10 EDITOR
EXIMIUS
2021
XV. ORGANIZATION OF PERIOPERATIVE PAIN MANAGEMENT
SERVICES
• The effective management of pain is a crucial component of
good perioperative care and recovery from surgery. The key
components to establishing a successful perioperative pain
management service begins with an institutional commitment
built around a physician leader with training and experience in
pain medicine, and other anesthesiologists.
IV PCA – Intravenous patient controlled analgesia – fewer analgesic gaps
and maintains analgesia with less total opiods consumption and less side
effects.
XVI. SPECIAL CONSIDERATIONS IN THE PERIOPERATIVE PAIN
MANAGEMENT OF CHILDREN
• Acute pain management in children undergoing surgery and
invasive procedures offers several specific and unique
challenges for anesthesiologists.
A. NONPARENTERAL ANALGESICS
• Nonopioid analgesics (oral or suppository acetaminophen,
ibuprofen, ketorolac) are important adjuvant analgesic
therapies, often with oral midazolam
• Opioid Analgesics. Codeine in combination with
acetaminophen is commonly used with good effect for the
management of moderate postoperative pain in ambulatory
patients. Intranasal sufentanil can also be used to manage
preoperative anxiety and postoperative analgesia in children.
PERIAGEMENT OF OPI
B. EPIDURAL NEURAXIAL ANALGESIA
• (single-shot technique or continuous catheter technique) has
become a key component of the perioperative pain
management plan for infants and young children undergoing
abdominal, urologic, and orthopedic procedures.EPENDE
NTPATIENTS (single-shot technique or continuous catheter
technique) has become a key component of the perioperative
pain management plan for infants and young children
undergoing abdominal, urologic, and orthopedic procedures
C. NERVE BLOCKS IN CHILDREN
• The introduction of small stimulating needles and ultrasound
imaging along with long acting local anesthetics and continuous
catheter techniques in selected patients has resulted in an
increase in the use of peripheral nerve blocks in children
undergoing orthopedic extremity procedures.
NOT BECAUSE YOU DON’T FEEL ANYTHING YOU CAN DO WHATEVER YOU WANT.
References: Reporters’ ppt
Rachel Lei Augustine P. Vite, RMT 7 of 7