PAIN MANAGEMENT

DR. Bambang Rahardjo, dr, SpOG-K

Maternal Fetal Division
Dr. Saiful Anwar General Hospital/Brawijaya University
 PAIN??

An unpleasant sensory and emotional experience

associated with actual or potential tissue damage
 CLASSIFICATION

 Physiological
- nociceptive
- neurophatic
- psycological

 Clinical
- acute
- chronic
- malignant
 PAIN???

Involves four physiological Processes:

- Transduction
- Transmission

- Modulation

- Perception
 PHATOPHYSIOLOGY

Noxious stimulus

NSAIDS 􀃆 release of inflammatory substances

 (PG, Hst, Srn, Bdks, Sub.P)

Transduction
 (generation & electrical impulses)
PHATOPHYSIOLOGY

Transmission
 (conduction by nerve fibers)

Opioids----􀃆 Modulation
 (Modification with spinal corel)

Opioids----􀃆 Perception
PHATOPHYSIOLOGY
 PHATOPHYSIOLOGY

Site of Action Analgesic Effect

1. Nocioceptors in skin and 1. NSAID

subcutan – stimulate by
inflamatory agent ec PGs
2. A-beta fibers –inhibits
2. TENS stimulate A-beta fibers
transmision of pain
3. Primary trans of neuron –
transmits impuls from 3. LA
nociceptor to spinal cord
4. Dorsal horn of spinal and
higers center – futher 4. Opioids
transmition of pain impuls to
cerebral cortex
 Physiological Effects of Pain

1- Respiratory Effects:
 − vital capacity
 − Functional Residual capacity
 − Ability to cough
 − Ability to breath deeply

Leading To
− Retention of secretions
− Atelectasis
− Pneumonia
 EFFECTS OF PAIN IN POST–OP
PATIENT

2- Cardio vascular effects:

 − Sympathetic out put
 − Tachycardia

 − Hypertension
 − Catecholamine blood levels.

 − Myocardial oxygen demand

Risk of ischemia
 EFFECTS OF PAIN IN POST–OP
PATIENT

3- Neuroendocrine effects:
 − Secretion of catecholamines & catabolic hormones
 − Na and water retention.

4- Effects an mobilization:
 − Delayed
 − Risk of DVT
 − Hospital stay
 Methods Of Controling

1. Non-pharmacological
Preoperativecounseling
TENS (Transcutaneus Electric Nerves Stimulation)

Acupuncture

2. Pharmacological
Opioids
•Im
• IV infusion
•IV PCA
Local anaesthetics:
•Local Infiltration
•Nerve Blocks
•Epidural Blocks
NSAIDS
•IM
•IV infusion
•IV PCA
 NON-PHARMACOLOGICAL METHODS

1. PRE-OP COUNSELLING:
Well informed patients about:
 • Nature of operation
 • Nature of post operative pain
 • Methods of analgesia available

Cope better with Post –op Pain

 NON-PHARMACOLOGICAL METHODS

TENS
(Trans Cutaneous electric nerve stimulation)

Stimulates afferent myelinated (A-beta) nerve fibers

at 70hz
Inhibitory circuits within sp cord activated
Nerve impulse transmission reduced
Maximum benefit in neurogenic pain
PHARMACOLOGICAL METHODS

OPIODS

• Activate opiod receptors within the CNS

• Reduce transmission of nerve impulses by

modulation in the dorsal horn
PHARMACOLOGICAL METHODS

LOCAL ANAESTHETICS

– Blocks the conduction of nerve impulses

– Can be given with adrenaline because
• DECREASES ABSORPTION OF L.A ALLOWING LARGER DOSES
• ALSO ACTS ON ALPHA 2 RECEPTORS WHICH POTENTIATES
ANALGESIC EFFECT
PHARMACOLOGICAL METHODS

NASIDS

– Blocks synthesis of PG’s

– Only suitable for miled to moderate pain
 PRINCIPLE OF MANAGEMENT OF PAIN

1. Pre-emptive analgesia

2. Balanced or combination analgesia

3. Analgesia ladder
 PHARMACOLOGICAL METHODS

Balanced Analgesia
a) – NASID are used in conjunction with opioids.

b) – Reduces amount of opioids

c) – Reduces side affect of opioids

PRINCIPLE OF MANAGEMENT OF PAIN
 Modified WHO Analgesic Ladder

Pain
Step 1
 ±Nonopioid
 ± Adjuvant
 Pain persisting or increasing
Step 2
 Opioid for mild to moderate pain
 ±Nonopioid ± Adjuvant
 Pain persisting or increasing
Step 3
 Opioid for moderate to severe pain
 ±Nonopioid ±Adjuvant
Step 4
 Invasive treatments
 Opioid Delivery
 Types of Pain

Chest –
Neuropathic – gabapentin, pregabalin
Cancer - opiates
Abdominal - NSAIDS
Pelvic - NSAIDS
Musculoskeletal - NSAIDS
Drug Seeking Behavior
 Acetaminophen

 Mechanism – unknown
 Route - PO, PR
 Onset - variable, half life = 2-3 h
 Side effects - hepatotoxicity, AIN/tubular necrosis
 Contraindications
 Relative—EtOH use, liver disease (max daily
dose reduction), renal disease (prolonged use)
 History – 1894, 35% current pain med market, more ER
visits for OD than all other pain meds.
 Salicylates

 Mechanism - COX inhibition

 Route - PO, PR
 Side effects - GI disturbance, bleeding
 Contraindications
 Relative - ASA/NSAID induced asthma, peri-op
CABG, GI bleed, Renal dysfunction, liver
disease.
 Absolute - small children with fevers, hypersensitivity
 NSAIDS
 Mechanism - COX inhibitors, lipoxygenase inhibitors
 Route - PO, PR, IV, IM
 Side effects- platelet inhibition, PUD, dyspepsia, CNS
dysfunction, headache, renal dysfunction
 Contraindications
 Relative - ASA/NSAID induced asthma, peri-
op CABG, GI bleed, Renal dysfunction, liver
disease.
NSAIDS
 Opiates
 Mechanism—variations on opioid receptor agonists, mixed
agonist
 Route—PO, PR, IV, IV-PCA, IM, transdermal, transmucosal,
epidural/intrathecal
 Side effects—sedation, respiratory depression, n/v, constipation,
itching
 Contraindications
 Relative—COPD, hypotension, impaired renal function,
impaired liver function, elderly patients
 Absolute—Hypersensitivity, paralytic ileus, respiratory
depression
Opiate MOA

Central Mu
 respiratory
depression
 analgesia
 euphoria
 miosis
Peripheral Mu
 cough suppression
 constipation
 Topicals/Local

 Mechanism—local receptor effect

 Route—topical
 Side effects—local reaction, accidental IV injection, burning,
erythema, hives, seizures, respiratory arrest, asthma
 Contraindications
 Relative—liver dysfxn, renal dysfxn, heart block
 Adjuvants/Other classes

 Gabapentin/Pregabalin, anticonvulsants - neuropathic pain

 Tricyclics - neuropathic and chronic pain
 Caffeine - useful as an adjuvant with NSAIDS
 Things we shouldn’t use acutely
 Benzodiazepines: no role for acute pain relief unless due
to muscle spasm
 Antihistamines, dextroamphetamine, steroids, intrathecal
clonidine
 General Approach

If on chronic pain meds  continue them

Mild pain  APAP, ibuprofen
Mild – Moderate  Scheduled NSAID +/- T3 or
opiate
 Mod-Severe  IV toradol + opiate
Prn Meds
Scheduled vs Prn in uncontrolled pain
TERIMA KASIH