What’s Pain Got to Do With It? PAD Launch Day March 30 th, 2015 Donald Griesdale MD MPH FRCPC Assistant Professor Department of Anesthesiology, Pharmacology & Therapeutics Division of Critical Care Medicine University of British Columbia

Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points 1.Objectives 2.Disclosure

 52 year old female, previously healthy  Immediate onset of pain and weakness in both hands  Immobilized at scene and transferred to hospital CC licence: Ludovic Peron Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 Neurology:  Grade 1 – 2 motor strength in bilateral upper extremities  4 – 5/5 strength in her legs  Decreased sensation in her hands  Conservative management  Transferred to spine ICU  Current pain management:  Acetaminophen 975 mg PO q6h regularly  Hydromorphone 2 – 4 mg q4h prn (used 16 mg in 24 hours) Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 Describes 2 types of pain  Neck pain (NRS 2 – 3 / 10)  “Burning, electrical shocks” in both arms and hands  NRS 8 – 10 / 10  Opioids dull the pain slightly, but don’t help much  Unable to sleep  Even the sheets touching her arms cause excruciating pain Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

NociceptiveNeuropathic Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

“Pain caused by a lesion or disease of the somatosensory nervous system” Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Other Ketamine IVOther AED 2 nd Line Strong opioidsTramadol Topical Agents Amitrip / Ketamine CRLidocaine 1 st LINE Gabapentin or PregabalinNortriptyline Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Gabapentin  Start at 300 mg / day  Titrate up to 4800 mg / day  tid  SE: dizziness, somnolence, nausea, rash, blurred vision Pregabalin  Start at 150 mg / day  Titrate up to 600 mg / day  bid  Similar SE to gabapentin  Better bioavailability Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 Initially started on:  Pregabalin 150 mg / day  Nortriptyline 10 mg in AM and 25 mg qHS  Topical amitriptyline – ketamine cream  Oxycodone prn  Despite increasing her pregabalin, her neuropathic pain worsened  Repeat MRI to ensure no obvious worsening pathology  Started on ketamine IV  Topiramate 25 mg BID  Methadone 1 mg PO TID Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 Recognize and consider neuropathic pain  What is the etiology of neuropathic pain?  Pharmacologic management is different than with nociceptive pain  Early use of gabapentin / pregabalin and TCA’s  Use of topical agents for allodynia  Referral to a pain specialist for refractory neuropathic pain Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 27 year old male, belted driver in high speed MVC  Intubated at the scene for respiratory distress  Isolated flail chest with pulmonary contusion  Rib 4 – 9# on right  Initially managed on IV morphine and regular acetaminophen Damnsoft 09 at en.wikipedia Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

"Pulmonary contusion" by Karim -

 Complications:  Pneumonia & empyema  Respiratory failure  Chronic pain & long term disability  Primary goals:  Excellent pain control  Pulmonary volume expansion Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 8 am the next day:  Currently on PSV 5, PEEP 5 with FiO  You are now wanted to extubate this patient  Try to wean his propofol infusion!  Tachypneic, fighting ventilator  Hypertensive, tachycardic  RASS +2 to +3 Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Behavioural Pain Scale BPS 7 Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

ICDSC Score Altered LOC1 Inattention1 Disorientation1 Hallucinations – delusions0 Psychomotor agitation or retardation1 Sleep/wake cycle disturbances0 Symptom fluctuation1 TOTAL5 Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 Overnight pain management:  Morphine total of 40 mg IV total  Tylenol 975 mg NG q6h  Methyltrimeprazine 20 mg IV total  Propofol infusion for sedation and ventilator synchrony  Report: “Either awake, agitated and confused or too sedated” Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Agitation PainDelirium

N Engl J Med 2010;362:1503 Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Infusion of local anesthetic & opioid Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Pro’s  Better pain control than PCA  Improve respiratory function  Minimizes complications of systemic opioids Con’s  Technically difficult  Complications  Local  Hemodynamic  Inadequate block Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Contraindications to epidural anesthesia:  Coagulopathy  Antiplatelet agents (e.g. Clopidogrel)  LMW heparin  Elevated ICP  Local or systemic infection Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

Epidural analgesia is a level1 recommendation for the management of severe blunt chest injury Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points

 Pain scales may not be specific  Consider the interactive effect of pain & delirium  Alternates to opioid analgesia where appropriate Case 1 Question 1 Question 2 Take home points Case 2 Question 3 Question 4 Take home points