1. Acute Pain Management Parisa Partownavid, MD Assistant Clinical Professor David Geffen School of Medicine at UCLA Department of Anesthesia

4. Definition of Pain
An Unpleasant Sensory and Emotional Experience Associated with Actual or Potential Tissue Damage, or Described in Terms of Such Damage.

5. Acute Pain Pain in Perioperative Setting
Pain in Patients with Severe or Concurrent Medical Illnesses (Pancreatitis)
Acute Pain Related to Cancer or Cancer Treatment
Labor Pain

8. Acute Perioperative Pain
Pain that is Present in a Surgical Patient Because of Preexisting Disease, the Surgical Procedure, or a Combination of Both

9. Importance of Pain Management
Adequate Pain Control
Reduce the Risk of Adverse Outcomes
Maintain the Patient’s Functional Ability, as well as Psychological Well-being
Enhance the Quality of Life
Shortened Hospital Stay and Reduced Cost

10. Adverse Outcomes Associated with Management of Acute Pain
Respiratory Depression
Circulatory Depression
Sedation
Nausea and Vomiting
Pruritus
Urinary Retention
Impairment of Bowel Function

11. Adverse Outcome of Undertreatment of Acute Pain
Thromboembolic or Pulmonary Complications
Needless Suffering
Development of Chronic Pain

12. The Incidence of Moderate to Severe Pain with Cardiac, Abdominal, and Orthopedic Inpatient Procedures has been Reported as High as 25%-50%, and Incidence of Moderate Pain after Ambulatory Procedures is 25% or Higher.

13. Goal Pain Management Interventions Should be Offered Around the Clock
Pain Management is to Provide Continuous Pain Relief
Patient Should be Assessed for Adequacy of Pain Control

16. Preoperative Evaluation of the Patient
Type of Surgery
Expected Severity of Postoperative Pain
Underlying Medical Condition (Respiratory or Cardiac Disease)

17. Preoperative Preparation of the Patient
Adjustment or Continuation of Medications (Sudden Cessation may Provoke a Withdrawal Syndrome)
Treatment to Reduce Preexisting Pain and Anxiety
Patient and Family Education

18. Pain Assessment Tools

19. Pain Assessment Tools
In Adults: Self Report Measurement Scales, such as Numerical Scales

20. Pain Assessment Tools In Pediatric Patients:
Physiologic and Behavioral Indicators of Pain ( Infants, Toddlers, Nonverbal or Critically Ill Children)
Face Scale (Age 3-10 yrs)
Visual Analogue Scales (Age 10-18)

23. Management of Acute Pain
Pharmacologic Interventional

24. Pharmacologic Management
Alter Nerve Conduction (Local Anesthetics)
Modify Transmission in the Dorsal Horn (Opioids, Antidepressants)

25. Routes of AdministrationPO PR IV IM
Transdermal
Transmucosal
Epidural
Intrathecal

26. Opioid Analgesics Bind to Opioid Receptors: Mu, Delta and Kappa
Morphine, Hydromorphone, Meperidine, Fentanyl, Codeine, Methadone, Oxycodone, Hydrocodone, Tramodol
Opioids may be Combined with NSAIDs to Enhance the Opioid Analgesic Effect

27. Opioid Analgesics
Equianalgesic Conversion Charts are used when Converting form one Opioid to Another, or Converting from Parenteral to Oral Form
Respiratory Monitors may be Used Depending on the Patients Age, Co-existing Medical Problems, or Route of Opioid Administered

28. Opioid Analgesics Conversions: Morphine
Oral Parenteral Epidural Intrathecal

29. Opioids Drug PO mg IV mg Comments 30 10 15-30 7.5 1.5 4-8 300 75 20
Starting Oral Dose mg
Comments
Morphine 30 10
15-30
MS Contin, Release 8-12 hrs
MSIR for BTP
Hydro-morphone
7.5
1.5
4-8
Duration Slightly Shorter than Morphine
Meperidine
300 75
Normeperidine Causes CNS Toxicity
Methadone 20
5-10 Qd
Long Half-Life, hrs
Accumulates on Days 2-3
Fentanyl
Fentanyl Patch, 12 hrs Delay Onset and Offset

30. Opioids Drug PO mg Comments Precautions Codeine 30-60 Oxycodone 5-10
Combined With Nonnarcotic Analgesics
Maximal Dose for Acetaminophen 4gm/d
Oxycodone
5-10
Percocet
Percodan
Oxycodone 10-30mg Q 4h
Oxycontin 10mg Q 12h
Acetaminophen or Aspirin toxicity
Hydro-codone
Vicodin or Lortab
Acetaminophen Toxicity
Tramodol
Q4-6hr
Central Acting, Affinity for Mu Receptors
Maximal Dose 400 mg/d

31. Patient Controlled Analgesia
Small Doses of Analgesic Drug (Usually Opioids), are Administered (IV) by Patient
Allows Basal Infusion and Demand Boluses
Over Dosage is Avoided
by Limiting the Amount
and Number of Boluses
in a Set Period of Time

32. Dose Regimens for PCA Drug Bolus Dose (mg) Lock-Out (Minutes) Morphine
0.5-2
5-15
Hydromorphone
5-10
Fentanyl

33. Non-Opioid Analgesics
Acetaminophen
NSAIDs (Aspirin, Ibuprofen, Ketorolac,
COX-2 Inhibitors)
Lidocaine Patch (Lidoderm)

34. NSAIDs Relieve of Mild to Moderate Pain Complication: GI Discomfort
GI Bleeding (Inhibition of COX-1)
Nephrotoxicity
Inhibition of Platelet Aggregation
Osteogenesis

35. Ketorolac Potent Analgesic Parenteral (IV or IM) 15-30 mg Q 6hr
Patients Older than 16 yrs
Should not Exceed 5 days

37. Cox-2 Inhibitors Drug Dose Celecoxib (Celebrex) 100-200mg PO Bid
Rofecoxib (Vioxx)
Valdecoxib (Bextra)
10-20mg PO Qd
Parecoxib
20-40mg IM
20-100mg IV

38. Lidoderm

39. Lidoderm 5% Lidocaine Patch
Indicates for Pain Relief in Post-herpetic Neuralgia
Each Patch Contains 700 mg of Lidocaine
Should be Applied to Intact Skin
About 3% is Absorbed
1-3 Patches Once a Day for 12 hrs

40. Interventional Management
Epidural Analgesia (Continuous Lumbar or Thoracic Epidural Catheter Placement, PCEA)
Spinal Analgesia
Peripheral Nerve Block ( Single Shot or Continuous)

41. Anatomy of Epidural Space
Surrounds the Dural
Sac
Anteriorly: Post.
Long. Ligament
Posteriorly:
Ligamentum Flavum
Laterally: Pedicles and
Intervertebral Foramina

42. Anatomy of Epidural Space
AP Dimension of the Epidural Space is Largest in the Lumbar Region, 5-6 mm
In Thoracic Region the AP Dimension Decreases but the Space is More Continuous

43.                                MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE

53. Epidural Anesthesia
Anesthestizes the Emerging Nerve Roots of the Spinal Cord
Epidural Injection of Anesthetic Produces a Regional Dermatomal “band” of Anesthesia Spreading Cephalad and Caudad from the Site of Injection
Level of Anesthesia Depends on :
Volume of the Drug
Level of Injection

54. Epidural Anesthesia
Lumbar Epidural: Lower Extrimity, Pelvic, and Lower Abdominal Procedures
Thoracic Epidural: Upper Abdomen and Thoracic Procedures
Caudal Injection: More Commonly Used for Pediatric Patients (Genitourinary and Lower Abdominal Procedures)

55. Advantages Superior Pain Relief Less Systemic Side Effects
Lower Incidence of DVT and Pulmonary Emboli
Decrease Blood Loss Intraoperatively during Orthopedic, Urologic, Gynecologic and Obstetric Procedures
More Rapid Recovery of Bowel Function
Earlier Ambulation
Better PFT
Suppression of Neuroendocrine Stress Response
Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative Outcome. Anesthesiol Clin North America 01-JUN-2000; 18(2):

56. Contraindications Absolute Patient Refusal Coagulopathy Increased ICP
Skin Infection
Relative
Uncooperative Patient
Pre-existing Neurologic Disorder
Anatomical Abnormalities

57. Factors Affecting Epidural Dosage
Patient Factors: Age , Height, Weight, Pregnancy
Site of Injection

58. Drugs Used for Epidural Anesthesia
Local Anesthetics
Opioids

59. Local Anesthetics in Epidural Space
Lidocaine: 1-2% , min.
Bupivacaine: % , min.

60. Opioids in Epidural Space
Drug
Dosage
Onset (min)
Duration (hrs)
Morphine
2-3 mg
30-90
6-24
Hydromor-phone mg
20-30
6-18
Fentanyl
mcg
5-15
2-4

61. Hydrophilic Opioids Morphine, Hydromorphone Slow Onset, Long Duration, High CSF Solubility
Advantages
Prolonged Single Dose Analgesia
Thoracic Analgesia with Lumbar Administration
Minimal Dose Compared with IV Administration
Disadvantages
Delayed Onset of Analgesia
Unpredictable Duration
Delayed Respiratory Depression

62. Lipophilic Opioids Fentanyl Rapid Onset, Short Duration, Low CSF Solubility
Disadvantages
Systemic Absorption
Brief Single Dose Analgesia
Limited Thoracic Analgesia with Lumbar Administration
Advantages
Rapid Analgesia
Ideal for Continuous Infusion or PCEA

63. PCEA
Technique that Allows Basal Infusion and Demand Boluses into the Epidural Space
Solutions Used:
Local Anesthetics: % Bupivacaine
Opioids: Morphine 50 mcg/ml
Hydromorphone 10 mcg/ml
Fentanyl 2-5 mcg/ml

64. Complications of Epidural Analgesia
Failure of Block (Patchy or Unilateral Block)
Injury to Nerve
Infection
Epidural Hematoma or Abscess
Dural Puncture (Total Spinal or PDPH)

65. Complications of Epidural Analgesia
Side Effect of Drugs in Epidural Space
- Hypotension Secondary to Sympathetic Blockade
- Intravascular Injection (Local Anesthetic Toxicity)
- Respiratory Depression
- Sedation
- Bladder Distention
- Difficulty in Ambulation

66. Spinal Anesthesia
Spinal Anesthesia is Induced by Injecting Small Amount of Local Anesthetic (Bupivicaine) in the CSF
Results in Rapid Onset of Block
More Rapid Onset and Requiring less Medicine Compared to Epidural Analgesia

67. Spinal Anesthesia CSE, Used in Labor
Preservative Free Morphine (Duramorph) Provides Pain Relief for Abdominal, Pelvic, or Lower Extrimity Surgeries
Complications Similar to Epidural Technique Except for Higher Risk of PDPH

70. Peripheral Nerve Block
Anesthetizing the Nerve that is Innervating Surgical or Painful Area
Single Shot or Continuous Infusion through Catheter
Upper Extrimity: Brachial Plexus, Median, Ulnar or Radial Nerve

71. Peripheral Nerve Block
Lower Extrimity: Sciatic, Femoral, Posterior Tibial, Sural, Saphenous, Deep and Superficial Peroneal Nerve
Intercostal Nerve Block
Surgical Wound Infiltration of Local Anesthetic

80. Acute Pain Management for Pediatric Patients
Consider Physiologic and Anatomic Differences
Pain Assessment and Communication
Pain and Anxiety Associated with Minor Procedures or Unfamiliar Situations

83. Caudal Block
Single Injection or Continuous Infusion through a Catheter
Excellent Intraoperative and Postoperative Pain Control
Easier to Perform in Children
Analgesia that Last About 12 hrs if Bupivacaine Used
Performed Following Induction of General Anesthesia

84. Indications for Caudal Block
Surgeries in Sacral Segments, (Circumcision and other Urologic Surgeries, Rectal Dilation)
Combined with Light General Anesthesia Provides Adequate Intraoperative Analgesia

85. Complications of Caudal Block
Infection
Dural Puncture and Spinal Anesthesia
Intravascular Injection of Local Anesthetics

87. Acute Pain Management in Elderly
Patient Population Older than 65 yrs of Age is Growing
Age Related Physiologic Changes (Decreased Muscle Strength): Decreased Cough
Decreased Mental Status (Dementia): Decreased Narcotic Dose

88. Acute Pain Management in Elderly
Age Related Anatomic Changes: Difficulty in Placing Epidural Catheter
Multiple Drug Therapy: Withdrawal or Interaction with Other Drugs