1. Prof. Krishna Boddu. MBBS, MD, DNB, FANZCA, MMEd MBBS, MD, DNB, FANZCA, MMEd University of Texas Health Sciences at Houston, Texas, USA University of Western Australia, Perth, Australia Director, Regional Anaesthesia, Royal Perth Hospital, Perth, Australia 1

2. Patient’s Colleagues Our staff Patient’s Family Patient’s Friends Our Patients All the people who are concerned about this patient 2

3. 3 Pain Control With an aim to Improve Functionality

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5. 5 Non-opioid Weak Opioid + Non-Opioid Strong Opioid + Non-Opioid Interventional ± Opioid ± Non-Opioid Acute Post-op Pain or Pain after Injury Pain Rx in the Community & Clinics

6. 6 Biological DVT, PE Pneumonia Poor wound healing Chronic Pain Angina & MI Social Delayed Rehab Prolonged Hosp Stay Increased Readmission Increased Cost Psychological Anxiety Dissatisfaction Depression Lack of motivation Effects of Family

7. 7 Ask Every Patient: 1. PPG (Personalized Pain Goal) is Important 2. Pain at Rest (Static Pain) Not of much value 3. Pain on Activity Dynamic Pain Ask Every Patient: 1. PPG (Personalized Pain Goal) is Important 2. Pain at Rest (Static Pain) Not of much value 3. Pain on Activity Dynamic Pain

9.  Background pain  Procedural pain  Breakthrough pain  Post procedural pain Background Pain Procedural Pain Breakthrough Pain 9 POST INTERVENTIONAL PAIN IS OFTEN NEGLECTED

10. 10 1.Four grams of Paracetamol / Acetaminophen (IV/PO)/day 2.NSAIDs (Parecoxib, Celecoxib, Diclofenac Na etc.) 3.Pregabalin 75-600mg/day ????. Tramadol along with antiemetic (SR or IR 400mg/day) 4. Lidoderm Patch 5. Ketamine 6. Clonidine 7. NERVE BLOCKS BENZODIAZEPINES ARE NOT ANALGESICS

11. 11 Suffering Medication Relief Regular/ Scheduled Medication Activity Activity Activity ORDER ONLY ONE PRN MEDICATION PER INDICATION ORDER ONLY ONE PRN MEDICATION PER INDICATION

12. 12 No Background Pain

13. 13 No Background Pain Baseline Pain Medication

14. 14 Biggest Fears In Treating Pain Respiratory Depression Most of the fears related to “Opioids” Severity of Side Effects are dose related Physical dependency is not addiction Most Side Effects can be effectively minimized by “Multimodal approach” And by Educating Patients & Providers Nausea & Vomiting Addiction Under Treated Pain Leads To “Pseudo Addiction” Behavior

15. Encourage 15 PCA Dose Lockout Interval (LOI) Basal Rate Pain down to patient’s satisfaction? Increase PCA Dose by 50 or 100% Is the pain relief lasting till next dose? Needing to press button many times LOI <8min Waking up with pain >7 day use of opioids prior to surgery Opioid abuse Decrease LOI

16. Encourage 16 PRN Dose Dose Interval ATC, ER or Patches Pain down to patient’s satisfaction? Increase PRN Dose Is the pain relief lasting till next dose? Needing to take all PRN doses PRN dose interval needing <3 hours Waking up with pain >7 day use of opioids prior to surgery Opioid abuse Decrease Dose Interval

17. 17 60-70% of 24 h consumption as PRN doses In Next Visit 50-60 % of 24 h consumption as basal/ ER in divided doses Look for Over dose Increase Basal /ER by 40-50% of 24hr PRN Consumption Continue the same PRN doses Calculate 24 hr PRN Opioid Consumption

18. Dose, Frequency, Peak levels & Steady State Plasma Level Required For Pain Relief Toxic Level Respiratory Depression Plasma Concentration of drug Time in hours Half Life 3 hours

19. First Optimize Non Opioids: Local Anesthetic Acetaminophen NSAIDs + Neuropathic Pain Medication Avoid Toxic Levels With Multimodal Approach Plasma Level Required For Pain Relief Toxic Level Respiratory Depression

20. 20 Pain Intensity Serious Adverse Effects Opioid Dose Time Pain Free: Trust the Patient What if Patient Getting Sedated with Poor Pain Control: ? Look at other systems ? Neuropathic Pain ? Drug Interaction

21. 21 Our Pledge to Patients Everything Possible will be Done to Provide Pain Relief Safely to Your Satisfaction We focus on “Improving your Functionality” Our team is available 24/7 to be reached by your Primary Nurse or Primary Team Our Pledge to Primary Team We are available 24/7 can be reached instantaneously We Accept Shared Accountability with You and Your Team We Educate Primary Nurses & Team rather than just help them by treating patient

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23. 23 Thank You