Management of Acute Pain Flashcards
What is Pain?
“an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
- Individual perception and reaction varies
- Influenced by psychological factors including previous experience
- Influenced by pre-existing pain (acute on chronic)
What are the three types of pain?
- Nociceptive
- No apparent cause
- Neuropathic
What is nociceptive pain?
Can be chronic
Can be acute –> immediate repose/delayed response
What is neuropathic pain?
Acute or chronic
The pain continuum (acute to chronic)
Acute pain:
- Usually obvious tissue damage
- Pain resolves upon healing
- Serves a protective function
Chronic pain (3-6 months)
- Pain for 3–6 months or more
- Pain beyond expected period of healing
- Usually has no protective function
- Degrades health and function
- Can result from dysfunctional activation of pain pathways
When treating acute pain aim to:
- Avoid acute becoming chronic
- Avoid memory of pain causing potentially harmful situation in future
Why is this important for you as Pharmacists?
- RPS survey: Around 35% of pharmacists speak to adult patients about acute pain two-to-five times per day.
- With the introduction of restrictions on prescribing over-the-counter (OTC) analgesics by NHS England, more patients will likely present to the pharmacy for advice.
Where is acute pain a problem?
Community Pharmacy -
Minor Ailments schemes include:
- Backache, strains and sprains, earache, headache
Advice and OTC sales for:
- Menstrual pain
- Migraine
- Post procedural pain
Secondary Care
- Trauma/burns
- Myocardial Infarction
- Kidney Stones
- Childbirth
- Post-operative pain
- Sickle cell crisis
Assessment of acute pain:
- Accurate assessment is essential in the development of a treatment plan:
Consultation skills:
- Where (watch out for colloquial terms!! )
- Intensity
- Anything aggravate pain/ improve pain
- Other symptoms
Before a treatment modality is decided upon:
- Co-morbidity
- Other medications
SOCRATES
What is SOCRATES:
Site– Where exactly is the pain? What body part/joint is involved?
Onset– When did the pain start? Was it constant or intermittent? Gradual or sudden? Is it progressive or regressive?
Character– What is the pain like? An ache? Stabbing? Sharp? Burning? Tight?
Radiation– Does the pain radiate or move elsewhere?
Associations– Are there any other signs or symptoms associated with the pain (e.g. sweating, vomiting, temperature)?
Time course– Does the pain follow any pattern? Is it constant or does it happen at a specific time of the day? How long does it last? When did he/she feel the most pain?
Exacerbating/relieving factors– Does anything change the pain? What makes the pain better or worse? Sometimes, a specific physical position or medication can relieve the pain.
Severity– How bad is the pain? The patient should be asked to give a number to describe the pain on a scale of 0–10, where 0 is the lowest and 10 is the most severe pain experienced.
Step Wise Approach to Pain Management:
- Paracetamol
- Substitute paracetamol for Ibuprofen
- Add paracetamol to Ibuprofen
- Substitute
Ibuprofen
(alt Naproxen). Keep paracetamol - Weak opioid + Paracetamol
And/or NSAID
Don’t keep adding – swap
Opioid is last resort
Analgesia Choice in Children(>3months):
- Paracetamol or Ibuprofen alone as first line
If no response:
- Check adherence
- Check dosing
- Switch
- Alternate dosing
Joint Pain:
Osteoarthritis is a common cause of activity related joint pain. Pain may be managed in community setting
Red Flags include:
- Deformity associated with pain
- Too painful to move / cannot bear weight;
- Severe swelling, discolouration, hot to the touch or bleeding;
- Persistent joint pain, tenderness or swelling;
- Prolonged or severe morning stiffness (more than 30 minutes duration);
- Feeling unwell or presence of fever;
- Tingling or numbness
Back Pain and treatment;
- Range from neck to lower back, buttocks and legs.
- 8 out of 10 people suffer lower back pain at some point in lives
- Important to determine if nociceptive or neuropathic
- Warning signs include: recent trauma or injury, pain down legs and below knees, loss of bladder/bowel control, weight loss –> immediate referral into secondary care
- Use pain ladder to treat. May be prescribed short course benzodiazepines if muscle spasm present.
- Key Messages! Keep moving, painkillers, manual therapy, hot/cold packs, stretching.
Practical issues when using Paracetamol. Doses:
Children:
- 3 to 6 months: 2.5ml of infant susp
- 6 to 24 months: 5ml of infant susp
- 2 yrs to 4 yrs: 7.5ml of infant susp
- 4 yrs to 6 yrs: 10ml of infant susp
- 6 yrs to 8 yrs: 5ml of paracetamol six-plus susp
- 8 yrs to 10 yrs: 7.5ml of paracetamol six-plus susp
- 10 yrs to 12 yrs: 10ml of paracetamol six-plus susp
Adult weight related dosing recommended (BNF) - max daily 4g if >50kg, 3g if 41-49kg, 2g <40kg
Practical Issues - NSAIDS
Key Message : Lowest effective dose for shortest period of time to control symptoms!
- First line: Ibuprofen - 400mg three times a day (OTC)
- Second line: Naproxen 250-500mg twice daily (OTC: menstrual pain only)
For single regional pain relief (especially wrists, hands, knees, elbows, or feet): consider a topical NSAID
Cautions and contra-indications:
- Elderly – renal function/co-morbidities
- Asthmatics, previous GI ulcer and/or bleed, renal impairment (incl AKI), cardiovascular disease (CI in failure)
Severe acute pain – may consider Paracoxib (COX-2 inhibitor) I.V.
Commonly used Opioids for Acute Pain?
- Codeine (oral, IM)
- Tramadol (oral, IV, IM)
- Morphine (oral, pr, IV, IM)
- Oxycodone (oral, IV)
- Fentanyl (IV, buccal, sublingual, nasal)
Key Principle for the safe and effective use of opioids:
- Carefully titrate dose against desired effect.
- Check previous exposure to opioids
- Consider patient age, size, renal function and other co-morbidities
- Monitor carefully (or advise patients if community prescription) e.g. Drowsiness, constipation etc
How to manage post-operative pain: PCA
Patient Controlled Analgesia (PCA):
Most effective 24-48hrs after an acute pain episode
Self administration of a small intravenous bolus dose of opioid
Have a predetermined “lockout” period (5 mins)
Usually morphine, fentanyl or oxycodone
Set up of PCA?
- Set-up: Need to administer IV opioid initial loading dose
Usually done by anaesthetic staff in recovery area. - Increase patient satisfaction (no need to wait for a nurse or two!)
- Avoids intermittent injections
- Reduced risks of sedation and respiratory depression
Chronic pain patients can continue with any long term analgesia
All patients should have Paracetamol + NSAID (if suitable) alongside a PCA
BUT need to check patient understanding and their dexterity to use the pump
Must be used by Patient only…………NOT relative, nurses!!
Monitor pain scores, sedation score, respiratory rate, N&V scores.
Record number of “requests”, total volume used.
“Stepping down” from PCA:
- Usually onto oral opioid such as morphine or oxycodone (or weak opioid if use has been low)
- Starting dose needs to take into consideration previous PCA use over the last 24 hours
e. g. 30mg IV PCA Morphine – convert to 60mg oral Morphine in divided doses - Dose may still need to be titrated to effect – prescribed as required and continue to monitor and score pain.
- Adjuncts should be also used where appropriate (opioid sparing effects)
What is Epidural analgesia?
Form of regional anaesthesiwith drugs delivered via a catheter directly into the epidural space:
- Use a combination of local anaesthetic and strong opioid (typically levobupivicaine 0.125% with fentanyl 2mcg/ml)
- Infusion rate dependant on position of epidural, pain score balanced with clinical observations.
- Patients able to mobilise with infusion in-situ post operatively
Used in childbirth and infusions after major surgical procedures
Positioning and monitoring in epidural:
Side-effects (from opioid and L.A.) - Itching - Nausea and vomiting - Drowsiness - Respiratory depression - Urinary retention - Hypotension - Bradycardia - Headache (dural puncture) - Motor Block - Essam (arms) and Bromage (lower limb)scores
Other techniques/drugs used for pain?
- Local Anaesthetic Infusions – acute post-op pain or trauma
- Transversus Abdominis Plane (TAP) block- newer technique in abdominal surgery
- Ketamine infusions - difficult pain cases. Carefully controlled and monitored as hypnotic and amnesic.
- Entonox (Nitrous oxide “Gas and Air”) – childbirth, wound dressings, joint manipulations
Drug Treatment Choices:
What should you consider when advising on analgesia?
- Type and severity of pain
- Efficacy of agents for type of pain
- Route available and mode of delivery: Enteral (oral, rectal, feeding tubes)
Topical (but not patches), I.V. incl P.C.A., subcutaneous
Epidural or spinal
Contra-indications (Incl: allergy status)
Co-morbidities
Other medication
