Week 6- Pain and post operative analgesia Flashcards
what is pain?
An unpleasant sensory and emotional experience associated with, or
resembling that associated with, actual or potential tissue damage,
how is pain measured?
• Usually measured on a scale, typically 1-10
• For younger children pictorial scales with faces are used to depict the level of pain
-In very young children and babies and patient unresponsive in critical
care behavioral and physiological signs are used to determine the level of pain
what is the WHO analgesic ladder?
step one- is mild pain use non-opioid
step 2- for pain increasing/persistent use non-opioid or opioid for mild to moderate pain
step 3- for increasing pain/persistent use opiodid
what are the non-opioid analgesic?
• Paracetamol - Weight, hepatic function • NSAIDs/COX-2 inhibitors • Topical treatments - NSAIDs - Capsaicin - Lidocaine
what are some opioids? strong and mild
• Opioids for mild/moderate pain – weak opioids – limited potency at mu receptor -Codeine - Dihydrocodeine • Opioids for moderate/severe pain – strong opioids – high potency at mu receptor - Morphine - Diamorphine - Oxycodone - Fentanyl
what are some considerations surround opioids analgesia?
• Metabolism - Several opioids, including codeine, tramadol and oxycodone, are affected by variations in CYP2D6 metabolism • Side effects - Constipation - Nausea/vomiting - Drowsiness - Sedation - Respiratory depression • Renal function • Dependance/addiction
what are some adjuvant therapies opioids be used with?
• Anti-epileptic drugs • Antidepressants • Other - Dexamethasone for bone pain in palliative care • Non pharmaceutical strategies - Physiotherapy - Exercise - Psychological therapy - Acupuncture
what is chronic pain? types?
• One of the most common reasons for GP consultation • May be classified as per type - Musculoskeletal - Neuropathic - Non-specific persistent pain - Chronic headache syndrome
what can musculoskeltal pain be broken down into?
Mechanical pain
• Osteoarthritis
• Lower back pain
• Rheumatoid arthritis
what is lower back pain/ sciatica?
- Low back pain that is not associated with serious or potentially serious causes
- Sciatica - leg pain secondary to lumbosacral nerve root pathology
- Worldwide lower back pain causes more disability than any other condition
what is the treatment for lower back pain/ sciatica?
• Treatment • Continue normal activities • Group exercise programs • Manual therapies • Psychological therapy • Oral NSAID • If NSAID contraindicated or not tolerated weak opioid +/- paracetamol for ACUTE pain only • Sciatica specific – epidural injections (local anaesthetic + corticosteroid), spinal decompression surgery • Surgical treatments • Radiofrequency denervation • Spinal cord stimulation
what is osteoarthritis? symptoms
• Most common form of arthritis • Breakdown of the cartilage in the joints, most commonly hips, knees, hands, lower back and neck - Symptoms • Joint pain during and after activity • Joint stiffness in the morning or after rest • Initial limited range of motion • Clicking or cracking in joints • Swelling around joints • Muscle weakness around the joint • Instability of the joint
what is osteoarthritis treatment?
- Treatment • Exercise and manual therapy • Weight loss if overweight/obese • Paracetamol +/- topical NSAID • Topical capsaicin • If the above are ineffective or insufficient oral NSAID/COX-2 inhibitor may be considered • Intra-articular corticosteroid
what is rheumatoid arthritis?
• Autoimmune disease causing inflammation of the synovium
• Can lead to erosion and deformation of the affected joints
• Other tissues may be affected in more advanced disease
- Symptoms
• Symmetrical pain and swelling of the small joints in the hands and feet lasting
>6 weeks
• Spread to the larger joints
• Joints may be warm and tender
• Stiffness on waking or following inactivity
• Fatigue, fever and loss of appetite
what can be used for musculoskeletal pain?
• Corticosteroids or NSAIDs may be used for symptomatic control of an acute flare • Physiotherapy • Hand exercise program • 'Treat to target strategy' • Surgical treatment
what is treat to target?
- Initial therapy
- Monotherapy
- Methotrexate/leflunomoide/ sulfasalazine
- Hydroxychloroquine as alternative in those with mild or palindromic (periodic) disease
- Step Up Strategy
- Additional DMARD (methotrexate/ leflunomide/ sulfasalazine /hydroxychloroquine) in combination where dose titration has not achieved remission/low disease activity
- Inadequate response to conventional DMARDs
- Biological DMARDs
- Upadacitinib/sarilumb/ adalimumab/ etanercept/infliximab…..
- Inadequate response to biological DMARDs
- Rituximab
what is neuropathic pain? diff types
• Definition - ‘Central neuropathic pain is defined as ‘pain caused by a
lesion or disease of the central somatosensory nervous system’, and
peripheral neuropathic pain is defined as ‘pain caused by a lesion or
disease of the peripheral somatosensory nervous system’.IASP 2011
• Types
• Peripheral neuropathy
• Complex regional pain syndrome
• Central pain
how is neuropathic pain? how is the pain exerted? treatment?
• Can be difficult to manage due to heterogeneity of its aetiologies, symptoms and underlying mechanisms
• Can be intermittent or constant, spontaneous or provoked pain
• Treatment
• Amitriptyline/duloxetine/gabapentin (or pregabalin)
• If initial drug ineffective try one of the others
• Tramadol may be considered for acute rescue therapy
• Consider capsaicin cream for people with localised neuropathic pain who wish
to avoid, or who cannot tolerate, oral treatments
• Carbamazepine should be offered for management of trigeminal neuralgia
what is included in non-specific persistence pain?
- Includes conditions that may be recorded as
- fibromyalgia
- complex regional pain syndrome
- myofascial pain
- somatoform disorder
- functional syndromes
- chronic widespread pain
- pelvic pain of unknown origin
what is the treatment for non-specific persistent pain
• Treatment
• Supervised group exercise program
• Psychological therapy
• Acupuncture
• Antidepressants
• Duloxetine/fluoxetine/paroxetine/ citalopram/sertraline/amitriptyline
• Several pharmacological therapies are not recommended for use in the
treatment of persistent pain including paracetamol, opioids, NSAIDS,
antiepileptic drugs, benzodiazepines….
what are chronic headaches?
• Cluster-type (idiopathic, intermittent, unilateral eye, lasting less than
2 hours, occurring more than 3 days per week)
• Analgesic overuse (bilateral, constant, lasting 8 to 24 hours)
• Tension-type (primary headache, bilateral, constant, lasting 8 to 24
hours, 7 to 9 days per month)
• Post-trauma (bilateral, constant, lasting 8 to 24 hours, 7 to 9 days per
month)
• Chronic migraine (primary headache, bilateral, lasting 1 to 4 hours)
what is acute pain?
- Sudden onset and result of something specific
- Usually <6 months duration
- Typically can be split into spontaneous insult/trauma and planned – surgery
- Spontaneous/trauma
- Broken bones
- Burns and cuts
- Toothache
- Headache
- Childbirth
what is the treatment for acute pain?
• Minor causes of acute pain
• OTC analgesia
• Paracetamol
• NSAIDs – PO/topical
• Low dose weak opioids
• Non-pharmacological
• More significant pain, where medical treatment is necessary, may
necessitate higher levels of analgesia and additional therapies
• The WHO pain ladder can be used as a basis for acute pain
management
what is palliative care?
• Palliative care is an approach that improves the quality of life of
patients and their families facing the problems associated with lifethreatening illness (World Health Organisation [WHO] )
• Recognised by the World Health Organisation as a priority are for
standardisation of care
• Development of the WHO analgesic ladder
• Adequate analgesia combined with other symptomatic control to
ensure patients are comfortable
• Palliative care ≠ end of life
what pain control is used in palliative care?
The WHO pain ladder should be adapted to the needs of individuals
• Basic principle of starting at the bottom may not be suitable for all
• Adjuvants should be considered at each step
• If pain control is not achieved move up a step
• Morphine is the most commonly used strong opioid analgesic, the
availability of prolonged and immediate release preparations allows
maintenance and breakthrough analgesia
• No maximum dose of morphine
what are some long-acting and breakthrough for palliative care?
• One long-acting opioid (prolonged release formulation) should be
used with a short acting opioid (immediate release formulation) for
breakthrough pain
• The breakthrough analgesia dose should be 1/10 to 1/6 of the daily
long-acting dose
• Example
• Zomorph 60mg BD
• Total daily dose = 120mg
• Breakthrough – oramorph 12 - 20mg 2 - 4 hourly
• Be aware of opioid equivalences when switching from one drug to
another
what are syringe drivers? how do they work? biggest concern
• If frequent doses of analgesics or other medications for symptom control
are required a constant subcutaneous infusion can be administered via a
syringe driver
• Drugs and diluent added to a syringe which is set to infuse over a defined
time period, usually 24 hours
• Major concern is stability of the contents of the driver, multiple drugs are
often combined and infused over a prolonged period of time
• Some resources to determine the compatibility of syringe driver contents
and other information surrounding palliative care
