Acute Pain Management and Acute

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					Acute Pain Management and Acute Pain
      Is it a Luxury or Necessity?

         Al-Amin A. Khalil, MD
     Consultant Anesthesiologist and Pain Medicine



- Pain is the commonest patient complaint encountered by
health professional, YET it remains poorly treated
(Raymond Sinatra)
- It is worldwide problem. (Angel M, 1983-Collin, J.C. •
Yearbook 92-Donovan M, 1989 – etc.)
- 3.5 million people experience pain everyday (WHO, 1986).
- Mather, LE and McGrath,PA found that 75 % 
treated by PRN analgesics experience moderate to severe
pain and the total dose of analgesics actually administered
is less than 25 % of amount ordered.
- In one survey of 500 US households, 77 % of adult 
reported postoperative pain and 80 % of those
experiencing moderate to severe pain.(Ashburn M, ASA-
- In simple design, limited questionnaire, pilot survey in 
KKNGH in surgical ward, showed that more than 70 % of
adult patients experienced moderate to severe pain (Tagwa,
- Economic and social cost of poorly controlled pain 
ranging of tens of billions of dollars (Raymond Sinatra –
Yale University.)
Analgesic under administration and the “Benign neglect” as
    described by R. Sinatra that patient’s experience have
    related to a variety of factors:

  1- Lack of formal education in pain management among
     health care professional.
  2- Attitude and misconceptions of health care professionals
     and patients.
  3- Error in pain assessment
  4- Poorly written orders
  5- Lack of formal pain assessment, documentation of pain
     intensity, pain relief and patient satisfaction after pain
  6-Deficiency associated with traditional analgesic delivery.
1- Lack of Formal Education in Pain Management

  Bonica 1980 identified inadequacies in both nursing and
       medical education curriculum as one of the major
       barriers to effective pain relief.

  loper, KA wrote an article in, PAIN 1989 entitled
       “Paralyzed with Pain” highlighted educational
       deficiencies including the fact that healthy
       professionals could not distinguish between opioid
       analgesic, neuromuscular blockade agents or
       sedative hypnotic.

  Physicians have little knowledge of opioid pharmacology,
      underestimate effective dose and overestimate
      analgesic duration and potential for overdose. In
      general, analgesic prescriptions are unrealistically
    2. Attitude and Misconceptions of Health
    Pain assessment is commonly performed and
     documented by observation alone ignoring the fact
     that: “Pain is a subjective experience and nobody
     can know other body experience unless he was told
     about it”.( Jo Ann Dalton, Nurses’Perceptions on their
     pain assessment, Oncology nursing forum, Vol.16, 1988)

    The common false belief with opioid usage.( Restrict
     the dose and prolong the interval)
     What is the fear?
     a-Physical and psychological dependence (Addiction)
     b-Respiratory depression

     With regard to opioid analgesics, may be restrict and
     often denied to elderly and critically ill patients.
Knowledge and Beliefs Regarding Pain in a Sample of
                  Nursing Faculty

  Betty R. Ferrel, PhD, FAAN, Deborah B. McGuire,PhD, RN, and
                 Marilee I. Donovan, PhD, FAAN
The Use of Opioids For the Treatment of Chronic Pain
A Consensus Statement From the AAPM and the APS
Consensus Statement from American Academy of
 Pain Medicine and American Pain Society 1997

    Compulsory disorder in which the individual becomes
    preoccupied with obtaining and using the substance,
    the continued use of it results in a decreased quality
    of life.

    Studies indicated that de novo development of
    addiction when opioids are used for pain relief is
Consensus Statement from American Academy of
 Pain Medicine and American Pain Society 1997

Respiratory Depression:

    It is now accepted as a short lived phenomenon,
    occurred in opioid naïve patients and it is antagonized
    by pain.


    Decreasing pain relief with same amount of analgesics
    has not proven to be treatment limitation in long term.
             3. Poorly Written Orders

Collins JC in historical review of pain management article
    1992, indicated that poorly written orders are
    commonly misinterpreted to the negative use of
    analgesics. This compounded by the fact that patient
    usually get as little as 25% of the prescribed doses.
  4. Deficiencies Associated With Traditional
              Analgesic Delivery

Several studies showed that on demand administration
    (PRN) of IM injection of analgesics have several
    deficiencies limits its clinical usefulness (Donovan,
    1987; Farrante 1990; Loper 1989; Melzack 1987,
    Owens 1990).


                       Sedation                  Call for Nurse
Patient Variables

                                                                          Nurse variables
                     Pain Relief           PCA       Nurse Responds

                    Absorption from site                   Screening

                        Administer Med.             Sign out Medication

                                   Prepare Medication
          Pathophysiology of Acute Pain

It is not only an Ethical and Humanitarian issue to minimize
       pain and suffering, there is also need to appreciate
       pain related anxiety, sleeplessness and release of
       stress hormones and cathecolamines which may
       have deleterious effect upon surgical outcome. This
       is particularly true in elderly and critically ill
       populations (Beattie, WS 1993; Breslow MN, 1990, et

Physiologic response to acute injury increases pain
    intensify and associated with increased morbidity.
    Pathophysiology of Acute Pain (Cont.)

   Peripheral sensitization
   Central facilitation (Sensitization)
   Sympatho-Adrenal Activation
   Neuro-Endocrine Activation
   Alteration of Pulmonary Function
   Deep Venous Thrombosis
   Decreased Immune Function
   GI System
          Peripheral Sensitization

Following tissue injury alogenic substances are
released (inflammatory soup) bradykinines,
prostaglandin’s, substance P , sensitize the
nociceptors immediately adjacent to the site of tissue
injury. Sensitization of peripheral nerve endings
results in a heightened inflammatory response,
neurogenic edema and primary hyperalgesia.

           What is the importance?
Central Facilitation (Sensitization) and Secondary

 Enhancement of nociceptive processing within dorsal horn cell.
     - Substance P released in DHC secondary to tissue injury.
        This promotes the release of excitatory amino acids like
        aspartate, glutamate and others. Which work on Nk and
        NMDA receptors. The initial phase of the central pain
        process is called Wind up phenomenon; short term only
        for few minutes and the intensity of pain matches the
        severity of tissue injury. This followed by a long term
        facilitation at the DHC-WDR.

      -   Increased sensitivity – Decreased threshold-Increased
          gain. Recruitment of more neurons beyond the initial
          tissue injury receptive area.

This second phase of excitability OUTLASTS the
     initial barrage of sensory output. This is not
     antagonized by inhalation anesthesia.

     - Secondary hyperalgesia
     - Ipsi and contralateral flexion reflexes
     - Alteration in regional symphatetic tone
     - Effort dependent pain
Sympatho-Adrenal Activation and Cardiovascular Effect

  Surgical stimulation, tissue injury and initiation of pain cascade
  lead to: Increased plasma level of epinephrine and
  norepineprhine and remain elevated post operatively.
  The magnitude and duration of this response is directly related to
  extent and duration of surgical procedures this may lead to:
        - Peri-operative ischemia
        - Hypertension
        - Altered perfusion
  Decreased perfusion in surgical site lead to impair wound-healing
  enhancement of nociceptors sensitivity, increased pain intensity,
  muscle spasm.
       Peri-operative mortality may reach up to 15 %
       in high-risk patients.
          Patho-physiology of Pain (Cont.)

Mangano DT and colleagues 1990 – 1992 showed that adequate
post operative analgesia significantly reduced both peri-operative
tachycardia and ischemic episodes.

Yeager and Glass found significant reductions in CVS morbidity,
mechanical ventilation, pulmonary infection, ICU stay and total
hospital stay in the group receiving epidural analgesia with
adequate pain relief than the control group.

De Leon Cassasola, in series of high risk patients with significant
CAD going for urgent abdominal surgery, found lower incidence of
tachycardia, ischemic changes and trend to lower frequency of MI
with epidural analgesia.
Neuro-Endocrine and Metabolic Effect

Stress response to surgical stimulation and pain
cascade leads to alteration in hypothalamic-adrenal
function with increased plasma level of cortisol,
glucagon and epinephrine. Hyperglycemia and
hypermetabolic state with negative nitrogen balance.
Short term benefits of enhanced energy production.
Prolonged stress response lead to prolonged catabolic
sate which lead to adverse effect on post surgical
outcome. Several studies showed adequate pain relief
with epidural analgesia significantly reduce the stress
response and improve the patient outcome.
        Alteration of Pulmonary Function

Beecher described increase in RR and decrease in TV, VC
     and FEV1 in post surgical patients. These changes are
     highest in upper abdominal and thoracic surgery.
These changes are mainly due to:
     - poorly controlled effort dependent pain
     - reflex spasm of chest wall
     - pleuritic irritation
Decreased FEV1 lead to:
     - decreased coughs       - Pneumonia
     - Atelectasis            - Respiratory failure
     - Hypoxia
This may lead up to 70 % morbidity in high-risk patients.
    Alteration of Pulmonary Function (Cont.)

Yeager and Glass found significant reduction in
    pulmonary complication in high-risk surgical
    population who treated with epidural analgesia post-

Rawal, LN showed significant reduction in post-operative
    pulmonary complication in grossly obese patients had
    adequate post-operative pain relief with epidural
    analgesia (Anesth-Analg., 1984)
              Deep Venous Thrombosis

Stress response to surgery and pain cascade lead to:
     - hypercoagulable state
     - increased platelets adhesion
     - damage of venous conduit from surgical
     - endothelial injury
     - venous stasis aggravated by poorly controlled effort
        dependent pain

All these factors increase the risk for deep venous
      thrombosis and pulmonary embolism
     Deep Venous Thrombosis (Cont.)

Usage of epidural analgesia intra and post operative has
    been associated with decrease in DVT in hip, knee
    and prostate surgery and decrease the incidence
    post-operative clotting of vascular graft.

Carpenter R, showed 5-fold reduction in DVT and 3-fold
     reduction in PE with epidural analgesia (CCF-1997).
              Persistent Pain Syndrome

1.   Continued sensitization of nociceptors secondary to
     compression, infection, inflammation
2.   Muscle, peritoneal and periosteal irritation lead to reflex
     muscle spasm
3.   Poorly controlled pain
4.   Humoral and neurologic alteration at the site of surgery

All result in acute pain disability and impaired rehabilitation

    Prolonged nociceptor sensitization-continued peripheral
     discharge lead to-prolonged central facilitation-spontaneous
     pain, hyperalgesia and allodynia.
    Heightened sympathetic tone and vasoconstriction-
     sympathetically maintained pain-chronic pain syndrome
           Immune Function and Pain

It has been demonstrated that stress response to surgery
      and pain decrease function of immune system in
      humans. This immune suppression could be
      attenuated by adequate control of pain and stress
      response and improve the outcome. (Ashburn, 1997).
            GI System (Bowel Function) and Pain

A-Post-operative ileus is a major surgical morbidity with financial
cost estimated at $750 million/year.

B-Post-operative ileus is thought to result from abdominal activation of
     spinal arc, which inhibits intestinal motility. Both nociceptive
     afferent and sympathetic efferent are believed to be the key initiators
     of ileus.

C-Thoracic epidural analgesia will produce selective, segmental
blockade of nociceptors afferent and sympathetic efferent leaving
parasympathetic stimulatory system unopposed which
theoretically improve the bowel function.
                         GI System (Cont.)

                         Epidural  Epidural       Epidural     IV PCA
                         MS+Bupiv. Bupiv.         MS.

Time to first flatus
                         43 +- 4*    40 + -2*     71 + -4*     83 + -3*

Time to D/C Criteria
                         57 + -8*    62 + -5*     102 + -13*   96 + -7

Time to Actual D/C
                         96 + -12*   101 + -11*   130 + -14    122 + -9

Orthostatic Hypotensio
                         14          57*          17           17

Scheinen B, Asantila R, Okro R (Acta Anesthesiol. Scand. 1987)
                Pre-emptive Analgesia

   Recent advances in pain management have resurrected ideas
    proposed 70 years ago that blockade of pain transmission
    prior to surgical injury reduce post operative morbidity and

   Wall in the late 1980 suggested that analgesic intervention
    is most effective when made in advance of pain stimulus
    rather than in reaction to it.

   It is well recognized that peripheral injury triggers state of
    neuro-excitability. In DHC (Central Facilitation – Spasticity)
    which outlast surgical inflammation. This could be prevented
    by pre-emptive neural blockade and administration of
    analgesics. Such treatment is much less effective following
    the injury.
               Acute Pain Service

   The practice of pain management comes under increased
    scrutiny over the last two decades.

   ACCPR, APS, ACS guidelines for acute pain management

   The first experience with acute pain service team (Read, B
    Anesth. 1988)

   The Joint Commission for the Accreditation of Health Care
    Organization and the Acute Pain Service.

   The current status of acute pain service in USA (Warefield
    Survey 1995).
       Models of Acute Pain Service

Pain service has been categorized by complexity of
therapy provided. Different models with different
settings. Whether it is anesthesia based or multi-
department whether they are associated with university
with high level of education or with pure private
           The Two Extreme Models Are:

A-Multidisciplinary Specialist – Directed Service
This includes:
      - Director
      - Consultant physicians from different discipline
      - Fellows
      - Residents
      - Clinical nurse
      - Co-coordinators
      - Acute pain service specialist
      - Psychologist
      - Therapist
      - Pharmacist
      - Social worker
      - Stakeholder representative
   The Two Extreme Models Are (Cont.)

Such service may exist in highly surgical performance
facility with highly dedicated teaching program setting
(ideal structure for big named universities).
     The Two Extreme Models Are (Cont.)

B-Nurse – Directed Service (Sweden)
-   Such model is much less costly in comparison to any other
    models with limited function.
-   It runs by acute pain nurse specialist in cooperation with
    ward nurse representative for pain service
-   Works in low surgical profile facility, with surgical procedures
    with healthy patients ASA – 1, 11 and non-complicated
-   Limited to IM and IV incremental doses of narcotics
-   Doesn’t cover painful medical procedures, painful medical
    disorder or trauma pain service
-   Follow strict guidelines

Modified limited multidisciplinary model:
     - More popular than the other two models. Anesthesia-
     based service. The other discipline may be involved in
     consultation basis.

The core of such service:
     - Director
     - Clinical Nurse Coordinator
     - Acute Pain Nurse Specialist
     - Pharmacist
     - Resident or Fellow

Director:   Is the key for the success of such service:

-   Have firm commitment for the project and has time and
-   Has the knowledge and expertise to facilitate work of the
-   Assume role of clinician, negotiator, educator and section
                  Characters (Cont.)

Co - Director:   From different discipline may be advantageous
    in some setting to give additional power and recognition with
    the health care facility and divide the work load.

Clinical Nurse Coordinator (CNC):             Is second in
    importance only to the Pain Service Director. The clinical and
    administrative responsibility of this individual will be
                     Character cont.

   Management level nurse, preferable with higher degree

   Appreciate the unique political structure of the institution will
    facilitate the work relationship different department

   Has research and education obligation to the residents and

   Follow up and supervision of surgical and nurse managed
                   Characters (Cont.)

Acute Pain Nurse Specialist:

Have the same character; duty and obligations like CNC
                  Characters (Cont.)

The Pharmacist:

-   Compound patient control analgesia (PCA) and epidural
    medication, in preservative-free normal saline using strict a
    septic technique
-   Utilizing Centers for Disease Control sterility guidelines
-   Drug information and patient education
-   Developing control system to identify potential misuse.
        Acute Pain Service Activity

-   Clinical
-   Administration
-   Education
-   Quality Improvement
                    Clinical Service

Type of Service:

    -   Post-operative pain control
    -   Post trauma pain control
    -   Pain control for painful medical procedure
    -   Pain control for painful medical disorders
    -   Acute pain control for cancer patients
                  Mode of Service

-   Consultation based
-   Consultation and management based
-   Spontaneous (pre-post surgical patients)
                     Form of Service

-   Complete clinical and pain assessment
-   Initiate the pain control modality that fits patient clinical
    status and acceptance
-   Maintain and modify the service as needed
-   Dealing with up coming problems
-   Close clinical observation for the patient progress in
    general and pain in particular and react accordingly.
    Keys for Successful Clinical Service

-           Availability
-           Consistency
-           Patient Safety
-           Patient Satisfaction

- Establishment and implement specific policies and
- Standardize the procedure to assess pain within the
health care setting. Let every one in the health care
facility speaks the same language

- Develop a method for documenting pain intensity
scores in the patient record. The 6th vital sign.
  (Bookbinder 1993 – 1996)
           Administration (Cont.)

- Delineate who is responsible for conducting an initial
   pain assessment when patient is admitted to the health
   care facility (MRP VS Acute Pain Service)

-The frequency with which acute pain should be assessed
    on and ongoing basis.
                  Administration (Cont.)

Policies and procedures for use of advanced pain tech. Including
IVPCA-EPCA-EOA – Intrathecal opioids regarding the following
      - Level of monitors
      - Roles, accountability, limits of practice for all groups of
         health care providers involved in using such advanced
         tech. Ward nurse, surgical team, pain resident, acute pain
         nurse, consultant pain physician

Define staff competencies, program of certification for staff skills in
providing of care using advance tech, program to update and re-
certify the staff skills.

Set forth criteria for patient suitable for such tech.

Health Care Professionals Education Program

-    Numerous surveys have documented inadequate knowledge
     of clinicians regarding pain management. Planned approach
     to the education of all health care professionals involved in
     pain management.

-    One way to demonstrate a need for staff education in pain
     management is to conduct a knowledge and attitude survey.
     By conducting such survey, can avoid “The not us
     phenomenon” from individual oppose education process.
                 Education (Cont.)

Having such survey:

-    Proves than an education is needed

-    The data can serve as base line to compare with the results
     following the education program

-    The data could be used to plan education program. If the
     worst scores are found on pharmacology items more
     attention and time would spend on this item.
                   Education (Cont.)

Disseminate Education Resources:

a)   Copy of AHCPR guidelines for pain management 1992 – 1999
b)   APS Principals of analgesic use 1999
c)   Equianalgesic dosing chart should be posted in strategic
            Quality Improvement Activity

Quality Improvement Activity:

-       American Pain Society Guidelines for Quality Improvement

    -      Assuring that a report of unrelieved pain rises “Red Flag” that
           attract clinician attention.
    -      Making information about analgesic available
    -      Promising patients attentive analgesic care
    -      Define explicit policies for use of advanced analgesic
    -      Examine the process and outcomes of pain management with
           goal of continuous improvement
What, Where, When and