Acute Pain Management and Acute Pain Service Is it a Luxury or Necessity? By Al-Amin A. Khalil, MD Consultant Anesthesiologist and Pain Medicine OBJECTIVES Recognition Appreciation Etiology Impacts PRACTICAL PROPOSAL INTRODUCTION - 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- 1998). - 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, 1999). - Economic and social cost of poorly controlled pain ranging of tens of billions of dollars (Raymond Sinatra – Yale University.) ETIOLOGY 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 therapy 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 low. 2. Attitude and Misconceptions of Health Professionals 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 c-Tolerance 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 Addiction: 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 LOW. Pseudo-Addiction? Consensus Statement from American Academy of Pain Medicine and American Pain Society 1997 (Cont. Respiratory Depression: It is now accepted as a short lived phenomenon, occurred in opioid naïve patients and it is antagonized by pain. Tolerance: 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). Variables: Pain 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 al). 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 Hyperalgesia Enhancement of nociceptive processing within dorsal horn cell. Mechanism: - 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. Effect This second phase of excitability OUTLASTS the initial barrage of sensory output. This is not antagonized by inhalation anesthesia. Clinically: - 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- operative. 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 manipulation - 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* (h) Time to D/C Criteria 57 + -8* 62 + -5* 102 + -13* 96 + -7 (h) Time to Actual D/C 96 + -12* 101 + -11* 130 + -14 122 + -9 (h) 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 mortality. 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. A B 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 practice. 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 surgery - 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 THE COMMOMEST MODEL 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 Characters Director: Is the key for the success of such service: - Have firm commitment for the project and has time and energy - Has the knowledge and expertise to facilitate work of the project - Assume role of clinician, negotiator, educator and section head 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 extensive. 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 nurses Follow up and supervision of surgical and nurse managed patients 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 Administration - Establishment and implement specific policies and procedures - 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 concern: - 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. Education 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: e.g. 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 location. Quality Improvement Activity Quality Improvement Activity: - American Pain Society Guidelines for Quality Improvement Include: - 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 technologies - Examine the process and outcomes of pain management with goal of continuous improvement What, Where, When and Who!