Dr. Fatma Al-Dammas is an anesthesiology professor and director of the anesthesia and acute/chronic pain management programs. She specializes in managing pain, which requires a multidisciplinary team approach. The goals of pain treatment are to improve quality of life, facilitate recovery, reduce morbidity, and allow for early hospital discharge. Pain management involves both pharmacological and non-pharmacological approaches, including the WHO pain ladder and various methods of drug delivery like epidural analgesia. Epidural analgesia provides effective post-operative pain relief, improves pulmonary function, and enables earlier ambulation.
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Managing Pain Through Multidisciplinary Approach
1. Dr .Fatma Al-Dammas
Assistant Professor
Anesthesia consultant
Anesthesia program director
Acute &chronic Pain management
2. The management of pain is a
multidisciplinary team effort involving
physicians, psychologists, nurses, and
physical therapists
3. GOAL OF PAIN TREATMENT
ďImprove quality of the pt .
ďFacilitate rapid recovery &return to full
function .
ďReduce morbidity .
ďAllow early discharge from hospital .
6. PAIN
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage or described in terms of
such damage.
( International
association of study of pain
1979)
7. CLASSIFICATION OF PAIN
SUPERFICIAL DEEP
SOMATIC
TRUEVISCERAL TRUEPARIETAL REFEREDVISCERAL REFEREDPARIETAL
VISCERAL
ACUTE
DEAFFERENTATION
PAIN
SYMPATHETICALLY
MEDIATEDPAIN
CHRONIC
PAIN
8. CLASSIFICATION OF PAIN
SUPERFICIAL DEEP
SOMATIC
TRUEVISCERAL TRUEPARIETAL REFEREDVISCERAL REFEREDPARIETAL
VISCERAL
ACUTE
DEAFFERENTATION
PAIN
SYMPATHETICALLY
MEDIATEDPAIN
CHRONIC
PAIN
9. According to Pathophysiology
⢠Nociceptive;
Due to activation, sensitization of peripheral
nociceptors.
⢠Neuropathic:
Due to injury or acquired abnormalities of
peripheral OR central nervous system.
CLASSIFICATION OF PAIN
13. ⢠Caused by noxious stimulation due to injury, a
disease process or abnormal function of muscle
or viscera
⢠It is nearly always nociceptive
⢠Nociceptive pain serves to detect, localize and
limit the tissue damage.
ACUTE PAIN
16. SUPERFICIAL SOMATIC PAIN
⢠Nociceptive input from skin, sub-cutaneous tissue
and mucous membranes
⢠Well localized and described as sharp, pricking,
burning and throbbing
17. DEEP SOMATIC PAIN
⢠Arise from Muscles, Tendons and Bones
⢠Dull, aching quality and is less well localized
⢠Intensity and Duration of stimulus affects the
degree of localization
18. VISCERAL PAIN
⢠Due to disease process, abnormal function of
internal organ or its covering, e.g. Parietal pleura,
Pericardium or Peritoneum.
19. SUBTYPES OF VISCERAL PAIN
â True localized visceral pain
â Localized parietal pain
â Referred Visceral pain
â Referred parietal pain
20. VISCERAL PAIN
⢠Dull, diffuse and in midline
⢠Frequently associated with abnormal sympathetic
activity causing nausea, vomiting, sweating and
changes in heart rate and blood pressure.
21. PARIETAL PAIN
⢠Sharp, often described as stabbing sensation
either localized to the area around the organ or
referred to a distant site.
31. GENERAL SENSE OF WELL-BEING
ď Anxiety
ď Sleep disturbances
ď Depression
32. POSITIVE ROLE OF PAIN
Acute pain plays a useful positive physiological role by
providing a warning of tissue damage .
33. Acute Pain management
ď Pain management continues to be a challenge to nurses.
ď PCA &epidural analgesia are advance in analgesia that
may assist nurse with this challenge
ď Pain management can be evaluated in terms of its ability
to meet 2 main goals:
â To relieve postoperative pain.
â To relieve patient of inhibition of respiratory movement
without sedation.
34.
35. CHRONIC PAIN
ď Chronic pain is defined as that which persists
beyond the usual course of an acute disease or after
a reasonable time for healing to occur
ď period varies between 6 or > months in most
definitions.
37. CHRONIC PAIN
ď Pt with chronic pain often have an absent
nuroendocrine stress response
ď Have prominent sleep and affective (mood)
disturbances.
38. Chronic pain Acute pain
Classification â division according to duration of time
ďŹ Is caused by external or
internal injury or damage
ďŹ Its intensity correlates
with the triggering
stimulus
ďŹ It can be easily located
ďŹ Has a distinct warning and
protective function
ďŹ Lasts longer than expected
ďŹ Is uncoupled from the
causative event
ďŹ Becomes a disease in its own right
ďŹ Its intensity no longer correlates
with a causal stimulus
ďŹ Has lost its warning and
protective function
ďŹ Is a special therapeutic challenge
ďŹ Requires interdisciplinary
procedures
44. What is the severity of the pain?
0 1 2 3 4 5 6 7 8 9 10
Visual analog scale -
Numerical intensity scale -
Descriptive intensity scale -
No pain Mild pain
Moderate
pain
Severe
pain
Worst possible
pain
No pain
Pain as bad as it
could possibly be
Pain Assessment:
11 of 16
45. PAIN RATING SCALE
⢠The WONG BAKER FACES
SCALE.
⢠0-No pain
⢠10-Severe pain.
⢠User friendly.
⢠Easy to explain to patient.
⢠Compact to carry
46. ⢠Wong Baker Faces Pain Rating Scale could be used as three scales
because it combines
⢠Facial expression.
⢠Numbers.
⢠Words.
⢠(Ask patient to point to the faces that matches their feeling.The
number used to record the score)
49. Children between 3-8 years
⢠Usually have a word for pain
⢠Can articulate more detail about the presence and
location of pain; less able to comment on quality or
intensity
⢠Examples:
â Color scales
â Faces scales
50. Children older than 8 years
⢠Use the standard visual analog scale
⢠Same used in adults
53. There are many different techniques,non-
pharmacological &pharmacological , both
regional and non-regional to provide post op
analgesia.
54. Nonpharmacologic Approaches to Relieve Pain and
Prevent Suffering
hydrotherapy
intradermal water blocks
movement & Positioning
touch and massage
acupuncture
(TENS)
aromatherapy
heat and cold
audioanalgesia.
58. WHO analgesic guidelines
⢠Oral medications whenever possible
⢠Dose âby the clockâ â but always have âas
neededâmedications for breakthrough pain
⢠Titrate the dose
⢠Use appropriate dosing intervals
⢠Be aware of relative potencies
⢠Treat side effects
63. Acute Pain
ďś Postop pain is a type of âAcute Painâ
ďś Recent onset,
ďś Limited duration,
ďś Has a causal relationship,
ďś Variable pain intensity,
ďś Variable response to analgesia
PCA
64. ⢠PCA is based on the belief that patients are
the best judges of their pain.
⢠They should be allowed an active role in
controlling their pain.
⢠That pain relief should be secured as
quickly as possible.
Patient Controlled Analgesia
65. P C A
PCA are modified infusion
pumps that allow patient
to self administer a small
dose of opioid when pain
is present , thus allowing
patients to titrate their
level of analgesia against
the amount of pain they
are experiencing.
66. PATIENT SELECTION
⢠Patient should not be denied access to
this modality simply because of age.
⢠Screen for cognitive and physical ability
to manage their pain by using the PCA.
⢠Should have the understanding of pain
relief , using the demand button and
when to use the demand button.
67. PCA not offered to confused patient and those who
become confused should have PCA discontinued.
The same patient selection guidelines and
consideration for the use of PCA apply to
children.
Important to remind parents and caregivers not to
press the demand button .
PATIENT SELECTION
68. ⢠PCA is well tolerated.
⢠Offer flexibility in dose size and dose interval in
individual patients.
⢠Therapeutic serum level can be reached relatively
quickly because the drug is administered into the
vascular system directly.
P C A
69. P C A
⢠Patient can secure an early therapeutic serum
level with loading doses titrated to individual
pain needs.
⢠A steady state plasma level occurs because the
elimination of the drug from the plasma is
balanced by the patients self administered drug
injection.
70. Relationship of mode of delivery of analgesia to serum
analgesic level
⢠IM and IV PCA
71. PCA
⢠PCA allows patient control over their pain and
therefore gives greater satisfaction.
⢠PCA also eliminates the lag time between pain
sensation and administration of analgesia.
72. PAIN CYCLE
I.M PRN ANALGESIA
Nurse Screen
Meds Prepared
I.M Given
Calls Nurse
Drug Absorbed
Sedation
PATIENT FEELS PAIN
74. PCA
⢠The pump documents the total number of mg of
drug delivered, the number of times the patient
requests a bolus and number of times
medication is delivered in response to demands.
⢠This information is helpful when assessing
whether the established PCA parameters are
appropriate to patientâs need.
75. ⢠Decreased nursing time
⢠Increased patient satisfaction.
⢠Used in a variety of medical and post-op surgical
conditions.
⢠Decreased narcotic usage.
⢠Decreased level of sedation.
⢠Earlier ambulation.
BENEFITS
76. ⢠Decreased overall pain scores reported by
patients.
⢠Increased compliance to post op care.
⢠Less anxiety.
⢠More autonomy regarding pain control.
⢠Improved rest and sleep pattern
BENEFITS
77.
78.
79. Benefits of Epidural Analgesia
ďźBetter pain control
ďźEarlier ambulation
ďźImproved Pulmonary Mechanics
ďźDecreased incidence of DVT
ďźFaster return of bowel function
82. SPINAL CORD
⢠Located and protected within vertebral column
⢠Extends from the foramen magnum to lower border 1st L1
(adult) S2 (kids)
⢠SC taper to a fibrous band - conus medullaris
⢠Nerve root continue beyond the conus- cauda equina
⢠Surrounded by the meninges,(dura,arachnoid &pia mater.)
83.
84.
85.
86. EPIDURAL SPACE
⢠Potential space
⢠Between the dura mater,luigamentum flavum
⢠Made up of vasculature, nerves, fat and lymphatic
⢠Extends from foramen magnum to the
sacrococcygeal ligament
87. INDICATIONS
ď§ The objective of epidural analgesia is to relieve pain.
Major surgery
Trauma (# ribs)
Palliative care (intractable pain)
Labour and Delivery
88. CONTRAINDICATIONS
⢠Patient refusal
⢠Known allergy to opioid or local anesthetic
⢠Infection/abscess near the proposed injection site
⢠Sepsis
⢠Coagulation disorder
⢠Hypotension / hypovolemia
⢠Spinal deformity/increased ICP
89.
90.
91. Patient assume a sitting or side-lying position
with the back arched toward the
physician.Help to spread the vertebrae apart
93. INSERTION OF EPIDURAL CATHETER
⢠Positioning of patient
⢠The site is dependent upon the area of pain
⢠Fixing the catheter
Incision Level
Thoracic T4-T6
Upper abdo T6-T8
Lower abdo T8-T10
Pelvic T8-T10
Lower extremity L1-L4
94.
95.
96.
97.
98.
99.
100.
101.
102. EPIDURAL CATHETERS
⢠Ideal Placement (adult) 10-12 cm at the skin
⢠Epidural catheters have markings that indicate their length.
= there is a mark at the tip of the catheter
= the 1st single mark up the catheter is 5cm
= double mark up the catheter is 10 cm
= triple mark on the catheter is 15 cm
= four mark together indicate 20cm
A change in depth of the catheter indicates migration either into or
out of the epidural space.
103. CATHETER MIGRATION
Catheter migration into a blood vessel in the epidural space or
subarachnoid space
ď§ rapid onset LOC
ď§ Decrease loss of sensory or motor loss (marcain)
ď§ Toxicity
ď§ Profound hypotension
104. CATHETER MIGRATION
Out of the epidural space
⢠ineffective analgesia
⢠no analgesia
⢠drugs deposited into soft tissue.
105. MEDICATION COMMONLY USED
⢠OPIOIDS-Fentanyl +Morphine
(affect the pain transmission at the opioid receptors)
⢠L.A.-Bupivacaine(marcaine)
(inhibits the pain impulse transmission in the nerves
with which it comes in contact)
106. METHODS OF ADMINISTRATION
ď§ BOLUS (FENTANYL, DURAMORPH)
ď§ CONTINUOUS INFUSION(MARCAINE+FENTANYL)
ď§ All drugs administered epidural should be preservative free.
ď§ All epidural opioids should be diluted with normal saline prior to
intermittent bolus administration.
107. Motor and Sensory Assessment
⢠Motor assessment
⢠Sensory assessment
109. Motor and Sensory Assessment
Sensory assessment:
Use ice in the tip of a glove
Start in upper neck and move down thorax bilaterally
assessing all potential dermatomes
Level of block is where intensity of cold changes or
the cold sensation is absent
assess the dermatomes below the pelvis
110.
111.
112.
113.
114.
115. Adverse Effects L.A
⢠Hypotension-
-assess intravascular volume status
-no trendelenberg positioning
⢠Teach patient to move slowly
from a lying position to sitting to
standing position.
Treatment
⢠fluids
116. Cont.
⢠Temporary lower-extremity motor
or sensory deficits.
Tx: lower the rate or
concentration.
⢠Urine retention
Tx: catheter
⢠Local anesthetic toxicity
(neurotoxicity)
Tx: stop infusion.
⢠Resp. insufficiency
Tx:stop infusion
- ABC(100% o2
call for help)
- Assess spread
and
height of block
- Alt.analgesia
117. OTHER COMPLICATIONS
⢠Headache (dural puncture)
Tx: symptomatic treatment
Autologous blood patch
⢠Infection
⢠nausea and vomiting.
⢠Intravenous placement of
catheter
⢠Subdural placement of catheter
⢠Haematoma
118. EPIDURAL ANALGESIA(GUIDELINES)
⢠Collect items
⢠Assess patient
⢠Inspect site
⢠Wash hands
⢠Aspiration test â Glucose test
⢠Administer
⢠Document
⢠Evaluate the outcome