pain management

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Pain Management:

Pain Management Speaker – Dr Bikram Gupta

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Definition Pain is not just a sensory modality but is an experience . The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

Terms used in pain management:

Terms used in pain management Term Description Anesthesia Absence of all sensation Analgesia Absence of pain perception Hyperalgesia Increased response to noxious stimulation H ypoalgesia Diminished response to noxious stimulation (eg, pinprick) Allodynia Perception of an ordinarily nonnoxious stimulus as pain Anesthesia dolorosa Pain in an area that lacks sensation Dysesthesia Unpleasant or abnormal sensation with or without a stimulus Hyperesthesia Increased response to mild stimulation

Terms used in pain management:

Terms used in pain management Hypesthesia (hypoesthesia) Reduced cutaneous sensation (eg, light touch, pressure, or temperature) Hyperpathia Presence of hyperesthesia, allodynia, and hyperalgesia usually associated with overreaction, and persistence of the sensation after the stimulus Neuralgia Pain in the distribution of a nerve or a group of nerves Paresthesia Abnormal sensation perceived without an apparent stimulus Radiculopathy Functional abnormality of one or more nerve roots

Visceral pain :

Visceral pain Features of visceral pain – Not all organs are painful Especially solid organs as liver ,kidney, lung …..uterus Limited innervation Pain is not strictly linked to injury Cutting the bowel : injury but no pain Stretching of bladder – no injury but pain Diffuse and poorly localised Few sensory afferents Extensive divergance in CNS 9

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Patterns of Referred Pain Central diaphragm C4 Lungs T2–T6 Heart T1–T4 Aorta T1–L2 Esophagus T3–T8 Pancreas and spleen T5–T10 Stomach , liver, and gallbladder T6–T9 Adrenals T8–L1

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Patterns of Referred Pain Small intestine T9–T11 Colon T10–L1 Kidney, ovaries, and testes T10–L1 Ureters T10–T12 Uterus T11–L2 Bladder and prostate S2–S4 Urethra and rectum S2–S4

Chronic pain:

Chronic pain A/C to ASA , Chronic pain is defined as “pain of a duration or intensity that adversely affects the function or well-being of the patient” . The IASP defines it as “pain without apparent biological value that has persisted beyond the normal tissue healing time usually taken to be 3 months.” 12

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When the intricate balance among biologic, psychological, and social factors becomes disturbed, chronic pain can develop. Pain is always a psychological state, even though it often has a proximate physical cause.

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Pain pathways from head & face region:

Pain pathways from head & face region Ist order – C arried by the trigeminal (V), facial (VII), glossopharyngeal (IX), and vagal (X) nerves Synapse with - V G asserian ganglion VII G eniculate ganglion IX S uperior and petrosal ganglia X J ugular ganglion (somatic) and the ganglion nodosum (visceral) 20

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2 nd order neuron from these ganglion get synapse with VPM nucleus of thalamus. 3 rd order neuron then relay sensation to somatosensory cortex. 21

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Spinal Cord Lamina:

Spinal Cord Lamina Lamina Predominant Function Input Name I Somatic nociception thermoreception A , C Marginal layer II Somatic nociception thermoreception C, A Substantia gelatinosa III Somatic mechanoreception A , A Nucleus proprius IV Mechanoreception A , A Nucleus proprius V Visceral and somatic nociception and mechanoreception A , A , (C) Nucleus proprius; WDR neurons 1   VI Mechanoreception A Nucleus proprius VII Sympathetic   Intermediolateral column VIII   A Motor horn IX Motor A Motor horn X   A Central canal 26

Modulation of Pain:

Modulation of Pain Peripheral Modulation Primary Hyperalgesia Secondary Hyperalgesia Central Modulation Facilitation Inhibition Segmental Inhibition Supraspinal Inhibition

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Central modulation (Facilitation) :

Central modulation ( Facilitation ) 21/10/2009 30

Central modulation ( segmental inhibition) :

Central modulation ( segmental inhibition) 31

Gate theory for pain:

Gate theory for pain 32

Central modulation (supraspinal inhibition) :

Central modulation ( supraspinal inhibition) 21/10/2009 33

Preemptive Analgesia:

Preemptive Analgesia Easier to prevent pain then reduce it Administer analgesic prior to procedure Prevent central sensitization & pain amplification 34

Systemic Responses to Pain:

Systemic Responses to Pain 21/10/2009 35

Systemic Responses to Pain:

Systemic Responses to Pain CVS RS GIT/URIN-ARY ENDOCRINE Hematologica l   Immune HTN Total body O2 consumption sphincter tone catabolic hormones Platelets adhesivene s s leukocytosis with lymphopenia HR CO 2 production intestinal and urinary motility anabolic hormones reduced fibrinolysis RES depress SVR MV / work of breathing Gastric acid secretion - ve nitrogen balance hypercoagulability predisposes to infection Myocardial O2 demand TV/FRC/VC due to guarding severe aspiration pneumonitis carbohydra t e intolerance , lipolysis Ppt. MI A telectasis , intrapulmonary shunting, hypoxemia Abdominal distention – aggr . Pulm . dysfunction S odium & water retention 36

Evaluating the Patient with Pain   :

Evaluating the Patient with Pain   Clinical history & examination Pain measurement Psychological evaluation Electromyography & nerve conduction studies 37

BOX 8-2 (continued) ASSESSMENT:

BOX 8-2 (continued) ASSESSMENT

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Pediatrics pain scale:

Pediatrics pain scale FLACC Pain Assessment Tool - facial expression; leg movement; activity; cry; and consolability, score from 0 to 2; yielding a total possible range of 0 to 10 Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) - six behaviors that include cry, facial, child verbal, torso, touch and legs,a scale of 0 to 3 NIPS ( neonatal infant pain scale ) Procedure Behavior Checklist (PBCL) COMFORT Scale 43

Pain Relief In Children:

Pain Relief In Children Pain assessment for children under four years If the patient is asleep, no further assessment is needed. If the patient is awake check the following- 44 SCORE Interpretation CRY Not crying Crying 0 1 POSTURE Relaxed Tense 0 1 Score 1 -Slight pain Score 2 –Moderate pain Score 3 –Severe pain Score 4 –Worst pain EXPRESSION Relaxed or happy Distressed 0 1 RESPONSE Response when spoken to No response 0 1

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Children over four are better able to report pain and are able to use colour scales, pictures of varying facial expression and often visual analogue scales 45

Neuropathic pain:

Neuropathic pain Major pathophysiological mechanisms include Peripheral sensitization Central sensitization Sympathetic activation Disinhibition 46

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Pharmacological Non Pharmacological TCA, amitriptyline Psychological Interventions Cognitive interventions - attention diversion and imagery Behavioral (operant) therapy – positive & negative reinforcers Relaxation techniques Hypnotic techniques SNRI Duloxetine Physical interventions Physiotherapy- Heat and cold application TENS Acupuncture Venlafaxine Specialist Interventions Neural blockade or ablation Surgical and chemical sympathectomy Surgery e.g. Microvascular decompression spinal cord stimulators intrathecal drug delivery systems Gabapentin Pregabalin Lignocaine 5% Tramadol 48

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TCA, amitriptyline SNRI Duloxetine Venlafaxine Gabapentin ADULT DOSE 10–25 mg/d at bedtime increase dose weekly by10–25 mg/d 60 mg once daily 37.5 mg once daily; increase dose weekly by 37.5 mg 300mg orally on day 1, 300mg twice daily on day 2, 300mg three times daily on day 3, increased according to response in steps of 300mg daily. MAXIMUM DOSE 50–150 mg/d 120 mg/ day 375 mg/d 3600 mg/day ADEQUATE TRIAL DURATION 6-8 weeks 4-6 weeks 3-8 weeks for titration plus1-2 weeks at maximum tolerated dosage. 50

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Pregabalin Lignocaine 5% Tramadol ADULT DOSE 150mg daily in 2-3 divided doses. Increase after 3-7 days to 300mg daily in 2-3 divided doses, increased if necessary after 7 days to max 600mg daily in 2-3 divided doses 1-3 patches every 12hrs. Plaster free period of atleast 12 hrs/ day 50 mg once or twice daily Increase by 50-100 mg/d in divided doses every 3-7 d as tolerated MAXIMUM DOSE 600mg Maximum 3 patches per 12 hrs 800mg/day ADEQUATE TRIAL DURATION 4 weeks 2-4 weeks 4 weeks 51

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Postoperative Pain:

Postoperative Pain Postoperative analgesic modalities include oral or parenteral analgesics, peripheral nerve blocks, neuraxial blocks with local anesthetics, intraspinal opioids, as well as adjunctive techniques such as TENS and physical therapy. Selection of analgesic techniques is generally based on three factors: the patient, the procedure, and the setting . 53

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LA for treatment of acute postop pain:

LA for treatment of acute postop pain Agent % solution for analgesic blocks Duration (hours) Max. single dose mg/kg. (Total mg in adults)* % solution for infusion Lignocaine Infiltration Epidural Plexus or nerve 0.5 – 1 1-2 0.75-1.5 1-2 1-2 1-3 7 (500) ------ 0.3-0.7 0.5 - 1 Bupivacaine Infiltration Epidural Plexus or nerve 0.125 – 0.25 0.25-0.75 0.25-0.5 1.5-6 1.5-5 8-24+ 3.5 (225) 0.125-0.25 ------ 0.0625-0.125 56

Intrathecal and epidural opioids for treatment of acute pain:

Intrathecal and epidural opioids for treatment of acute pain Drug Single dose ( mg) Onset ( min) Duration of single dose ( h) Epidural Morphine Pethidine Methadone Fentanyl 1-6 20-150 1-10 0.025-1 30 5 10 5 6-24 4-8 6-10 2-4 Subarachnoid Morphine Pethidine Fentanyl 0.1-0.3 10-30 0.005-0.025 15 ? 5 8-24 10-24 57

Patient Controlled Analgesia:

Patient Controlled Analgesia When pain is experienced, the patient self-administers a small bolus dose of opioid and experiences the benefit of this action. Thus they can adjust the level of analgesia required, according to the severity of the pain. 58

Guidelines for patient controlled intravenous opioid administration :

Guidelines for patient controlled intravenous opioid administration Drug ( conc.) Size of bolus ( mg) Lockout interval( min.) Morphine (1mg/ml) 0.5-2.5 5-10 Pethidine (10mg/ml) 5-25 5-10 Methadone (1mg/ml) 0.5-2.5 8-20 Fentanyl (0.01mg/ml) 0.01-0.02 3-10 59

Management of cancer pain:

Management of cancer pain 21/10/2009 60

WHO analgesic ladder :

WHO analgesic ladder 21/10/2009 61

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T ENS produce analgesia by stimulating large afferent fibers Based on gate theory of pain A current of 10–30 mA with a pulse width of 50–80 s is applied at a frequency of 80–100 Hz. 21/10/2009 63

Spinal Cord Stimulation (SCS):

Spinal Cord Stimulation (SCS) Due to dorsal column stimulation because it was thought to produce analgesia by directly stimulating large A fibers in the dorsal columns of the spinal cord. ( gate theory ) Proposed mechanisms include activation of descending modulating systems and inhibition of sympathetic outflow. 21/10/2009 64

Spinal cord stimulation :

Spinal cord stimulation Indication S ympathetically mediated pain S pinal cord lesions with localized segmental pain P hantom limb pain I schemic lower extremity pain due to peripheral vascular disease A dhesive arachnoiditis 21/10/2009 65

Intracerebral Stimulation:

Intracerebral Stimulation Indication :- intractable cancer pain intractable neuropathic pain of nonmalignant origin Electrodes are implanted stereotactically into the periaqueductal and periventricular gray areas for nociceptive pain (primarily cancer and chronic low back pain); for neuropathic pain, the electrodes are implanted into specific sensory thalamic nuclei. 21/10/2009 66

Radiofrequency ablation :

Radiofrequency ablation High frequency ,alternating current emitted through electrode placed within tumour via probe. the heating temperature generated at the electrode is precisely controlled (60–90°C for 1–3 min) to ablate the nerve without causing excessive tissue damage Liver ,lung, kidney,bone ,heart ,breast,adrenals Leads to cell death through heat 67


Cryoneurolysis temporary neurolysis for weeks to months by freezing and thawing tissue The temperature at the tip of a cryoprobe rapidly drops as gas (carbon dioxide or nitrous oxide) at a high pressure is allowed to expand. It may be particularly useful for postthoracotomy pain 68

Alcohol & Phenol Neurolytic Blocks:

Alcohol & Phenol Neurolytic Blocks Neurolytic blocks are indicated for patients with severe intractable cancer pain. Injection of alcohol or phenol to deaden the nerve causing pain. Neur olytic techniques are most commonly employed with celiac plexus, lumbar sympathetic chain, hypogastric plexus, and ganglion impar blocks in cancer patients but may be used for somatic or cranial nerves or even neural axial blocks . 69

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Trigeminal Nerve Blocks:

Trigeminal Nerve Blocks Indications – T rigeminal neuralgia In tractable cancer pain in the face Block performed on gasserian ganglion itself or one of the major divisions (ophthalmic, maxillary, or mandibular), or one of their smaller branches.   78

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Facial nerve block:

Facial nerve block Indications T o relieve spastic contraction of the facial muscles T o treat herpes zoster affecting this nerve 83

Facial nerve block:

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Glossopharyngeal nerve block:

Glossopharyngeal nerve block Indications – M alignant growths at the base of the tongue , the epiglottis, and palatine tonsils 85

Glossopharyngeal nerve block:

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Occipital nerve block:

Occipital nerve block Indications Occipital nerve block is useful diagnostically and therapeutically in patients with occipital headaches and neuralgias.  

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Suprascapular Nerve Block:

Suprascapular Nerve Block Indications This block is useful for painful conditions arising from the shoulder (most commonly arthritis and bursitis).   89

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Cervical Paravertebral Nerve Block:

Cervical Paravertebral Nerve Block Indications Selective paravertebral blockade at the cervical level can be useful diagnostically and therapeutically for cancer patients with pain originating from the cervical spine or the shoulder. 91

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Thoracic Paravertebral Nerve Block :

Thoracic Paravertebral Nerve Block useful in patients with pain originating from the thoracic spine, thoracic cage, or abdominal wall, including compression fractures, proximal rib fractures, and acute herpes zoster 93

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Lumbar Paravertebral Somatic Nerve Block:

Lumbar Paravertebral Somatic Nerve Block Indications Paravertebral block at this level is useful in evaluating pain due to disorders involving the lumbar spine or spinal nerves.   95

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Lumbar Medial Branch & Facet Blocks   :

Lumbar Medial Branch & Facet Blocks   Indications These blocks may establish the contribution of lumbar facet (zygapophyseal) joint disease in back pain 97

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Trans-Sacral Nerve Block:

Trans-Sacral Nerve Block Indications This technique is useful in the diagnosis and treatment of pelvic and perineal pain. Blockade of the S1 spinal root can help define its role in back pain. 21/10/2009 104

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Pudendal Nerve Block:

Pudendal Nerve Block Indications Pudendal nerve block is useful in evaluating patients with perineal pain.   106

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Sympathetic Blocks:

Sympathetic Blocks The most common indications include reflex sympathetic dystrophy, visceral pain, acute herpetic neuralgia, postherpetic pain, and peripheral vascular disease. 108

Cervicothoracic (Stellate) Block:

Cervicothoracic (Stellate) Block Indications U sed in patients with head, neck, arm, and upper chest pain . Stellate blocks may also be used for vasospastic disorders of the upper extremity. 109

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The point of injection is at the level of the stellate, which lies posterior to the origin of the vertebral artery from the subclavian artery, anterior to the longus colli muscle and the first rib, anterolateral to the prevertebral fascia, and medial to the scalene muscles. 110


Technique Paratracheal technique patient's head extended, a 4- to 5-cm 22-gauge needle is inserted at the medial edge of the sternocleidomastoid muscle just below the level of the cricoid cartilage at the level of the transverse process of C6 (Chassaignac's tubercle) or C7 (3–5 cm above the clavicle). 111

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Correct placement of the needle is usually promptly followed by an increase in the skin temperature of the ipsilateral arm and the onset of Horner's syndrome. The latter consists of ipsilateral ptosis, meiosis, enophthalmos, nasal congestion, and anhidrosis of the neck and face.   113

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THANK YOU 21/10/2009 117

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