MANAGEMENT OF ACUTE PAIN

Prof. Dr.Tatang Bisri, dr., SpAn-KNA

Bag/SMF Anestesiologi
FK Unpad/ RS Hasan Sadikin
Bandung
Definition of Acute pain
 Pain that result from noxious stimuli
produce by injury or disease of body
tissue. Acute pain is self-limited and
should not persist beyond 1 month of the
usual course of the disease or injury.
 Example: a patient fractures the right
finger, resulting in pain that persist for 3
weeks and the slowly disappears.
Pain is clinically defined as unpleasant sensory and
emotional experience associated with actual or potential
tissue damage or described in terms of such damage ( IASP,
1994).
The most important indication for treatment pain after
surgery is humanitarian (Commission on The Provision of
Surgical Service, 1990).
Treat pain because the autonomic and somatic reflex
responses to pain can compromise patient recover (Kehlet
H, Br J Anaesth 1994)
Ethical Consideration
“ Treatment of pain after surgery is central to care of
postoperative patients. Failure to relieve pain is
morally and ethically unacceptable”

The Royal College of Surgeon of England, The

College of Anesthetist, Commission on the
Provision of Surgical Services. report on the
Working Party on pain After Surgery 1990
Ethical Consideration
“The Ethical importance of pain management is
further increased when additional benefits for the
patient are realized – earlier mobilization, shortened
hospital stay, and reduced cost”

Agency for Health Care Policy and Research,

Public Health Service, US Department of
Health and Human Services. Acute pain
Management; Operative of Medical
Procedures and Trauma. Clinical Practice
Guideline
What the patients want for their
surgery?
The answers always are:
1. They want the surgery to be successful

2. They don’t want any complications

3. They don’t want it to hurt (no pain)

4. They don’t want any side effect of analgesic.

What the Patients say for his/her
anesthesiologists?
Before 1990, most patients say
“I’M WORRIED THAT I WON’T WAKE UP
AFTER THE SURGERY”
After 1990, due to the safe of anesthesia,
now, most patients concern about their
pain
“I’M WORRIED TO HAVE PAIN AFTER THE
SURGERY”
Postoperative pain is associated with
high morbidity

 Increases in morbidity and mortality,

prolonged recovery time, consequent
increases in hospital length of stay and
resultant cost, and reduction in patient
satisfaction.

Pavlin DJ et al, Anest Analg 2002

Shang et al. Drugs 2003
Postoperative pain is associated with
high morbidity
 Hypoxemia/atelectasis/pneumonia.
 Deep venous thrombosis/pulmonary embolus
 Residual psychological trauma
 Delayed recovery of bowel function
 Myocardial ischemia and infarction
 Urinary retention

Commission on the Provision of Surgical Services 1990

Bonica JJ.1990
 Severe acute pain will increase morbidity and
mortality.
 Prolonged recovery
 Prolonged hospital length of stay
 influence Respiratory system, cardiovascular, GIT,
neuro-endocrine, musculosceletal and
psychological
Possible harmful effect of under-treated
severe acute pain

 Respiratory: decreased lung volume, atelectasis,

decreased cough, sputum retention, infection,
hypoxemia.
 Cardiovascular : Tachycardia, hypertension,
increase peripheral vascular resistance, increase
myocardial oxygen consumption, myocardial
ischemia, altered regional blood flow, deep vein
thrombosis.
Possible harmful effect of under-treated
severe acute pain

 Gastrointestinal : decrease gastric and bowel motility

 Genitourinary : urinary retention.
 Neuroendocrine : increase the level of catecholamine,
cortisol, glucagon, growth hormone, vasopressine,
aldosteron and insulin.
 Psychological: anxiety, fear, sleeplessness
 Musculosceletal : muscle spasm, immobility (increasing risk
of deep vein thrombosis).
Postoperative pain management is
still sub-optimal
 Despite a heightened awareness regarding the
importance of postoperative pain management, many
studies describe high incidence pain following surgery
(Kuhn et al ,BMJ 1990, Puig et al . Acta Anesthesiol
Scand 2001).
 46.4% severe pain during 24 hour following surgery
(Poisson Solomon, 1996).
 22-67% (Vallano et al, Br J Clin Pharmacol 1999)
 At UK showed that up to 82% of day case surgery
patient leave the ward in pain (McHugh et al. Anaesth
2002)
Mark RM and Sachar EJ: Ann Intern Med 1993;78:173-
81
Nearly 73% postoperative patients remain in
moderate/severe pain.

Cohen FL. Pain 1980 1980;9:265-74

Delivered dose were less than those prescribed
 Pain Continues to be Undertreated
Postoperative pain U.S., 1993 and 20031,2
100%

90%
82%
80% 77%
1993 (n=135)
70% 2003 (n=250)

60%
Patients

50% 49% 47%

40%

30%
23%
19% 21%
20% 18%
13%
10% 8%

0%
Any Slight Moderate Severe Extreme
Pain Pain Pain Pain Pain

1Adapted from Apfelbaum JL et al. Anesth Analg. 2003;97:534-540.

2Warfield CA et al. Anesthesiology. 1995;83:1090-1094.
Why postop pain continue to be
undermanaged ?
Some Bariers
1. Confusion about who is responsible for
postoperative pain management ?
2. Inadequate knowledge of analgesics (opioid &
non-opioid analgesics).
3. Administration of analgesic is too late, when
the patient complain of pain.
4. Using single modality and similar to every
surgery.
5. etc
 Pain in hospital from a survey of 36 NHS hospitals

Problem Number / total Percent

Pain was present all or most of the 1042 / 3162 33
time
Pain was severe or moderate 2755 / 3157 87
Pain was worse than expected 182 / 1051 17
Had to ask for drugs 1085 / 2589 42
Drugs did not arrive immediately 455 / 1085 41

S Bruster et al. National survey of hospital patients. BMJ 1994 309:1542-6

in http:// www.ebandolier.com
The reasons for inappropriate pain
management
Organization problems 62.5%
Lack of time 61.9%
Lack of motivation 38.8%
Complexity of pain management 37.7%
Difficulty of pain management 37.9%
Poor knowledge of pain management 30.1%

Klopfenstein et al. Acta Anaesth Scand 2000. Meissner et al. Anaesth

2001. Nolli et al. Acta Anaesth Scand 1997
Reducing postoperative pain is
beneficial
 To address sub-optimal postoperative pain
management, recommendation and guidelines
for improving postoperative pain management
have been published.
 Use written protocols, standardized assessment
of pain intensity, appropriate medical and
nursing staff training, use balanced analgesia.
 Result: recovery accelerated, post operative
morbidity reduced, overall hospital cost reduced
by minimizing postoperative complications
Kehlet H. Br J Anesth 1997
 JCAHO Pain Management Standards
Strive for Better Patient Care

 The standards include:

 Patient Rights1
 Appropriate assessment and management of pain

 Care decisions

 Assessment of Patients1
 Identification of patients with pain

 Care of Patients1
 Appropriate selection and administration of pain

1Phillips
medications
DM. JAMA. 2000;284:428-429.
Effective pain management
depend on:

 Knowledge pain pathophysiology.

 Pharmacology analgetic
 Delivery technique
 Providing Pain Relief

Perception

Modulation

Transmission

Transduction

FIGURE. The pain pathway and interventions that can modulate activity at each point.
(Redrawn with permission from Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia" in
postoperative pain treatment. Anesth Analg 1993;77:1049)
 Pain Rating Scales

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
Pain threshold
Pain tolerance
Choosing pain killer and its
combinations
10 Pain Intensity Scale

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe
paracetamol NSAID Strong opioid
or/+ ± ±
NSAID weak opioid NSAID
± ± ±
adjuvant adjuvant adjuvant
analgesic analgesic analgesic
Current view in selecting analgesic
and anti-inflammatory drugs
 Efficacy (indication)
 Safety (side effect)
 Not only GI toxicity
 Cardiovascular toxicity
 Renal toxicity
 Bleeding
 Bone healing impairment etc
 Suitability (contra-indication)
 Availability
 Pharmacokinetics and drug interaction
 Daily cost
 Evidence based medicine
 Less GI side effects
More GI side effects
Diclofenac Celecoxib
Acetosal Indomethacin Ibuprofen
Ketorolac Piroxicam Ketoprofen
Meloxicam COXIB
Rofecoxib
Nimesulide Valdecoxib

preferentially non- preferentially

COX-1 COX-1 COX-2 COX-2
selective
selective selective selective selective
COX
inhibitor inhibitor inhibitor inhibitor
inhibitor

anti-inflammatory
analgesic
Several Technique for
Postoperative Pain Management
PCA (Patient Controlled Analgesia)
 Epidural / Intrathecal with opioid
 Epidural / Intrathecal with local anesthetic
 Nerve block (infiltration, intercostals, intrapleural,
etc).
 NSAIDs (COX1, COX 2 and COX3)
 MULTIMODAL ANALGESIA
 etc.
Modern Acute Pain Management
Focus on alternative delivery :
 CEA (Continuous epidural Analgesia)

 PCA (Patient Controlled Analgesia)

 PCEA (Patient Controlled Epidural

Analgesia),
 intravenous via syringe pump/infusion
pump.
Benefits of Balanced Analgesia
 Dissatisfaction with management postoperative
pain may due to the use of unimodal treatment
Kehlet et al, Anesth Analg 1993.

 Opioid, although effective associated with side

effect (nausea, vomiting, rash, urticaria/itching,
addiction, respiratory depression)  limit their
use.
Oderda, J Pain Symptom Manage 2003.
Anonymous. Lancet 1991.
The concept of Balanced Analgesia is that
sufficient analgesia can be achieved due to
additive or synergistic effect between different
analgesic, with concomitant reduction in side
effect, due to resulting lower dose of analgesic and
difference side effect profiles

Kehlet H et al. Anesth Analg 1993

Benefits of Multimodal Analgesia

Opioids
• Reduced doses of each
analgesic
• Improved pain relief due
Potentiation to synergistic or additive
effects
• May reduce severity of
side effects of each drug
NSAIDs,
acetaminophen,
nerve blocks

1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

Monitoring narcotic analgesia
 BP, HR, RR, sedation scale, pain scale,
nausea scale.
 Target: VAS 3 (patient satisfaction),
sedation scale 2, respiratory rate >
8x/minute.
Effect of opioid on assessment
parameters
Parameter Effect
Blood pressure Hypertension indicate hypercarbia secondary to
overnarcotization.
Hypotension : narcotic do not cause hypotension.
Opioid, especially Mo can cause vasovagal reaction,
which can cause hyper/hypotension
Respiratory Rate 8 x/min, indicate significant narcotization
Heart rate Increase HR, indicate inadequate analgesia
Behavioral changes Agitation: indicate inadequate analgesia, hypoxia.
Somnolen may indicate overnarcotization.
Confusion, nay indicate hypoxia, hypercarbia
Ramsay Sedation Scale
Level of sedation:
1 Patient is anxious and agitated or restless,
or both
2 Patient is cooperative, oriented and tranquil
3 Patient responds to commands only
4 Patient exhibits brisk response to light
glabellar tap or loud auditory stimulus
5 Patient exhibits a sluggish response to light
glabellar tap or loud auditory stimulus
6 Patient exhibits no response
Nausea scale
 3 vomiting or retching
 2 severe nausea
 1 slight nausea
 0 no nausea.
 Table 2: NSAID-related deaths and admissions to hospital

Event UK USA Canada

Annual NSAID
25 million 70 million 10 million
prescriptions
NSAID-related
12,000 100,000 3,900
admissions
NSAID-related
2,600 16,500 365
deaths

From: http:// www.ebandolier.com

 NSAID-related deaths compared with deaths from
other causes in the USA, 1994

G Singh. American Journal of Medicine 1998 105(1B): 31S-38S.

 The burden of NSAID adverse effects in the UK

AL Blower, A Brooks, CG Fenn et al. Aliment Pharmacol Ther 1997 11: 283-91.
CJ Hawkey, DJ Cullen, DC Greenwood et al. Aliment Pharmacol Ther 1997 11: 293-8.
TM MacDonald, SV Morant, GC Robinson et al. British Medical Journal 1997 315: 1333-7.
Conclusion
 Pain is a personal experience, not surprisingly
there are no objective measurements.
Measurement of pain must therefore rely on
recording the patient’s report.
 Adequate analgesia, good pain management
will improve out come, reduce morbidity,
mortality, reduce hospital length of stay and
cost. Better pain control in perioperative period
contributes to better surgical outcomes
Conclusions

 There are always harms and benefits in all

methods used in pain management.
 Balance Analgesia is the best method : NSAID for
transduction, Local anesthetic for transmission,
Opioid for modulation.
 But, There is no good pain management but there
is only a good pain manager.
Tatang Bisri, Bandung 2008