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Pain Management

The clinical assessment, diagnostic evaluation and hopeful curative treatment of noxious stimuli whic is acute or chronic in nature. (The source of these stimuli may be due to traumatic or surgical means.)

Lili Leavell-Hayes

on 30 April 2010

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Transcript of Pain Management

Acute Pain Chronic Pain What is pain? Que es Dolor? Objectives (6) Pain is "the unpleasant SENSORY and EMOTIONAL experience associated with ACTUAL or POTENTIAL TISSUE DAMAGE." > 6 months duration < 6 months duration Pain Definitions I Pain Definitions II Somatic Pain Visceral Pain nocieptive pain located within the main body cavity due to injury or illness to an internal organ. corresponds to thorax, abodomen, and pelvis. pain receptors in the visceral cavities respond to stretching, swelling and oxygen deprivation. "deep ache" with cramping. may radiate to chest and back. nocieptive musculoskeletal pain, as originating in the skin, muscles, joints, bones, and ligaments. "sharp", identified with injury. associated with swelling, cramping, and bleeding. responsive to opioids and NSAIDS Allodynia: Pain due to a stimulus
that does not normally provoke pain. Anesthesia Dolorosa: Spontaneous pain in an area or region that is anesthetic. Central pain: Pain initiated or caused by a primary lesion or dysfunction in the central nervous system. Dysesthesia: An unpleasant abnormal sensation whether spontaneous or evoked. Hyperesthesia: Increased sensitivity to stimulation excluding special senses. Hyperpathia: A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus as well as an incfreased threshold. Hypoalgesia: Diminished pain in response to a normally painful stimulus. Paresthesia: An abnormal sensation whether spontaneous or evoked. Somatic Pathways Basic Definitions of Pain Mechanism (Description) of Pain A. Visceral

B. Somatic

C. Neuropathic

D. Mixed

Neuropathic Pain nocieptive pain which originates in the nerve tissue...either peripheral or central. common example is RSD, Herpetic Neuralgia, or Phantom Limb pain after an amputation. described as "burning, pins and needles, or shooting pains". extremely difficult to treat effectively with opiates or NSAIDS. Autonomic blockade is the most effect form of treatment. Mixed Pain may contain pain sensations which are characteristic of each. E. Malignancy Malignancy Pain the most agonizing pain of all.
described as "unrelenting and unforgiving."
Also, the most difficult to treat...examples include pain from pancreatic, breast or bone cancers.
Autonomic plexus blocks or intravenous narcotics are our best options.
How is pain perceived? The exact physiology of pain processes is unknown There are many theories... Central Summation
Fourth Theory of Pain
Sensory Interaction
Gate Control Theory
*A-delta and C fibers Acute pain Acute Injury

Examples include:
sprained ankle, minor lacerations, or burned finger, etc.
Symptomatic treatment may include heat or ice packs, wound care, p.o. analgesics, and /immobilization of the affected extremity. Trauma

Motor vehicle accident, gunshot wounds, multiple broken bones, etc.

More aggressive pain management required such as regional blockade or general anesthetics. Surgical

Cholecystectomy, Total Hip Replacement, Laparoscopic procedures are a few examples.

Surgical interventions required...obvious perioperative and postoperative pain control required. Chronic Pain Low back pain

Most common chronic pain complaint
Musculoskeletal involvement
vertebral abnormalities, i.e. spinal stenosis,* osteophytes
Discogenic pain
Facet pain
Epidural adhesions
Tumors of the spine
acute processes, i.e. abscess, cyst, or hematoma

Peripheral Neuropathies
i.e., Diabetes, Post-herpetic Neuralgia
Regional Myofascial Pain*

General surgery, regional blockade such as epidurals, spinals or peripheral approaches, on-site pumps. Disease States Mechanical States
Low Back Pain* Pharmacology
i.e., Xylocaine (Lidocaine), Voltaren (Diclofenac)
i.e., Ibuprofen, Aleve, Advil, Toradol, Naprosyn
i.e., Elavil, Cymbalta, Paxil
i.e., Dilantin, Tegretol, Neurontin, Lyrica
Muscle relaxants
i.e., Flexeril
Alpha-2 agonists
i.e., Clonidine, Dexmedetomidine
i.e., MSO4, Meperidine, Hydromorphone (Dilaudid), Methodone, Codeine, Fentanyl
Regional Anesthetics
Spinal Blockade
"Solid" Block
Relatively easy to perform

Difficulty in obtaining exact level

Pain management
Avoids supraspinal mediated toxicity
Is typically 1/10th of the epidural dose
Requires dural puncture, delivers drug closer to the spinal receptors
Increased potential for meningitis and postdural headache

Selectivity of levels
Good for laboring females
Excellent for other surgeries
Surgical or Postoperative pain relief
Chronic pain relief

Sometimes "patchy" block
Dural puncture results in postdural headache 95% of the time

Pain management
Slower systemic side effects
Allows for dermatoal placement without dural puncture
Requires larger doses (10 x the intrathecal dose)

Regional Blocks
Supra or Infrascapular
Supra or Infraclavicular
Digital Dexmedetomidine
Alpha-2 agonist
used intravenously (single injections or infusions) OR in regional blockade
no respiratory depression
no pruritis
surgical, postoperative or chronic pain relief
ease of use
no active metabolites
1 mcg/kg IV x 1, then 0.7 mcg/kg/hr IV, then maintenance dosing of 0.2 mcg/kg/hr IV
dosage must be decreased in renal failure
dosage must be decreased in Child-Pugh Class A, B, or C hepatic failure patients
dosage must be decreased in the elderly

Opiates -mu receptor agonists
-multiple side effects
-excellent for pain relief
-can be given by multiple routes
P.O., parenteral, rectal, sub-lingual, transdermal, transmucosal, epidural, intrathecal
Opiates- Side Effects
Relief of anxiety, euphoria, dysphoria
mental clouding
constipation*, urinary retention
constriction of pupils*
anti-tussive effect
androgen deficiency* - decreased testosterone
physiologic effects...decreased heart rate, blood pressure and respiratory drive Opiate Withdrawal
"anxious and wet" Anxiety
Abdominal cramping
"crying for more drugs" Terms Associated with Opioid Use Addiction
- psychological component
- drug-seeking behaviors
- nonmedical use of drug despite potential harm

- iatrogenic problem - inadequate analgesia

Tolerance - "need to increase the dose to get the same effect"
- rare in cancer patients
- not relevant to efficacy if agents and dosage are adjusted

Physical Dependence
- natural process; weaning from drug is a simple medical process

Surgical Disease states
Chronic Pain Syndromes
Residual from previous injury
Abnormal pain sensitization Understand the definitions surrounding acute and chronic pain.

Describe the common causes of acute and chronic pain syndromes.

Identify neuropathic, somatic nocioceptive and visceral pain.

Understand the common pathways of pain.

Be familiar with modalities of treatment utilized for acute and chronic pain patients.

Be able to answer the 5 questions so that we can get our CME credit!!! :o)

Pain is a physiologic process Pain is not objective, but is a SUBJECTIVE phenomenon in which the sensation, interpretation, and expression of that pain
varies between patients based on previous experiences, superimposed depression and cultural identifications! 2. The sensation of pain is an objective finding in all patients. The anatomy of pain Clonidine Alpha-2 agonist
can be used P.O., transdermal or in regional blockade
mimicks the activation of descending inhibitory pathways...in the dorsal horn area.
clincally used to treat hypertension as well, i.e. Catapress
also used to treat cancer pain, i.e., Duraclon
effects are additive to other pain medications, therefore may decrease other dosages
3. Clonidine can be used as an adjunctive medication for pain management. Types of Nerve Fibers

Type Size Myelinated Function

A-alpha Large Yes Motor

A-beta Proprioception, pressure, touch

A-delta Pain

A-gamma Muscle spindles

B Medium Preganglionic autonomic

C Small No Autonomic and Pain

1. a-delta and C fibers carry pain sensations to the central nervous system. Spinal Stenosis Symptoms:
Low back pain with or without radiculopathy encroachment of the nerves as they exit the spinal cord (narrowing of the canal, osteophyte formation or thickening of the ligamentum flavum are common causes).
numbness or weakness in buttocks or legs
symptoms improve with rest, lying down or bending forward at waist (shopping cart posture).

Phantom Limb Pain caused by Central Sensitization
"amplification of a simple stimulus"
exhibits "Deafferentiation pain"
Most difficult of all pain syndromes to treat!
nerves of CNS "remember" the limb and many times remember the last pain stimulus elicited Phantom Limb Syndrome Treatment of Phantom Limb Pain
Local Anesthetics
Muscle Relaxants
Sympathetic Blocks i.e., Stellate Ganglion or Lumbar Sympathetic Block
Spinal Cord Stimulators
Peripheral nerve stimulators
Spinal drug delivery systems

4. Phantom pain is not a real pain sensation and therefore can be controlled with NSAIDS. Regional Myofascial Pain includes any muscle/fascial disease including fibromyalgia
"tender everywhere", "I hurt all over" are common complaints
diffuse, difficult to pinpoint, aching pain that may refer to deeper somatic structures
pain must be present in 3 of 4 quadrants of body for this diagnosis
Trigger points are the hallmark of this disease
11 of 18 trigger points must be present on digital palpation
Digital palpation of 4 kg of pressure causes pain Trigger Point:
- a "hyper-irritable spot in skeletal muscle that
is associated with a hypersensitive palpable nodule in a taut band". Treatment heat, moist hot compresses
exercise, especially yoga or stretching
deep massage
physical therapy
rest for muscles
adequate sleep and relaxation
good nutrition
T.E.N.S. units
trigger point injections (lidocaine, bupivacaine)

5. T.E.N.S., biofeedback and acupuncture are examples of alternative modes of pain control. Phantom limb sensation - sensation that amputated or missing limb is still attached to the body and moving appropriately. Majority of these sensations are painful.
- caused by "reorganization" of somatosensory cortex.
- described as warmth, cold, itchy, squeezing, tightness, tingling and/or painful.
- Phantom Eye Syndrome has painful phantom pains in the eye area with/without visual hallucinations after removal of the eyeball.
- visual hallucinations are described as basic shapes and colors.

Pain management emcompasses a wide array of acute and chronic pain syndromes and disease states. Various treatment modalities are available for the patient who is suffering from pain.

As providers we must continue to provide education for fellow physicians and patients.

We are obligated to remain up-to-date in each of these treatment modalities so that we can treat them in the most effective way possible.

Summary questions:

1. Alpha-delta and C fibers carry pain sensations to the central nervous system. True
2. The sensation of pain is an objective finding in all patients. False
3. Clonidine can be used as an adjunctive medication for pain management. True
4. Phantom pain is not a real pain sensation and therefore can be controlled with NSAIDS. False
5. T.E.N.S., biofeedback and acupuncture are examples of alternative modes of pain control. True Thank you! Clinical Pain Management
Lili A. Leavell-Hayes, MD
Department of Anesthesiology
St. Joseph St. Vincent's Hospital
Kokomo, Indiana
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