Managing Pain in the Surgical Patient

1. Managing Pain in the Surgical Patient LUCILLE LUTZ, RN, MSN, APRNBC CLINICAL NURSE SPECIALIST PAIN MANAGEMENT

2. Objectives Discuss preop pain assessment Discuss intraop pain management Discuss postop pain management

3. Background Acute Pain Immediate Serves as a warning Easier to treat (generally) Has an end (generally)

4. Background Chronic Pain Lasts longer than 3-6 months Serves no purpose Cannot identify a cause Can lead to pain behaviors Very difficult to treat

5. Pain Conduction Injury triggers release of bio-chemicals Inflammation takes place Stimulation of nerve fibers Bio-chemicals causes pain impulses to begin

6. Pain Perception Impulse is sent to the brain via ascending tracts in spinal cord Neurotransmitters released by C fibers (substance P) Message to the brain (Thalamus) Sends message down descending pathway= pain response

7. Why Pain Control Persistent acute postoperative pain: Decreases the body’s physiologic reserves May exacerbate co-morbid conditions (e.g.) increase risk of MI in patients with CAD Contributes to pulmonary complications.

8. Impairs rehabilitation and functional outcome May lead to development of chronic pain syndromes and long-term disability. Increases hospital stay and the cost of patient care Decreases patient satisfaction.

9. Metabolic Stress Response Surgical insult results in post op pain Increased circulating catecholamines Resulting in tachycardia and hypertension Leading to increased cardiac work Resulting in increased myocardial oxygen consumption

10. Cardiovascular ↑ HR, ↑ BP, ↑ SVR, altered regional blood flow, ↑CMO2, ↑ DVT Respiratory: – ↓ VL (atelectasis), ↓ cough (sputum retention) – hypoxemia and infection

11. Gastrointestinal: – ↓ gastric and bowel motility, nausea, vomiting • Genitourinary: urinary retention • Neuroendocrine: ↑ catabolic hormones – ↑ blood glucose, Na + H20 retention

12. Musculoskeletal: Muscle spasm, immobility (↑ DVT) Psychological: fear, anxiety, insomnia • Chronic pain

13. Pre Op Assessment Indication for surgical procedure Allergies and intolerances to medications, anesthesia, or other agents Known medical problems Surgical history Trauma (major) Current medications (incl.OTC herbal & dietary supplements,and illicit drugs) Gayatri,P (2005). Post-op pain services. Indian J.    Anaesth. 49 (1) : 17-19

14. Discuss History of Acute or Chronic Pain Identify history of pain control methods What has worked How long on pain meds Do they work True allergies, ask what happens

15. Differentiate between tolerance and physical dependence Discuss pain management problems (ie) anxiolytic therapy with pain meds Identify if there is a need to wean from any pain medications prior to surgery Do not stop suddenly

16. Consider Patients with: Multiple back operations Abdominal pain patients (ie) Crohn’s disease Recurrent cancer Chronic joint pain, (ie) RA or DJD

17. If with a history of chronic opioid use for pain management may require higher doses for pain control This will include using PCA and/or meds for break through pain May not get adequate relief with “standard” doses of “standard” post op pain orders

18. Do a directed pain history Type of pain Location, description, duration, exacerbation and relieving factors Directed pain examination Discussion of post-op pain control plan

19. What about the Elderly Evaluate each patient individually Do not assume that aging is the same in all patients Evaluate for side effects of narcotics Need complete list of meds to check for interactions

20. Dispel myths Concerns about opioids Concerns about addiction Fear of tolerance Age related expectation of pain

21. Pre Op Teaching Educate patient/family/staff Pain plan How & when to evaluate Use of alternative methods of pain control Patient and/or Family education on use of PCA

22. Explain blocks !!!!!! Provide pre-anesthetic evaluation, brochures, and videotapes to educate patients about therapeutic options (music and/or guided imagery, other)

23. Preoperative Preparation of the Patient Instruct on bedside postoperative evaluation Include instruction in behavioral modalities to control anxiety Distraction, deep breathing, visualization (etc)

24. Preoperative Preparation of the Patient Instruct on pain ranking tools prior to surgery Use age appropriate tools, why, when and how to be used. Instruct S.O., parents if needed. May want to use personalized tool (i.e.Randall)

25. Generally there is decreased cardiac and pulmonary reserve with increased age Opioids may produce confusion or cause some delirium postoperatively in some patients An elderly patient taking six medications is likely to have adverse reactions 14 times more than a younger person taking the same number of medications.

26. Consider additive respiratory depressant effect of both opiates and anxiolytics Most elderly patients metabolize drugs at a slower rate and may require less-frequent dosing or a reduction in dosage Certain medications should be avoided in elderly patients, based on their adverse effects (Beers list)

27. Sedative effects with an increased risk of falls Constipation related to opiates & NSAIDS May have reduced gastrointestinal motility Stool softener with stimulant Start pain meds at a lower dose and increase to pain relief if opioid naive

28. Special Populations Pediatrics Use pain scales specific to age FLACC (pre-op instruction) Observe frequently Medication dose wt specific Guided Imagery Distraction Music/video

29. Special Populations Pediatrics Allergies Sensitivities Comfort frequently If non verbal anticipate painful procedures result in pain Be an advocate

30. Special Populations Special needs: Identify what works for this patient Ask the family or caregiver Comfort frequently If non verbal anticipate painful procedures result in pain Again be an advocate

31. Cultural Considerations Be aware of specific needs and beliefs Respect the patient/family tradition Internalize (how would I feel if) Do not pre judge Explain need for pain control

32. Intra Op Consideration Therapy selected should reflect the individual needs of the patient. Ability to recognize and treat adverse effects during surgery Special caution during continuous infusion modalities Drug accumulation may contribute to adverse events

33. Patients who are pretreated with pain meds, anxiolytics or NSAIDS prior to surgery Have a greater decrease in postoperative pain Decrease in postoperative anxiety Olorunto,W & Galandiuk, S. 2006. Managing the Spectrum of Surgical Pain: Acute Management of the Chronic PainPatient. American College of Surgeons

34. Surgeries to upper abdominal and thoracic areas associated with severe pain can lead to: Restrictive lung defect Depressed diaphragmatic activity Gayatri,P (2005). Post-op pain services. Indian J.    Anaesth. 49 (1) : 17-19

35. Study: Early and aggressive use of pain medications after surgery results in shorter hospital stays, fewer chronic pain problems later, and use less pain medication overall than people who avoid pain medication. Taylor, M. (2001).Managing postoperative pain.  Hosp Med; 62:  560-563.

36. Intra Op Consideration Patient Advocate Continue to assess for anxiety/pain Provide comfort Positioning Guided imagery Music

37. Adequately treating Post-surgical Pain Increased Comfort =quicker healing Increased activity= increased strength Decreased complication= improved post-op period

38. The risk of addiction to pain medication is low for patients using such medications for post-surgical pain Addictive personality leads to addiction Dependency is another issue

39. Effective Pain Control Listen to the patient Believe the patient’s pain ranking Support the patient/family Answer questions Provide information Instruct re: need for pain control

40. Sources of postoperative pain Acute nociceptive pain from incision. • Musculoskeletal pain from abnormal body positioning and immobility during and after surgery • Neuropathic pain from excessive stretching or direct trauma to peripheral nerves

41. Post Operative Pain Control Decreases risk of Myocardial ischemia Tachycardia and dysrhythmia Impaired wound healing Atelectasis Thromboembolic events Peripheral vasoconstriction

42. Post Operative Pain Near the surgical site. Acute exacerbation of pain may be added to the basal pain Increases with activities such as coughing, turning, dressing changes Generally self limiting Progressive improvement over a relatively short period

43. With Special Populations Geriatric Be aware of renal/hepatic function Sensitivities/allergies Be pro-active with medication Opioids Combination meds Be aware of drugs to be avoided in the elderly

44. ASSESS & RE-ASSESS Before and after pain medications Put it in the patient’s own words Assess for non verbal cues Be aware of special needs of the cognitively impaired patient Use appropriate pain scale Document, Document, Document,

45. ASSESSMENT TOOLS VAS PAIN FACES PAINAD FLACC

46. Post Op of Special Populations Geriatric If with Cognitive Impairment PAINAD scale Observe & re-assess frequently Guard/observe for delirium superimposed on dementia Know drug side effects Know method of elimination

47. Medication Use Review information gathered during pre op assessment If something has not worked in the past don’t use it. Explain what you are doing and what you are giving When in doubt, follow the WHO guidelines

48. World Health Organization (WHO) 3- Step Ladder approach to pain management Step 1- Mild Pain (1-3/10) Nonopioid Add adjuvant analgesic agent (i.e.) Ice, heat

49. WHO cont’d Step 2 Mild to moderate pain (4-7/10) This step builds on step 1 Treat with opioid combination drug (hydrocodone/acetaminophen) Watch ceiling effect of adjuvant drug Peds are dosed by weight Watch special needs patients/elderly

50. WHO cont’d Step 3- Severe pain (8-10/10) Use opioids Add adjuvant (i.e.)anti-anxiety,anti-emetics, muscle relaxants Start with short acting opioids to determine pain relief, breakthrough needs and frequency. Switch to long acting use equianalgesic dosing chart for conversion