Analgesia and Procedural Sedation

1. Analgesia and Procedural Sedation • Dave Choi • PGY-4 ER Edmonton • Dr. A. Storck

2. Objectives • Very basic pain pathophysiology • Pain assessment • Management of pain • Will not cover nerve blocks, local anesthetics, or chronic pain management

4. Pain • Most common complaint in ED • Essential goal of healthcare is to prevent and relieve pain • Patients judge us by how we treat pain • We cause pain • Physiologic / psychologic outcomes

5. Case 1 • 45 yo male • Left flank pain x 8 hrs • 8/10 pain, can’t get comfortable • PmHx: HTN, renal colic • Please help doc!

6. Case 2 • 70yo female • Slipped on stairs 2 hrs ago • Obvious deformity to left ankle • PmHx: HTN, NIDDM, MI last year • Grimacing in pain

7. Case 3 • 21 yo male • RLQ pain x 2/7 • Anorexia, mild nausea, fever • PmHx: healthy • Please don’t touch my stomach doc!

8. Pain Physiology • Nociceptor (pain receptor) • Superficial somatic • Deep somatic • Visceral • Neuropathic • Peripheral • Central • Psychogenic

9. Pain Definition • An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. • International Association for the Study of Pain (IASP) 2007

11. Judging pain • Patient complaint • Physician impression, HR, BP, facial expression poor indicators • Age, Sex, Race, cognitive functioning • Numeric scale • All very subjective

12. We any good?

13. Study • Convenience cohort of 71 patients >18yo • Pt rated pain with VAS and NRS • ER docs and nurses rated patients pain

14. Conclusion • Docs and nurses consistently rated pain less than the patient • Only 30% of patients were satisfied with their pain control • Mild/moderate pain unlikely to receive any analgesia • 2/3 of severe pain received analgesia

15. Pain Control • We suck at estimating pain • We undertreat pain • Patients not happy • Should give patients benefit of the doubt

16. Are we getting better? • Use of analgesics increased by 18% from 1997 to 2001 • McCaig. National Hospital Ambulatory Medical Care Survey: 2001 ED Summary. National Center for Health Statistics, 2003

17. Pain control options • Local / Regional • Systemic • Anti-inflammatories • Opioids • Others: TCAs, anti-convulsants, relaxants, cannabis, distractions, music

18. Pain control • We can make pain better • No reliable objective measures • Avoid the “squeaky wheel gets the oil” • Individualized pain control • Anticipate pain and treat it • Let patient control pain if possible

19. NSAIDS • Inhibit enzyme cyclooxygenase (COX) • Enzyme responsible for formation of prostaglandin and thromboxane • Messenger molecules for inflammation, pain, and fever • Also gastric lining and platelet function

20. Ibuprofen • Contraindications • GI ulcer • Pregnancy (esp 3rd trimester) • Acute bleeds • Renal dysfunction • Recent CABG

21. Ibuprofen • Cautions • ASA sensitive asthma • ASA for cardioprotection • ACE inhibitors / ARB

22. Ibuprofen • Dosing? • Evidence?

23. Ibuprofen vs Toradol CJEM Jan 2007

24. Ibuprofen vs Toradol • Numerous studies show no benefit of parenteral ketorolac over oral ibuprofen • Belief that IM/IV medication are perceived as being stronger has been shown to be false • Ketorolac has higher cost, risk of extravasation, risk of needle stick injuries

25. Other NSAIDS • Diclofenac 50mg TID • Naproxen 250-500mg BID • Indomethacin 25-50mg TID

26. Opioids • Opioid receptors • Mu: analgesia, respiratory depression, euphoria • Kappa: analgesia, sedation, respiratory depression, miosis • Sigma: dysphoria, hallucinations, tachypnea, tachycardia

27. Opioids • Metabolized by liver, excreted by kidney • Should be given IV • Fixed intervals with PRNs

28. Morphine • Onset: 5-10min • Peak: 15-30min • Duration: 2-4hrs • Routes: IV/IM/PO • Dose: IV 0.05-0.2mg/kg, PO 0.2-0.5mg/kg

29. Morphine: the GOOD • Reliable • Lots of experience with it • Reversal agent

30. Morphine: the BAD • Histamine release • Decreased GI motility • Nausea • CVS/Resp depression

31. Demerol • Generic: meperidine • Onset: 5-10min • Peak: IV 5-15min, IM 30-60min • Duration: 3-4hrs • Route: PO/IV/SC/IM • Dose: 1-2mg/kg (for all routes)

32. Demerol: the GOOD • Theoretical benefit of Sphincter of Oddi relaxation • Helps some chronic migraine patients • NOT MUCH ELSE

33. Demerol: the BAD • Cerebral irritant (anxiety, disorientation, tremors, seizures, hallucination, psychosis) • Not very good analgesic compared to other opioids • Nausea • Dependence • Serotonin syndrome

34. Demerol = Ugly

35. Fentanyl • Onset: 1-2min • Peak: 3-10min • Duration: 30-75min • Routes: IV/IM/TM • Dose: IV 0.5-3ug/kg

36. Fentanyl: the GOOD • Fast acting • Potent (100x morphine) • No histamine release

37. Fentanyl: the BAD • Doesn’t last very long • Cardiorespiratory depression • Nausea, itchy nose • Chest wall, glottis, diaphragm rigidity • Potential AV prolongation and bradycardia in pediatrics with rapid dosing

38. Percocet • Acetaminophen 325mg, oxycodone 5mg • Onset: 30min • Peak: 1hr • Duration: 2-4hrs • Route: PO • Dose: 1-2tabs (max 12/day)

39. Tylenol #3 • Acetaminophen 300mg, codeine 30mg, caffeine 15mg • Onset: 30min • Peak: 1hr • Duration: 2-4hrs • Route: PO • Dose: 1-2tabs (max 12/day)

40. Codeine • Metabolized (cytochrome P450) by liver to morphine • 10% caucasians lack enzyme • Good cough suppressant

41. Tylenol vs Tylenol+Codeine • Systematic Review by Craen et al. BMJ 1996 • 5% increase in analgesia with added codeine for single dose (stat significant) • Multiple doses increased side effects • NNT = 9 for 50% pain reduction • Use if patient says it works for them

42. Dilaudid • Generic: hydromorphone • Onset: IV 5-10min • Peak: IV 15-30min • Duration: 2-4hrs • Route: IV/SC/IM/PO • Dose: IV 0.01-0.05mg/kg, PO x2-3 dose

43. Anti-emetic • Opioid induced nausea multifactorial: histamine, direct gastroparesis, central chemoreceptor • ~20% emesis • No need to pre-treat unless history of significant emesis/nausea previously

44. Competence • Some say use of opioids affects competence and ability to give consent • 2 studies which show otherwise • Maybe patients even pressured to sign consent if they’re in pain? Smithline HA, Mader TJ, Crenshaw BJ. Do patients with acute medical conditions have the capacity to give informed consent for emergency medicine research? Acad Emerg Med. 1999;6:776-80 Vessey W, Siriwardena A. Informed consent in patients with acute abdominal pain. Br J Surg. 1998;85:1278-80

45. Masking pathology • Lee study • how much is too much opioids?

46. Pediatrics • Yes, they feel pain too • We are especially bad at treating kids with pain • Choices? • Tylenol, Ibuprofen, Opioids • Topical / Sucrose / Sprays

47. Double blind RCT • Term newborns within 2 days • 24% sucrose PO • Venipuncture, IM Vit K injection, heel poke for c/s

48. Conclusion • Overall decrease in pain scores (Premature Infant Pain Profile) • Reduction for venipuncture • No reduction for IM injections

49. Double blind RCT • Children 6-12yo venipuncture • Vapocoolant spray vs placebo • All distracted • Visual analogue scale

50. Results • Modest reduction in pain • 56.1 vs 36.9 (out of 100) • Higher success rate first attemt (NNT 5) • ?why