Pain Scenarios

1. Pain Scenarios Sue Millerchip Lead Nurse Pain Team

4. What do you need to know? • How to manage severe acute pain • How to manage respiratory depression • How to manage post-op pain • How to manage cancer pain • How to manage chronic pain

5. Severe acute pain • Mr Smith (38yrs old) is admitted to ED with severe abdominal pain and back pain. He has been vomiting, is pale and sweaty and has a history of alcohol abuse. • What do you do?

6. Mrs Williams (62) is admitted with severe central chest pain, radiating to jaw and down left arm. • How do you manage her?

7. Management Points • The safest and most effective way to manage severe acute pain is by an IV bolus of morphine / diamorphine • Always dilute to 1mg/ml • Always administer slowly • Always titrate to effect • Always monitor closely for side effects • What are you not going to use?

8. Side effects of opiates • Respiratory depression • Depressed conscious level • Hypotension • Nausea and vomiting • Constipation • Itch

9. Treating side effects of opiate analgesia Respiratory rate < 8 and sedation score = 3 or sedation score 3 regardless of respiratory rate • give naloxone 100 micrograms IV every 5 minutes • Call for anaesthetic help • Prevent vomiting with regular antiemetics

10. Case 3 • 3 days post hemicolectomy a 62 year old woman reports severe abdo pain that is increasing in intensity. She also has a rapid rise in temperature, is tachycardic and feels sick. The PCA 100mg morphine analgesia that has previously been effective is not helping.

11. Management points • Always investigate sudden unexpected pain, especially later in the post-op period • Effective analgesia does not interfere with the ability to diagnose surgical conditions either before or after surgery • Examination showed clinical signs of peritonism and AXR revealed gas under the diaphragm - theatre for leaking anastamosis

12. Solution • Intravenous morphine to achieve comfort • Increase dose of PCA to 200mg/50ml or convert to a morphine infusion • Add IV paracetamol if not already prescribed

13. Case 4 • A 23 yr old woman – RTA • Compound # of the tibia and fibula • Extensive soft tissue trauma, vascular injury and neuropraxia of the common peroneal nerve – needs surgery • Severe pain lateral aspect of leg with burning and sensitivity, deep aching leg and foot • Very anxious and tearful

14. Management points • IV morphine titrated to comfort then PCA • IV paracetamol 1g qds • PR/ oral NSAID if no contra-indications • Gabapentin for persistent burning pain start at 300mg - od/bd/tds • Step down to oral morphine and paracetamol • Convert to slow release preparation for rehab • Refer to chronic pain clinic if necessary

15. Key points • Patients with burns / trauma may require a range of strategies which vary during emergency, healing and rehab phases • Combination of nociceptive / neuropathic pain is common • Psychological and environmental issues • Use of long acting opioids is appropriate • Treatment of neuropathy may need to continue after healing • Prolonged need for opiates should prompt referral to Pain Service

16. Case 5 • An 65 year old female is admitted from a residential home with a # NOF • H/O dementia • Quiet and withdrawn pre-op • Post-op noisy and disruptive • No formal pain assessment but analgesia given 4 hours previously • IM morphine prescribed 4-6 hourly – nil else

17. Management Points • Poor prescribing with regard to frequency • No adjuvant therapy – IV paracetamol • Poor pain management had changed normal quiet behaviour to noisy and disruptive

18. Case 6 • Mrs Y, Stills disease admitted pre THR • Currently uses MST 180mg am, 120mg pm with regular voltarol and paracetamol. • Consider optimal analgesia postoperatively

19. Discussion • How long has this patient used opiates for? • Why is she using opiates? • Will her pain be relieved or will it increase postoperatively? • Will she be suitable for IV PCA? • Will her mst need to be decreased if she uses IV PCA? • What will you use for prn analgesia?

20. Case 8 • 30 year old male, post refashioning above knee amputation stump • Illicit drug user – Heroin • Rx drugs recently included Dihydrocodeine and diclofenac • Discuss this patient’s postoperative pain assessment and management

21. Options • Epidural infusion • PCA / Paracetamol / NSAID • Ketamine infusion

22. Aims of treatment • Provide analgesia • Prevent withdrawal • Management of withdrawal from other drugs/ alcohol /nicotine • Treatment of co-morbidities • Manage aberrant drug-taking behaviours - CDT

23. Case 9 • Mr Jones, 65, is admitted with right sided chest pain, SOB and a cough, vomiting and weight loss. He has a history of rectal carcinoma and had a resection 6 months ago. He has recently been diagnosed with liver mets. His current analgesia is a Fentanyl patch 50mcg but this is inadequate. • How do you manage this?

24. Plan • Manage nausea / vomiting – cyclizine / ondansetron / dexamethasone • Consider converting patch to a sc driver to establish analgesia and requirements • Add rescue parenteral analgesia • Ensure correct doses are prescribed to manage background and breakthrough pain

25. Fentanyl patches • Fentanyl / Durogesic 12, 25, 50, 100mcg • Approximate conversion –50mcg = 5.0mg parenteral morphine / hr OR 2.5mg parenteral diamorphine / hr So pt would need 60mg diamorphine / 24 hrs in a sc driver • Rescue sc injection = 1/6th of 24 hr dose = 10mg

26. Other patches • Butrans Buprenorphine • Transtec

27. Case 10 • Miss Harris, 34, is admitted with a sudden onset of severe low back pain radiating down her left leg. • ? Cause • Treatment options?

28. Options • Morphine / Paracetamol / NSAID / diazepam • ? MRI • ? Epidural steroid

29. Key messages • Pain is an individual, multifactorial experience influenced by culture, previous experience, mood and ability to cope • Successful acute pain management involves teamwork • Regular assessment of pain = improved outcomes • Uncontrolled or unexpected pain requires reassessment of diagnosis / reinvestigation • Assessment of sedation level is a more reliable indicator of early opioid-induced respiratory depression • The use of pethidine should be discouraged

30. Paracetamol is an effective analgesic for acute pain • Adverse effects of NSAIDs are significant and may limit their use • Provision of analgesia does not interfere with the diagnostic process in acute abdominal pain • Reduction in dose of analgesics may be required in elderly patients • Consideration of drug and dosages in patient with concurrent hepatic and renal impairment is required

31. Other than in the treatment of severe acute pain, and providing there are no contra-indications to its use, the oral route is the route of choice for the administration of most analgesic drugs • Controlled release (CR) opioid preparations should only be given at set time intervals • Immediate release opioids should be used for breakthrough pain and titration of CR opioids • Do not forget rectal routes when other routes are unavailable but bioavailability is unpredictable and consent should be obtained

32. To conclude…. • Effective pain management results from appropriate education and organisational structures for the delivery of pain relief rather than the analgesic techniques themselves

33. Thank you