Pain Management Back To Basics

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Pain ManagementBack To Basics Pain is
inevitable. Suffering is optional
Prof. Krishna Boddu .
MBBS, MD, DNB, FANZCA, MMEd University
of Texas Health Sciences at Houston, Texas,
USA University of Western Australia, Perth,
Australia Director, Regional Anaesthesia, Royal
Perth Hospital, Perth, Australia
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Poor Pain Control Causes distress to
Effective Pain Control Relieves distress to
Patients Friends
Patients Colleagues
Our staff
Patients Family
Our Patients
All the people who are concerned about this
patient
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Our Mission Zero Suffering For 100 Of Our
Patients
Pain Control With an aim to Improve Functionality
It Is Possible.
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Good pain control means.

• No pain/suffering during and after intervention
• Cooperative welcomes you without fear and
  anxiety of pain
• Minimal/ no side effects from pain meds
• Functionality maintained during and after
  intervention
• Cheerful and happy

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WHO Pain Management Ladder
Difference in Managing Acute Acute Pain Other
Pains
Acute Post-op Pain or Pain after Injury
Interventional Opioid Non-Opioid
Strong Opioid Non-Opioid
Weak Opioid Non-Opioid
Non-opioid
Pain Rx in the Community Clinics
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Consequence of Poorly Managed Acute Pain

• Biological
• DVT, PE
• Pneumonia
• Poor wound healing
• Chronic Pain
• Angina MI

• Social
• Delayed Rehab
• Prolonged Hosp Stay
• Increased Readmission
• Increased Cost

• Psychological
• Anxiety
• Dissatisfaction
• Depression
• Lack of motivation
• Effects of Family

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Pain Expression varies from patient to patient
Ask Every Patient 1. PPG (Personalized Pain
Goal) is Important 2. Pain at Rest (Static
Pain) Not of much value 3. Pain on Activity
Dynamic Pain
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Types of Pain
Post-op pain can be a mixture of different
types of pains
Chronic
Chronic
Chronic
Nociceptive
Neuropathic
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Classification of pain

• Background pain
• Procedural pain
• Breakthrough pain
• Post procedural pain

POST INTERVENTIONAL PAIN IS OFTEN NEGLECTED
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Optimizing Non-Opioid Analgesics

1. Four grams of Paracetamol / Acetaminophen
   (IV/PO)/day
2. NSAIDs (Parecoxib, Celecoxib, Diclofenac Na etc.)
3. Pregabalin 75-600mg/day

4. Lidoderm Patch
5. Ketamine
6. Clonidine
7. NERVE BLOCKS
BENZODIAZEPINES ARE NOT ANALGESICS
????. Tramadol along with antiemetic (SR or IR
400mg/day)
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PRN Regular Pain Medications
ORDER ONLY ONE PRN MEDICATION PER INDICATION
Suffering
Medication
Relief
You Need To Know The Pattern of Pain, Dose
Response
Activity Activity Activity
Activity Activity
Activity
Regular/ Scheduled Medication
You Can Eliminate Suffering Safely
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No Background Pain
To effectively treat BTP, a rapid-onset opioid is
needed to match the temporal profile of the pain.
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Baseline Pain Medication
No Background Pain
Preventing Over dose with Effective and Safe
Coverage for BTP Baseline Pain Medication
Quick short acting PRN Medication
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Biggest Fears In Treating Pain
Respiratory Depression
Under Treated Pain Leads To Pseudo
Addiction Behavior
Nausea Vomiting
Addiction

• Most of the fears related to Opioids
• Severity of Side Effects are dose related
• Physical dependency is not addiction
• Most Side Effects can be effectively minimized
  by Multimodal approach
• And by Educating Patients Providers

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How to make PCA work better for your patients?
PCA Dose
Lockout Interval (LOI)
Basal Rate

• Needing to press button many times
• LOI lt8min
• Waking up with pain
• gt7 day use of opioids prior to surgery
• Opioid abuse

Pain down to patients satisfaction?
Is the pain relief lasting till next dose?
Encourage
Encourage
Increase PCA Dose by 50 or 100
Decrease LOI
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How to make PO meds work better for your
patients?
PRN Dose
Dose Interval
ATC, ER or Patches

• Needing to take all PRN doses
• PRN dose interval needing lt3 hours
• Waking up with pain
• gt7 day use of opioids prior to surgery
• Opioid abuse

Pain down to patients satisfaction?
Is the pain relief lasting till next dose?
Encourage
Encourage
Increase PRN Dose
Decrease Dose Interval
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Adjusting Pain Medication
Calculate 24 Hour Opioid Consumption
Look for Over dose
60-70 of 24 h consumption as PRN doses
50-60 of 24 h consumption as basal/ ER in
divided doses
In Next Visit
Increase Basal /ER by 40-50 of 24hr PRN
Consumption
Continue the same PRN doses
Calculate 24 hr PRN Opioid Consumption
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Dose, Frequency, Peak levels Steady State
Plasma Concentration of drug
Time in hours
Half Life 3 hours
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Avoid Toxic Levels With Multimodal Approach
Margin of safety
Margin of safety
First Optimize Non Opioids Local
Anesthetic Acetaminophen NSAIDs Neuropathic
Pain Medication
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Principles to Titrate Opioids Pseudo Addiction
Addiction
Serious Adverse Effects
Pain Free Trust the Patient
Pain Intensity
Opioid Dose
Time
What if Patient Getting Sedated with Poor Pain
Control ? Look at other systems ?
Neuropathic Pain ? Drug Interaction
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Our Pledge to Patients
Our Pledge to Primary Team

• We are available 24/7 can be reached
  instantaneously
• We Accept Shared Accountability with You and
  Your Team
• We Educate Primary Nurses Team rather than
  just help
• them by treating patient

• Everything Possible will be
• Done to Provide Pain Relief
• Safely to Your Satisfaction
• We focus on Improving your Functionality
• Our team is available 24/7 to be reached by your
  Primary Nurse or Primary Team

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Pain Nurse ChampionsProgram Components

• 3 Day Hands On Supervised Acute Pain Medicine
  Orientation
• Attend the Biannual Hands-On Acute Pain
  Management Workshop
• Pass American Society of Pain Management Nursing
  Exam

200 Pain Champion Nurses!
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Thank You