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Pain

Definition:
An pleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage
Nociception
• Nonciceptive pain results from tissue
damage causing continual nociceptor
stimulation

• It may be either somatic or visceral in


origin
Somatic pain
Somatic pain results from activation of
nociceptors in cutaneous and deep tissue,
such as bone.

It is well localized and described as aching,


throbbing or gnawing.

Somatic pain usually sensitive to opioids.


Visceral pain
Visceral pain arises from internal organs.
It is vague in distribution and quality and is
often as described as deep, dull or
dragging.
It may be associated with nausea, vomiting
and alteration in arterial pressure and
heart rate.
Mechanism of visceral pain include
abnormal distension or contraction of
smooth muscle, stretching of the capsule
of solid organs, hypoxia or necrosis and
irritation by substances.

Visceral pain is often referred to cutaneous


sites distant from the visceral lesion (like
shoulder pain resulting from
diaphragmatic irritation.
Etiology
1. Middle aged more than infant and elderly
patients.
2. Neurotic personality.
3. Fear of pain
4. Site of operation like thorasic, upper
abdominal and orthopedic being the
most painful
Management
The management of pain is important not
just for humanitarian also to improve and
reduce postoperative complications.

Pain assessment: visual, verbal, numerical,


Faces pain scale.
Routes of analgesic delivery
Oral:
• Simplest route available
• The bioavailability is limited to 1st pass
metabolism
• The oral route is not suggested following
major surgery due to potential delays in
gastric emptying
Intermittent subcutaneous or
intramuscular injection

Advantages:
• Safe if it administered more regularly
• Familiar practice
• Gradual onset of side-effects
• Inexpensive.
Disadvantages:
• Fixed dose not related to
pharmacovariability
• Painful injections
• Fluctuating plasma concentration
• Delayed onset of analgesia
Intravenous bolus
• For the management of severe acute pain.
• It gives the quickest onset and repeated
doses can be titrated against effect.
• Close supervision of the patient is
required.
• This method is not appropriate for
continuing pain management at ward level
Intra nasal bolus
• Efficacy and speed of action are similar to
that I.M.

• It offers an alternative method of


administration for areas such as
emergency department and pediatric units
Continuous intravenous infusion
Advantages:
• Rapid onset of analgesia
• Steady-state plasma concentrations
• Painless
• Pain control may be superior to PCA spc.
For major surgery
Disadvantages:
• Fixed dose not related to
pharmacodynamic variability
• Errors may be fatal
• Expensive fail-safe equipment required
• Close monitoring of the patient is
important to detect respiratory depression
or over-sedation
Patient-controlled analgesia (PCA)
• Intravenous PCA is now a standard
method of providing postoperative
analgesia in many hospital worldwide
• PCA can give high-quality analgesia but
can fail if not applied appropriately
• PCA can be used for most surgery where
moderate to severe postoperatively pain is
expected
• With PCA the patient determines the rate
of i.v. administration of the drug thereby
providing feedback control.
• PCA equipment comprises an accurate
source of infusion, coupled to an i.v.
cannula and controlled by patient-machine
interface device. Safety features are
incorporated to limit the preset dose, the
number of doses which may be
administered and the lock out period
between doses. The drug that has been
most commonly used with PCA is
morphine
Advantages:
• Dose matches patient’s requirements and
therefore compensates for
pharmacodynamic variability
• Doses given are small and therefore
fluctuations in plasma concentrations are
reduced
• Reduces nurses’ workload
• painless
Disadvantages:

• Technical errors may be fatal

• Expensive equipment

• Requires ability to cooperate and


understand
Epidural
• Its superior to i.v. PCA for the management of
pain following major abdominal surgery and
lower limb amputation

• Its safe to use at ward level, but this dependent


on adequate monitoring and on nursing staff
who have received specific training in caring for
patient with epidural infusions
• Used mainly for the management of pain during
child birth and following major abdominal,
thoracic orthopedic and vascular surgery
• Opioids exhibit 10 times the potency when
administered via the epidural route as opposed
to the intravenous route
• A combination of local anesthetic and opioid is
usually administered the two drugs act
synergistically resulting in superior analgesia
and improved side effect profile
Contraindication to epidural:
2. Anticoagulation or coagulopathy
3. Hypovolemia
4. Local infection, septicemia
5. Lack of patient consent

In addition to its analgesic effects, the


utilization of epidural analgesia may
decrease the incidence of DVT following
orthopedic surgery and improve
circulation following vascular surgery
Thank You