Part 2: Acute pain management

image credit: ZngZng | OxyNorm

Part 2: Acute pain management

Nov 28, 2016 0
anaesthetics,emergency,onthepods

James talks to Dr Tim Suharto about Acute pain management, in the second of a two-part podcast series.

You can listen to Part 1: Acute pain management here.

Summary Writer:  Hayden Alicajic

Editor:  James Edwards

Interviewee: Tim Suharto

About Dr Tim Suharto

Tim is a specialist anaesthetist and one of the supervisors of training at Nepean Hospital.  He is involved in the anaesthetic education program and leads the Group for Anaesthetic Simulation (GAS), which delivers in-situ crisis scenarios involving critical care doctors and nurses. Tim is an instructor for the Nepean Difficult Airway course as well as the Nepean Can’t Intubate Can’t Oxygenate (CICO) workshop. He is a strong advocate for innovation in medical education and developing links between sub-specialties in medicine to enhance understanding and collaboration.

Tim’s clinical work encompasses both public and private practice with regular sessions in acute pain medicine, anaesthesia for orthopaedics, ENT, neurosurgery and interventional radiological procedures.

Part 2: Acute Pain Management

 With Dr Tim Suharto, Staff Specialist Anaesthetist at Nepean Hospital, New South Wales, Australia

 Introduction

Postoperative pain is a common clinical scenario in hospitals for junior doctors. Sound postoperative pain management using multimodal analgesia provides many benefits other than patient comfort. It reduces postoperative pulmonary complications, the neuro-endocrine stress response and the incidence of myocardial ischaemia. It also promotes early mobilisation and discharge.

  • In the acute pain setting, there should always be regular simple analgesia (paracetamol/NSAIDS) prescribed along with PRN on top as breakthrough analgesia
  • You should be mindful when prescribing NSIADs of their adverse effect profile
    • They may cause or exacerbate gastrointestinal upsets, peptic ulcers, platelet dysfunction, renal impairment and asthma NB: The platelet dysfunction is irreversible and requires the production of new platelets is needed to restore haemostasis
  • Think about regional blocks if the patient is elderly especially with multiple comorbidities
  • Don’t forget about non-pharmacological measures such as traction
  • Panadeine Forte require relatively fixed dosing and cannot be easily titrated due to the risk of paracetamol induced hepatotoxicity and therefore can only be given TDS or QID
  • Oxycodone is more flexible with the frequency of doses and therefore can be titrated to its analgesic effects more effectively than Panadeine Forte
  • Codeine is a pro-drug and is metabolised to morphine by the CYP2D6 hepatic enzyme. 10% of Caucasians and 1-2% of Asians lack the required hepatic enzyme (CYP 2D6) and therefore get minimal analgesic effect
  • Reduced effect may be an issue in patients with hepatic dysfunction
  • Which NSAID would you choose for acute pain?
  • Which age group do you start to worry about their use?
    • There are two types of NSAIDS – Non-selective COX1+2 and COX2 selective
    • COX2 NSAIDS are associated with thrombosis and cardiac adverse effects through the activation of thromboxane A2
  • NSAIDS can cause or exacerbate gastrointestinal upsets, peptic ulcers, platelet dysfunction, renal impairment and asthma
    • The renal impairment effects of NSAIDs are potentiated by other factors such as: older age, dehydration and the presence of other nephrotoxins (ACEI/A2-antagonists, metformin and gout medications)
  • Some orthopaedics surgeons may tell you to avoid NSAIDs because it may delay bone healing
    • In the acute setting, there is little evidence that NSAIDs delay bone healing (there is some evidence in spinal surgery). The organ impairment effects should be considered more so than potential for delayed bone healing
  • There are IV formulations that last 24hr
    • g. Paracoxib
  • NSAIDs can be also administered as suppositories
    • g. Indomethacin 100mg PR
  • Take an analgesic history. What has worked for them in the past? Ibuprofen/Diclofenac? This is helpful for discharge planning so that you can discharge patients on medications they have used before and are comfortable with
  • These are very difficult patients for everybody!
  • Get advice from chronic pain specialists early
  • Clarify with the surgeon/anaesthetist the plan for the patient and can we give their usual medications e.g. Methadone
  • It is possible to covert from oral to transdermal, however, this would be under the advice of a chronic pain specialist
  • Don’t forget to take a good history from the patient and a multidisciplinary approach
  • Junior doctors are reluctant to call an anaesthetist
  • Anaesthetists would rather know about acute pain issues early rather than later
  • You should call for advice if you are uncomfortable with increasing doses of analgesia and/or with chronic pain patients
  • Recognise the risk to patients on high dose opioids
    • Patients on more than 80mg/24hrs of opioids areat risk of respiratory depression
  • Think about this in 3 categories: surgical issues, patient issues and anaesthetic/pain issues
    • Surgical problem – e.g. patient with abdominal pain with increasing analgesia. What is the actual problem and diagnosis? Is there a post-operative complication? Don’t just keep prescribing more analgesia blindly.
    • Patient history – what’s their baseline? Do they have pre-existing chronic pain? Other issues in their history, e.g. have they come in with acute pain and missed their morning methadone?
    • Medication problems – some people respond to some mediations and not to others, consider the adverse and psychological effects.
  • If you are uncomfortable, get advice early.
  • Start with simple analgesia and work up from there.
  • If there is an escalation of analgesic requirements – have a second look at what’s going on and think if it could be pathological.
  • Think about discharging planning – opioid naive patients that are being discharged on opioids need to have a plan for weaning them along with clear instructions – the GP also needs to be aware of this plan – there are a lot of social issues with prescription analgesics.

Related Podcasts

Tags: #acute pain management,#Anaesthetics,#analgesia,#codeine,#discharge planning,#methadone,#multimodal analgesia,#NSAID,#opioids,#oxycodone,#pain management,#panadeine forte,#postoperative pain

If you enjoyed listening to this week’s podcast feel free to let us know what you think by posting your comments or suggestions in the comments box below.

 

If you want to listen to this episode while not connected to WiFi or the internet, you can download it. To find out more go to Apple support (https://support.apple.com/en-us/HT201859)

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