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Thinking About Pain: Multimodal Pain Management. October 26, 2013. Sarah Derman, RN, MSN Clinical Nurse Specialist: Pain Management Fraser Health: Surgical Program. The amount of tissue trauma is an indicator of how much pain a patient will have. Which surgery results in more pain?.

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slide1

Thinking About Pain:

Multimodal Pain Management

October 26, 2013

Sarah Derman, RN, MSN

Clinical Nurse Specialist: Pain Management

Fraser Health: Surgical Program

which surgery results in more pain
Which surgery results in more pain?

Total Knee Replacement?

Bowel Surgery?

slide5

"Fast moving particles of fire ..the disturbance passes along the nerve filament until it reaches the brain..." Descartes (1664)

slide7

"Fast moving particles of fire ..the disturbance passes along the nerve filament until it reaches the brain..." Descartes (1664)

pain perception and experience
Pain Perceptionand Experience

Genetics

Co-morbidities

Chronic pain, hepatic, renal function

Other medications

Demographics

Age, Gender, Ethnicity

Emotional

Anxiety, mood, catastrophizing,

Beliefs, Values, goals

Previous experiences

Tissue damage

Nerve involvement Invasiveness of surgery

SOCIAL

Family, social situation, culture

8

genetic variability and pain
Genetic Variability and Pain
  • Pain Pathway / processing
    • Ion channels
    • Neurotransmitter metabolism
  • Drug metabolisim
    • CYP2D6
  • Endogenous opioid production
associated physiological changes in pain management of the elderly
Associated Physiological Changes in Pain Management of the Elderly

Pharmacokinetics (absorption, distribution, duration & excretion) changes:

  • Decrease in renal function, ↓ GFR
  • Decrease liver function
  • Decrease in gastric emptying
  • Decrease protein levels - protein bound drugs will have higher serum levels
  • Less muscle and more fat – lipid soluble medications have longer half life

Meds stay in system longer, metabolites build up

acute on chronic
Acute on Chronic

Changes occur in the CNS with repeated pain stimuli:

  • Rewiring of brain (neural plasticity)
  • NMDA (N-methyl-D-asparate) involvement

TAKES less to send a pain signal, things not normally painful can cause pain signal and things mildly painful can cause ++pain

slide12

Impulse is translated into experience of pain.

Affected by thoughts, beliefs, sleep, mood, fear, anxiety

Pain Pathway

PERCEPTION

TRANSMISSION

MODULATION

Tissue damage

Inflammatory Process (released prostaglandins, substance P)

Spinal

Impulse travels along neuron axon to spinal cord (dorsal horn) then up spinal cord to the brain.

cord

TRANSDUCTION

Nociceptors translate tissue damage (heat, chemical, mechanical) into impulse.

Dorsal Horn

Descending pathway that inhibits or decreases pain impulse (endogenous opioids, noradrenalin pathway.)

slide13

Impulse is translated into experience of pain.

Affected by thoughts, beliefs, sleep, mood, fear, anxiety

Pain Pathway

PERCEPTION

TRANSMISSION

MODULATION

Tissue damage

Inflammatory Process (released prostaglandins, substance P)

Spinal

Impulse travels along neuron axon to spinal cord (dorsal horn) then up spinal cord to the brain.

cord

TRANSDUCTION

Nociceptors translate tissue damage (heat, chemical, mechanical) into impulse.

Dorsal Horn

Descending pathway that inhibits or decreases pain impulse (endogenous opioids, noradrenalin pathway.)

changes with chronic pain
Changes with Chronic Pain

Substance P

Glutamate

Glutamate

Substance P

Glutamate

Glutamate

Magnesium

NMDA Receptor

AMPA receptor

AMPA

receptor

pain perception and experience1
PAIN PERCEPTION AND EXPERIENCE

What about marijuana use?

Genetics

What about methadone?

Co-morbidities

Chronic pain, hepatic, renal function

Other medications

Demographics

Age, Gender, Ethnicity

Emotional

Anxiety, mood, catastrophizing,

Beliefs, Values, goals

Previous experiences

Tissue damage

Nerve involvement Invasiveness of surgery

What about addiction?

SOCIAL

Family, social situation, culture

What about opioid abuse?

15

addiction and pain
Addiction and Pain
  • Tolerance
  • Opioid Hyperalgesia?
what about marijuana use
What about marijuana use?
  • Endocannibinoid system
multi modal balanced pain management
Multi Modal - Balanced Pain Management

Increases pain relief and decreases side effects

Additive pain management or Synergistic pain management

Focus on non-opioids around the clock (regularly)

Outcomes:

Reduction in PONV, and sedation

Increased early mobilization

Earlier recovery of bowel function

ketamine
Ketamine
  • NMDA (N-Methyl D-Aspartate) receptor agonist
  • Low Dose
    • Introperatively
    • Post operatively
  • Opioid sparing
local anaesthetic
Local anaesthetic
  • Intrathecal
  • Epidural
  • Nerve blocks
  • Intra-articular local Anesthetic bolus
lidocaine intravenously
Lidocaine Intravenously
  • Low dose infusion introperatively
  • Outcomes
    • Lower rates of illeus post abdominal surgery
    • Improved pain control
    • Less opioid use
  • Challenges
    • ? Evidence (small studies)
    • Local anaesthetic toxicity?
slide28
“Multiple studies have consistently found a

strong correlation between the severity of acute

postoperative pain and the development of

persistent postsurgical pain”

(IASP, 2011).