Pain Management. Dr Kelly Reilly Dr Serena Martin

Transcription

1 Pain Management Dr Kelly Reilly Dr Serena Martin

2 Contents 1- Introduction 2- WHO ladder 3- Non-opioids 4- Opioids 5- Conversion 6- Conclusion

3 Introduction Why do we give pain relief? Improve quality of life Normalise abnormal physiological variables (tachycardia, high blood pressure, tachypnoea etc) Inadequate pain relief can be detrimental to respiratory and cardiac function (increased myocardial oxygen demand, decreased respiratory effort) Improve mobility Decrease anxiety and depression

4 As an F1... You will be bleeped numerous times on various wards to see patients in pain o Surgical wards- pre and post op... o Medical wards- chest and abdominal pain, headaches... o Orthopaedic wards- fractures, compartment syndrome... o and many more...

5 What to do?- medication factors If asked to prescribe pain relief o Review medical kardex- what regular/prn medication has been prescribed o If they are receiving their regular medications, what time did they receive their last regular/prn medication i.e can they have another dose o Check allergies o Review other medication for interactions

6 What to do?- patient factors Assess patient- cause for pain? See if pain can be relieved by simple measures- repositioning, laxatives etc Review medical history-contra-indications Check NEWS chart (ensure RR etc appropriate for opioids) Check blood results (deranged U and E - contraindication to NSAIDS)

7 WHO pain ladder

8 Step 1 (mild to moderate pain) NON-OPIOID Paracetamol- antipyrexic and analgesic o PO, IV, PR o if weight less than 50kg- 15mg/kg/day o caution in those with alcohol dependence/ liver disease o usual dose 1g QID/PRN

9 Step 2 (moderate to severe pain) MILD OPIOIDS Codeine Phosphate- analgesic o Can be given as a combination with paracetamol o PO, IM o Should not be given in head injury or to those with respiratory depression/ paralytic ileus o SE- constipation, N+V, drowsiness o usual dose 30-60mg QID/PRN

10 Step 2 (moderate to severe pain) Tramadol- analgesic o PO, IM, IV o Should be used with caution in elderly (delirium) o Should not be used in those with respiratory depression, paralytic ileus or head injury o SE- N+V, confusion, constipation,drowsiness o usual dose mg QID/PRN o NB now a class 3 drug with tighter prescribing restrictions

11 Step 3 (severe pain) Morphine sulphate o IV, IM, SC, PCA o IV MUST be given by doctors o Titrate dose up, some patients are morphine sensitive and may require much less than anticipated o SE- N+V (usually give antiemetic to pre-emptively treat this), drowsiness, itch (piriton), respiratory depression, urinary retention

12 Step 3 (severe pain) Other forms of morphine include: Oramorph (oral morphine sulphate) Sevredol (oral morphine tablets) Oxynorm (oxycodone) Oxycontin (longtec) Diamorphine

13 Conversion Drug Strength compared with oral morphine Equivalent dose to 10mg morphine sulphate (PO) Codeine Phosphate 1/10 100mg Tramadol 1/10 100mg Dihydrocodeine 1/10 100mg Oxycodone (PO) mg Oxycodone (IV/IM) 4 2.5mg Morphine (IV/IM) 2 5mg Diamorphine mg

14 Adjuvants Important to know that at any stage of the pain ladder adjuvant medication can be added e.g. NSAID s o diclofenac, ibuprofen, aspirin, etc o Do not use in renal impairment or history of ulcers o Use with caution in elderly and asthma

15 Other drugs to consider If patients are on regular opioids important to consider o laxatives o anti-emetics o anti-histamines

16 Prescribing in elderly Elderly people are more at risk of developing delrium Not advised to prescribe tramadol for this reason Be very cautious with prescribing strong opioidselderly may be more sensitive therefore more susceptible to respiratory depression Avoids NSAIDS for GI and renal side-effects

17 Conclusion Pain relief is a very important part of the F1 task list Knowing how to provide it appropriately and safely is key If any doubts on which analgesic and when ask senior for advice!!