Pain Relief & Common Drugs. Henrik Jörnvall MD, PhD
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1 Pain Relief & Common Drugs Henrik Jörnvall MD, PhD MKAIC May
2 Pain Definition An unpleasant sensory and emotional experience assocated with actual or potential tissue damage or described in terms of such damage
3 Pain Effects Behavioural and physiological responses designed to minimise the impact of any painful stimulus
4 Pain Consequences Unpleasant + tissue damage Behavioural + physiological responses Pain relief/treatment improves recovery! Respiratory function Cardiovascular Metabolic / endocrine Mobilisation Nutrition, GI function Nursing Level of care Psycological Sympathetic / stress
5 Assessment All patients will respond differently No objective measurement Visual Analogue Scale (VAS) Verbal Numerical Rating Scale Scales 0 to 10 0 to 4 0, +, ++ No pain, mild, moderate, severe Document!
6 Treatment WHO Analgesic Ladder Strong opioids: morphine, fentanyl, pethidine Weak opioids: codeine, tramadol Paracetamol, NSAID Administer by the clock, not on demand!
7 WHO 1:st Step Paracetamol 1 g QED (po/pr/iv) Hepatotoxicity! NSAID Diclofenac mg TDS (po/pr/im) Ibuprofen mg TDS (po) Astma! Pregnancy (!) Hemorrhage or GI ulcer! Hypovolemia / kidney failure! Not if uterine atonia!
8 WHO 2:nd Step Codeine Prodrug; 5-10% converted to morpine 30 mg QDS (po) Non-responders! Tramadol 50 mg TDS (po/iv/im)
9 WHO 3:rd Step Morphine 0.1 mg/kg po/sc/im/iv PRN Fentanyl 1 μg/kg (iv) Pethidine 1 mg/kg (im/iv) Minor respiratory depression if in pain! No addictive potential if in pain! Naloxone!
10 Evaluation Assess and re-assess! Document! Step up the ladder! Step down the ladder! Warning: Surgical complications must always be suspected and ruled out!
11 Suggested Pain Relief for Caesarian Surgical anaesthesia Spinal anaesthesia Wound infiltration of local anaesthetic 1:st step of WHO ladder Paracetamol po 1 g QDS x III Ibuprofen po 400 mg TDS x III 2:nd or 3:rd step of WHO ladder if needed Tramadol po/sc 50 mg TDS Morphine sc 5 mg PRN
12 Pain Summary Definition and effect Assessment Treatment Actual or threatened tissue damage leading to an unpleasant feeling with behavioural and physiological consequences Pain score - documentation WHO-ladder Evaluation Assessment, re-assessment, step up/down, adjuctants
13 Normal Saline Ringer Lactate Ephedrine Magnesium Pethidine Ketamine Vecuronium Pancuronium Suxamethonium Diazepam Thiopentone Atropine Adrenaline NSAIDs Paracetamol Insulin Hydrocortisone Chloramphenicol Gentamycin Ampicillin Penicillin Halothane Oxygen Blood Dextrose Nitrous oxide Cephalosporins Dopamine Bupivacaine Isoflurane Atracurium Fentanyl Morphine Hydralazine Beta-blockers Naloxone LMWH Heparin Platelets Plasma Colloids Remifentanyl Alfentanyl Midazolam Propofol Sevoflurane Rocuronium Dobutamine Noradrenaline Meropenem Lidocaine Ropivacaine
14 What is safe? What is evidence based? When? What dose? Expected side effects? Accepted side effects?
15 Antepartum WHO pain ladder Not NSAID in late pregnancy; premature closure of DA Co-current disease Insulin Beta-blockers Complications of pregnancy (Pre-)eclampsia: labetalol, hydralazine, magnesium Insulin
16 Peripartum WHO pain ladder Opioids can cause respiratory depression of the fetus Tocolysis Terbutaline / GTN (NSAIDs) Uterotonics Syntocinon / oxytocin Ergometrin Prostaglandins Antibiotics Not tetracyclin
17 Caesarean Spinal anaesthesia Bupivacaine hyperbaric 12.5 mg (Fentanyl 10 μg) Ephedrine 5 mg iv as needed to correct hypotension Fluid preload (colloid) or co-current (cristalloid) Post operative WHO pain ladder General anaesthesia Rapid Sequence Induction Thiopentone 4-7 mg/kg Suxamethonium 1 mg/kg Inhalation anaesthesia as maintenance Preferably N 2 O and opioid Post operative WHO pain ladder
18 Postpartum WHO pain ladder Basically no contraindications to breast feeding Uterotonics Syntocinon / oxytocin Avoid NSAID
19
20 Summary WHO pain ladder 1:st Paracetamol + NSAID 2:nd Weak opioid; tramadol 50 mg TDS or codeine 30 mg QDS 3:rd Strong opioid; morphine 5-10 mg sc QDS and/or PRN Ante-/peri-/postpartum Uterus contraction (NSAIDs) Fetal effects (opioids) Caesarean Spinal: bupivacaine General anaesthesia: thiopental + suxamethonium + inhalation + opioid
21 The End
Drugs & Everything Else
Pain Relief, Common Drugs & Everything Else Henrik Jörnvall MD, PhD MKAIC November 11 2011 Lidocaine Noradrenaline Isoflurane Morphine Ropivacaine Platelets l t Pethidine Dobutamine Propofol Normal Saline
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