PS41 2013: Acute pain management

 

List:

·        Premise

·        Acute pain service

·        Acute pain consult

·        Analgesics

·        Red flag groups

 

Premise:

·        Patients have a right to pain relief

·        Too much pain is harmful to mind and body

·        Too much pain occupies hospital beds and costs money

·        Analgesics can be dangerous if inappropriately prescribed

·        Complex regimens require an Acute Pain Service

 

Components of an Acute Pain Service:

Staff

·      Anaesthetists

·      Trained nurses

·      ±Multi-disciplinary input: home team, pharmacist, physio, psychology

Policies

·      Treatment

·      Monitoring

·      Complications

Services

·      Daily review

·      Consultation

·      Referrals

·      Discharge planning

Quality assurance

·      Record keeping

·      Audit

Academic

·      Education: medical students, hospital residents, ward nurses

·      Research

 

Acute pain consult:

Assessment

·      Type of pain: somatic vs neuropathic

·      Severity of pain:

o  Subjective (score, function) vs objective (appearance, vital signs)

o  Rest vs activity

o  If out of proportion: suspect new diagnosis

·      Side effects?

·      Complications? (especially if epidural)

·      Suitability of oral route?

Education

·      Patient + family: expectations, goals

·      Treating nurse

Plan/suggestion

·      Discuss with home team

·      Discuss with treating nurse

 

Analgesics:

Principles

·      Multi-modal

·      Individualised doses

·      Titration to effect

Non-drug

·      Physical therapy

·      Cognitive behavioural therapy

·      Other: TENS, acupuncture etc

Oral drugs

·      Paracetamol

·      NSAIDs, COX-2 inhibitors

·      Oxycodone, morphine

·      Tramadol, tapentadol

·      Clonidine

·      Gabapentinoids

IV infusions*

·      Opioid PCA

·      Ketamine infusion

Local anaesthetic*

·      Neuraxial

·      Regional

·      Subcut

*Requires APS input

 

Red flag groups:

Risk of overdose

·      Pregnant (also teratogenicity)

·      Child

·      Obese

·      OSA

Risk of underdose

·      Chronic pain

·      Opioid tolerant

·      Substance abuse

Difficulty communicating

·      Cognitive impairment

·      Non-English speakers

·      Aborigines

 

 

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