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

·         Good pain relief is good for the mind and body (and reduces risk of chronic pain)

·         Good pain relief frees up beds for the hospital and saves money

·         Analgesics can be dangerous if inappropriately prescribed

·         Complex regimens require an Acute Pain Service

 

Components of an Acute Pain Service:

*Multi-disciplinary approach*: home team, pharmacist, physio, psychology

Staff

·      Anaesthetists and trained nurses

Policies

·      For treatment and monitoring

Services

·      Daily review

·      Consults and referrals

·      Discharge planning

Quality assurance

·      Rrecord keeping, audit

Education

·      Medical students

·      Ward nurses

·      Residents

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

·      Suitable for oral route?

·      Side effects?

·      Complications? (especially if epidural)

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 flags groups:

Risk of over-doing it

·      Pregnant (also teratogenicity)

·      Child

·      Obese

·      OSA

Risk of under-doing it

·      Chronic pain

·      Opioid tolerant

·      Substance abuse

Difficulty communicating

·      Cognitive impairment

·      Non-English speakers

·      Aborigines

 

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