Acute Pain Management A Practical Guide

Cover
Half Title
Title Page
Copyright Page
Contents
Preface
Disclosures
Notice
Authors
1. Introduction
1.1. Effectiveness of Acute Pain Management
1.1.1. Assessment of Effectiveness
1.1.2. Variability in Effectiveness
1.2. Role of Acute Pain Management in Patient Outcomes
1.2.1. Short-Term Outcomes
1.2.2. Longer-Term Outcomes
References
2. Delivery of Effective Acute Pain Management
2.1. Education
2.1.1. Staff
2.1.1.1. Medical Staff
2.1.1.2. Nursing Staff
2.1.2. Patients
2.2. Guidelines and Protocols
2.3. Acute Pain Services
References
Appendix 2.1. Further Resources: Patient information
Appendix 2.2. Example of an Epidural Analgesia Information Card Given to Patients on Discharge from Hospital
3. Assessment and Monitoring
3.1. Types of Pain
3.2. Assessment of Pain and Pain Relief
3.2.1. Pain History
3.2.2. Measurement
3.2.2.1. Unidimensional Measures
3.2.2.1.1. Visual Analog Scale
3.2.2.1.2. Verbal Numerical Rating Scale
3.2.2.1.3. Verbal Descriptor Scale
3.2.2.1.4. What Degree of Pain Relief Is Desirable?
3.2.2.2. Assessment of Function
3.2.2.3. Assessment of Neuropathic Pain
3.2.2.4. Other Measures of Pain
3.2.2.5. Pupil Size
3.2.2.6. Patient Satisfaction
3.2.3. Effect of Psychological Factors on Acute Pain
3.3. Assessment of Adverse Effects
3.3.1. Opioid-Induced Ventilatory Impairment
3.3.1.1. Measurement of Sedation Score and Respiratory Rate
3.3.1.2. Measurement of Oxygen and Carbon Dioxide Levels
3.3.1.2.1. Oxygen Saturation
3.3.1.2.2. Carbon Dioxide Levels
3.3.1.3. When and Whom to Monitor for OIVI
3.3.2. Motor and Sensory Function, Back Pain
3.3.3. Other Parameters
References
4. Pharmacology of Opioids
4.1. Mechanism of Action
4.1.1. Endogenous Opioids
4.1.2. Opioid Receptors
4.1.3. Placebo and Nocebo Responses
4.2. Analgesic Effects of Opioids
4.3. Adverse Effects of Opioids
4.3.1. Effect on the Respiratory System
4.3.1.1. Depression of Ventilation
4.3.1.2. Sleep-Disordered Breathing
4.3.1.3. Cough Suppression
4.3.2. Nausea and Vomiting
4.3.2.1. Antiemetics
4.3.2.1.1. 5-HT3 Receptor Antagonists
4.3.2.1.2. Dopamine Receptor Antagonists
4.3.2.1.3. H1-Receptor Antagonists
4.3.2.1.4. Neurokinin-1 (NK-1) Receptor Antagonists
4.3.2.1.5. Anticholinergic Agents
4.3.2.1.6. Corticosteroids
4.3.3. Other Central Nervous System Effects
4.3.3.1. Miosis
4.3.3.2. Cognitive Function
4.3.4. Gastrointestinal and Genitourinary Systems Effects
4.3.5. Cardiovascular Effects
4.3.6. Pruritus
4.3.7. Allergy
4.3.8. Tolerance, Opioid-induced Hyperalgesia, Physical Dependence
4.3.9. Other Effects
4.3.9.1. Serotonin Syndrome
4.3.9.2. Immune and Endocrine Functions
4.3.9.3. Postoperative Outcomes
4.3.9.4. Trauma Risk
4.4. Predictors of Opioid Dose
4.5. Titration of Opioid Dose
4.5.1. Dose and Dose Interval
4.5.2. Titration to Pain Relief, Sedation, and Other Side Effects
4.6. Commonly Used Opioid Agonists
4.6.1. Conventional Opioids
4.6.1.1. Codeine
4.6.1.2. Diamorphine
4.6.1.3. Fentanyl and Its Analogs
4.6.1.4. Hydrocodone
4.6.1.5. Hydromorphone
4.6.1.6. Methadone
4.6.1.7. Morphine
4.6.1.8. Oxycodone
4.6.1.9. Pethidine
4.6.1.10. Propoxyphene
4.6.2. Atypical Opioids
4.6.2.1. Buprenorphine
4.6.2.2. Tapentadol
4.6.2.3. Tramadol
4.7. Agonist-Antagonists
4.8. Opioid Antagonists
4.8.1. Naloxone
4.8.2. Naltrexone
4.8.3. Peripherally Acting Opioid Antagonists
References
5. Pharmacology of Local Anesthetics
5.1. Mechanism of Action
5.2. Efficacy of Local Anesthetics
5.3. Adverse Effects of Local Anesthetics and Their Management
5.3.1. Local Tissue Toxicity
5.3.2. Systemic Toxicity
5.3.2.1. Central Nervous System Toxicity
5.3.2.2. Cardiovascular Toxicity
5.3.3. Management of Systemic Toxicity
5.4. Commonly Used Local Anesthetic Drugs
5.4.1. Amides
5.4.1.1. Lidocaine
5.4.1.2. Bupivacaine
5.4.1.3. Ropivacaine
5.4.1.4. Levobupivacaine
5.4.1.5. Mepivacaine
5.4.1.6. Prilocaine
5.4.1.7. Dibucaine (Cinchocaine)
5.4.1.8. Etidocaine
5.4.2. Esters
5.4.2.1. Cocaine
5.4.2.2. Chloroprocaine
References
6. Nonopioid and Adjuvant Analgesic Agents
6.1. Paracetamol
6.1.1. Mechanism of Action
6.1.2. Clinical Efficacy and Use
6.1.3. Adverse Effects
6.2. Nonselective Nonsteroidal Anti-inflammatory Drugs
6.2.1. Mechanism of Action
6.2.2. Clinical Efficacy and Use
6.2.3. Adverse Effects
6.2.3.1. Gastrointestinal
6.2.3.2. Renal
6.2.3.3. Platelet Function
6.2.3.4. Respiratory
6.2.3.5. Other Effects
6.2.4. Precautions and Contraindications
6.3. COX-2 Selective Inhibitors (Coxibs)
6.3.1. Mechanism of Action
6.3.2. Clinical Efficacy and Use
6.3.3. Adverse Effects
6.3.3.1. Gastrointestinal, Platelet Function, Respiratory, and Renal
6.3.3.2. Cardiac
6.4. NMDA Receptor Antagonists
6.4.1. Ketamine
6.4.1.1. Clinical Efficacy and Use
6.4.1.2. Adverse Effects
6.4.2. Dextromethorphan
6.4.3. Magnesium
6.4.4. Amantadine and Memantine
6.5. Alpha-2-Adrenergic Agonists
6.5.1. Clonidine
6.5.2. Dexmedetomidine
6.6. Antidepressants
6.6.1. Tricyclic Antidepressants
6.6.1.1. Clinical Use
6.6.1.2. Adverse Effects
6.6.2. Serotonin Norepinephrine Reuptake Inhibitors
6.6.2.1. Clinical Use
6.6.2.2. Adverse Effects
6.7. Anticonvulsants
6.7.1. Gabapentinoids
6.7.1.1. Mechanism of Action
6.7.1.2. Clinical Use
6.7.1.2.1. Treatment of Neuropathic Pain
6.7.1.2.2. Perioperative Setting
6.7.1.3. Adverse Effects
6.7.2. Carbamazepine
6.7.3. Clonazepam
6.8. Membrane-Stabilizing Medications
6.8.1. Lidocaine
6.8.1.1. Clinical Use
6.8.1.1.1. Neuropathic Pain
6.8.1.1.2. As a Component of Multimodal Analgesia
6.8.1.2. Adverse Effects
6.8.2. Mexiletine
6.9. Inhalational Agents
6.9.1. Nitrous Oxide
6.9.1.1. Clinical Efficacy and Use
6.9.1.2. Adverse Effects
6.9.1.2.1. Air-Containing Spaces
6.9.1.2.2. Toxicity
6.9.2. Methoxyflurane
6.10. Calcitonin and Bisphosphonates
6.10.1. Calcitonin
6.10.2. Bisphosphonates
6.11. Corticosteroids
6.12. Cannabinoids
References
7. Systemic Routes of Opioid Administration
7.1. Oral
7.1.1. Immediate-Release and Slow-Release Formulations
7.1.1.1. Immediate-Release Opioids
7.1.1.2. Slow-Release Opioids
7.1.2. Titration of Oral Immediate-Release Opioids
7.1.2.1. Dose Range
7.1.2.2. Dose Interval
7.1.2.3. Monitoring
7.1.2.4. Selection of Subsequent Doses
7.2. Subcutaneous and Intramuscular
7.2.1. Titration of Intermittent SC or IM Opioids
7.2.1.1. Dose Range
7.2.1.2. Dose Interval
7.2.1.3. Monitoring and Selection of Subsequent Doses
7.3. Intravenous
7.3.1. Titration of Intermittent IV Opioids
7.3.1.1. Dose Range
7.3.1.2. Dose Interval
7.3.1.3. Monitoring and Selection of Subsequent Doses
7.3.1.4. Subsequent Analgesic Regimens
7.3.2. Titration of Continuous IV Opioid Infusions
7.3.2.1. Dose Range
7.3.2.2. Monitoring
7.3.2.3. Alterations of Infusion Rates
7.4. Rectal
7.5. Transdermal
7.5.1. Fentanyl
7.5.2. Buprenorphine
7.6. Transmucosal
7.6.1. Intranasal
7.6.2. Oral Transmucosal (Sublingual and Buccal)
7.6.3. Pulmonary
References
8. Patient-Controlled Analgesia
8.1. Equipment
8.1.1. Programmable PCA Pumps
8.1.1.1. "Smart Pumps"
8.1.1.2. Consumables
8.1.2. Disposable PCA Devices
8.2. Analgesic Drugs Used with PCA
8.2.1. Opioids
8.2.2. Other Drugs
8.3. The PCA "Prescription"
8.3.1. Loading Dose
8.3.2. Bolus Dose
8.3.3. Dose Duration
8.3.4. Lockout Interval
8.3.5. Continuous (Background) Infusion
8.3.6. Concentration
8.3.7. Dose Limits
8.4. Requirements for the Safe Management of PCA
8.4.1. Suitable Patient and Patient Education
8.4.2. Nursing and Medical Staff Education
8.4.3. Standard Orders and Nursing Procedure Protocols
8.4.3.1. Standard Orders
8.4.3.2. Nursing Procedure Protocols
8.5. Management of Inadequate Analgesia
8.5.1. Inadequate Loading Dose
8.5.2. Inadequate Bolus Dose
8.5.2.1. "Successful" and "Unsuccessful" Demands
8.5.2.2. Side Effects
8.6. Complications of PCA
8.6.1. Side Effects Related to the Opioid
8.6.1.1. Opioid-Induced Ventilatory Impairment
8.6.1.2. Confusion
8.6.1.3. Nausea and Vomiting
8.6.1.4. Masking of Postoperative or Postinjury Complications
8.6.2. Complications Related to Equipment or Human Factors
8.6.2.1. Equipment Malfunction
8.6.2.2. Operator-Related Errors
8.6.2.3. Patient-Related Errors
8.7. "Step-Down" Analgesia
8.7.1. Oral Opioids
8.8. Alternative Systemic Routes of PCA Administration
8.8.1. Subcutaneous PCA
8.8.2. Transmucosal PCA
8.8.3. Transdermal PCA
8.8.4. Epidural and Other Regional PCA
References
9. Epidural and Intrathecal Analgesia
9.1. Anatomy
9.2. Contraindications
9.2.1. Untrained Nursing and Medical Staff
9.2.2. Patient Rejection
9.2.3. Contraindications to the Placement of an Epidural Needle or Catheter
9.2.3.1. Local and Systemic Infection
9.2.3.2. Central Nervous System Disease
9.2.3.3. Hypovolemia
9.2.3.4. Coagulation Disorders or Concurrent Treatment with Anticoagulant or Antiplatelet Medications
9.2.3.5. Presence of a Dural Puncture
9.3. Drugs Used with Epidural Analgesia
9.3.1. Local Anesthetic Drugs
9.3.1.1. Site of Action
9.3.1.2. Doses
9.3.1.3. Side Effects
9.3.1.3.1. Respiratory System
9.3.1.3.2. Cardiovascular System
9.3.1.3.3. Sedation
9.3.1.3.4. Nausea, Vomiting, and Pruritus
9.3.1.3.5. Motor/Sensory Block
9.3.1.3.6. Urinary Retention
9.3.1.3.7. Gastrointestinal System
9.3.2. Opioids
9.3.2.1. Site of Action
9.3.2.2. Doses
9.3.2.3. Side Effects
9.3.2.3.1. Respiratory System
9.3.2.3.2. Cardiovascular System
9.3.2.3.3. Nausea and Vomiting
9.3.2.3.4. Pruritus
9.3.2.3.5. Motor/Sensory Block
9.3.2.3.6. Urinary Retention
9.3.2.3.7. Gastrointestinal System
9.3.3. Combinations of Local Anesthetics and Opioids
9.3.3.1. Dose Regimens
9.3.4. Alpha-2 Receptor Agonists
9.3.4.1. Clonidine
9.3.4.2. Epinephrine (Adrenaline)
9.3.4.3. Dexmedetomidine
9.3.5. Corticosteroids
9.3.6. Other Adjuvant Drugs
9.4. Requirements for the Safe Management of Epidural Analgesia
9.4.1. Standard Orders and Nursing Procedure Protocols
9.4.1.1. Standard Orders
9.4.1.1.1. Monitoring and Documentation Requirements
9.4.1.2. Nursing Procedure Protocols
9.5. Patient-Controlled Epidural Analgesia
9.6. Programmed Intermittent Epidural Bolus
9.7. Management of Inadequate Analgesia
9.8. "Step-Down" Analgesia
9.9. Complications and Side Effects of Epidural Analgesia
9.9.1. Postdural Puncture Headache
9.9.2. Nerve or Spinal Cord Injury
9.9.3. Epidural Hematoma
9.9.3.1. Diagnosis
9.9.3.2. Treatment
9.9.3.3. Prevention
9.9.4. Epidural Space Infection
9.9.4.1. Diagnosis
9.9.4.2. Treatment
9.9.4.3. Prevention
9.9.5. Catheter Migration
9.9.6. Problems Related to Equipment
9.9.6.1. Epidural Catheter or Filter
9.9.6.2. Infusion Pumps, Lines, and Connections
9.9.7. Side Effects Related to Drugs
9.10. Concurrent Anticoagulant or Antiplatelet Therapy
9.10.1. Warfarin
9.10.2. Heparins and Fondaparinux
9.10.2.1. Standard Unfractionated Heparin (Intravenous)
9.10.2.2. Standard Unfractionated Heparin (Subcutaneous)
9.10.2.3. Low-Molecular Weight Heparin
9.10.2.4. Fondaparinux
9.10.3. Direct Oral Anticoagulants (DOACs)
9.10.3.1. Dabigatran
9.10.3.2. Rivaroxaban
9.10.3.3. Apixaban
9.10.4. Nonsteroidal Anti-inflammatory Drugs and Other Antiplatelet Agents
9.10.4.1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
9.10.4.2. Other Antiplatelet Drugs
9.10.5. Thrombolytic and Fibrinolytic Therapy
9.11. Intrathecal Analgesia
9.11.1. Drugs Used for Intrathecal Analgesia
9.11.2. Opioid Doses
9.11.3. Possible Side Effects
9.11.4. Management of Inadequate Analgesia
References
Appendix 9.1. Example of a "Standard Order" Form for Epidural and Intrathecal Analgesia
10. Other Regional and Local Analgesia
10.1. Continuous Peripheral Nerve Blockade
10.1.1. Upper Limb
10.1.2. Lower Limb
10.1.3. Thoracic
10.1.4. Abdominal
10.1.5. Drugs Used with CPNB Analgesia
10.1.5.1. Local Anesthetics
10.1.5.2. Opioids
10.1.5.3. Clonidine and Epinephrine
10.1.5.4. Dexamethasone
10.1.6. Requirements for the Safe Management of CPNB
10.1.6.1. Equipment
10.1.6.2. Standard Orders
10.1.6.2.1. Monitoring and Documentation Requirements
10.1.6.2.2. Drug Orders and Management of Inadequate Analgesia or Side Effects
10.1.6.3. Nursing Procedure Protocols
10.1.7. Patient-Controlled CPNB
10.1.8. Ambulatory CPNB
10.1.9. Complications of CPNB
10.1.9.1. Complications Arising from the Drugs Used
10.1.9.2. Neurological Injury
10.1.9.3. Complications Arising from Infection
10.1.9.4. Complications Arising from Bleeding
10.1.9.5. Other Complications
10.1.10. Concurrent Anticoagulant or Antiplatelet Therapy
10.2. Single-Injection Peripheral Nerve Blockade
10.2.1. "Step-down" Analgesia After Single-Injection Peripheral Nerve Blockade
10.2.2. Adjuvants to Single-Injection Peripheral Nerve Blockade
10.3. Intraarticular Analgesia
10.4. Wound Infiltration
10.5. Local Infiltration Analgesia
10.6. Topical Analgesia
References
Appendix 10.1. Example of a "Standard Order" Form for Continuous Regional Analgesia
11. Nonpharmacological Therapies
11.1. Psychological Interventions
11.1.1. Information Provision
11.1.2. Relaxation Techniques
11.1.3. Hypnosis
11.1.4. Attentional Strategies
11.1.5. Cognitive Behavioral Interventions
11.2. Transcutaneous Electrical Nerve Stimulation
11.3. Acupuncture
11.4. Physical Interventions
References
12. Acute Neuropathic Pain
12.1. Pathophysiology of Neuropathic Pain
12.2. Clinical Features and Diagnosis of Acute Neuropathic Pain
12.3. Acute Neuropathic Pain Syndromes
12.3.1. Postamputation Pain Syndrome
12.3.2. Complex Regional Pain Syndrome
12.4. Treatment of Acute Neuropathic Pain
12.4.1. Pharmacological Treatments
12.4.1.1. Specific Treatment of Acute Neuropathic Pain States
12.4.1.2. Treatment Approaches to Neuropathic Pain in General
12.4.1.3. Topical Treatments
12.4.2. Regional Neural Blockade
12.4.3. Transcutaneous Electrical Nerve Stimulation
12.4.4. Treatment of Postamputation Pain Syndromes
References
13. Chronic Postacute Pain
13.1. Chronic Postsurgical Pain
13.2. Chronic Posttraumatic Pain
13.3. Preventive Strategies
13.4. Recognition and Management
References
14. Nonsurgical Acute Pain
14.1. Burns Injury
14.1.1. Pharmacological
14.1.1.1. Initial Pain Relief
14.1.1.2. "Background" Analgesia
14.1.1.3. Procedural Analgesia
14.1.2. Nonpharmacological
14.2. Spinal Cord Injury
14.2.1. Management of Pain Associated with Acute Spinal Cord Injury
14.3. Rib Fractures
14.3.1. Management of Pain Associated with Fractured Ribs
14.4. Abdominal Pain
14.4.1. Renal and Biliary Colic
14.4.2. Pancreatitis
14.5. Other Specific Conditions
14.5.1. Herpes Zoster
14.5.2. Hematological Disorders
14.5.2.1. Sickle Cell Disease
14.5.2.2. Hemophilia
14.5.3. Neurological Disease
14.5.3.1. HIV Infection
14.5.3.2. Guillain-Barré Syndrome
14.5.3.3. Multiple Sclerosis
References
15. More Complex Patients
15.1. Older Patients
15.1.1. Assessment of Pain
15.1.1.1. Perception of Pain
15.1.1.2. Reporting of Pain
15.1.1.3. Cognitive Impairment
15.1.1.4. Measurement of Pain
15.1.2. Changes in Pharmacokinetics and Pharmacodynamics
15.1.2.1. Pharmacokinetics
15.1.2.2. Pharmacodynamics
15.1.3. Analgesic Medicines
15.1.3.1. Opioids
15.1.3.1.1. Choice of Opioid
15.1.3.1.2. Opioid Dose and Dose Intervals
15.1.3.1.3. Side Effects of Opioids
15.1.3.2. Other Analgesic and Adjuvant Drugs
15.1.4. Specific Analgesic Techniques
15.1.4.1. Patient-Controlled Analgesia
15.1.4.2. Epidural and Intrathecal Analgesia
15.1.4.2.1. Anticoagulant Drugs
15.1.4.3. Other Regional Analgesia
15.2. Opioid-Tolerant Patients
15.2.1. Opioid Tolerance, Hyperalgesia, Dependence, and Addiction
15.2.1.1. Tolerance and Opioid-Induced Hyperalgesia
15.2.1.2. Physical Dependence
15.2.1.2.1. Withdrawal (Abstinence) Syndrome
15.2.2. Aims of Treatment
15.2.3. Review Prior to Commencement of Pain Relief
15.2.4. Effective Analgesia
15.2.4.1. Opioids
15.2.4.1.1. Opioid Doses
15.2.4.1.2. Monitoring for Effectiveness of Analgesia and Side Effects
15.2.4.2. Attenuation of Tolerance and Opioid-induced Hyperalgesia
15.2.4.2.1. Antitolerance and Antihyperalgesic Medications
15.2.4.2.2. Opioid Rotation
15.2.4.3. Other Analgesic Agents and Techniques
15.2.5. Specific Analgesic Techniques
15.2.5.1. Patient-Controlled Analgesia
15.2.5.2. Regional Analgesia
15.2.6. Prevention of Withdrawal
15.2.7. Involvement of Multidisciplinary and Other Specialist Teams
15.2.8. Discharge Analgesia
15.3. Patients with a Substance Use Disorder
15.3.1. Use of Opioids in Patients with a Past Opioid Use DISORDER (OUD)
15.3.2. Withdrawal from Other Drugs
15.3.3. Management of Aberrant Behaviors
15.3.4. Medicines Used in the Treatment of Opioid Addiction
15.3.4.1. Methadone
15.3.4.2. Buprenorphine
15.3.4.3. Naltrexone
15.3.5. Discharge Analgesia
15.4. Patients with Sleep-Disordered Breathing
15.5. The Obese Patient
15.6. Pregnant or Lactating Patients
15.6.1. Analgesic Use During Pregnancy
15.6.2. Analgesic Use During Lactation
15.7. Patients with Renal or Hepatic Impairment
References
16. Opioid Analgesia After Discharge from Hospital
16.1. Potential Risks
16.1.1. Adverse Effects of Opioids
16.1.1.1. Opioid-Related Side Effects
16.1.1.2. Inadvertent Initiation of Long-term Use
16.1.1.3. Effect on Driving Ability
16.1.2. Risk of Diversion and Harm
16.1.2.1. Identification of the "at Risk" Patient
16.2. Choice of Discharge Opioid Regimen
16.2.1. Choice of Opioid Regimen
16.2.1.1. More Complex Patients
16.2.1.1.1. Patients Taking Long-Term Opioids Prior to Admission
16.2.1.1.2. Patients with an SUD or High ORT-R Score
16.2.1.1.3. Other More Complex Patients
16.2.2. Relevant Legislation and Regulations
16.2.3. Duration of Treatment
16.3. Information for Patients, Carers and Treating Doctors
16.3.1. Patient and Carer Information
16.3.2. Information for the Treating Doctors
References
17. Self-Assessment Questions
Index