Pain & Its Management

Anaesthetic House Officer

Training Module

Kementerian Kesihatan
Malaysia

Those who do not feel

pain seldom think that it is
felt.
Dr. Samuel Johnson
(1709-1784)

Definition of Pain
An unpleasant sensory and emotional
experience associated with actual and
potential tissue damage or described
in terms of such damage
IASP Subcommitee on Taxonomy.
Pain 1980; 8:249-252

Definition of Pain

Pain is what the patient says,

hurts

Nociceptors
1. A-delta fibers
myelinated
2-30 m/sec
(1st pain)
2. C-fibers
unmyelinated
<2 m/sec
(2nd pain)

The Pain Pathway

First Order Neurons
Neurons

Second Order

Ascending Pain Pathway (Acute

Pain)
Cerebral cortex

3rd Order

Thalamus

Midbrain
Spinomesencephalic

Pons

Medulla

2nd Order
Dorsal Root

1st Order
Nociceptors

Sensory Cortex
Spinothalamic

Spinoreticular

Pain
Pathway

PAI
N

Sensory
cortex
Thalamu
s

PAG / RAS
Descendin
g
inhibitory
fibres

Ascending ST
tracts

Free nerve
endings

Spinal cord

Afferent nerve ( A /
c)
5th Vital Sign: Doctors training module: Pain Physiology

Dorsal
horn

Effects of Pain
I. Physiological
-

Cardiovascular System
Respiratory system
Gastrointestinal system
Genitourinary system
Central Nervous System
Endocrine system

II. Psychological
III. Economic

Cardiovascular System
Increased Heart Rate
Increased Blood Pressure
increased myocardial work load
myocardial oxygen consumption
increased risk of myocardial
ischaemia

5th Vital Sign: Doctors training module: Pain Physiology

Respiratory system
Inhibition of normal respiration
(unable to take deep breaths)
Atelectasis
Hypoxia

Inability to cough
Retention of secretions
Increased risk of lung infection /
pneumonia

5th Vital Sign: Doctors training module: Pain Physiology

Gastrointestinal System
Increased sympathetic and
reduced parasympathetic activity
Reduced smooth muscle + sphincter
tone
Reduced gut motility
Ileus, nausea + vomiting
Impedes early feeding
5th Vital Sign: Doctors training module: Pain Physiology

Genitourinary System
Increased sympathetic and
reduced parasympathetic tone
reduced smooth muscle +
sphincter tone
urinary retention

5th Vital Sign: Doctors training module: Pain Physiology

Musculoskeletal system
Prevent mobilisation & increases
muscle tone
Increased risk of deep vein
thrombosis

5th Vital Sign: Doctors training module: Pain Physiology

Central Nervous System

sympathetic activity
parasympathetic activity

Hyperalgesia
scarring of pain pathways

Increased risk of developing

chronic pain
5th Vital Sign: Doctors training module: Pain Physiology

Endocrine System
Stimulation of stress response

Increased sympathoadrenal activation

Metabolic response to stress
Hyperglycemia
Catabolic state

Immunosuppression

risk of infection
5th Vital Sign: Doctors training module: Pain Physiology

Psychological
Anxiety
Agitation
poor sleep
uncooperative patient

5th Vital Sign: Doctors training module: Pain Physiology

Economic
Delayed ambulation and feeding
Increased postoperative
complications
Delayed recovery
Prolonged hospital stay
Increased cost

5th Vital Sign: Doctors training module: Pain Physiology

Spectrum of Pain
ACUTE
PAIN

Healing

NO PAIN

Insidious onset

CHRONIC
PAIN

ACUTE
PAIN

post-surgical syndromes /
cancer

5th Vital Sign: Doctors training module: Pain Physiology

CHRONIC
PAIN

Acute vs Chronic Pain

Acute Pain

Chronic Pain

Onset and
timing

Sudden onset, short duration.

Resolves/disappears when
tissues heal.

Onset may be insiduous.

Pain persists despite tissue
healing.

Signal

A warning sign of actual or

potential tissue damage

Not a warning signal of

damage : a false alarm

Severity

Severity is correlates with

amount of damage.

Severity not correlated with

damage.Good days and
Bad days.

CNS
involvement

CNS intact acute pain is a

symptom

CNS may be dysfunctional

chronic pain is a disease

Psychological
effects

Less, but unrelieved pain

anxiety & sleeplessness (which
improves when pain is relieved)

Often associated with

depression, anger, fear,
social withdrawal, etc

Common
causes /
examples

Surgery, fracture, burns,

myocardial infarct, labour and
childbirth, inflammatory
conditions e.g. abscess

Chronic headache, back

pain, chronic pelvic / abd
pain, cancer pain,
neuropathic pain PHN,
DPN, post stroke pain, etc

5th Vital Sign: Doctors training module: Pain Physiology

Assessment of Pain
Pain is both a physical and a psychological
phenomenon

The pain experience is subjective

Meaningful evaluation and successful
treatment of a patient with pain requires
quantification of the patients pain

Pain as the 5th Vital Sign

Guidelines for Doctors
(Management of Adult Patients)

Pain as the 5th Vital Sign

Guidelines for Doctors
(Management of Paediatric Patients)

How to assess pain:

P : Place or site of pain
Where does it hurt?
(a body chart might help
describe their pain)

A : Aggravating factors
What makes the pain worse?

I : Intensity
How bad is the pain?

N : Nature and neutralizing

factors
What does it feel like What
makes the pain better?

5th Vital Sign: Doctors training module: Pain

Guideline 1
Pain Assessment Guide: Taking a Brief Pain
History
TELL ME ABOUT YOUR PAIN
P Place
A Aggravatin
g factors
I Intensity

N Nature
Neutralizin
g factors

Where is your pain?

What makes the pain worse?
If 0 is no pain and 10 is the worst pain
imaginable: What is your pain score now?
What is the worst level of pain (score) you
experience in a day?
What is the least pain (score) you experience
in a day?
Describe your pain e.g. aching, throbbing,
burning, shooting, stabbing, sharp, dull, deep,
pressure, etc
What makes the pain better?

Pain Measurement Tools :

Adults
Combined NRS/ VAS Scale

NRS/

NRS : Numerical Rating Scale

VAS : Visual Analog Scale

Combined NRS/ VAS Scale

(KKM)

Pain Measurement Tools :

Paediatrics

FLACC Scale

Wong-Baker Faces
Scale

WHICH TOOL TO USE

to measure pain?

Use the standard tool for pain

assessment as recommended by Ministry
of Health, Malaysia
adult patients : combined NRS / VAS scale
paediatric patients 1 month to 3 years old
: FLACC
paediatric patients > 3-7 years : WongBaker FACES scale
paediatric patients >7 years : combined
*Always use the same tool for the same patient
NRS/VAS scale (same as for adults)
5th Vital Sign: Doctors training module: Pain

Flow Chart : Pain as the 5th Vital Sign

(Nurses)

Flow Chart for Pain Management in

Adult Patient: (Doctors)

Analgesics

Opioids
Non Opioids

Paracetamol
NSAIDS
COX 2 inhibitors

Weak
Strong

31
5th Vital Sign: Doctors training module: Pharmacology

Formulations And Dosage Of Commonly Used

Analgesics

Guideline 4
Drugs in Acute Pain Management: The Analgesic Ladder
Analgesic Ladder for Acute
Pain Management

SEVERE
7-10

MODERATE
4-6

MILD
0-3
Regular
No
medicati
on or
PCM
1gm
6hrly

PRN
PCM
&/or
NSAID /
COX2
inhibitor

Regular
Weak
Opioid
PCM 1gm
QID oral
NSAID /
COX2
inhibitor

PRN
Additional
weak
opioid

Regular
Higher dose
of weak
opioid
Or
IV/SC
Morphine 510mg 4 hrly
OR
Aqueous
morphine
10-20 mg
PCM 1gm
QID oral /
rectal
NSAID /
COX2
inhibitor

PRN
IV/SC
Morphine
5-10mg
OR
Aqueous
morphine
*Oral or
SC
Morphine
may be
safely
given at
hourly
intervals

UNCONTROLLED

To refer to APS
for:
PCA or Epidural
or other form of
analgesia

Post Operative Pain

Management
1.Conventional Methods
i. Oral Analgesics Opioids
NSAIDS
ii. IV Injections Opioids
NSAIDS
2. Common Methods
i. Patient Controlled Analgesia
(PCA)
ii. Epidural Analgesia
iii. Patient Controlled Epidural
Analgesia (PCEA)
iv. Subcutaneous Morphine

3. Other Methods
i. Nerve & Nerve Plexus
Blocks
ii. Transcutaneous
Electrical
Nerve Stimulation
(TENS)
iii. Rectal NSAIDS
4. Multi-modal
Concepts

PATIENT CONTROLLED
ANALGESIA
(PCA)

Method of analgesic
delivery : computerised
syringe pump is set to
deliver bolus doses
whenever patient
presses button (patient
demand)
Allows small amounts of
analgesic to be given at
frequent intervals
Patient titrates according
to individual needs

DILUTION OF PCA DRUGS

Morphine:

Adults: 5 amp (50 mg) = 5 mls

Dilute with N/S 45 mls
Concentration : 1mg/ml (50mls)

Paeds: 0.5mg/kg of morphine and make

upto 50mls with N/S.
Concentration: 1ml = 10mcg/kg

Recommended settings
(example )
Drug concentration: morphine 1mg/ml
Mode: PCA
Loading dose: usually zero for post
operative patients
Bolus dose:

<60 years morphine 1mg

>60 years morphine 0.5mg

Lockout interval :5 minutes

4 hour limit : usually not set

EPIDURAL ANALGESIA

Introduction of
analgesic drugs
into epidural space
via an indwelling
catheter

EPIDURAL ANALGESIA :
DRUGS USED
LOCAL ANAESTHETICS ALONE

BUPIVACAINE

OPIODS ALONE

FENTANYL
- MORPHINE

MIXTURES (COCKTAIL)
- FENTANYL + BUPIVACAINE