Acute Pain Management A Practical Guide

Description

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