وقل رب زدنى علماً

1. بسم الله الرحمن الرحيم وقل رب زدنى علماً صدق الله العظيم

2. Acute pain service , clinical application in ICU By SaharElkaradawy Professor in Anaesthesia MRI, Alexandria University 2012

3. Objectives • Acute pain service • Why pain service should be built in our hospitals? • And how? • What pain service teamhas to do? • The pain management protocols in peri-operative field. • Multimodal analgesia and multidisciplinary approach for pain relief.

4. Acute pain service It is peri-operative good quality service introduced by physicians and well trained nurse to educate patient about post operative pain and choose the best methods available to relieve his /her pain and speed up recovery. • Physicians • Patient Nurse Documentations Paperwork Sheets

5. Why pain service should be built in our hospitals? Aims of APS are to: • Reduce pain intensity and increases patient’s wellbeing. • Decrease morbidity and mortality • Speed up recovery • Decrease patient's short-and long-term use of healthcare facilities, and subsequent costs to society.

6. How can we build acute pain service? Multidisciplinary approach: • Patient’s education ( audio- visual aids) • Personnel training (Physicians and nurses) • Protocols for management of pain. ( Sheets) • Concept of multimodal analgesia and perioperative rehabilitation

7. Patients’ education • Discuss pain issue with your patient. Patient can help if he understood methods to measure his pain • Patient’s education decreases anxiety and makes patient involved in postoperative pain management plans so his pain becomes easier to treat. • Booklet for education: postoperative pain,medicines for pain relief, analgesia and addition non-drug methods for pain relief ( appendix 1)

8. Personnel training Physician and nurse should to know: Definition and pathophysiology of pain and understand consequences of unrelieved pain Pain scales ( to measure pain) Be familiar with the pharmacologic therapy ( drugs, side effects, how to manage) Protocols of acute pain management Multimodal analgesia

9. Physician and nurse should to know: • Definition. • Pathophysiology of pain. • Understand consequences of unrelieved pain.

10. Definition of pain • Unpleasant sensation associated with actual or potential tissue damage.

11. Neurotransimission of sharp pain

12. Neurotransimission of sharp pain

13. Peripheral mediators

14. Neurotransimission of sharp pain

15. Spinal cord transmission of pain

16. SPINAL CORD TRANSMISSION OF PAINFUL STIMULI :

17. SP and excitatory amino-acids prostanoids nitric oxid calcitonin gene related peptide are excitatory peptides that produce long lasting depolarization of DH neurons and facilitates transmission of impulses leading to production of central hypersensitization. Central hypersensitization can augment responses of DH neurons by up to 20 fold in amplitude and prolong responses even after cessation of peripheral impulse.

19. Spinal cord • Accentuation of pain

20. :Spinal cord Accentuation of pain.

21. Neurotransmission of nociceptive pain

22. On

23. Multimodal analgesia • The concept of multimodal analgesia involves the use of different classes of analgesics(NSAID, Opioids, local anaesthetics and adjuvants e.g. alpha 2 agonist, neurontin) • Or different sites of analgesic administration e.g. PNB or neuroaxial with iv PCA • Aiming to provide superior dynamic pain relief with reduced analgesic-related side effects.

24. I.V PCA

25. Neurotransimission of sharp pain

26. CONSEQUENCES OF POSTOPERATIVE PAIN • Inadequately controlled pain can: • Prolong recovery time • Delay return to normal living • Decrease satisfaction with care. • Increase the use of health care resources, thereby increasing total healthcare costs. • Lead to chronic pain specially after breast surgery, thoracotomy, and inguinal hernia

27. What Physician and nurse should to do?: • Help in patients’ education • Decide with his patient a protocol for post operative pain relief. • Assess pain • Intraoperative and post operative pain management • Make sure that APS modality is working and patient is OK • Make sure that patient is stable before discharging home.

28. Patient’s education

29. Multimodal analgesia • The concept of multimodal analgesia involves the use of different classes of analgesics(NSAID, Opioids, local anaestheticsand adjuvants e.g. alpha 2 agonist, neurontin) • Or different sites of analgesic administration e.g. PNB or neuroaxial with iv PCA • Aiming to provide superior dynamic pain relief with reduced analgesic-related side effects.

30. I.V PCA

33. Multimodal analgesia sheet

34. Assessment of pain ( pain scales)

35. Assessment of pain Pain Intensity

36. This is an actual patient in the recovery room, minutes after surgery on her hand. She is smiling because she doesn't hurt, and she doesn't hurt because of post-operative pain programme application. Acute postoperative pain management programme

37. Thank you