Abdominal Pain Management

Toar JM LalisangDigestive Surgery Division Cipto Mangunkusumo Hospital.Jakarta

25 % of patients do not think their doctors know how to control their pain,

20% feel that their doctor does not consider their pain a problem,

and 1 in 8 state their physician never asks them about their pain.

4 of 5 patients think they must live with their pain.

1 Patients also need to feel that their pain is important and that there are many options for improving their pain and level of daily activities.

Unpleasant sensation and emotional experience accompanied with potential and actual tissue damage

PAINFUL ?Pain Seminar, Lecture #4, PAIN MECHANISMS: CNS, p. 29

DiseasepaindiseasePainDoctorPatient

Believe Your PainPain is always subjectivePatientsSelf-report of pain is thegold Standard for assessmentIASP 1999; Portenoy RK, Lesage P. lancet, 1999

Pulse Blood pressureTemperatureRespiratory ratePain:The Fifth Vital Sign1*1American Pain Society Web site.*Trademarks are the property of their respective owners.

Vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly.

We need to train doctors and nurses to treat pain as a vital sign.

Quality care means that pain is measured and treated

James Campbell

But Not only as a symptomDisease of pain

Investigators viewMILDMODERATESEVERE

Patients viewNO PAINPAIN

Negative self-talkPoor sleepMissing workMuscle atrophy & weaknessWeight loss/gainLess activeDecreased motivationIncreased isolationDisability

Belief that pain is not harmful to the patient

Normal consequence of surgery and injury

Concerns that pain relief will obscure a surgical diagnosis or mask signs of surgical complications Underestimation of a patients pain

Failure to recognize variability in patients perceptions of pain

Lack of regular and frequent assessment of pain and any pain relieving measures

Fear that the patient will become addicted to opioids Inadequate perioperative pain education regarding postoperative analgesia Patients reluctance to request analgesia and/or fear of taking pain medications Lack of understanding of the wide variability in opioid requirements among patients, and the need to titrate analgesics to meet the needs of each patient Lack of recognition that age is a better predictor of opioid requirement than weight in the adult patient Prolonged dosing intervals/short-acting opioids have short elimination half-lives Lack of accountability for pain management

1Beauregard L et al. Can J Anaesth. 1998;45:304-311.

Worst Pain: Moderate to SevereAverage Pain: Moderate to Severe

Pain as a SymphonyComplex dynamic Sensors Emotions Memory Hormones

Opiat & NSAIDPowerfull drugs treating painMANY SIDE EFFECT GI problem Dependence

SpinothalamictractPeripheralnerveDorsal HornDorsal root ganglionPainMedulation

AscendinginputDescendingmodulationPeripheralnociceptorsTraumaAdapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. Perception

transmissionPain Transmission

Surgeon makes wounds for treatment. Wounds caused pain

Type of surgerySevere postoperative pain

Lower abdominal surgery Major joint surgery2to 3 days Osteotomies Maxillofacial surgery

Perineal SURGERY3to 4 days

Thoracotomies Upper abdominal surgery

Multi modal approach

Preemptive analgesia

Procedure specific pain management

2 analgesic agents that act by different mechanisms via a single route for providing superior analgesic efficacy with equivalent or reduced adverse effects.

epidural opioids with epidural local anesthetics or clonidine, Intravenous opioids in combination with ketorolac or ketamine.

2routes of administration may be more effective

epidural or intrathecal opioid analgesia with intravenous, intramuscular, oral, transdermal subcutaneous analgesics intravenous opioids combined with oral NSAIDs, COXIBs, or acetaminophen

1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.Lowering each dosageEffective in sinergy & additiveDecrease side effectMulti Modal Analgesic (KEHLET, 1993)

Tidak ada satu pun analgesik yang sempurna dan dapat mengatasi semua jenis nyeriMasing-masing memiliki kelemahan dan keunggulanSecara klinis akan memberikan hasil yang lebih baik daripada pemakaian analgesik tunggal Kenapa harus multi modal?Dari sisi obatnya

Nyeri akan bersifat dinamis dan berubah sesuai progresifitas penyakitnya.Sebagian besar nyeri bersifat multi facet dan multi source.Dari sisi nyerinya

SpinothalamictractPeripheralnerveDorsal HornDorsal root ganglionPainAscendinginputDescendingmodulationPeripheralnociceptorsTraumaAdapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049. PERCEPTIONTRANSMISSIONTRANSDUCTIONOPIOID- Systemic- Epidural- SubarachLOCAL ANESTHETIC- Epidural- Subarachnoid

LACOX-1COX-2

No single drug can produce optimal analgesia without adverse effectTramadol *

PERCEPTION:Tramadol, opioidMODULATION: Tramadol,opioids,antidepressants

TRANSMISSION:Paracetamol, tramadol,opioidsTRANSDUCTION:NSAIDs, COX-2 inhibitors, local anestheticsMekanisme Multi Modal

Pre-emptive

introduction of an analgesic regimen before the onset of noxious stimuli prevent sensitization of the nervous system to subsequent stimuli that could amplify pain

Preventive analgesia:

any perioperative analgesic regimen able to control pain-induced sensitization of the central nervous system to decrease both the development and the persistence of pathologic pain

the pain intensity and its consequences may be procedure-relatedSome analgesic modalities may only apply to certain surgical proceduresThe risk-benefit ratio of different analgesics may also vary according to the surgical procedurethe risk and clinical implications of postoperative bleeding associated with certain analgesics are also procedure-specificPostoperative pain may also depend on the choice of surgical technique

Tramadol+ APAP

NSAIDSNonspecificCOX-2 specific

Opioids

Local anesthesia

Adjunctive therapy

Gastrointestinal1,2Peptic ulceration; gastrointestinal hemorrhagesEsophagitis and stricturesSmall and large bowel erosive disease

Inhibition of platelet aggregationIncreased risk of bleeding

Reversible acute renal failureFluid and electrolyte disturbance/edemaChronic renal failure and interstitial fibrosisInterstitial nephritisNephrotic syndrome

Exacerbation ofHypertensionCongestive heart failureAngina1Brooks P. Am J Med. 1998;104(suppl 3a):9S-13S.2Girgis L et al. Drugs Aging. 1994;4(2):101-112.3Atcheson R et al. Management of Acute and Chronic Pain. 1998:23-50. Hematologic3Cardiorenal1

Pain relief requirements can vary greatly from one individual to another, and even in the same individual from one time to another. Side-effects also vary from person to person. The prescription therefore needs to be tailor-made to benefit the patient

Multimodal analgesia using local anesthetic, NSAIDs and opiates provides improved pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy. (I, A [Michaloliakou et al., 1996]) Pain following upper abdominal surgery produces inspiratory muscle dysfunction. This dysfunction is reduced with analgesia. (I, A [Vassilakopoulos et al., 2000]) IV PCA morphine produces better analgesia than IM morphine, without any increase in postoperative hypoxemia. (I, A [Wheatley et al., 1992]) Patients using IV PCA morphine used more morphine and had better analgesia than patients receiving IM morphine on demand. IV PCA patients also experienced more fatigue and had less vigor than patients receiving IM morphine. (I, A [Passchier et al., 1993]) Epidural analgesia, with a combination of opiates and local anesthetic, provides better pain control during rest and activity, and is the treatment of choice. It is also associated with more rapid recovery of bowel function. (I, A [George et al., 1994; Mann et al., 2000; Liu et al., 1995]; III, A [Mulroy et al., 1996]) Epidural analgesia is associated with less postoperative myocardial ischemia (than IV PCA with morphine). (II-2, A [deLeon-Casasola et al., 1995]) For optimal analgesia, the thoracic epidural route should be used for pain relief after upper abdominal surgery. (I, A [Wiebalck et al., 1997; Chisakuta et al., 1995; George et al., 1994])

Pain control with intercostal nerve block in combination with opiates is more effective than opiates alone after subcostal incisions. Intercostal nerve blocks do not significantly improve analgesia following midline incisions. (I, B [Engberg et al., 1985]) Phenol with local anesthetic has been shown to increase the duration of intercostal block and improve analgesia following cholecystectomy. (I, B [Maidatsi et al., 1998]) Infiltration of the incision/wound with local anesthesia improved postoperative analgesia provided by epidural bupivicaine/morphine during mobilization and reduced the need for supplemental intramuscular morphine. (I, B [Bartholdy et al., 1994]) Ketorolac given before or after laparoscopic cholecystectomy reduced postoperative pain and facilitated the transition to oral pain medication. (I, A [Lane, 1996]) Pain relief promotes return of respiratory function. (I, A [Vassilakopoulos et al., 2000]) Aggressive perioperative management with epidural, NSAIDs, early feeding, and ambulation is associated with improved recovery and rapid discharge after laparoscopic colonic surgery. (II-3, B [Kehlet et al., 1999]; II-3, A [Bardram et al., 1995]) Laparoscopic cholecystectomy is associated with less pain than open cholecystectomy. (I, A [McMahon et al., 1994]) Patient-controlled epidural analgesia with a background infusion is more effective than patient-controlled epidural analgesia alone after gastrectomy. (I, A [Komatsu et al., 1998])

Multimodal analgesia using local anesthetic, NSAIDs, and opiates provides improved pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy. (I, A [Michaloliakou, 1996]) Active removal of residual pneumoperitoneum reduces postoperative pain following laparoscopic cholecystectomy. (I, A [Fredman et al., 1994]) Suprahepatic suction drains placed by the surgeon have been shown to reduce shoulder tip pain following laparoscopic cholecystectomy. (II-3, B [Jorgensen et al., 1995])

Epidural analgesia produces better pain control at rest and with activity. It is also associated with earlier return to normal mental status in the elderly, better satisfaction, and more rapid recovery of bowel function. (I, A [Liu et al., 1995; Mann et al., 2000]) Aggressive perioperative management with epidural, NSAIDs, early feeding, and ambulation is associated with improved recovery and rapid discharge after laparoscopic colonic surgery. (II-3, A [Bardram et al., 2000]; II-3, B [Kehlet, 1999; Bardram et al., 1995])

Epidural opiates in the postoperative period provide better analgesia with fewer side effects than IV PCA morphine. (I, A [Eriksson-Mjoberg et al., 1997]) Ambulation in the perioperative period is associated with a decreased risk of thromboembolic complications and more rapid recovery of bowel function. (II-3, A [Bardram et al., 2000])

Benefits of Effective Pain Management are simple and straightforward. Effective pain management can: Increase patient satisfaction.Increase the speed of recovery. Decrease hospital length of stay. Decrease overall hospital costs.Reduce the likelihood of chronic pain.Decrease the likelihood of complications. Increase productivity.Decrease suffering. Improve quality of life.

Pain is a major health problem and remains a challenge to healthcare providers Pain is subjective and must be frequently assessed on an individual patient basis.

Undertreatment of pain can lead to serious negative sequelae, including: Cardiac complications Respiratory depression Anxiety Depression

Summary

Benefits of pain management are: Increased speed of recovery Decreased length of hospital stay and overall hospital costs Decreased likelihood of developing chronic pain Increased patient satisfaction and productivity

Long-acting opioids are proven effective for treatment of around-the-clock pain.

Thorough documentation and patient contracts allow healthcare professionals to safely provide effective pain management to their patients.

Post operative pain is still a challenging problem, with a wide variations of treatment options

Therefore treatment of post operative pain needs a good collaboration of several disciplines to provide good post operative pain care.

Which one is your patient ???????

To chose an adequate painkiller Solve the problems without create a problems

THX for U Attention

*To elevate the awareness of the unmet need for effective pain treatment, the American Pain Society (APS) has redefined pain as the Fifth Vital Sign.1It is recommended that healthcare professionals assess patients for pain every timethey check for temperature, blood pressure, pulse, and respiration1 According to the APS, quality care includes the measurement and treatmentof pain1Reference: 1. Pain: the 5th Vital Sign. American Pain Society Web site. Available at: http://www.ampainsoc.org/advocacy/fifth.htm. Accessed November 14, 2003. *The percentage of patients reporting moderate to severe pain is high even a week following surgery. The severity and duration of pain after day surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols.1The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery11 patient in 4 (25%) needed contact with a health care provider because of pain at home1The most common concerns patients had about using pain medication were fear of drug addiction and side effects1Study Design: A group of 89 consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hours and 7 days after discharge. The survey instrument was composed of pain intensity scales from 0 to 10, selected items from the Brief Pain Inventory, the Patient Outcome Questionnaire, and the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods.1

Reference: 1. Beauregard L, Pomp A, Choiniere M. Severity and impact of pain after day-surgery. Can J Anaesth.1998;45(4):304-311. ****Multimodal therapy may be beneficial from both efficacy and safety/tolerability perspectives.1 The benefit in the use of 2 or more analgesics with differing mechanisms of action for the treatment of pain is the additive or synergistic analgesia. Multimodal analgesia may allow the use of lower doses of each agent than would be used during monotherapy. The use of lower doses is particularly appealing for analgesics with significant or dose-limiting adverse effects, such as opioids1When used as part of a multimodal pain strategy, DYNASTAT (parecoxib sodium for injection) was shown to enhance the analgesic effect of morphine (vs morphine alone)2This multimodal approach works on different mechanisms of pain. For example, a COX-2 selective inhibitor, such as DYNASTAT, may be added to an opioid to reduce the amount of opioids needed to achieve pain control while enhancing pain relief over opioids alone. Reducing opioid use can be instrumental in reducing traditional opioid-related side effects3

References: 1. Kehlet H, Dahl JB. The value of multimodal or balanced analgesia in postoperative pain treatment. Anesth Analg. 1993;77:1048-1056. 2. Hubbard RC, Naumann TM, Traylor L, Dhadda S. Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia. Br J Anaesth. 2003;90:166-172. 3. Cousins N, Power I. Acute and postoperative pain. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed. Edinburgh, UK: Churchill Livingstone; 1999:447-491.

***There are many ways to effectively treat acute and chronic pain. Each of these options offers its own benefits and risks. No single option is right for every patient.

NOTE: for more information on treatment options, see:Kehlet H, Dahl JB. The value of multimodal or balanced analgesia in postoperative pain treatment. Anesth Analg. 1993;77:1048-1056. *The major problem with use of nonspecific NSAIDs is the occurrence of adverse events, which can limit their utilization in perioperative analgesia. Gastrointestinal: Gastropathy associated with the use of both Rx and OTC nonselective NSAIDs is the most frequent adverse drug event in the U.S. It was conservatively estimated that it is associated with approximately 16,500 deaths and 107,000 hospitalizations annually in patients with arthritis1Hematologic: Hematologic reactions associated with nonspecific NSAIDs include inhibition of platelet aggregation and function, which can lead to an increased risk of bleeding and bruising2 Cardiorenal: Nonspecific NSAIDs can increase blood pressure and interfere with the blood pressure-lowering effects of certain antihypertensive agents, especially the ACE inhibitors, beta blockers, and diuretics.3 Because they inhibit renal prostaglandins, use of nonspecific NSAIDs can result in acute renal failure, fluid and electrolyte imbalances, exacerbation of chronic renal insufficiency, interstitial nephritis, and nephrotic syndrome4 References: 1. Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med. 1998;105(1B):31S-38S. 2. Atcheson R, Rowbotham DJ. Pharmacology of acute and chronic pain. In: Rawal N, ed. Management of Acute and Chronic Pain. London, England: BMJ Books; 1998: 23-50. 3. Brooks P. Use and benefits of nonsteroidal anti-inflammatory drugs. Am J Med. 1998; 104(suppl 3a):9S-13S. 4. Girgis L, Brooks P. Nonsteroidal anti-inflammatory drugs: differential use in older patients. Drugs Aging. 1994;4(2):101-112.