Pain-Assessment-and-Management-疼痛评估和管理英文课件

PainAssessment&Management M3PalliativeMedicineCurriculumSeemaS.Limaye,MDUniversityofChicagoGOALSDescribemethodsofpainassessmentincognitivelyimpairedolderadults.Understandvarioustypesofpain.DescribethebasicpharmacologyofopioidsUnderstandhowtoinitiateandtitrateopioids.Self-DirectedLearningModules BasicsofNeuropathicpainSideEffectsofOpiodsandManagementOptionsTreatmentofPaininPersonswithh/oSubstanceAbuseMrs.P70y.o.femaleh/oPaget’sdisease,renalinsufficiency,osteoporosispresentstoclinicwithnewbackpain.Whatdoyouwanttoobtainfromthehistory?PainHistoryPainCharacteristics–onset,duration,location,quality,intensity,associatedsymptoms,exacerbatingandrelievingfactorsPastandcurrentmanagementtherapiesRelevantmedicalandfamilyhistoryPsychosocialhistoryImpactofpainondailylife–work,dailyactivities,personalrelationships,sleep,appetite,emotionalstatePatient(andfamily’s)expectedgoalsfortreatmentPain:AComplexPhenomenonPainSensorystimuliand/orneurologicinjurymodifiedbyanindividual’smemory,expectations,emotionsBioculturalModelofPain:Societyalsoinfluencesanindividual’spainexperiencesPainAssessmentisNOT….RelyingonchangesinvitalsignsDecidingapatientdoesnot“lookinpain”Knowinghowmuchaprocedureordisease“shouldhurt”AssumingasleepingpatientdoesnothavepainAssumingapatientwilltellyoutheyareinpainConsequencesofUntreatedPainAcutepain:increasemetabolicrateandbloodclotting,impairimmunefunctioninducenegativeemotionsWithoutintervention,painreceptorsbecomesensitiveandmayhavelonglastingchangesintheneuronsConsequencesofUntreatedPainChronicpainmayleadto:fatigue,anxiety,depression,confusion,increasedfalls,impairedsleep,anddecreasedphysicalfunctioning/deconditioningBedsideAssessmentASKthepatientaboutpainAskingaboutADL’sandIADL’sAskingaboutphysicalactivity,mood,sleep,appetite,energylevelIdentifypreferredpainterminology-hurting,aching,stabbing,discomfort,sorenessUseapainscalethatworksfortheindividual-Insureunderstandingofitsuse-ModifysensorydeficitsFerrelletal.JPainSymptomManage1995.ChinballandTaitPain2001.HerrandGarand.PainManagementintheElderly2001

UseastandardscaletotrackthecourseofpainFacesPainScaleandPainThermometerWhataresomecommonbarriers topaintreatment?Rememberthecommonpatient-relatedbarrierstopainmanagementDrugs..areaddictingshouldbesavedforwhenitisreallyneededhaveunpleasantordangeroussideeffectspillsarenotaseffectiveasashotnarcoticsareonlyfordyingpeoplePainassessmentinavulnerablegroup:CognitivelyImpairedOlderAdultsAssessingpain:Nonverbal,ModeratetoSevereImpairmentFormalassessmenttoolsavailablebutnotnecessarilyusefulinroutineclinicalsettings

UniquePainSignatureNonverbalPainIndicators

KaasalainenetalPerspectives1998.HerrandGarandClinicsinGeriatricMedicine2000UniquePainSignatureHowdoesthepatientusuallyact?Whatchangesareseenwhentheyareinpain? familymembers nursingstaffCommunicationacrosscaregiversettingsiskey!Kovachetal.JPainSymptomManage1999.Feldtetal.JAGS1998.Weineretal.Aging1998.NonverbalPainIndicatorsFacialexpressions(grimacing) -Lessobvious:slightfrown,rapidblinking,sad/frightened,anydistortionVocalizations(crying,moaning,groaning) -Lessobvious:grunting,chanting,callingout,noisybreathing,askingforhelpBodymovements(guarding) -Lessobvious:rigid,tenseposture,fidgeting,pacing,rocking,limping,resistancetomoving KaasalainenetalPerspectives1998.HerrandGarandClinicsinGeriatricMedicine2000SelectionofpainmedsSource/typeofpainDuration/timing/frequencyHistoryofmedicationuseImpactonqualityoflifePresenceofassociatedfactorsTypesofPain:ABriefReviewNociceptivePainVisceralSomaticNeuropathicPainMixed/UnspecifiedPainPsychologiccauseQuality:VisceralPainDescriptors:cramping,squeezing,pressureDistribution/Examples:Referredheartattack,kidneystoneColickyBowelobstruction,gallstoneDiffusePeritonitisAnalgesics:opioids;acetaminophenQuality:SomaticpainDescriptors:

aching,deep,dull,gnawingDistribution/Examples:Welllocalized—patientscanoftenpointwithonefingertothelocationoftheirpainbonemets,strainedankle,toothacheAnalgesics:

NSAIDS,acetaminophenopioidsGeneralPrinciplesofManagementSetagoalofreductionofpaintotolerablelevels,notagoalofcompleterelief“Startlowandgoslow”MakesurepatientandfamilyareawareofgoalsFrequentclinicvisitsatfirstforassurance,validation,andmonitoringoftitration

WHO3-StepladderSource:WorldHealthOrganization.TechnicalReportSeriesNo.804,Figure2.Geneva:WorldHealthOrganization;1990.Reprintedwithpermission.Non-opioidmedicationsAcetominophen650mgtid-qid:concernforhepatictoxicity>3-4gramsNSAIDsincludingIbuprofen,Naproxen,COX-2inhibitors:concernforgastric/renaltoxicity,plateletdysfunction,mayinhibitanti-hypertensivemedsOpioidcombinationproductsThefollowingopioidsareavailableascombinationproductswithacetaminophen,aspirin,oribuprofenCodeine;hydrocodone;oxycodone;propoxypheneTypicallyusedforModerateepisodic(PRN)painBreakthroughpaininadditiontoalong-actingopioid.Neverprescribemorethanonecombinationdrugatanyonetime.Whichcombinationproduct?Analgesicpotency:hydrocodoneandoxycodonearemorepotentthancodeine,whichismorepotentthanpropoxyphene,whichsomestudiessuggestisequipotenttoaspirin.thereislittledifferencebetweenhydrocodoneproductsandoxycodoneproductsintermsofpotency.Note:propoxypheneproductsarenotrecommendedforpaininmostnationalpainguidelines,duetosideeffectsandunclearefficacycomparedtootherproductsAdjuvantsNon-pharmacologicTopicalsTylenolNSAIDS,Celecoxib,steroidsAnticonvulsantsAntidepressantsAntiarrhythmics

OpioidPharmacologyBlockthereleaseofneurotransmittersinthespinalcordAgonistofMu,delta,kappareceptorsConjugatedinliverExcretedviakidney(90%–95%)OpioidpharmacologyCentralandperipheraleffectsofopioidsThisleadstodesiredeffects,aswellassideeffectsReceptorClinicalEffectsMu1SupraspinalanalgesiaPeripheralanalgesiaSedationEuphoriaProlactinreleaseMu2SpinalanalgesiaRespiratorydepressionPhysicaldependenceGIdysmotilityPruritisBradycardiaGHreleaseReceptorClinicalEffectsKappa1SpinalanalgesiaMiosisDiresisKappa2PsychotomimesisDysphoriaKappa3SupraspinalanalgesiaDeltaSpinalandsupraspinalanalgesiaNociceptin/orphaninAnxiolysisAnalgesiaClearanceconcernsConjugatedbyliver90%–95%excretedinurineDehydration,renalfailure,severehepaticfailure

dosinginterval(extendtime)or

dosagesizeifoliguriaoranuriaSTOProutinedosingofmorphineuseONLYprnOpiodPharmacology…Whatisthepeakeffect(Cmax)ofmorphine:PO?30-60minIV?5-15minSC/IM?Variable…usually30-60minWhatisthedurationofeffectofmorphine?PO?3-4hoursIV?Usually1-2hours,butwetypicallydoseitq2-3hoursPlasmaConcentration0Half-life(t1/2)TimeIVpo/prSC/IMCmax...MoreOpioidPharmacologySteadystateafter4–5half-livessteadystateafter1day(24hours)SideEffects:sedation,confusion,respiratorydepression,constipation,urinaryretention,nauseaandvomitingShortActingOpioidsParenteralorOralmorphinehydromorphone(Dilaudid®)meperidine

(Demerol®)codeineOralonlyoxycodone(Percocet®,Tylox®)hydrocodone(Vicodin®Lortab®,Lorcet®)propoxyphene(Darvon®,Wygesic®)Note:hydrocodoneisonlyavailableasacombinationproduct.Routineoraldosing

extended-releasepreparationsImprovecompliance,adherenceDoseq8,12,or24h(productspecific)don’tcrushorchewtabletsmayflushtime-releasegranulesdownfeedingtubesAdjustdoseq2–4days(oncesteadystatereached)TransdermalFentanylDuration24-72hours12-24hourstoreachfullanalgesiceffectNotrecommendedasfirst-lineinopiatenaïvepatientsLipophilicSimpleConversionrule:-1mgpomorphine=½mcgfentanyl-(60mgmorphineroughly25mcgpatch)DOSEFINDINGADDINGANOPIOIDToachievequickpainrelief:(LOAD) 1. Startlowdose,short-acting 2. Doseqpeak 3. Re-evalin4hrs.tofigureoutwhatdoseisneededBreakthroughdosingUseimmediate-releaseopioids10%of24-hdose(or1/3ofoneERdose)offerafterCmaxreachedpo/pr

q1hSC,IM

q30minIV

q10–15minDoNOTuseextended-releaseopioidsforbreakthroughOngoingassessmentIncreaseanalgesicsuntilpainrelievedoradverseeffectsunacceptableBepreparedforsuddenchangesinpainplanforbreakthroughs(priortodressingchangesorpatientcareactivities)OpioidDoseEscalationAlwaysincreasebyapercentageofthepresentdosebaseduponpatient’spainratingandcurrentassessmentMildpain1-3/10

25%increaseModeratepain4-6/10

25-50%increaseSeverepain7-10/10

50-100%increaseIncompletecross-tolerance Ifaswitchisbeingmadefromoneopioidtoanotheritisrecommendedtostartthenewopioidat~50%oftheequianalgesicdose.Thisisbecausethetoleranceapatienthastowardsoneopioid,maynotcompletelytransfer(“incompletecross-tolerance”)tothenewopioid.from100%to50%ofnewOpioidPainProblem#1YoustartedMrs.Ton10mgmorphineevery4hrsaroundtheclockforhercancerpainwithgoodeffect.Shesaysshe’stiredoftakingapillevery4hours.Converthertolong-actingmorphinewithappropriateprndoses.PainProblem#1:Answer24houruse:10mgPOmorphinex6=60mgPOmorphineConverttolong-actingtwiceadaydosing:60mgPOmorphine/2=30mgPOmorphineSRBIDCalculateprndosingofmorphinesulfate-immediaterelease:60mgPOmorphinein24hx10%=6mgPOmorphineq3hprnbreakthroughpainPart2Sheisadmittedtothehospitalandunabletotakeoralmedications--convertMrs.Tto:IVmorphinePart2:AnswerRatioofIV:POmorphinesulfate:1mg:3mgTherefore:60/x=3/1X=20mgIVmorphinein24hrperiodDoseq3h=20mg/8=2.5mgIVq3hrPRNdose?2m