Acute Pain Targets
This post has been inspired by an excellent article by @anaestricks (Dr. Gavin Doolan http://anaestricks.tumblr.com ) entitled Acute Pain Targets.
Here Gavin drew a simple diagram of the nociceptive pain pathway with analgesic targets and corresponding drugs responsible at each level.
I have become obsessed with this, thinking about it during all my GA’s and sharing it with my patients, to motivate and educate them to take their regular paracetamol, NSAIDS and GABA’nergic medication.
As a GP anaesthetist I didn’t need to delve deep into the depths of pharmacology but rather I did an apprenticeship over a year, using perioperative and acute pain regimes based on what we were thought and what we saw as useful.
Thinking about pain diagrammatically in the form of receptor targets is not new but a great way for GPA’s to know pharmacologically what how they should be managing acute, perioperative and chronic pain.
Here are a few examples from my past week of anaesthetics to help illustrate this point.
Nociceptor transduction blockade (inflammatory mediator inhibition): Paracoxib 40mg IV + Dexamethasone 8mg iv
Peripheral Nerve Transmission: 20ml 0.75% Ropivacaine infiltration by surgeon
Spinal Cord Modulation: Ketamine 50mg (induction) +30mg + 30mg, Tramadol 100mg iv + Morphine 15mg
Brain transmission: Paracetamol 1gm iv, Tramadol 100mg iv
Post operatively I relied on
Regular:
Ibuprofen 400mg TDS
Paracetamol 1gm QUID
Fentanyl PCA (20mcg 5min lock out)
Later that day, she was happy and in relative comfort. This is very different from her last hysteroscopy/laparoscopy where she needed 28mg of morphine, 2 hours in recovery and a ketamine infusion for 24hours together with her Fentanyl PCA.
20yo well woman for a 3rd molar extraction day case.
Nociceptor Blockade: Paracoxib 40mg iv + dexamethasone 8mg iv
Peripheral Nerve Conduction: Alveloar block + Local infiltration by surgeon
Spinal Cord Transmission: Fentanyl 150mcg on induction (blunt sympathetic response to laryngoscopy + perioperative analgesia)
Brain perception: Paracetamol 1gm iv
Simple case but well illustrates effective blockade at each level so that she woke up comfortable and pain free.
The winner in this case is the local anaesthetic infiltration by the surgeon, after that block takes effect, the patient effectively “relaxes” physiologically on the monitor, less tachycardic/hypertensive. This works beautifully post operatively too, together with the long acting Cox-2 inhibition and regular paracetamol.
50yo medically well man with chronic back pain from osteoarthritis, hip OA, on the waitlist for a THR, seen in the rooms.
Debilitated by pain with difficulty mobilizing and preforming ADL’s. He was only taking Tramadol SR 150mg BD.
He had not wanted to take tablets in the past but now was ready to listen to some options.
With using the pain targets diagram, we agreed on the following plan.
Nociceptor Blockade: Celecoxib 100-200mg BD
Spinal Cord Transmission: Fentanyl patch (12-25mcg/hr)
Brain perception: Paracetamol 1330mg SR TDS (Considering Amitryptiline/Gabapentin/Pregabalin in the future on follow up)
I am hoping that this regime will work but with an understanding of analgesic targets, we are not stabbing in the dark and hoping for the best with our patient’s pain. We have options with dosages and different targets at each level.
This may be teaching most of you to suck eggs but this simple way that Gavin has outlined will help your anaesthetic and GP patients.
Hope that was helpful!
Sepsis Kimberley style: Dr Laura Smith
First10EM Journal Club: July 2018
Clinical Case 043: Post-op pain puzzle
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Maybe this is pedantic (OK it’s definitely pedantic) shouldn’t there be a transition from 2nd to 3rd order nerurone through the thalamus in there? And i thought that’s precisely where ketamine was thought to act? (i always describe ketamine to students as “unplugging the thalamus” – i may be totally wrong so please let me know!!!)
Andy, the original aim of this diagram was to simplify the pain pathway so that medical students and residents could use it as a framework on which to hang ideas about managing pain.
The main analgesic (NMDA) action of ketamine happens in the doral horn of the spinal cord.
There is also some analgesic noradrenergic and seritonergic action which works by top-down modulation from the midbrain.
I am not actually exactly sure of the mechanism of action for anaesthesia, so I had better go and look it up!
Jonathan, such a great idea to use this diagram to educate and empower patients in ther management of their pain, whether it be chronic or acute post-operative pain! I wish i had thought of it…
Thanks Gavin,
I really appreciate the input and the diagram is a great simplification of the pain pathway and helps me think about what drugs I am giving when anaesthetising patients.
More than that, I have used it to explain analgesia to my patients who know understand a little more about why they take regular panadol and how that differs from their e.g celecoxib/ pregabalin/ fentanyl patch etc.
Great post Gavin!
Jonathan
As an Australian student and then Swedish doctor I thought I’d share the “Swedish” approach to your first patient. The standard where I work for patients having a vaginal hysterectomy is spinal anesthesia with marcain, clonidine and morfin and then propofol sedering with preoperative paracetamol and NSAID and peroperative betamethasone. When they changed from general to spinal anesthesia the post-op pain problems that can occur with this operation decreased drastically.
Hey Tom
Remember me from Tamworth?
Absolutely. A vaginal hysterectomy under spinal is the standard in many institutions. A few of the UK trained anaesthetists that I have worked with do this routinely. A spinal works beautifully together with preoperative NSAID and paracetamol.
Thanks for your comment Tom!
Hi Jonathan! A long way from Tamworth to Albany, even longer to Sundsvall…
How accepting of spinal anesthesia are patients in Australia (if you can generalise). Is there a relatively low acceptance or is it my misreading of things?
Fantastic pain pathways diagram, I think I might borrow it when teaching interns over here.
Tom spinal anaesthesia is standard in the majority of lower limb joint replacements (knee/hip), trans urethral resection of prostate procedures, caesarean sections (emergency and elective) and some gynaecological and general surgical procedures. Patients are pretty accepting of this, especially spinals for c-sections and joint replacements.
I have used spinals for patients with difficult airways, large BMI and elderly patients (with no aortic stenosis) for various procedures which have worked well.
The diagrams are all Gavin Doolan’s work from Anaestricks http://anaestricks.tumblr.com/. They are an excellent resource.
Hej Tom,
Var i Sverige jobbar du?
Jag var på Astrid Lindgrens förra året.