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    New Pain Pathophysiology DA DV 2020

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    Sarper Hikmet TAZE

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    © All Rights Reserved
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    New Pain Pathophysiology DA DV 2020

    Uploaded by

    Sarper Hikmet TAZE
    15 views51 pages

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    new Pain pathophysiology DA DV 2020

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    © All Rights Reserved
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    15 views51 pages

    New Pain Pathophysiology DA DV 2020

    Uploaded by

    Sarper Hikmet TAZE

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 51

    PAIN PATHOPHYSIOLOGY

    AND TREATMENT

    Dr Didem Akçalı
    2020
    Pain

     An unpleasant sensory and emotional


    experience associated with actual or
    potential tissue damage.
     Pain is whatever the experiencing person
    says it is.
     May not be directly proportional to amount
    of tissue injury.
     Highly subjective, leading to
    undertreatment
    PERCEPTION

    Korteks

    Talamocortikal
    junction
    MODULATION C
    Thalamus
    SYSTEMIC TRANSMISSION

    C
    OPİOİDs

    TRANSDUCTION

    SPİNOTALAMİK
    Primer
    efferent Ağrılı
    nosiceptor uyaran
    NOCICEPTION
     Nociceptors for pain
     A delta& C fibers
     SEROTONIN

     BRADYKININ

     PROSTAGLANDIN

     OTHER N. MEDIATORS ACTİVATE A delta& C fibers

    NOCICEPTION
     A delta thin myelinated
     Fast pain

     Sharp pain

     C unmyelinated
     Slow pain

     Chronic pain
     FAST PAIN- A delta fibers
     First WARNING

     Slow pain-C fibers
     To protect
     To help recovery
    Lamina II substantia gelatinosa
    PERCEPTION

    Korteks

    Talamocortikal
    junction
    MODULATION C
    Thalamus
    SYSTEMIC TRANSMISSION

    C
    OPİOİDs

    TRANSDUCTION

    SPİNOTALAMİK
    Primer
    efferent Ağrılı
    nosiceptor uyaran
    Cell injury

    Membrane
    phospholipids

    Steroids
    Arachidonic acid

    5-Lipooxigenase Cyclooxygenase

    NSAID
    5-LO inhibitors Prostaglandines
    Leucotriens
    Prostacyclines
    LTC4, D4, E4
    Natural Opioids-Endorphins

     released from their storage areas in the brain


    when a pain impulse reaches the brain,

     bind to receptors in the pain pathway to


    block transmission and perception of pain.
    Gate Control Theory
    Melzack and Wall 1965.

     Physiological and psychological interactions


     Suggested spinal gates in the dorsal horn at
    each segment of the spinal cord
     Competition at each gate for heat, touch or
    pain to be transmitted at each point
    Ascending pathways

     Spinothalamic pathways
     Spinomezencephalic pathways
     Spinoreticular pathways
     Spinolimbic pathways
     Postsynaptic dorsal colon pathways
    Neuromatrix
     Genetic effects
     somatosensorial inputs, experience
    form NEUROMATRIX

     NEURAL SIGNATURE
     Genetic and sensorial effects
     Cognitive effects

     Sympathetic nervous system


     Immune system
     Chronic physical and physiologic stresses

     There are inadequacies of current


    pain treatment!
    Pain
    Assessment
    PAIN HISTORY
     Description: severity, quality, location,
    temporal features, frequency, aggravating
    & alleviating factors
     Previous history
     Context: social, cultural, emotional,
    spiritual factors
     Meaning
     Interventions: what has been tried?
    VAS (Visuel analog skala)
    Types of Pain

     1. Acute
     2. Cancer
     3. Chronic non-malignant
    The most common chronic pain

    1. Persistent low back pain


    – result of poor muscle tone,inactivity,
    muscle strain, sudden vigorous exercise

    2. Chronic pain associated with cancer


    TYPES OF PAIN

    NOCICEPTIVE NEUROPATHIC

    Somatic Visceral
    • bones, joints • Organs –
    • connective tissues heart, liver,
    • muscles pancreas, gut,
    etc.

    Deafferentation Sympathetic Peripheral


    Maintained
    Somatic Pain
    • Aching, often constant
    • May be dull or sharp
    • Often worse with movement
    • Well localized

    Eg/
    – Bone & soft tissue
    – chest wall
    Visceral Pain
    • Constant or crampy
    • Aching
    • Poorly localized
    • Referred

    Eg/
    – CA pancreas
    – Liver capsule distension
    – Bowel obstruction
    Clinical Terms For The Sensory Disturbances
    Associated With Pain

     Dysesthesia – An unpleasant abnormal sensation,


    whether spontaneous or evoked.
     Allodynia – Pain due to a stimulus which does not
    normally provoke pain, such as pain caused by light touch
    to the skin
     Hyperalgesia – An increased response to a stimulus
    which is normally painful
     Hyperesthesia - Increased sensitivity to stimulation,
    excluding the special senses. Hyperesthesia includes both
    allodynia and hyperalgesia, but the more specific terms
    should be used wherever they are applicable.
    FEATURES OF NEUROPATHIC PAIN
    COMPONENT DESCRIPTORS EXAMPLES
    Steady, • Burning, Tingling • Diabetic neuropathy
    Dysesthetic • Constant, Aching
    • Post-herpetic
    • Squeezing, Itching neuropathy
    • Allodynia
    • Hypersthesia

    Paroxysmal, • Stabbing • trigeminal neuralgia


    Neuralgic
    • Shock-like, electric • may be a component
    • Shooting of any neuropathic
    pain
    • Lancinating
    Pain
    Treatment
    Non-Pharmacological Pain Management

     Acupuncture
     Cognitive/behavioral therapy
     Meditation/relaxation
     Guided imagery
     TENS
     Therapeutic massage
     Others…
    WHO Analgesic Ladder
    = due to pain 7-10, Severe pa
    severity
    Morphine
    4-6, Medium Fentanyl
    Oxycodone

    Codeine
    1-3, Weak pain Tramadol

    Aspirin Meperidine (pethidine)


    Paracetamol
    NSAID

    WHO. Geneva, 1996.


    Medication(s) Taken

    • Dose
    • Route
    • Frequency
    • Duration
    • Efficacy
    • Adverse effects
    Opioid Side Effects
     Constipation – need proactive laxative use
     Nausea/vomiting – consider treating with dopamine
    antagonists and/or prokinetics (metoclopramide, domperidone,
    prochlorperazine [Stemetil], haloperidol)
     Urinary retention
     Itch/rash – worse in children; may need low-dose naloxone
    infusion. May try antihistamines, however not great success
     Dry mouth
     Respiratory depression – uncommon when titrated in
    response to symptom
     Drug interactions
     Neurotoxicity (OIN): delirium, myoclonus  seizures
    Adjuvants Used In Pain Treatment

     General / Non-specific
     corticosteroids
     cannabinoids (not yet commonly used for
    pain)
     Neuropathic Pain
     gabapentin
     antidepressants
     ketamine
     topiramate
     clonidine

     Bone Pain
     bisphosphonates
     (calcitonin)
    Treatment of Neuropathic Pain
    Pharmacologic treatment
    • Opioids
    • Steroids
    • Anticonvulsants – gabapentin, topiramate
    • TCAs (for dysesthetic pain, esp. if depression)
    • NMDA receptor antagonists: ketamine, methadone
    • Anesthetics

    Radiation therapy
    Interventional treatment
    • Spinal analgesia

    • Nerve blocks
    WHAT DOES ALGOLOGIST DO?
    Pain Assessment
    Pain treatment
    Interventional treatment
    Chronic Pain Treatment

    1.Pharmacological treatment
    2.Physical treatment
    3.Interventional techniques
    4.Surgery
    5.Comprehensive and Alternative Treatment
    Transdermal fentanyl

     Strong Mu agonist
     Severe pain
     Changed every 72 hours
     Indications
     When patient cannot use oral drugs
     In morphine toxicity
     Severe nausea, vomiting
     GIS obstruction
    Opioid antagonist
    NALOXONE

    <5Y. <20 kg: IV / IM 0.1 mg/kg.


    >5Y >20 kg 2 mg
    Adult: 0.4 mg - 2 mg, repeat in 2 - 3 min (maks 10 mg)

    Partial reversal
    <5Y 0.01 to 0.03 mg/kg
    0.1 - 0.2 mg adolescent and adult
    MEPERIDINE

    • AVOID IN CHILDREN AND ELDERLY


    • Half life 3 hr
    • 100-150 mg / higher dose, Half life 4-5 hr
    • In cirrhosis 10 hr
    • In renal disease>34 hr!
    • No definite analgesic effect
    • METABOLITE NORMEPERIDINE IS
    NEUROTOXİC, half life 24 hr
    MEPERIDINE

    • CANNOT BE REVERSED WITH NALOXONE !


    OPIOID ROUTES
     Oral
     IV
     SC
     Transdermal
     Transmucozal
     Epidural /spinal catheter
     Peripheral nerve block/catheter
     Elastomeric pump
     PCA - Patient controlled
    analgesia
    INTERVENTIONAL TREATMENTS

     Facet block, radiofrequency


     Transforaminal injection, DRG PRF
     Stellate block
     Cervical epidural steroid injection
     Lumbal sympathetic block
     Caudal epidural steroid injection
     Epiduroscopy
     Spinal cord stimulator
    CANCER PAIN
     75-85 % IS TREATED BY
    PHARMACOLOGIC TREATMENT
     SC/ IV TREATMENT
     INTERVENIONAL TREATMENT

     Neurolysis, neuromodulation
     Spinal / Epidural port/pump
     NEUROSURGICAL TREATMENT
    Sympathetic blocks

    Stellat ganglion

    Thoracal ganglion

    CeliacPlexus

    Hypogastric plexus

    İmpar ganglion
    Celiac Plexus Block-
    Transaortic Approach

    31.12.2020
    ST: Sempatik Zincir grc: Gri
    Komminikan
    Port-pump systems
    [email protected]

    NO
    COMMUNICATION
    NO SUCCESS!

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