This document was developed by the Surgical and Emergency Medicine Services Unit,

Medical Development Section of the Medical Development Division, Ministry of Health

Malaysia and the Editorial Team for the Pain Management Handbook

Published in October 2013

A catalogue record of this document is available from the library and Resource Unit of the
Institute of Medical Research, Ministry of Health;

MOH/P/PAK/257.12 (HB),
MOH Portal: www.moh.gov.my

And also available from the National Library of Malaysia;

ISBN 978-967-0399-38-6

All rights reserved. No part of this publication may be reproduced or distributed in any
form or by any means or stored in a database or retrieval system without prior written
permission from the Director of Medical Development Division, Ministry of Health
Malaysia (MOH).
CONTENTS
Editorial Team/Contributors viii
Foreword ix
Preface x

CHAPTER 1: PRINCIPLES OF PAIN MANAGEMENT

Objectives of Pain Management Services
Principles of Pain Management

CHAPTER 2: PHYSIOLOGY OF PAIN

Definition of pain
Pain pathway
Problems of postoperative pain
Spectrum of pain

CHAPTER 3: PHARMACOLOGY OF ANALGESIC DRUGS

Opioid Analgesics
Mechanism of Action
Pharmacokinetics of Opioids
Pharmacodynamics of Opioids
Indications
Precautions
Side Effects
Dosages
Important Points about Commonly Used Opioids
Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 selective inhibitors
Mechanism of action
Indications
Contraindications
Side effects
Dosages
Local anaesthetics
Mechanism of action
Pharmacokinetics
Indications
Contraindications
Toxicity of Local Anaesthetics
Other analgesic drugs
Paracetamol
Ketamine
Methoxyflurane
Nitrous oxide
Adjuvants
Pharmacology of analgesics in special groups
Renal disease
Liver Disease
Elderly Patients
CHAPTER 4: ASSESSMENT AND MONITORING
Assessment of pain
Taking a Brief Pain History
Pain assessment tools
Pain as the 5th vital sign
Monitoring of patients on APS

CHAPTER 5: MANAGEMENT OF ACUTE PAIN

Acute Pain Service (APS)
Setting up an APS
Pain management techniques
Factors to consider when choosing a technique
Non-pharmacological approaches
Pharmacological approaches
Multi-modal Analgesia
Patient controlled analgesia (PCA)
Indications
Contraindications
Advantages
Disadvantages
Features of PCA and programming modes
Common problems with PCA and what to do
When to stop PCA
Analgesia after PCA is stopped
Adverse effects of PCA opioids
Complications related to PCA
Responsibilities of doctors and nurses
Central neuraxial block
Anatomy relevant to epidural analgesia
Definitions
Indications
Contraindications
Advantages
Disadvantages
Drugs used
Mechanism of action of drugs used
Epidural analgesia using mixtures of LA and opioids (“cocktail”)
Patient-Controlled Epidural Analgesia (PCEA)
Epidural analgesia using opioids alone
Intrathecal Opioid Analgesia
Subcutaneous morphine
Peripheral nerve blocks
Types of blocks
Local anaesthetic selection
Catheter placement
Contraindications
Complications
Transversus Abdominis Plane (TAP) Block
Pain management in non-APS patient

CHAPTER 6: COMPLICATIONS AND MANAGEMENT

Complications related to drugs
Complications related to technique
Management of complications
Nausea and vomiting
Excessive drowsiness
Respiratory Depression
Pruritus
Ileus / Constipation
Hypotension
Urinary Retention
Motor Blockade
Post Dural Puncture Headache
Neurological complications

CHAPTER 7: ACUTE NEUROPATHIC PAIN

Characteristic of neuropathic pain
Causes of acute neuropathic pain
Recommended treatment

CHAPTER 8: ACUTE PAIN MANAGEMENT IN OPIOID TOLERANT PATIENT

Identification of opioid tolerant patient
Acute pain management in opioid tolerant patient

CHAPTER 9: ANALGESIA FOR PROCEDURAL PAIN

Management of procedural pain
Non-pharmacological
Pharmacological
Oral route
Subcutaneous route
IV route
Topical
Inhalational

CHAPTER 10: PAEDIATRIC ACUTE PAIN MANAGEMENT

Principles of pain management in children
Pain assessment in children
Methods of pain management in children
Non-pharmacological methods
Pharmacological methods
Management of procedural pain
Guidelines for pain management in children with burns
Management of post-operative pain
Paracetamol
 NSAIDs
Tramadol
Intravenous opioid infusion
How to prescribe an IV opioid infusion
Standard orders for opioid infusion
Management of major complications
Patient Controlled Analgesia (PCA)
Indications
Contraindications
How to prescribe PCA
Preparation of solution for PCA infusion
Standard orders for ward nurses and doctors
Management of major complications
Local and Regional Analgesia
Instillation LA
Wound infiltration
Peripheral nerve blocks
Epidural Infusion
How to prescribe an epidural infusion
Standard orders
Management of major complications
Pain Scoring Systems for Paediatric Patients
FLACC Score
Faces Scale
Numerical Scale
Grading Severity for all three Pain Scales
Sedation Score
Vomiting Score
Bromage Score

CHAPTER 11: OBSTETRIC ANALGESIA AND ANAESTHESIA SERVICE (OAS)

Principles of pain relief in the obstetric patient
Mechanisms of pain transmission in the parturient
Factors that may influence the pain of childbirth
Physiological changes in labour
Guidelines for regional techniques for labour analgesia
Prior to performance of regional technique
Criteria for initiation of epidural analgesia
Monitoring
Techniques
Protocols for management of labour pain
Lumbar Epidural
Combined Spinal-Epidural
PCA Fentanyl
Management of complications of regional analgesia
Hypotension
Unintentional dural puncture
 Post Dural Puncture Headache (PDPH)
Unintentional intravascular injection of Local Anaesthetic
Unexpected high block
Inadequate analgesia
Pruritus
Post-operative analgesia
Intrathecal Morphine
Epidural Morphine
Epidural Cocktail (LA + fentanyl)
Patient Controlled Analgesia (PCA)
Supplemental analgesia
Prevention of post-LSCS nausea and vomiting (PONV)

CHAPTER 12: MANAGEMENT OF PAIN IN ADULT DAY SURGERY PATIENTS

General Principles
Techniques for Intraoperative analgesia
Regional Analgesia
Parenteral and oral analgesics
Pain management in the Post-Anaesthesia Care Unit (PACU)
Pain management in the Day Surgery Unit before discharge
Non-pharmacological methods of pain management
Analgesic therapy on discharge
Analgesia according to the anticipated severity of pain
Special considerations

CHAPTER 13: CHRONIC NON-CANCER PAIN

Differences between Acute and Chronic Pain
Making a diagnosis of chronic pain
Principles of management of chronic non-cancer pain
Management of chronic pain patients in the Pain Clinic

Appendices
Appendix 1: Instructions for Medical Officers and APS nurse
Appendix2: APS Nursing Observation Chart
Appendix 3: Acute Pain Audit Form
Appendix 4: Guidelines for Use of Oxynorm® in Patient Weaned off
PCA Morphine
Appendix 5: IV Morphine Pain Protocol
Appendix 6: Analgesic Ladder for Acute Pain Management
Appendix 7: Recommendations on Neural Blockade and Anticoagulant
Appendix 8: Management of Severe Local Anaesthetic Toxicity
Appendix 9: Drug Formulary
List of Figures
Figure 2.1: Pain Pathway
Figure 2.2: Spectrum of Pain
Figure 3.1: Plasma concentration for Intermittent IM/SC Injection
Figure 3.2: Plasma concentration for Intermittent IV Injection
Figure 3.3: Plasma concentration for Continuous IV Infusion
Figure 3.4: Plasma concentration for Continuous IV Infusion plus Loading Dose
Figure 3.5: Plasma concentration for IV Patient Controlled Anaesthesia
Figure 3.6: Cyclo-oxygenase Pathways
Figure 3.7: Chemical Structure of Local Anaesthetics (LAs)
Figure 3.8: The relationship between Lignocaine Plasma Concentration and
Pharmacological Effects
Figure 5.1: Anatomy of the Vertebra column
Figure 5.2: Cutaneous innervations of upper limb
Figure 5.3: Cutaneeous innervations of lower limb
Figure 5.4: Surface Landmark of Triangle of Petit
Figure 10.1: WHO analgesic ladder
Figure 11.1: Pain Pathways in a parturient
Figure 11.2: Dermatomes of the lower abdomen, perineal area, hips and thighs

List of Tables

Table 3.1: Analgesic Medications for Acute Pain Management

Table 3.2: Features of Opioid Receptors
Table 3.3: Pharmacokinetic & Pharmacodynamic Profile of Opioids
Table 3.4: Commonly Available Local Anaesthetics (LAs)
Table 3.5: Use of IV Ketamine as Analgesic Adjuvant to General Anaesthesia
and PCA
Table 3.6: Commonly Available Adjuvants
Table 3.7: Recommended Use of Selected Opioids in Patient with Renal dysfunction &
Dialysis Patients
Table 3.8: Recommended Dosage Adjustments for Selected Opioids in renal insufficiency
Table 3.9: Recommended Use of opioids in Hepatic Dysfunction
Table 5.1: Comparison of Effects between Opioids and Local Anaesthetics
Table 5.2: Recommended Epidural Bolus dosing
Table 5.3: Epidural Opioids: Dosage, Onset and Duration of Action
Table 5.4: Pharmacological Properties of Common Opioids Used for Intrathecal
Analgesia
Table 5.5: Optimal Intrathecal Opioids Dose for Specific Surgical Procedures
Table 5.6: Incidence, Proposed Mechanism and Treatment for Intrathecal Opioids related
Side Effects
Table 5.7: Upper Extremity Blocks and Indications
Table 5.8: Lower Extremity Blocks and Indications
Table 5.9: Truncal Blocks and Indications
Table 5.10: LA Selection & Concentration
Table 5.11: Concentration for intermittent IV injection Dose of LA for continuous infusion
with or without PCA bolus
Table 8.1: Terminology
Table 8.2: Signs and Symptoms of Opioids Withdrawal
Table 8.3: Comparison of oral Morphine and Transdermal Patch Dosage
Table 8.4: Suggested Dose Conversion Ratio
Table 8.5: Recommendation and Equianalgesia Dose Conversion Ratios for Peri-operative
Pain Management
Table 10.1: Suggested Ketamine Dose for infusion
Table 10.2: Guildeline for Paracetamol dosing for analgesia in healthy children
Table 10.3: Guildeline for Intravenous Paracetamol Dosing
Table 10.4: NSAIDs, Preparation, Dose and Route
Table 10.5: Suggested Morphine Infusion
Table 10.6: Suggested Fentanyl Infusion (only to be used >1 year of age)
Table 10.7: Suggested Maximum doses of bupivacaine, Levobupivacaine and Ropivacaine
Table 11.1: Factors That Influence pain
Table 11.2: Labour Epidural Infusion Regimes
Table 11.3: Incidence of PONV by Number of Risk Factors
Table 12.1: Anticipated Postoperative Pain by Surgery and Aelective of Peri-operative
Analgesia
Table 12.2: Suggested Regime for Home Analgesia in adult Day Surgery Patient according
to Pain Severity
Table 13.1: Differences between Acute and Chronic Pain
Table 13.2: Summary of Differences between Acute and Chronic Pain
Editorial Team
1. Dr Mary S. Cardosa, Hospital Selayang
2. Dr S. Sushila, Hospital Selayang
3. Dr R. Usha S. Rajah, Hospital Pulau Pinang
4. Dr Mohd Rohisham Zainal Abidin, Hospital Tengku Ampuan Rahimah, Kelang
5. Dr Harijah Wahidin, Hospital Melaka
6. Dr Seet Sok Noi, Hospital Sg Buloh
7. Dr Shireen Sree Jayan, Hospital Melaka
8. Dr Devanandhini Krisnan, Hospital Raja Permaisuri Bainun, Ipoh
9. Dr Vinodh Suppiah, Hospital Wanita dan Kanak-kanak Sabah, Likas
10. Dr Patimah Amin, Medical Development Division, Ministry of Health

Other contributors
Dr Kavita M. Bhojwani, Hospital Raja Permaisuri Bainun, Ipoh
Dr Nita Salina Abdullah, Hospital Sultanah Aminah JB
Dr Ng Kim Swan, Hospital Selayang
Dr Tan Hung Ling, Hospital Kuala Lumpur
Dr Chong Kwong Fei, Hospital Fatimah,Ipoh
Dr. Felicia Lim Siew Kiau, PPUKM

This book is based on the “Pain Management Handbook” 2004, published by the
Malaysian Society of Anaesthesiologists, the College of Anaesthesiologists, Academy of
Medicine Malaysia and the Malaysian Association for the Study of Pain.
Foreword
Pain management or pain medicine is a branch of medicine which employs a
multidisciplinary approach for easing the suffering and improving the quality of life of
those patients living with pain. The typical pain management team includes
anaesthesiologists, occupational therapists, physiotherapists, clinical psychologists and pain
nurses. Together the multidisciplinary team can help create a package of care suitable to the
patient. While acute pain usually resolves once the underlying trauma or pathology has
healed, and is treated by one practitioner, effective management of chronic pain frequently
requires the coordinated efforts of the pain management team.
Medicine treats injury and pathology to support and speed healing; and treats distressing
symptoms such as pain to relieve suffering during treatment and healing. When a painful
injury or pathology is resistant to treatment and persists, when pain persists after the injury
or pathology has healed, and when medical science cannot identify the cause of pain, the
task of medicine is to relieve suffering. Treatment approaches to chronic pain include
pharmacologic measures, such as analgesics, tricyclic antidepressants and anticonvulsants,
interventional procedures, physical therapy and psychological measures.
In Ministry of Health hospitals, pain specialists are specially trained anaesthesiologists who
have been leading pain management services. To date not less than 15 chronic pain clinics
have been established while acute pain services are provided by anaesthesiologists in 84
hospitals.
The World Health Organization (WHO) estimated that approximately 80 percent of the
world population has either no or insufficient access to treatment for moderate to severe
pain. Every year tens of millions of people around the world suffer from such pain without
treatment. Yet the medications to treat pain are cheap, safe, effective, generally
straightforward to administer, and international law obliges countries to make adequate
pain medications available.
In 2008, the Ministry of Health (MOH) recognised Pain as the Fifth Vital Sign through a
Director General of Health‟s circular as a strategy to improve pain management in our
hospitals. Reasons for deficiencies in pain management in MOH hospitals include cultural,
societal, religious, and differences in health-seeking behaviour or attitudes, as well as lack
of awareness on human rights and limited access to pain services. Moreover, the
biomedical model of disease, focused on pathophysiology rather than quality of life,
reinforces entrenched attitudes that marginalize pain management as a priority. Other
reasons may have to do with inadequate training, personal biases or fear of prescription
drug abuse.
One strategy for improvement in pain management includes guidelines and standards of
practice such as this handbook. At the same time awareness programs and training need to
be continually conducted for medical and allied health professionals. We envisage that this
handbook will be an important resource for ongoing training and as a reference for
managing pain.

Datin Dr V.Sivasakthi
Head of Service for Anaesthesiology and Intensive Care Services, Ministry of Health
Preface
All anaesthesiologists need a working knowledge on pain management, with information
about latest developments in analgesic drugs and the methods of administration in various
situations. It is important that anaesthesiologists, as well as other clinicians and
paramedical staff, have a basic understanding about the strategies used in pain
management.

This handbook aims to provide an overall view on pain management, both acute and
chronic pain and the principles upon which treatment is based. It initially started as an
update of the “Handbook on Pain Management” (2004), which included a compilation of
various guidelines on different aspects of pain management namely acute pain in adults and
children, obstetric analgesia, pain management for day care surgery as well as cancer pain
management.

In this edition, we have included practical information about pain management in our daily
practice and pharmacology of analgesics. New sections include Acute Neuropathic Pain,
Peripheral Nerve Blocks, Procedural Pain, Acute Pain Management in Opioid Tolerant
Patients and Chronic Non Cancer Pain. The section on cancer pain has been left out as
there is now a Clinical Practice Guideline (CPG) on Cancer Pain Management (2010).

We hope that anaesthesiologists – both specialists and medical officers - will find this
handbook a useful source of information on the management of pain. We further hope that
clinicians and paramedical staff will find it a helpful guide in managing pain in their
patients.

Editorial Team
 CHAPTER 1
PRINCIPLES OF PAIN MANAGEMENT

Pain is a common symptom in hospitalised patients. Acute pain is pain that is associated
with tissue injury. It is usually limited in duration (less than 3 months) and diminishes as
the tissues heal. Chronic pain is pain that persists beyond the healing period, after recovery
from the acute injury or disease.

Pain is a complex physiological and psychological phenomena that is subjective in nature.

Pain may be acute or chronic and may persist even when tissue healing has occurred. The
assessment of pain and documenting the effectiveness of any intervention are the basic
principles of successful pain management.

The implementation of Pain as the 5th Vital Sign in Minsitry of Health (MOH) hospitals is
aimed at ensuring that all medical staff are trained in the assessment and management of
pain so that patients admitted to hospital will not have to suffer unrelieved pain.

Objectives of Pain Management Services

 To improve the quality of pain management in hospitalized patients, including those

with postoperative pain, post-trauma pain and painful medical conditions not
requiring surgery.
 To expand the range of analgesic techniques used.
 To make analgesic therapy cost effective.
 To increase the safety and efficacy of analgesia.
 To facilitate recovery in patients with acute pain.
 To avoid or effectively manage side effects of analgesic treatment.
 To increase awareness among health care providers of the importance of good pain
management and the analgesic drugs and techniques available.
 To improve pain management in all patients including those in medical wards.
 To conduct audit and research in pain management.

Principles of Pain Management

 Good pain management is necessary to avoid adverse physiological and

psychological effects resulting from unrelieved pain.
 Morphine is the gold standard for managing acute pain.
 Proper assessment and control of pain requires frequent assessment and
reassessment of pain intensity, documentation of analgesia and patient involvement.
 Pain that is established and severe is difficult to control; therefore pain has to be
treated early and continuously. The current practice is to use preventive analgesia*
rather than pre-emptive analgesia**.
  Treatment should be individualized. Analgesia should be planned preoperatively
with consideration given to the type of surgery, medical condition of the patient,
peri-operative use of analgesics and regional anaesthetic techniques.
 The aim of good pain management is to reduce pain to a tolerable or comfortable
level, not necessarily to eliminate pain completely.
 A multidisciplinary approach to the management of acute pain leads to improved
pain relief and better patient outcomes, including the long-term benefit of reduced
risk of developing chronic pain.
 Adequate monitoring of side effects is necessary to prevent morbidity and mortality
of patients using pain management techniques provided by the Acute Pain Service
(APS). Protocols for routine monitoring and treating of adverse effects must be
implemented in all areas where APS is provided.
 Multimodal analgesia may be used to improve efficacy and reduce side effects. This
means using a combination of analgesic agents such as paracetamol, NSAIDs,
opioids and local anaesthetics to achieve synergistic analgesic effects with reduced
doses of each component drug.
 Restoration of function e.g. early postoperative mobilization and discharge should
be a clear goal of acute pain management.

*Preventive analgesia is an analgesic intervention used pre-, intra- and post-operatively

which leads to persistence of analgesic efficacy beyond the expected duration, e.g.
Ketamine, epidural analgesia.

**Pre-emptive analgesia is an analgesic intervention that is initiated before a surgical

incision to reduce central and peripheral sensitization; it is a component of preventive
analgesia. e.g. preoperative paracetamol and NSAIDs, pre-incisional local anaesthetic
infiltration, nerve blocks and epidural analgesia.
 CHAPTER 2
PHYSIOLOGY OF PAIN

Definition of pain (International Association for the Study of Pain)

Pain is defined as “An unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described in terms of such damage”

Figure 2.1: Pain Pathway

Pain Pathway

It is convenient to describe the pain pathway in three components:

Peripheral, Spinal and Supraspinal

1. Peripheral:
 Nociceptors (free nerve endings that respond exclusively to intense stimuli) are
present at the skin, muscles, joints and viscera.
 When triggered, the stimulus is carried through A-delta and C nerve fibers to the
next level (spinal cord).
 2. Spinal:
 A delta and C fibers (first order neurons) synapse with second order neurons in
the dorsal horn (substantia gelatinosa) of the spinal cord.
 The pathway continues through the contralateral spinothalamic/spinoreticular
tract to the next level (Supraspinal).

3. Supraspinal:
 The brainstem and thalamus relay stimuli to the sensory cortex where pain is
perceived.
 Modulation (inhibition or excitation) of perception and response to pain occurs
through descending pathways from the reticular activating system (RAS) and
periaqueductal grey (PAG).

Problems of Postoperative Pain

 Unpleasant to patient
 Increases surgical stress response
 Impedes nursing and physiotherapy
 Delays mobilization
 Increases postoperative complications
 Prolongs postoperative stay
 Physiological consequences, which may lead to detrimental effects

Physiological Consequences of Acute Pain

Major physiological systems are affected by pain as a form of stress response.

1. Cardiovascular system
 Pain increases sympathetic response, resulting in an increase in heart rate and blood
pressure.
 This would increase myocardial work and oxygen consumption that would be especially
hazardous in patients with poor myocardial function.

2. Respiratory system
 Pain from thoraco-abdominal wounds may produce widespread pulmonary changes, an
increase in abdominal muscle tone and an associated decrease in diaphragramatic
function.
 This results in an inability to cough and clear secretions, which leads to atelectasis and
pneumonia.

3. Gastrointestinal tract
 Pain increases sympathetic tone, causing
o Increased gastric and intestinal secretions
o Decreased gut motility
o Leading to ileus, nausea and vomiting.
4. Genitourinary tract
 Pain increase sympathetic tone, causing an increase in smooth muscle and sphincter
tone, leading to urinary retention.

5. Musculoskeletal system
 Pain prevents mobilization and increases musle tone resulting in deep vein thrombosis.

6. Endocrine system
 Pain increases the release of stress hormones, which in turn results in increased load on
the cardiovascular and renal systems.
 Stress can also lead to sleeplessness and poor healing.

7. CNS complications
 Anxiety, stress and sleeplessness

8. Long term complications

 Increased risk of developing of chronic pain

Spectrum of Pain

 Pain can be acute or chronic.

 Acute pain usually resolves after a short while, once the injured tissues have healed.
This is what normally occurs.
 Chronic pain may begin with acute pain e.g. after an injury, accident or surgery, where
the pain persists even after healing occurs. Examples are neuropathic pain after brachial
plexus injury, post-thoracotomy pain, chronic abdominal pain from adhesions.
 However there are also types of chronic pain which begin insiduously, with no obvious
precipitating event. Examples are chronic back pain, chronic neck pain.
 The time courses of different types of pain are illustrated in Figure 2.2

Figure 2.2: Spectrum of Pain

 The majority of patients managed by the Acute Pain Service have acute pain, mainly
post-operative pain or post-trauma pain.
 However, there may be some patients referred to APS who have acute exacerbations of
chronic pain, and it is important to recognize these patients, as they are best managed by
a multidisciplinary pain management team.

For more information on the differences between acute and chronic pain, and the principles
of management of chronic non-cancer pain see Chapter 13.

References

1. Coniam SW & Mendham J, 2005: Principles of Pain Management for Anaesthetists,

Hodder Arnold Publication
2. Mesky H & Bogduk N, 1994: Classification of Chronic Pain.Second Edition.Seattle,
International Association for the Study of Pain
 CHAPTER 3

PHARMACOLOGY OF ANALGESIC DRUGS

Table 3.1: Analgesic Medications for Acute Pain Management

DRUG GROUP DRUG CLASS EXAMPLES

Simple analgesics Paracetamol

Non-selective NSAIDs Diclofenac Sodium

Mefenamic Acid
NON OPIOID Ibuprofen
MEDICATIONS Naproxen Sodium
Meloxicam
Ketorolac

Selective COX-2 Celecoxib

inhibitors Etoricoxib
Parecoxib
Weak opioids Dihydrocodeine
Tramadol
Strong opioids Morphine
Fentanyl
OPIOIDS Remifentanil
Oxycodone
Pethidine
Partial agonist opioids Nalbuphine

Opioid antagonist Naloxone

OPIOID ANALGESICS

Introduction

The term opiate usually refers to drugs derived from opium e.g. morphine and codeine.
Morphine is the chief analgesic component of opium, obtained from the unripe seed
capsule of the poppy plant. Opioids refer to all drugs (natural and synthetic) that have
morphine-like properties and act on the opioid receptors in the body. Narcotic originally
referred to any psychoactive compound with sleep inducing properties; today, it is
associated more with morphine and morphine-like drugs; this term has negative
connotations and is used more in legal terms for enforcement purposes. The preferred term
for morphine and morphine-like drugs is opioid.

Opioids are among the most effective known analgesics and have been a mainstay in the
management of pain for centuries. Pharmacology of opioid analgesics is determined by
pharmokinetics of individual opioid analgesics and their opioid receptor properties.

Commonly available opioids are listed in Table 3.1

Mechanism of Action

 Opioids bind to opioid receptors (Table 3.2), located throughout the CNS and in some
other tissues.
 Pharmacodynamic properties of specific opioids depend on which receptor is bound,
the binding affinity and whether the receptor is activated.
 Opioid receptor activation inhibits the presynaptic release and postsynaptic response to
excitatory neurotransmitters (e.g. acetylcholine, substance P) from nociceptive neurons.
 Table 3.2: Features of Opioid Receptors

Receptors Mu1 Mu2 Kappa Delta

Analgesia Analgesia Analgesia Analgesia

(supraspinal, (spinal) (supraspinal, (supraspinal,
spinal) spinal) spinal)
Depression of
Euphoria ventilation Dysphoria Depression of
ventilation
Low abuse Physical Sedation
potential dependence Physical
Effects Low abuse dependence
Miosis Constipation potential
(marked) Constipation
Bradycardia Miosis (minimal)
Emesis
Hypothermia Diuresis Urinary Retention

Urinary Retention
Emesis

Endorphins Endorphins Dynorphins Enkephalins

Agonists
Morphine Morphine

Synthetic opioids Synthetic opioids

Antagonists Naloxone Naloxone Naloxone Naloxone

Naltrexone Naltrexone Naltrexone Naltrexone

Pharmacokinetics

This is the study of what happens to a drug once it is administered into the body. For effective
analgesia, the plasma level of the analgesic is important. This varies according to the dose of the
drug given, the dosing interval and the route of administration.

The Analgesic Corridor

This is the range of plasma concentration of opioid analgesic within which there is pain relief
(Figure 3.1-3.5). When the plasma concentration of analgesic drug is below the analgesic corridor,
the patient has pain. If the plasma concentration is within the analgesic corridor, the patient will
have pain relief. The aim is to achieve a plasma concentration of opioid within this analgesic
corridor so as to provide comfort without serious side effects, which we expect to occur with
analgesic plasma levels above the analgesic corridor.

With opioids, there is up to a five-fold variation in the plasma concentration required for analgesia
among different patients. It is therefore difficult to predict the dose of analgesic required to reach an
individual's analgesic corridor. The plasma concentration required for analgesia may also vary
throughout the day, e.g. according to activity levels.

Variability in dose requirements has led to the concept of titration to effect (i.e. pain relief) so that
each patient is given adequate analgesia, whatever drug or technique of administration chosen.
Patient Controlled Analgesia (PCA) is a technique that allows self-titration of opioids to achieve
safe and effective analgesia for patients with acute pain.

Figure 3.1: Plasma Concentration for Intermittent IM/SC Injections

Side Effects
Analgesic Drug Concentration

Analgesia
Pain

0 6 12 18 24 30 36
Time (hours)

Figure 3.1 shows the plasma level of an opioid when given IM/SC 6 hourly.The pharmacokinetics
of intramuscular and subcutaneous injections are the same, i.e. they have the same onset of time and
duration of action. The plasma level of analgesic is frequently below the analgesic corridor, and is
therefore experiencing pain. If analgesia is required to last for 6 hours, a larger dose must be given,
increasing the risk of developing serious side effects like respiratory depression. It would therefore
be better to give smaller doses of opioid more frequently, allowing the drug plasma levels to remain
within the lower part of the analgesic corridor.

Another problem with IM / SC opioid injections is that the onset of action is about 30 minutes.
Thus, there is a delay for pain relief while the drug is being absorbed.
One way to overcome this slow onset of action of IM/SC injections is to give the opioids
intravenously. However, although onset of analgesia is faster with IV opioids, (5-10 minutes) the
peak plasma levels are higher if the same dose as for IM/SC is used, thereby increasing the risk of
serious side effects (Fig 3.2).

Figure 3.2: Plasma Concentration for Intermittent IV Injections

Side Effects
Analgesic Drug Concentration

Analgesia
Pain
0 4 8 12 16 20 24
Time (hours)

Figure 3.3 Plasma Concentration for Continuous IV Infusion

Side Effects
Analgesic Drug Concentration

Analgesia
Pain

0 4 8 12 16 20 24
Time (hours)
Continuous IV infusion is not a safe way to administer opioids in non-ventilated patients, because
the infusion pump will continue to deliver the opioid whether the patient is oversedated (i.e.
overdosed) or not.

The other problem when an infusion is given at a constant rate (e.g. 2 mg/h), 4-5 half lives of the
drug are required to reach a steady state plasma concentration. This means that it may take up to 20
hours to reach a steady state plateau within the “analgesic corridor”. Although a higher infusion rate
(e.g. 10 mg/h) will achieve plasma concentrations within the “analgesic corridor'' faster, the higher
dose may result in steady state plasma levels above the analgesic corridor, i.e. in the toxic range.

Figure 3.4 Plasma Concentration for Continuous IV Infusion plus Loading Dose

Side Effects
Analgesic Drug Concentration

Analgesia
Pain

0 4 8 12 16 20 24
Time (hours)

The time taken to achieve the “analgesic corridor” can be hastened by administering a 'loading dose
of the analgesic to the patient. Frequent small doses of analgesic e.g. 1-2mg of iv morphine every 5-
10 minutes till achievement of “analgesic corridor” followed by repeated doses of the analgesic
whenever necessary is the solution to proper acute pain management. This forms the concept
behind Patient Controlled Analgesia (PCA). The “analgesic corridor” is said to have occurred
when patient's pain is first relieved. This is illustrated in Figure 3.5.
 Figure 3.5 Plasma Concentration for IV Patient Controlled Analgesia

Side Effects
Analgesic Drug Concentration

Analgesia
Pain
0 4 8 12 16 20 24
Time (hours)

Achieving Rapid Control of Severe Acute Pain – IV Morphine Pain Protocol (See Appendix 5)

In the immediate postoperative period, the analgesic corridor may be attained by giving small and
frequent boluses of analgesic. This is achieved using the “morphine pain protocol”.

Alternatively, patient controlled analgesia (PCA), allows the patient to load him/herself by pressing
the PCA demand button every 5 minutes till comfortable. Subsequently, s/he can press the button
whenever feels the pain worsening (i.e. the plasma level drops below the analgesic corridor)
thereby attaining the analgesic corridor again. Thus analgesia is maintained with little risk of
toxicity.
 Table 3.3: Pharmacokinetic & Pharmacodynamic Profile of Opioids
Drugs Mechanism of Half life Duration of Metabolism Excretion Equivalent
action (hours) action (hours) dose to
Morphine 10
mg
Morphine Agonist : µ, 4-5 2-4 L L.K 10
delta,kappa Active metabolites
receptors (M3G,M6G)

Fentanyl Agonist : µ 3-4 0.5-1 L K 0.1

receptor

Remifentanil Agonist : µ 0.2-0.3 - Tissue Esterase K 0.05

receptor

Oxycodone Agonist : µ, 2-4 3-4 L,K K,Sweat 6

delta,kappa
receptors
Pethidine Agonist: : µ, 3-4 3-4 L K 100
kappa receptors Active metabolite
Anticholinergic (Norpethidine) has
effect long half life;
Na Ion channel: accumulation causes
LA effect neuroexcitation)

Tramadol Agonist: µ, 4-6 4-6 L K 100

TRPV 1
Receptor
Antagonists:
NMDA,
Nicotinic, Ach,
M1,M3
Muscarinic
Receptors.
Inhibit 5-HT,
NA reuptake
Codeine/Dihyd Agonist : µ, 2-4 4-6 L K -
roxycodeine kappa, delta Activated in liver to
receptors morphine

Buprenorphine Agonist: µ 10-12 L L -

receptors
Antagonist:
kappa, delta
Nalbuphine Agonist: kappa 4-6 4-6 L K 10
receptors
Antagonist: µ
Naloxone Antagonist: : µ, 1-1.5 0.5-1 L K -
kappa, delta

TRPV-Transient Receptor Protein Vanilloid

L-Liver, K-Kidney
Pharmacodynamics of Opioids

1. Central Nervous System

 Euphoria, sedation, miosis, reduced cough reflex, nausea & vomiting
 Decreased ICP and CBF
 Overdosage: marked miosis, respiratory depression, convulsions

2. Cardiovascular System
 Decreased BP (large doses): decreased systemic vascular resistance
 Postural hypotension: peripheral venodilatation & venous pooling
 Sinus bradycardia: central vagal stimulation

3. Respiratory System
 Bronchoconstriction: histamine mediated
 Respiratory depression: decreased sensitivity of brainstem respiratory centre to PaCO2

4. Gastrointestinal System
 Increased reflux: decreased lower oesophageal sphincter pressure
 Constipation : decreased peristaltic activity and increased (smooth muscle) tone of anal
& ileocolic sphincters

5. Genitourinary System
 Difficulty in micturition : increased ureteric tone , contraction of detrusor & vesicular
muscle
 Antidiuretic effect

6. Skin
 Pruritus & vasodilatation : histamine mediated

Indications

 Moderate to severe acute postoperative pain

 Moderate to severe cancer pain
 Chronic pain (selected cases)

Precautions

1. Hypersensitivity
2. Concomitant use of sedative drugs
3. Renal and liver impairment
4. Impaired respiratory function eg. Obstructive Sleep Apnoea (OSA) , acute severe
asthma
5. Head injury
Side Effects

1. Nausea and vomiting

2. Sedation
3. Respiratory depression
4. Ileus / constipation
5. Urinary retention
6. Pruritus

Dosages: Refer Drug Formulary (Appendix 9)

Important Points about Commonly Used Opioids

1. Morphine

 Naturally occurring opioid, derived from the unripe seed capsule of the poppy plant.
 Remains as the gold standard for analgesics.
 Available in oral and parenteral formulations.
o Parenteral formulation is most commonly used for acute postoperative pain
management.
o Oral preparations may be immediate release (IR) e.g. aqueous morphine, or
controlled/sustained release (SR) e.g. MS Contin.
 Metabolised in the liver to Morphine-3-Glucuronide and Morphine-6-Glucuronide
 Dose must be adjusted in hepatic and renal impairment.

2. Fentanyl

 Semi-synthetic opioid with high lipid solubility

 Faster onset of action compared to morphine
 Available as parenteral and transdermal preparations.
o Parenteral formulation is used for acute pain, IV and intrathecal.
o Transdermal (TD) preparation is only for use in chronic cancer pain
 TD Fentanyl is NOT suitable for management of ACUTE PAIN
 TD Fentanyl is NOT TO BE USED IN OPIOID NAÏVE PATIENTS
 Metabolised in the liver to inactive metabolite
 Safe alternative to morphine in patients with renal impairment.

3. Oxycodone

 Semi-synthetic opioid
 Available in oral and parenteral formulations.
o Parenteral formulation may be used for acute postoperative pain management (only
recently registered in Malaysia)
o Oral preparations may be immediate release (IR) e.g. Oxynorm, or controlled
release (CR) e.g. Oxycontin
 Metabolised in liver to active metabolites
 Dose must be adjusted in hepatic and renal impairment

4. Pethidine

 Synthetic opioid with low oral bioavailability

 Available in parenteral formulation only
o IM pethidine demonstrates variable absorption and is associated with widely
fluctuating plasma concentrations with variable levels of analgesia.
 Metabolised in liver to active metabolite (Norpethidine) which has a long half life and
is neurotoxic (tremors and convulstions)
 It is believed that long term pethidine usage may have a higher risk of addiction
compared to morphine.
 There is no evidence that pethidine is better than morphine in the management of renal
colic or obstetric pain.
 NOT RECOMMENDED FOR USE IN ACUTE OR CHRONIC PAIN
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS & CYCLO-OXYGENASE-2
SELECTIVE INHIBITORS
Introduction
Non-steroidal anti-inflammatory drugs (NSAIDs) act by inhibiting the enzyme cyclo-
oxygenase (COX), involved in the metabolism of arachidonic acid, thereby inhibiting the
synthesis of prostaglandins, which play a part in the transmission of pain.
Commonly available NSAIDs and COX2 inhibitors are listed in Table 3.1

Mechanism of action
 The cyclo-oxygenase (COX) enzyme is present in two forms:
o COX-
1 (Constitutive) – physiological function of maintaining the normal prostaglandin
functions of the kidney and gastric mucosa. Inhibition of this enzyme is responsible for
the renal and gastric toxicity of NSAIDS.
o COX-
2 (Inducible) – expressed in response to tissue injury and inflammation, which releases
the inflammatory mediators of pain.
 NSAIDs vary in the selectivity of inhibition of the COX enzymes. Traditional NSAIDs
inhibit both COX-1 and COX-2 enzymes while selective COX2 inhibitors (Coxibs)
inhibit mainly the COX-2 enzyme.
 All NSAIDs and Coxibs are used for their analgesic and anti-inflammatory effects.
 Some NSAIDs, e.g. low-dose aspirin, are also used for their anti-platelet effect.
 Figure: 3.6: Cyclo-oxygenase Pathways

MEMBRANE PHOSPHOLIPIDS

Phospholipase A2
( PLA2 )

ARACHIDONIC
ACID

LIPOXYGENASE CYCLO-OXYGENASE

⊗ NSAIDS

LEUCOTRIENES COX-1 COX-2

 Infiammation bronchoconstriction
airway obstruction COX-2
⊗ inhibitors

Normal
Inducible
Constituent
 Gastric protection  Infiammation
 Renal sodium and  Swelling
water balance  Pain
 Platelet  Fever
aggregation
Indications

1. Parenteral, as a supplement to epidural analgesia or PCA, as a component of

multimodal analgesia.
Example: Parecoxib 40 mg stat followed by 20-40 mg BD for 24 H may be given to a
postoperative patient on PCA morphine or epidural cocktail.
2. Oral analgesics, ordered when the patient starts taking orally and the PCA or epidural
has been stopped.
 Coxibs provide better overall safety than traditional NSAIDs in terms of GI side effects
and effects on platelet function but do not prevent renal impairment.
 Coxibs have the same analgesic efficacy compared to traditional NSAIDs and are
mainly used in patients who are unable to tolerate the side effects of NSAIDs.

Contraindications
1. Histor
y of coagulopathy or bleeding tendencies
2. Histor
y of peptic ulcer disease (may use Coxibs instead)
3. Patient
s with renal impairment
4. Post-
Coronary Artery Bypass Graft (immediate post-op period)
5. Histor
y of hypersensitivity to NSAIDS

Side effects

All NSAIDs have similar side effects, which are independent of the route of administration.

Gastrointestinal (less with COX2 inhibitors):

 Nausea, anorexia, abdominal pain, gastritis, ulcers, gastrointestinal hemorrhage,
perforation, diarrhoea

Hematological (less with COX2 inhibitors)

 Inhibition of Platelet function

Cardiovascular
 Increased risk of stroke and myocardial infarction.
 Hypertension: decreased effectiveness of anti-hypertensive medication.

Renal
 Reduced renal blood flow, deterioration of kidney function, salt and water
retention, oedema
 Analgesic nephropathy with long term use
.
Hypersensitivity reactions including Anaphylactic shock.
  Cross allergy is common between different NSAIDs / COX2 inhibitors

1. Main difference between NSAIDs and COX2 inhibitors is that COX2 inhibitors have a
lower incidence of peptic ulceration and upper GI bleed.
2. COX2 inhibitors can also lead to renal impairment and adverse cardiovascular effects,
particularly with long term use.

Dosages: Refer Drug Formulary (Appendix 9)

LOCAL ANAESTHETICS

Introduction

The local anaesthetics (LA) commonly used in our hospitals are Lignocaine, Bupivacaine,
Levobupivacaine and Ropivacaine. These are metabolised in the liver and rarely cause
allergic reactions.

Mechanism of action

Local anaesthetics reversibly block the conduction of electrical impulses along central and
peripheral nerve pathways by binding to the voltage-gated sodium channel receptors thus
preventing conduction of action potentials and therefore neural conduction.

Pharmacokinetics

Structural Classification
LA consists of 3 structural components:
- A lipid soluble hydrophobic aromatic group
- An intermediate chain (ester or amide bond)
- An ionisable hydrophilic tertiary amide group.

Figure 3.7: Chemical Structure of LAs

Examples of esters: cocaine and procaine

Examples of amides: lignocaine, bupivacaine, levobupivacaine and ropivacaine
 Table 3.4: Commonly Available LAs

AGENT ONSET DURATION PROTEIN POTENCY MAXIMUM ADVERSE

OF ACTION BINDING DOSE (mg/kg) EFFECTS

Cocaine rapid medium 91% Medium 1 CVS

Lignocaine rapid medium 60-80% Medium 4 (plain) CVS and CNS

7 (with
adrenaline)

Bupivacaine slow long 90-97% High 2 (plain) More

cardiotoxic than
2.5 (with lignocaine
adrenaline)

Levo- slow long > 97% High 2-2.5 Less

bupivacaine cardiotoxic than
bupivacaine

Ropivacaine slow long 94% High 3-4 Less

cardiotoxic than
bupivacaine

Factors affecting LA activity:

1. Site of injection and dose – peak plasma concentrations are influenced by the site of
injection. Subarachnoid and subcutaneous routes are associated with a more rapid
onset, whereas epidural and brachial plexus blocks are associated with a slower
onset of action.
2. Addition of vasoconstrictor –eg adrenaline, prolongs duration of action and
decreases systemic absorption.
3. Tissue pH – infection produces acidic tissue and decreases activity of local
anaesthetics.
4. Plasma protein binding is inversely related to the plasma concentration. Decreases
in pregnancy, protein deficiency, neonate, malignancy and increases in sepsis, stress
and renal failure.
5. Hepatic impairment leads to decreased metabolism of local anaesthetics.
6. Hyperkalaemia leads to a increased resting membrane potential and an increased
local anaesthetic affect while hypercalcaemia has the opposite effect.
 7. Pregnancy increases CNS sensitivity to local anaesthetics and increases
cardiotoxicity.
8. Overall circulatory state affects systemic absorption.
9. Some drugs can interfere with the action of local anaesthetics e.g. Metoprolol,
Cimetidine, Dextran.

Indications:

1. Central neuraxial block (Subarachnoid block, epidural block)

2. Peripheral Nerve or plexus block
3. Infiltration anaesthesia & Field block
4. Surface anaesthesia : bronchoscopy, cystoscopy
5. Local anesthesia of body cavities : interpleural anesthesia, intraarticular anesthesia
6. Transincision or transwound catheter anesthesia
7. Topical application (EMLA, Cocaine)
8. Transdermal : Lignocaine 5% patch
9. Intravenous regional anaesthesia (Bier‟s Block)
10. IV lignocaine infusion for neuropathic pain (refer Chapter 7)
11. IV Lignocaine for ventricular arrythmias (Anti-arrythmic, Class 1B)

Contraindications:
1. Porphyria: Only Lignocaine is known to be porphyrogenic; other LA agents are safe.
2. True allergy to local anaesthetics

Toxicity of Local Anaesthetic

 Occurs with an overdose of local anaesthetic, or with an accidental intravascular
injection. Increasing blood concentrations of local anaesthetic will result in progressive
signs of local anaesthetic toxicity (Figure 3.8)

Local
 Allergic reaction to para-aminobenzoic acid (PABA): ranging from urticaria to
anaphylaxis.
 PABA is a metabolic product of the degradation of esters such as procaine,
benzocaine, and to a lesser degree, amide class anaesthetics such as lignocaine. It is
also a metabolic by-product of pramod methylparaben, a preservative in multi-dose
vials of lignocaine.
 The amide class of local anesthetics is far less likely to produce allergic reaction.

Systemic
1. Immune system
 Allergic reaction to metabolic break-down of anesthetic agents and preservatives
(PABA) can cause anaphylaxis.
2. Hematologic
 Methemoglobinemia – caused by lignocaine and more notably, prilocaine
3. Central Nervous System
 CNS symptoms are progressive as the level of the LA in the blood rises.
 Initial symptoms suggest CNS excitation: ringing in the ears (tinnitus), metallic
taste in the mouth, perioral tingling or numbness.
 Advanced symptoms include motor twitching in the periphery followed by grand
mal seizures, coma, and eventually respiratory arrest.

4. Cardiovascular
 Myocardial depression, bradycardia and cardiac arrhythmias
 Cardiovascular collapse

Figure 3.8: Relationship between Lignocaine Plasma Concentration and

Pharmacological Effects
Plasma Concentration

(g/ml) 26 CVS depression

24

22

20 Respiratory arrest

18

16
(15) Coma
14

12 Unconsciousness

10 Convulsions

8 Muscular twitching

6 Visual disturbances

Positive Inotropy, 4 Light-headedness, tinnitus, circumoral and tongue

Anti-arrhythmics, numbness
Anti-convulsant
2
OTHER ANALGESIC DRUGS

PARACETAMOL

Introduction
 Simple analgesic used for the relief of mild to moderate pain.
 May be given by oral, per rectum or intravenously.
 Used as part of a multimodal technique along with NSAID/COX 2 inhibitors and
opioids.

Mechanism of Action
 Not completely understood.
 Main mechanism is the inhibition of cyclooxygenase (COX). Selectively blocks a
variant of the COX enzyme that is different from COX-1 and COX-2. This enzyme
is now referred to as COX-3.
 Antipyretic properties - reduced amount of PG E2 in the CNS, lowers the
hypothalamic set-point in the thermoregulatory centre, resulting in peripheral
vasodilation, sweating and hence heat dissipation

Pharmacodynamics

IV Perfalgan®
 Provides rapid, higher and more predictable plasma drug level with greater
bioavailability than oral dosing.

Indications

 Management of mild to moderate pain where oral and rectal paracetamol is not
appropriate
 For its opioid sparing effect in the perioperative management of moderate to severe
pain

Contraindications

 Hypersensitivity to paracetamol or to propacetamol hydrochloride (prodrug of

paracetamol) or to any of the excipients (sodium phosphate dibasic dehydrate,
hydrochloric acid, sodium hydroxide, cysteine hydrochloride and mannitol).
 Patients with hepatic failure or severe hepatocellular insufficiency
 Concomittent administration of other medications which contain paracetamol

Side Effects

 Injection site pain

 Injection site reaction
 Nausea / Vomiting
Precautions
  Hepatic insufficiency.
 Severe renal insufficiency (Creatinine clearance ≤ 30 mL/min).
 G6PD deficiency (may lead to haemolytic anaemia).
 Chronic alcoholism or excessive alcohol intake.
 Anorexia, bulimia or cachexia, chronic malnutrition (low reserves of hepatic
glutathione).
 Dehydration and hypovolemia.

Dosages: refer to Drug Formulary (Appendix 9)

KETAMINE

Introduction

 Ketamine is a drug with anaesthetic and analgesic properties depending on the

dosage administered.
 When used in subanaesthetic doses, it assists in controlling acute and chronic pain,
particularly severe forms with evidence of central sensitization not well controlled
with other agents.
 When used for acute pain, it is usually combined with an opioid.

Mechanism of action

 NMDA –receptor antagonists (main mechanism)

Persistent nociceptive (e.g. tissue damage) and neuropathic pain states can activate
N-methyl-D-aspartate (NMDA)-receptors in the spinal dorsal horn, producing the
phenomenon of “wind-up” with spinal hyperexcitability, allodynia and hyperalgesia
(central sensitisation).
 Mild opioid agonist- mu (µ) and kappa (κ)
 Inhibits calcium and sodium channel at high doses
 Inhibits serotonin and noradrenalin reuptake
 Inhibits muscarinic and nicotinic receptors
 Acts on β2 receptor causing bronchodilatation
 Inhibits nitric oxide (NO) synthase, inhibiting production of NO

Pharmacokinetics

 May be given oral and parenteral (most common is parenteral)

 Metabolised to norketamine in the liver and excreted through the kidneys

Pharmacodynamics

 CNS: euphoria, sedation, hallucination, delirium, emergent reactions, nystagmus,

disorientation, lacrimation.
 Respiratory system: hypersalivation, bronchodilatation
 CVS: tachycardia, hypertension, increase cardiac output, myocardial depression in
absence of autonomic control
 GIT: nausea and vomiting
 GUT: bladder dysfunction on long term use

Indications (refer to Table 3.5)

 Adjuvant to opioids in postoperative pain especially in opioid tolerant patients

 Rescue analgesia in difficult- to- control pain (acute and chronic)
 Chronic neuropathic pain conditions such as central pain syndromes, Complex
Regional Pain Syndrome (CRPS), fibromyalgia and ischaemic pain.
 Treatment of opioid-resistant cancer pain
 Analgesia for painful procedures (usually in children)
 Midazolam may be added to ketamine to minimize the dysphoric effects

Contraindications

Ketamine should be avoided in patients with:

 Raised intracranial pressure.
 Severe systemic hypertension.
 Raised intra-ocular pressure.
 Recent history of epilepsy.
 Recent history of psychosis.
 History of hypersensitivity to Ketamine
 Hepatic impairment
 Chronic alcoholism, acute alcohol intoxication and substance abuse.

Precautions

 Elderly patients.
 Cardiac arrhythmia and hypertension

Dosage and Adminstration

 Starting doses of Ketamine are usually 10 to 25mg IV for intermittent dosing, or 50 to

100mg per 24 hours by IV infusion. Lower dose ranges should be used in the elderly.
 Adverse effects of hallucinations and delirium may be reduced by the co-administration
of a benzodiazepine (e.g. oral Midazolam 7.5mg ON, Midazolam 5-10mg in syringe
driver over 24 hrs) or Haloperidol (1.5mg – 3mg in syringe driver over 24hrs).
 Studies show that adverse effects of short term systemic administration of low dose
Ketamine to be low.
 Ketamine should only be used in consultation with a specialist in pain medicine,
anaesthesia or palliative care.
 Table 3.5: Use of IV Ketamine as an Analgesic Adjuvant to GA and PCA

Procedure Before incision During surgery After surgery

Very painful, e.g. 0.5mg/kg Infusion 0.5mg/kg/h or Background infusion:

major visceral bolus 0.25mg/kg, repeated 0.12mg/kg/h for 24h, then
surgery at 30 min intervals. 0.06mg/kg/h for 48h (or
longer if necessary) and
If procedure is ≥2h, stop opioid based PCA
use 60min before end of
surgery.

Less painful e.g. 0.25mg/kg Infusion: 0.25mg/kg/h or PCA, bolus 1mg Ketamine
hip surgery bolus; 0.125mg/kg, and 1mg Morphine
repeated at 30min
intervals

(Adapted from Himmelseher S and Duriex ME, 2005: Ketamine for Peri-operative Pain
Management, Anaesthesiology; 102:211-20)
METHOXYFLURANE

Introduction
 Methoxyflurane (MOF) is a highly lipophilic inhalational anaesthetic agent which is
no longer used in routine anaesthetic practice.
 Very low concentrations of methoxyflurane produce analgesia. It is now available
via a disposable inhalational device (Penthrox™ inhaler) for analgesia in various
clinical settings.
 MOF is metabolised in the liver by the enzyme CYP2AE into free fluoride,
dichloro-acetic acid, oxalic acid and difluromethoxyacetic acid. No toxic effects
have been recorded if MOF is used for less than 2.5 MAC hours.

Advantages of Methoxyflurane
 Potent analgesic with rapid onset (6 – 10 breaths)
 Cardiovascular and respiratory stability
 Easy administration
 Good pain relief
 No significant adverse effects

Indications
 Traumatic injuries in A&E department
 Minor surgical procedures
 Incident pain or breakthrough pain in patients with advanced cancer
 Dressing of burns and other painful wounds

Contraindications
 malignant hyperthermia
 severe renal or hepatic impairment / failure
 hypersensitivity
 head injury

Precautions
 Patients should be warned that they should not drive for 24 hours after using
methoxyflurane.

Side effects
 Drowsiness
 Headache
 Dizziness

Dosage: Refer to Chapter 9, Analgesia for Procedural Pain

NITROUS OXIDE

Introduction

Nitrous oxide (N2O) is a potent, short-acting inhaled analgesic gas with rapid and predictable onset
and offset. In general anesthesia, it is used in high concentrations (e.g. 70% N2O with 30% oxygen).
A 50:50 mixture of N2O with oxygen, Entonox®, is used for its analgesic properties to provide
short term analgesia for minor surgical procedures, labour pain or incident pain. Nitrous oxide
possesses synergistic effect if given with other analgesics and sedatives.

Indications for Entonox®

 Labour pain
 Paediatric inpatient and outpatient settings: removing sutures, redressing wounds,
lumbar puncture and venepuncture
 During outpatient treatments: laser for diabetic retinopathy, biopsies,
sigmoidoscopies, wound dressings, dental procedures, removal of drains and
sutures

Contraindications for Entonox®

 Pneumothorax, bowel obstruction, air embolism, pulmonary air cysts, intraocular air
bubbles, tympanic membrane graft and other conditions where there may be air trapping.
 Decompression sickness or those after a recent underwater dive.
 Maxillofacial injuries, head injury, impaired consciousness or substance intoxication.

Side effects

 Nausea and vomiting

 Diffusion hypoxia
 Prolonged use results in inactivation of methionine synthetase leading to megaloblastic
anaemia and neuropathy from subacute combined degeneration of the spinal cord.

Precautions

When N2O is used repeatedly:

 Exclude patients with known vitamin B12 deficiency
 Exclude female patients who may be in the early stages of pregnancy
 Limit exposure to N2O to the briefest possible time
 Monitor for clinical signs and symptoms of neuropathy on a regular basis

As nitrous oxide may obtund conscious levels,

o Adequate fasting is required
o Monitoring is essential including pulse oximeter
o Resuscitative equipment should be available.
ADJUVANTS
Adjuvants are medications which are not typically used for pain but may have analgesic effects in
specific conditions.

Commonly used adjuvants are as below:

Table 3.6: Commonly Available Adjuvants

Drug classes Examples Used in the following

conditions

Antidepressants Tricyclic Antidepressants (TCA): Neuropathic pain

Amitriptyline, Nortriptyline

Serotonin Norepinephrine Reptake

Inhibitors(SNRI):
Duloxetine, Venlafaxine

Anticonvulsants Carbamezepine Neuropathic pain

Gabapentin
Pregabalin
Sodium Valproate
Topiramate
Phenytoin
PHARMACOLOGY OF ANALGESICS IN SPECIAL GROUPS

Renal diseases

Two groups of patients to be considered

 Renal dysfunction
 Haemodialysis

Table 3.7: Recommended Use of Selected Opioids in Patients with Renal Dysfunction &
Dialysis Patients

Opioid Renal dysfunction Haemodialysis Patient

Recommended Comments Recommended Comments
use use
Morphine Use Cautiously ; Metabolites can Use Cautiously Both parent drug
adjust dose as accumulate causing and monitor patient and metabolites
appropriate increased for rebound pain can be removed
therapeutic and effect with dialysis ;
adverse effects or do not use watch for
“rebound “pain
effect
Oxycodone Use cautiously Metabolites and Do not use No data on
with monitoring; parent drug can oxycodone and its
adjust dosage if accumulate causing metabolites in
necessary toxic and CNS – dialysis
depressant effects
Codeine Do not use Metabolites can Do not use The parent drug
accumulate causing and metabolites ca
adverse effects n accumulate
causing adverse
effects
Fentanyl Appears safe; No active Appears safe Metabolites are
however a dose metabolites and inactive, but use
reduction is appears to have no use caution
necessary added risk of because fentanyl is
adverse effects; poorly dialysable
monitor with high
long term use
(Adapted from Aronoff 1999 & Dean 2004)

In patients known to have renal impairment, renal function should be checked before prescribing
any analgesics as the drug may require dose modification because plasma levels of analgesics and
their active metabolites will increase and duration of action of analgesics are prolonged.
 Table 3.8: Recommended Dosage Adjustments in Renal Impairment
- Selected Opioids

GFR (mL/min) Morphine Oxycodone Fentanyl

>50 100* 100* 100*

10-50 50-75* 50* 75-100*

< 10 25-50* Do not use 50*

(Adapted from Aronoff 1999 & Dean 2004)

*= % of normal dose

Important considerations:

1. Pethidine

 metabolized to toxic metabolite norpethidine

 accumulated especially with repeated dosing can cause tremors, myoclonus and
seizures
 DO NOT USE IN RENAL FAILURE PATIENTS

2. Morphine

 The elimination half –life of morphine and the duration of analgesic effect may be
prolonged
 The metabolites are morphine-3-glucuronide (M3G) and morphine-6-glucuronide
(M6G) which tend to accumulate in renal dysfunction
 M6G is a potent analgesic and contributes to the analgesic effect when morphine is
given for long term
 M3G has no analgesic activity itself , on the other hand it may antagonize the
analgesic activity of morphine and may be responsible for neurotoxic symptoms:
o Hyperalgesia
o Allodynia
o Myoclonus & seizures
 Patients should be commenced on a lower dose and/or with extended dosage
intervals. Doses should be slowly titrated upwards depending on response towards
any side effects
 In renal impairment, fentanyl is a suitable alternative to morphine.
 3. NSAIDs

 NSAIDs cause sodium and water retention and decreases glomerular filtration rate
 The use of NSAIDs (including COX-2 Inhibitors) may lead to impairment of renal
function, especially in the elderly, those with heart failure or volume depletion, or
those on ACE Inhibitors, ARBs or concurrent nephrotoxic drugs. NSAIDs can
induce acute renal failure in these vulnerable groups even with a single dose.
 They may worsen renal function in those with established renal disease. NSAIDs
should be avoided even in mild renal impairment. They may be used in dialysis
patients with complete anuria.
 Patients with end stage renal failure (ESRF) are more prone to develop ureamic
gastritis. Regular use of heparin during haemodialysis predisposes them to
gastrointestinal bleed.

Liver Disease

1. Opioids

Table 3.9: Recommended Use of Opioids in Hepatic Dysfunction

Opioid Recommended usage Comment Dosing recommendations

Morphine Use cautiously and In severe hepatic Increase the dosing interval
monitor patient for impairment, the parent by twice the usual time
sedation drug may not be readily period
converted to metabolites

Oxycodone Use cautiously and In severe hepatic Decrease initial dose by 1/2
monitor patient carefully impairment, the parent to 1/3 of the usual amount
for symptoms of opioid drug may not be readily
overdose converted to metabolites

Codeine Avoid use In severe hepatic -

impairment, codeine may
not be converted to the
active metabolite,
morphine.

Fentanyl Appears safe, generally no Decreased hepatic blood Dose adjustment usually
dose adjustment necessary flow affects metabolism not needed
more than hepatic failure
 2. Paracetamol

 Prudent to restrict its use in these patients as regular paracetamol can lead to possible
hepato-toxicity, especially if the patient:
o Is fasting or dehydrated (poor oral intake for more than 24 hours)
o Has a concurrent acute illness causing dehydration (e.g. fever, vomiting, diarrhea)
o Has chronically poor nutrition or has chronic or heavy (binge) alcohol intake
o Is concurrently taking liver enzyme-inducing drugs (e.g. phenobarbitone,
phenytoin).

Elderly Patients

Elderly people are more likely to experience pain than general population, in many cases they are
undertreated.

Problems with elderly patient

1. Co-morbidities.
2. Concurrent medications: higher risk of drug interactions.
3. Age related physiological, pharmacokinetic and pharmacodynamic changes.
4. Difficulties with pain assessment e.g. dementia and post operative delirium.
5. Reported frequency and intensity of acute pain may be reduced in the elderly patient.

Principles of management:

1. Consider non-pharmacological options to reduce reliance on medication.

2. Select each medication based on a balance of its risks and benefits.
3. Start with low doses and titrate upwards slowly.
4. Monitor for pain relief, functional improvement and adverse effects including worsening of
cognitive function.
5. Consider handling adverse effects by changing treatment, using a lower dose or by treating
symptoms such as constipation or nausea.
6. Cease the medication if proven ineffective after an adequate trial.

Points to note when prescribing analgesics for the elderly patient:

Non-opioid Analgesics

 Paracetamol is the preferred non-opioid analgesic, unless contraindicated (e.g. in liver disease).
 The use of NSAIDs and COX-2 inhibitors in elderly people requires extreme caution, and
should be generally avoided unless there are no other alternatives available.

Opioid analgesics

 When using opioids, dose adjustment is necessary as there are age-related decreases in
opioid requirements and significant inter-patient variability.
 Oral weak opioids that may be used include
o Tramadol 50 mg once daily to TDS
 o Dihydrocodeine 30-60 mg once daily to TDS
 There are also mixtures of weak opioids and paracetamol which may be useful
o Ultracet® (Paracetamol 325 mg + Tramadol 37.5 mg) 1-2 tablets once daily to QID
o Panadeine® (Paracetamol 500mg and Codeine 8mg) 1-2 tablets once daily to QID
 Oral strong opioids available include
o Aqueous morphine 2.5 - 5 mg 4-6 hourly
o Oxynorm® 5 mg 6-8 hourly
o Oxycontin® 5-10 mg once to twice daily.

References

1. Analgesic Expert Group, 2007: Therapeutic Guidelines Version 5, Therapeutic

Guidelines Limited, Melbourne
2. Aronoff GR,1999: Recommended Use of Selected Opioids in Patients with Renal
Dysfunction, Clinical Nephrology, Dialysis and Transplantation 43:63-71
3. Dean M, 2004: Opiods in Renal Failure and Dialysis Patients, J.Pain Symptom
Manage,28 (5): 497-504
4. Guay DRP et al, 1988: Pharmacokinetics and pharmacodynamics of codeine in
endstage renal disease, Clin Pharmocol Therapy; 43:63-71
5. Johnson SJ, 2007: Opioids Safety in Patients with Renal or Hepatic Dysfunction,
Pain Treatment Topics,6 no 1:1
6. Macintyre PE et al, 2010: SE Working Group of the Australian and New Zealand
College of Anaesthetists and Faculty of Pain Medicine, Acute Pain Management:
Scientific Evidence (3rd edition), ANZCA & FPM, Melbourne
7. Malaysian Association for the Study of Pain The Malaysian, 2009: Low Back Pain
Management Guidelines 1st Edition
8. Murphy EJ,2005:Acute Pain Management Pharmacology for the Patient with
Concurrent Renal or Hepatic Disease.Anaesth Intensive Care;33:311-22
9. Pain as the 5th Vital Sign Guidelines for Doctors, 2008: 1st Edition,MOH
 CHAPTER 4

ASSESSMENT AND MONITORING

ASSESSMENT OF PAIN

Taking a Brief Pain History

P: Place or site of pain -“Where does it hurt?”

A: Aggravating factors -“What makes the pain worse?”

I: Intensity -“What is your pain score at rest and on movement?”

N: Nature and neutralizing factors -“What does it feel like, e.g. aching, throbbing, burning,
electric shock, shooting, stabbing, sharp, dull, deep, pressure….” “What makes the pain
better?”

Other questions to ask on pain:

 Pattern of pain: intermittent or continuous/constant?

 Associated symptoms: numbness, tingling, allodynia, hyperalgesia, dysaesthesia

 Impact of pain: pain affect sleep, appetite, mood, daily activities, relationships and
work?

 Other important information: medical / surgical / psychosocial / drug / allergic

history

In summary, history is important to make a diagnosis, and to differentiate the following:

1. Acute vs Chronic pain

2. Nociceptive vs Neuropathic or Mixed pain

3. Somatic vs Visceral +/-referred pain

4. Severity - mild, moderate or severe

5. Psychosocial conditions contributing to the pain

Pain assessment tools

Why measure pain?

 To be able to titrate the amount of analgesic drugs given (eg morphine) to achieve the
best analgesia with the least side effects.
 Facilitates communication between staff looking after the patient
 For research and documentation

As pain is very subjective and varies greatly from patient to patient, we need to ask the
patient themselves about their pain. There are various ways of doing this.
 Self reporting by the patient (best method)
 Observer assessment
 Observation of behaviour and vital signs
 Functional assessment

Pain measurement

Unidimensional scales

 Numerical Rating Scale (NRS)

 Verbal Analogue Score (VAS)
 Categorical Scale or Verbal rating scale

Multidimensional scales

 Brief Pain Inventory (BPI)

 McGill Pain Questionnaire (MPQ)
 Memorial Pain Assessment Card

Scales used in children / infants and in cognitively impaired patients

 Wong Baker Faces Scale

 FLACC scale

Numerical Rating Scale (NRS)

“If „0‟ = no pain, and „10‟= the worst pain you can imagine, what number is your pain
now?”

Visual Analogue Score

Patient is asked to slide a small bead along a scale to indicate the severity of pain
Total length of scale is 100 mm (10 cm)
Combination Rating Scale (NRS & VAS),*Recommended for Ministry of Health*
MOH Pain Scale

a. Side that faces the patient

b. Side that faces the nurse/paramedic/doctor

“On a scale of „0‟ – „I0‟ (show the pain scale), if „0‟ = no pain and „10‟ = worst pain you
can imagine, what is your pain score now?”
The patient is asked to slide the indicator along the scale to show the severity of his/her
pain. The nurse records the number on the scale (zero to 10)

Categorical Scale:
The patient is asked to rate their pain on a score of 1 to 4, where
1 = No pain at all
2 = mild
3 = moderate
4 = severe
This is a simple way of scoring pain, and is easy for patients to understand and respond, but
not preferred method (not sensitive, difficult to record)
The Visual Analogue Score and the Verbal Analogue Score (zero to ten) are the most
commonly used pain scoring systems.
PAIN AS THE 5TH VITAL SIGN
In 2008, the MOH implemented “Pain as the 5th Vital Sign” in MOH hospitals which
mandates measuring and documenting pain score for all patients whenever other vitals are
measured. Pain should be measured at rest, or movement, coughing and deep breathing.In
addition pain scores should be taken:

 Half to one hour after administration of analgesics and nursing intervention for pain
relief
 During and after any painful procedure in the ward e.g. wound dressing
 Whenever the patient complains of pain

MONITORING OF PATIENTS ON APS

 To provide effective analgesia for patients

 To detect serious and potentially dangerous side effects and complications of
analgesic techniques

What to monitor?
 Respiratory Rate
 Sedation Score
 Pain Score
 Blood Pressure
 Pulse Rate

RESPIRATORY RATE (RR)

 Respiratory depression is one of the most serious and potentially harmful side
effects of opioids
 Respiratory depression is defined in an APS patient as a sedation score of 2 with
RR less than 8 or sedation score of 3 irrespective of RR
 Shallow respiration may occur without a large decrease in respiratory rate
 Actual decrease in respiratory rate may occur later

SEDATION SCORE
 Respiratory depression due to opioid overdose is ALWAYS accompanied by
depression in conscious level

Sedation Score
0= Awake and alert
1= Mild (occasionally drowsy)
2= Moderate (frequently drowsy but easy to arouse)
3= Severe (difficult to arouse)
S= Sleeping
PAIN SCORE
 Given by patient
 Necessary to determine effectiveness of analgesia
 Determines when to give the next dose of analgesic drug in techniques that use
intermittent bolus doses
o High Pain Score (≥4)  inform APS doctor
o Low Pain Score (<4)  maintain present dose

BLOOD PRESSURE AND PULSE RATE

 Usual vital signs that are monitored for all patients
 Usually not directly affected by opioids
 If an epidural cocktail infusion is administered, sympathetic block may cause
hypotension

NAUSEA AND VOMITING

 Frequency to be charted in APS observation chart
 Chart when and what anti-emetic is given
 Check if nausea and vomiting is relieved after anti-emetic is given
 If no relief, call APS doctor

When to call the APS doctor?

The APS doctor or anaesthesiologist on call should be informed if

 Sedation score = 2, respiratory rate < 8
 Sedation score = 3, does not matter what respiratory rate is
 Pain score is >4 in 2 observations
 Vomiting is persistent despite anti-emetics
 Hypotension (systolic < 90 mmHg)

What to do if patient has respiratory depression?

 Call ward doctor and APS doctor
 Give oxygen to patient
 Try to wake patient up and remind patient to breathe
 Stop epidural or PCA
 Get resuscitation trolley
 Give iv Naloxone 0.1 mg stat; repeat up to 0.4 mg at 2-3 minute intervals

References
1. Pain as the 5th Vital Sign Guidelines for Doctors, 2008: 1st Edition,MOH
 CHAPTER 5
MANAGEMENT OF ACUTE PAIN

ACUTE PAIN SERVICE

Anaesthesiology-based Acute Pain Services (APS) were introduced in the mid-1980s in the
USA, and in 1993 the first APS in the Ministry of Health (MOH) was set up in Hospital
Kuala Lumpur, followed rapidly by similar services in other MOH hospitals and by 2006
all MOH hospitals with anaesthesiology specialists had APS. In 2007, a multicenter audit
of postoperative pain relief carried out in 21 MOH hospitals still showed that 64% of post-
laparotomy patients under the care of APS still reported experiencing moderate to severe
pain in the first 24 hours; worse still, 76% of patients not under the care of the APS had
moderate to severe pain. Reports from western countries showed similar results, with little
change in the proportion of patients experiencing moderate to severe pain in 1999
compared to 1993.

Overall, the problem of inadequate postoperative analgesia is multi-factorial, attributable to

staff attitude, inexperience or overwork, fears of addiction to opioids and of serious side
effects like respiratory depression as well as failure of the patient to ask for pain relief.
The introduction of better techniques of pain relief by the anaesthesiologist like epidural
analgesia, patient-controlled analgesia (PCA) and ambulatory analgesia using a multi-
modal approach has resulted in an improvement in the management of acute pain. The
setting up of pain clinics to evaluate and manage patients with persistent pain using a
multidisciplinary approach has also proven to be beneficial in improving the management
of chronic pain.

The Role of the Acute Pain Service is summarised as follows:

1. To improve the management of acute, particularly postoperative pain by introducing

new methods and improving old methods of pain relief. This will result in more
comfortable patients, less postoperative complications and shortened hospital stay.

2. To train hospital staff in the management of acute pain - this includes ward nurses,
surgeons, anaesthesiologist, medical officers and house officers from anaesthesiology
and surgical-based disciplines.

3. To provide standardized protocols in various techniques of acute pain management -

including the early detection and management of complications and the standard
monitoring necessary for patients. This will minimize the adverse effects associated
with the provision of good pain relief.

4. To develop awareness towards the role of pain management clinics in managing

chronic pain using a multidisciplinary approach.

5. To conduct audit and clinical research in pain management.

Setting Up an Acute Pain Service

Acute Pain Services are usually run by the Department of Anaesthesiology and Intensive
Care, and in Malaysia the model that has been found to work well is a nurse-based APS
where we have a full time nurse responsible for the APS. In large hospitals where the
patient load is high, there may be more than one APS nurse and they may work two shifts.
At the same time, the APS is usually overseen by a Specialist Anaesthesiologist and
Anaesthetic Medical Officers do daily ward rounds with the APS nurse. The Anaesthetic
Medical Officer on call also attends to problems and starts new patients on APS techniques
after office hours.
At the daily morning ward rounds, the doctor and nurse will review the adequacy of
analgesia, treat side effects and solve any problems that the patient or ward staff may have
which are related to the provision of analgesia. In the afternoon and evening, another ward
round is done to review any problems and all new patients started on APS techniques that
day. Ideally, patients on APS should be seen within an hour of having returned from post-
anaesthetic care unit to ensure that pain scores remain minimal i.e. less than 4.
The Acute Pain Service has Standard Orders for all patients under the care of the APS,
which includes the orders for pain relief, monitoring and management of complications. At
the same time, there are standard orders NOT to administer other opioids or sedatives by
other routes in patients already on PCA or epidural. This is an important practice and needs
to be strictly enforced to ensure the safety of patients under the care of the APS.
In order to have an effective APS, there must be regular in-service training courses for
ward nurses and lectures on acute pain management for surgical doctors and new
anaesthetic medical officers. This is to ensure that everyone involved understands the
principles of APS techniques used and the rationale behind the management of patients
with acute pain, so as to ensure the effectiveness of the analgesia as well as the safety of
patients using the techniques. Keeping an audit of your practice is also important for
continuous quality improvement.

PAIN MANAGEMENT TECHNIQUES

Objectives:

 To offer the best possible pain relief at reasonable cost and labour.
 To achieve early ambulation.
 To reduce postoperative morbidity and mortality
 To facilitate early discharge and shorten hospital stay
 To increase patient satisfaction

Factors to consider when choosing a technique:

1. Patient factors
 patient acceptability (age, anxiety)
 patient‟s ability to cooperate (children, senile, head-injured, language barrier )
2. Surgical factors
 site of surgery
 severity of postoperative pain
 When can the patient take orally?

3. Nursing factors
 adequacy of nursing staff
 familiarity with the various techniques
 availability of monitoring

4. Cost
 equipment
 drugs
 disposables
 manpower

5. Other factors
 incidence of side-effects
 risk of respiratory depression
 risks associated with various techniques e.g. epidural abscess
 effectiveness of pain control

Methods

Treat pain early and effectively.

Methods include non- pharmacological and pharmacological approaches.

Non-pharmacological approaches

Techniques proven to be useful in acute pain management:

1. Psychological approaches: including music, preoperative information, distraction,

cognitive methods, relaxation training, hypnosis, guided imagery

 Music- reduction in postoperative pain and opioid consumption.

 Pre-operative information- effective in reducing procedure-related pain.
 Distraction- effective in procedure-related pain in children
 Cognitive methods-training in coping methods or behavioural instruction prior to
surgery, reduces pain and analgesic use.
 Hypnosis and relaxation-inconsistent evidence of benefit in the management of acute
pain

2. Complementary therapies and other techniques: including massage, acupuncture,

TENS, hot and cold packs.
Pharmacological approaches

 Oral analgesics- NSAIDs / COX2 Inhibitors / Opioids

 Intravenous injection – NSAIDs / COX2 Inhibitors / Opioids
 Patient-controlled analgesia (PCA) - Morphine / Fentanyl
 Epidural analgesia – Intermittent / infusion/ PCEA
o Mixtures of local anaesthetics and opioids (“cocktail”)
o Opioids
 Intrathecal analgesia
o Opioids
 Subcutaneous morphine
 Peripheral nerve blocks

Multi-modal Analgesia

Also known as “Balanced Analgesia”, involves the use of two or more analgesic agents or
techniques of controlling pain. Drugs with different mechanisms of actions potentiate the
analgesia by additive or synergistic effects and may reduce severity of side effects due to
the lower doses of the individual drugs used.

Examples are:
 Epidural with NSAIDs and Paracetamol
 PCA morphine with Paracetamol, NSAIDs and local wound infiltration
 Peripheral nerve block with PCA morphine
PATIENT CONTROLLED ANALGESIA (PCA)

 One of the most common methods for postoperative pain control.

 A method of opioid delivery where a computerized syringe pump is set to deliver bolus
doses whenever the patient presses a button (patient demand). It allows small amounts
of an opioid to be given at frequent intervals. Hence the patient titrates the required
dose of the analgesic according to individual needs.
 Analgesics can be given by the following routes – Intravenous, subcutaneous, epidural
and through peripheral nerve catheters.
e. g. subcutaneous PCA opioids as effective as intravenous PCA in controlling
pain, very suitable and practical in patient with difficult IV access
 PCA has several modes of administration.The two most common are demand dosing
and continuous infusion + demand dosing.
 Morphine is by far the most commonly used opioid for PCA. The alternative is
fentanyl, which is used in patients with renal failure.
 One opioid may be better tolerated than the others. Therefore, changing from one
opioid to another opioid may be beneficial if the patient is suffering from severe
intolerable side effects.
 The routine use for pethidine is strongly discouraged because pethidine has a
neurotoxic metabolite, norpethidine, which can lead to CNS excitation e.g anxiety,
tremors and grand mal seizures. Drug interaction with MAOI can also occur, causing
Malignant Hyperpyrexia Syndrome.

Indications

 Post –operative pain

 Severe acute pain e.g. burn, trauma, invasive procedures
 Severe cancer pain
 Patients unable to take oral medications

Contraindications

 Untrained staff
 Patient preference
 Patient inability to safely comprehend the technique (language barrier, confusion)
 Patient who are not able to use the PCA (severe deformity or weakness of both hands,
bilateral fracture of upper limbs)

Advantages

 Effective for severe pain regardless of the site of surgery.

 Patient controls the amount of opioid used and therefore the analgesic dose matches the
patient‟s requirement.
 May reduce opioid consumption and side-effects.
 Patients are actively involved with their own recovery and feel better.(high rating for
patient satisfaction)
 Nursing made easy as patient is comfortable, and nurses do not have to administer
medication for pain relief.
 Risk of overdose is low
 Can be used for incident pain

Disadvantages

 Not suitable for all patients.

 Need to educate patients and relatives.
 Doctors and nurses need to be trained on the safe and effective use of PCA.
 High cost of PCA machine and disposables.
 Human and pump errors

Features of PCA and Programming Modes

PCA pump
 microcomputer for programming
 syringe pump
 device for activation by patient (usually a button that the patient pushes)
 lock & key for access only by trained staff
 delivery system
 display window
 alarms

Programming of PCA machine

Mode : PCA mode, Continuous mode, PCA + Continuous mode

Drug concentration: in milligrams per milliliters (e.g. morphine 1mg/ml, fentanyl
10mcg/ml)
Loading dose: initial dose delivered on commencing PCA
Bolus dose: dose delivered by the PCA machine when the demand button is pressed.
Continuous infusion /background infusion that can be used with or without the patient
demand facility.
Lock-out interval: period during which the patient cannot initiate another dose, a safety
feature to prevent overdose.
4 Hourly Limit: Maximum drug doses which can be delivered within the 4 hour period

PCA with Background/Continuous Infusion

 Not routinely used. The additional use of a background infusion during PCA may
increase opioid consumption by up to 50% and increases the risk of respiratory
depression about 5 fold.
 There is also increased incidence of sedation, nausea, vomiting and hypoxaemia, does
not improve pain relief or sleep or reduce the number of PCA demand.
 Therefore background infusion is not recommended for routine postoperative analgesia
in the ward especially in patients with risk of respiratory depression.
 The background infusion rate should be less than the bolus dose.

Indications

1. In opioid tolerant patients. (Refer to Chapter 8)

2. In patients who complain of repeatedly waking in severe pain (night time analgesia).
3. In patients with severe acute pain in ICU/HDU e.g. chest injury
4. After major surgery e.g.laporotomy, coronary by-pass surgery etc

General Guidelines

Decision to use PCA for postoperative pain relief should be made preoperatively at the the
anaesthetic clinic. This will allow the patient to receive instructions on the use of the PCA
machine.

 Patients on PCA must be mentally alert and able to comply with instructions. Friends
and relatives must understand that ONLY the patient should activate the machine.
The PCA is delivered through an IV line which has a one way “anti-reflux valve” to
prevent accidental opioid overdose. If an anti-reflux valve is not available, use a
dedicated line for the PCA.
 Patient monitoring which include Pain Score, Sedation Score, Respiratory rate, blood
pressure and pulse rate, amount of drug used and complications must be recorded every
hour for the first 4 hours, then every 4 hours.
 Patients on PCA are NOT to receive other opioids or sedatives.
 Recommended settings: Age affects opioid dosing but not gender and body weight.
 Drug concentration should be standardised to reduce the chance of programming errors.

Drug concentration:
 Morphine 1 mg/ml OR
 Fentanyl 10 mcg/ml

Mode:
 PCA mode

Loading dose:
 Usually not set for patients who are receiving postoperative PCA as they will usually
already have received opioid intraoperatively.
 For those patients who have not received any opioid prior to start in the PCA, a loading
dose of 2-3 mg morphine may be administered.
 PCA is essentially a maintenance therapy; therefore a patient‟s pain should be
controlled before starting PCA.

Bolus dose:
< 60 years: morphine 1 mg
> 60 years: morphine 0.5 mg

Lock-out interval:
 5 minutes

4 hour limit:
 Usually not set

Common problems with PCA and what to do

1. Patient is not comfortable:

 Repeat patient education
 Look at the number of times the patient has pressed the demand button each hour.
On the whole, most patients will not continue to press if they are getting an
appreciable effect from the bolus dose. If the patient needs more than 3 or 4 bolus
doses every hour, the size of the bolus should be increased by 50-100%.

2. Machine alarms
 Check cause - ?syringe empty ? occlusion
 Inform APS or ICU doctor on call if ward nurses are unable to correct the cause.

When to stop PCA?

 Patient requests.
 Low opioid requirements for analgesia, e.g. patient using less than 10 mg morphine/day
 Patient is tolerating fluid intake and able to take oral analgesics.

Analgesia after PCA is stopped

 Oral paracetamol 1 gm 6 hourly

 Oral tramadol 50 mg 6-8 hourly
 Oral dihydrocodeine (DF118) 30-60mg (1 to 2 tabs) 6-8 hourly
 NSAIDs or COX2 inhibitors (dose as appropriate)
 Oral Oxynorm (See Appendix 4)

Adverse effects of PCA opioids

1. Respiratory Depression
Possible causes:
 drug interaction – especially if patient is on another drug with sedative
effect
 continuous (background) infusion
 inappropriate use of PCA by relatives
 human error
  programming error
 equipment error

2. Nausea & vomiting

3. Pruritus
4. Sedation

Complications related to PCA

 Factors related to Health care providers - human factor is the main cause
o programming errors (setting of a continuous infusion)
o error in clinical judgment
o improper dose
o unauthorized drug
o prescribing error
o wrong administration technique
o wrong drug preparation
o wrong patient
o wrong route
o inexperienced staff
o omission of patient monitoring

 Patient‐related errors – e.g. family members activating PCA

 Problems due to the equipment

Responsibilty of doctors and nurses

Although the patient has control of PCA, that does not free the nurse/doctor from the
responsibility of managing and assessing the patient frequently. It is extremely important
for nurses/doctors to monitor medication use and accuracy of the prescription that is
programmed into the PCA pump.

In order to use PCA safely, the “just push the button” concept should be discouraged.
Rather focus should be on proper patient selection, patient education and consistent
assessment and monitoring of the patient

PCA should not be used as “stand alone” therapy. Regular NSAIDs, LA wound infiltration,
peripheral nerve blocks and catheter techniques can all be used as part of a multimodal
regime, together with PCA, to improve analgesia and reduce opioid requirements.
CENTRAL NEURAXIAL BLOCK

Anatomy relevant to epidural analgesia

The spinal cord and brain are covered by 3 membranes -- the meninges.
 Outer layer - duramater
 Middle layer - arachnoid mater (lies beneath the dura)
 Inner layer - pia mater (adheres to surface of spinal cord and brain)

Figure 5.1: Anatomy of the Vertebral Column

 Outside the dura lies the epidural space. This is a potential space containing blood
vessels, fat and connective tissue.
 Below the arachnoid membrane is the subarachnoid or intrathecal space, which is filled
with cerebrospinal fluid (CSF), and the spinal cord (above L1/L2) or cauda equina
(below L1/L2).

Definitions

Epidural analgesia
This is the introduction of analgesic drugs into epidural space, usually via an indwelling
epidural catheter.

Intrathecal / Subarachnoid analgesia

This is the introduction of analgesic drugs into the CSF in the intrathecal space. This is
usually done as a „single shot‟ technique but indwelling intrathecal catheters can be used.

Indications

 Management of acute pain in adults and children, particularly after surgery,and in

procedures involving the thorax, abdomen, perineum or lower limbs
 Management of post trauma pain
 For labour analgesia

Contraindications

 Patient refusal
 Untrained staff
 Local infection or general sepsis
 Central neurological disorders e.g. stroke, head injury, brain tumour
 Coagulation disorders / patient on anticoagulants
 Hypovolemia
 Severe fixed cardiac output states

Advantages

 Compared to parenteral opioids, neuraxial block provides:

o Good quality of analgesia at rest and at movement (incident/dynamic pain),
early mobilization and resume normal activities unlimited by pain.
o Less sedation.
o Less nausea and vomiting
 Faster return to normal lung function, decreased incidence of pulmonary infection
especially patients with lung disease, chest injury, thoracotomy and upper abdominal
surgery.
 Reduced duration of ileus in colorectal surgery
 Reduced rate of arrhythmias, earlier extubation, reduced intensive care unit (ICU) stay,
reduced stress hormone cortisol and glucose concentrations as well as reduced
incidence of renal failure.

Disadvantages

 Technical difficulty
 High cost of equipment
 Weakness and numbness with local anaesthetics

Drugs used

 Two classes of drugs are commonly used for neuraxial analgesia:

o Local anaesthetics e.g.bupivacaine,ropivacaine,levobupivacaine
o Opioids e.g. fentanyl, morphine

 Both produce analgesia but differ in their mechanisms of action and their side effects.
 Usually a combination of local anaesthetics and fentanyl (“cocktail”) is used for
postoperative epidural analgesia.
Table 5.1: Comparison of Effects between Opioids and Local Anaesthetics
SYSTEM OPIOIDS LOCAL ANAESTHETICS

CVS Usually no drop in BP Hypotension due to sympathetic

blockade

Bradycardia with high block

RESPIRATORY Early respiratory Usually unimpaired unless there is

depression from a high block involving the
systemic absorption intercostal muscles and diaphragm

Late resp. depression

due to rostral spread in
CSF

MOTOR No effect Motor block resulting in muscle

weakness

CNS Nausea and vomiting Nausea and vomiting only as

sequel to hypotension
Pruritus (more
commonly seen with No pruritus
morphine)

URINARY Urinary retention may Urinary retention with lower

occur motor blocks

GIT Decreased motility Increased motility

Mechanism of action of drugs used

Opioids:
 An opioid introduced into the epidural space diffuses across the dura into the CSF and
reaches the opioid receptors in the dorsal horn of the spinal cord to bring about
analgesia
 Antinociception is further augmented by descending inhibition from mu‐opioid receptor
 Activation in the periaqueductal gray (PAG) area of the brain
 Affect the modulation of nociceptive input but do not cause motor or sympathetic
blockade

Local Anaesthetics:
 Block the conduction of impulses along nerves and spinal cord
Epidural analgesia using mixtures of LA and opioids (“cocktail”)

 Local anaesthetic (LA) drugs introduced into the epidural space reach the CSF via dural
cuffs surrounding each spinal nerve root, and also gain access to spinal cord.
 Epidural infusion of LA alone or combined with opioids are better than opioids alone.
 Methods of administration include
o Continuous infusion
o Patient controlled (PCEA)
 Side effects occur as a result of:
o sympathetic blockade
o motor blockade
o sensory blockade

 The extent of these side effects depends on the amount and concentration of local
anaesthetic and the site of drug deposition.
 To obtain good analgesia with minimum side effects, mixtures of low concentrations of
local anaesthetic and opioids i.e. „cocktail‟ are used.
 Once the epidural catheter is inserted, a bolus dose is given.
 “Every dose is a test dose”

Table 5.2: Recommended Epidural Bolus Dosing (Adapted from NYSORA)

Drug Concentration Bolus Interval Remarks

Lignocaine 2% 3-5mls 3-5 min Assess
Bupivacaine 0.25-0.5% 3-5 mls 3-5 min response to
dosing and
Ropivacaine 0.5-0.75% 3-5 mls 3-5 min establish
Levobupivacaine 0.25-0.5% 3-5 mls 3-5 min sensory level
as required
Note:
1. Volume is the key factor in the height of the block
2. The guideline for dosing and epidural in adults is 0.5-0.7 mls (thoracic) and 1-2 mls
(lumbar) per segment to be blocked
3. Adjust the guideline for shorter patients (less than 155 cm) or taller patients (more
than 185 cm)
4. Beware of intravascular and intrathecal injection during the administration of the
bolus dose

The usual epidural cocktails and rates of administration are shown below:

“Cocktail”
 0.1% Bupivacaine + 2 mcg/ml Fentanyl
 0.2% Ropivacaine + 2 mcg/ml Fentanyl
 0.1% Levobupivacaine + 2 mcg/ml Fentanyl

Rate of infusion
 Varies according to the site of the epidural and surgical wound
 Recommended rates of infusion
o Thoracic 4-8 mls/hr
o Lumbar 6-12 mls/hr

Note:
1. Concurrent opioids or sedatives must not be given.
2. Local anaesthetic solutions MUST be diluted with normal saline. Water is
hypotonic and therefore neurotoxic.
3. Ambulation may not be possible because of weakness of the lower limbs but
patients are allowed to sit up and out of bed with assistance.

Patient Controlled Epidural Analgesia (PCEA)

 PCEA decreases the requirement for epidural top-ups, lowers consumption of LA and
decreases incidence of motor block and reduces the consumption of systemic rescue
analgesia, with a consequent reduction in the requirement for intervention by ward
nurses, physicians, and the APS
.
 PCEA with background is more effective in reducing incident pain than PCEA without
a background infusion. Currently in Malaysia, PCEA is used more in labour analgesia
(refer to Chapter 11, Obstetric Analgesia Service).

Epidural analgesia using opioids alone

 Epidural opioids alone have limited benefit and are not commonly used.
 Risk of delayed respiratory depression is greater with morphine when compared to
fentanyl.
 Concurrent opioids and sedatives must not be given by other routes.
 Opioid solutions used must be preservative-free (as preservative may be neurotoxic).
 Patients receiving epidural opioids alone may ambulate, as there is no motor
blockade.
 A bolus dose of epidural morphine alone may provide up to 24 hours of analgesia.
Epidural fentanyl alone is not used as the duration of action is too short to be of any
significant benefit. (refer Table 5.3)

Table 5.3: Epidural Opioids: Dosage, Onset and Duration of Action

OPIOID DOSE (mg) ONSET (min) DURATION (hrs)

Fentanyl 0.05 – 0.1 5 - 10 2-3
 Morphine 2-5 30 - 45 6 - 24

Intrathecal Opioid Analgesia

 This is the introduction of opioid drugs into the CSF, which acts directly on the opioid
receptors in the spinal cord and brain.
 The lipid solubility of opioids determines the onset and duration of intrathecal
analgesia; hydrophilic drugs (e.g. morphine) have a slower onset of action and longer
half‐life in cerebrospinal fluid compared with lipophilic opioids (e.g. fentanyl).
 Therefore, neuraxial administration of bolus doses of hydrophilic opioids has greater
dorsal horn bioavailability and greater cephalad migration and thus carries an increased
risk of delayed sedation and respiratory depression compared with lipophilic opioids.
 Sedation Scores & Respiratory Rate must be monitored regularly for at least 24 hours
after the last dose of intrathecal opioid.

Table 5.4: Pharmacological Properties of Common Opioids for Intrathecal Analgesia

Opioid Usual dose Onset Duration IT:IV Time to peak Respiratory

range (mins) (hours) potency Depression
(µg) ratio

Morphine 100-500 45-75 18-24 1:200 6-10hrs

Fentanyl 5-25 5-10 1-4 1:10 5-20min

Indications
 Intraoperative and postoperative analgesia e.g.analgesia post caesarian section
 Intractable cancer pain

Contraindications
 Allergy to morphine
 Sensitivity to opioids, e.g. previous severe nausea / vomiting
 Additional sedative drug use
 Morbidly obese
 Severe Respiratory Disease
 Obstructive Sleep Apnoea(OSA)

Table 5.5 Optimal Intrathecal Opioid Dose for Specific Surgical Procedures
(Adapted from Rathmell JP et al. Intrathecal Drugs for Acute Pain. Anesthesia Analgesia

Optimal IT opioid &

Procedure Comments
dose

Fentanyl 25 µg Fentanyl improves intraoperative analgesia, faster onset

Caesarean Delivery + Morphine 100 µg of block but does not produce significant postoperative
analgesia.

Intrathecal lipophilic opioids speed onset of block, short

Day Care Surgery duration of action and improve both intraoperative and
under spinal immediate postoperative analgesia without prolonging
Fentanyl 10-25 µg
anesthesia (e.g. knee motor block.
arthroscopy) Minimal cephalad spread, least likely to cause delayed
respiratory depression

Transurethral Ultra low dose of intrathecal morphine was equivalent to

resection of the Morphine 50 µg 100 µg after TURP.
prostate (TURP) Used to control pain by detrusor muscle spasm

Morphine 100-300 µg
Although these doses of intrathecal morphine provide
(Total Hip
Major orthopedic excellent analgesia after total hip arthroplasty they are
Arthroplasty 100-
surgery (e.g. joint inadequate for pain relief after total knee arthroplasty,
200ug,
arthroplasty) reflecting the greater degree of pain reported by patients
Total Knee
undergoing knee replacement.
Arthroplasty 300ug)
Lumbar intrathecal morphine improves pain relief but
Morphine 300-500 µg
Thoracotomy does not eliminate the need for supplemental IV opioid
analgesics.

Lumbar intrathecal morphine provided more intense

Major analgesia than IV patient-controlled analgesia with
abdominal/vascular morphine.
Morphine 300- 500 µg
surgery (e.g., open Its role in major abdominal surgery is less clear due to
abdominal aortic fact that the analgesic effects wear off after first 24 hr
aneurysm repair) necessitating the change in analgesia to either an
epidural or PCA

Effective in alleviating pain with minimal side effects,

improved respiratory function and postoperative mobility
Spinal Surgery Morphine 150-300ug after multilevel instrumentation and lumbar fusion
surgery.
Can be injected under direct vision at the end of surgery.
2005; 101: S30-43)

Note: Intrathecal morphine doses of 300 mcg or more is required to produce superior analgesia in
major thoracothomy and abdominal / vascular surgery but it increases the risk of respiratory
depression.
Advantages:

 Higher intrathecal success rate

 Earlier onset of sensory block than LA alone
 Enhance intraoperative analgesia (sensory blockade) without increased motor blockade
 Allows lower dosage of LA with faster recovery from spinal anaesthesia
 Postoperative analgesia longer than duration of LA motor block
 Less nausea and vomiting in cesarean delivery
 Early extubation, significantly reduces MAC

Disadvantages:

 Pruritus
 Sedation mainly with hydrophilic opioids
 Respiratory depression, rare with lipophilic opioid, delayed/late with hydrophilic and
more likely in parturients.
 Urinary retention (more likely with morphine).
 Herpes simplex reactivation - clear association after intrathecal morphine has not been
established but avoid morphine if there is strong history of herpes
Table 5.6. Incidence, Proposed Mechanisms and Treatment for Intrathecal Opioid-Related Side Effects

Complication Incidence Proposed mechanism Treatment Commentary

Pruritus  30%-100% Exact mechanism Reassurance Propofol may be less effective for
 Increased in unclear. Postulates /Calamine Lotion the parturient
parturients include:
 More with Naloxone 40 mcg
Morphine  opioid receptor- titrating to a max of
 Dose mediated central 400mcg Histamine release does not appear to
dependent mechanism be causative
 "itch center" in Propofol 10 mg IV
the central bolus +/- small dose
nervous system, 30mg/24hr infusion.
 Modulation of
the serotonergic Nalbuphine 4 mg IV
pathway Ondansetron 4-8mg
 Prostaglandins IV

Granisetron –3mg IV
Sedative properties of
antihistamines may be
helpful in interrupting
the itch-scratch cycle.

Urinary  35% with Interacts with opioid Opioid antagonist and In ability to void postoperatively is a
retention morphine receptors in the sacral agonist-antagonist multifactorial problem.
 Morphine > spinal cord, causing including naloxone
fentanyl detrusor muscle Look for primary cause
relaxation and an
increase in maximal Unable to void for > 6
bladder capacity hrs -CBD

Nausea and  30%  Cephalad Use smallest effective Intrathecal opioids appear to have a
vomiting  morphine>fen migration in the dose protective effect against
tanyl cerebrospinal intraoperative nausea and vomiting
 Likely dose fluid (CSF) during caesarean delivery when
dependent interacts with
compared with LA alone
opioid receptors For ambulatory
in the area procedures,
postrema.
 Sensitization of use lipophilic opioid
the vestibular
system to motion
 Dexamethasoneand
 Decreased droperidol have
gastric emptying. shown efficacy

Ondansetron 4-8mg
IV

Granisetron 1-3mg IV

Respiratory  Infrequent Secondary to rostral Prevention: training Risk factors include

depression <1% spread in CSF and monitoring
 Dose . large dose;
dependent  Opioid
 Fentanyl antagonist . hydrophilic opioids
early onset (naloxone)
(<2 h) and . concomitant use of opioid
morphine
both early and sedatives,
and late
. age>65 yr,
onset (6-12
h)
.opioid naïve patients
Late onset depression more apparent
with morphine

(Adapted from Rathmell JP et al. Intrathecal Drugs for Acute Pain, Anesthesia Analgesia 2005;
101:S30-43)

Recommendations on Neural Blockade and Anticoagulant

Refer to Appendix 7
Subcutaneous Morphine

 Subcutaneous morphine injection is the injection of morphine into the

fatty layer just beneath the skin - the subcutaneous tissue.
 The rate of uptake of morphine into the circulation is similar to the
uptake following an intramuscular injection.
 An indwelling canula (22 G or less) is left in position, commonly just
below the clavicle or the upper outer aspect of the arm. Injections are
administered through this canula, avoiding repeated skin punctures.
 Morphine is the drug of choice. Fentanyl and Tramadol can also be
given subcutaneously.

Dosage

 <60 years old: 5-10 mg morphine, undiluted, 4 hourly

 >60 years old: 2.5-5 mg morphine, undiluted, 4 hourly

Advantages

 Less pain on injection compared to intramuscular injections

 No need for needles, hence less risk of needle stick injury
 Patient can be mobile

Disadvantages

 May have a burning sensation at injection site.

 Onset of pain relief is delayed.
 There may be a delay between request for pain relief and actual
administration.
 There is a risk of opioid overdose and respiratory depression.
Peripheral Nerve Block (PNB)

 Peripheral nerve block (PNB) is gaining popularity in management of post-

operative pain relief as well as intra-operative anaesthesia either as regional
anaesthesia alone or in combination with general anaesthesia.
 The greatest potential benefit of this technique is that it reduces the use of
opioid analgesics intra and post-operatively.
 It has been shown to reduce the incidence of post operative nausea and
vomiting (PONV).
 The other advantage of this technique is it reduces the length of stay in
hospital and is very useful in ambulatory day-care surgical procedures.
 In recent years, with the introduction of the ultrasound as a new technique for
performing nerve blocks, PNB is easier to perform with infrequent or lesser
complications being reported.

Indications

 To provide prompt and effective analgesia

 To allow adequate examination, intervention and mobilisation of an injured area without the
requirement for sedation or general analgesia.

TYPES OF BLOCK

A. Peripheral Nerve Blocks

 Upper extremity Nerve Blocks

 Lower extremity Nerve Blocks

B. Nerve Blocks of the Abdomen and Thorax

 Two different pain pathways control pain in the abdomen and

thorax, one for the organs (visceral) and another for the walls and
other components (somatic) of those regions.
 The visceral components can be controlled by central neuraxial
nerve blocks. The somatic components can be controlled by
peripheral nerve blocks. Peripheral nerve blocks are therefore
quite useful in the settings of operations involving the walls of the
abdomen or the thorax.
 Nerve blocks applicable for abdominal & thoracic surgery include:

- Thoracic Paravertebral block (TPVB)

- Lumbar Paravertebral block (LPVB)
- Transversus abdominis plane (TAP) block
- Intercostal nerves block (used for fracture ribs)
 Table 5.7: Upper Extremity Blocks and Indications

Block Indication
Shoulder surgery
Interscalene Block
Rotator cuff repair
Supraclavicular/infraclavicular Lower arm/elbow surgery
Block Forearm surgery
Forearm surgery
Axillary Block
Hand & Wrist surgery
Median/Radial/Ulnar Nerve Block
which may be done at the elbow or Hand & Wrist Surgery
below as a supplement to Brachial Plexus Block

Table 5.8: Lower Extremity Blocks and Indications

Block Indication
Lumbar Plexus Block
Hip surgery / Knee Surgery
or Fascia-iliaca Block.
Arthroplasty / Arthroscopy
Femoral/Saphenous Nerve Block
Knee Surgery
Sciatic Nerve Block
ACL Repair
(with or without Femoral /
Leg, ankle and foot surgery
Saphenous Nerve Block)

Popliteal Nerve Block

Ankle / Foot surgery
Tibial Nerve Block or
Ankle Block

Table 5.9: Truncal Blocks and Indications

Block Indication
Breast surgery
Thoracic Paravertebral Block Chest Surgery
Chest injury / Fracture Ribs

Chest injury
Intercostal Nerve Block
Fracture Ribs

Thoraco-Lumbar paravertebral Lower abdominal surgery – Hernia Repair

Block Lateral abdominal wall surgery
 Transversus Abdominis Plane
Abdominal surgery
(TAP) Block

Table 5.10: LA selection & concentration

Local Anaesthestic Initial Bolus Infusion Maximum dose

mg/kg
Bupivacaine 0.25%-0.375% 0.1% 2-3

Ropivacaine 0.375%-0.5% 0.2% 3

Levobupivacaine 0.25%-0.375% 0.1%-0.2% 2-3

Table 5.11: Dose of LA for Continuous Infusion with or without PCA bolus

Type of block Initial bolus Basal Bolus Lockout

(mls) Infusion Volume Interval
(ml/h) (ml) (minutes)
Brachial plexus Block 20-30 5-10 2-5 20-60
Lumbar Plexus Block 30-40 5-10 2-5 20-60
Paravertebral Block 20-30 5-10 2-5 20-60

Note: LA must be titrated according to analgesic effects and maximum doses in mg/kg (refer to
Table 5.10)

Catheter Placement

 Place the catheter 1-2 cm distal to the tip of the needle in brachial plexus, sciatic and
femoral nerve blocks.
 For the lumbar plexus and paravertebral block, place it 3-5 cm distal to the tip of the
needle.
Tunneling and securing catheter

Secure the catheter by tunneling it through the subcutaneous layer.

Contraindications
 Patient refusal
 Drug allergy – allergy to local anaesthetics
 Coagulopathy – INR ≥ 1.5
 Infection at the injection site

Complications
 Systemic toxicity of the local anaesthetic including perioral or tongue numbness,
dizziness, tinnitus, blurred vision, tremors, sedation, seizures, respiratory arrest and
arrhythmias.
 Nerve injury
 Damage to other structures around the site of the injection
 Pain at the site of the injection
 Local haematoma secondary to vascular injury
 Infection
 Total spinal anaesthesia
 Quadriceps muscle weakness
 Paravertebral muscle spasm
 Figure 5.2: Cutaneous Innervation of the Upper Limbs

Figure 5.3: Cutaneous Innervation of the Lower Limbs

Transversus Abdominis Plane (TAP) Block

 Transversus abdominis plane is a potential space between the internal oblique and
transversus abdominis muscles.
 The space can be identified and clearly visualised using the ultrasound and the local
anaesthetics is injected into the plane between the two muscle layers; hence called the
transversus abdominis plane block
 Using the ultrasound guided nerve block, the TAP block has been described with promises of
better localization and deposition of the local anesthetics with improved accuracy. This block
can be performed either pre-induction or post-induction of anaesthesia aiming to provide
analgesia peri-operatively.

Anatomy

 Anterior abdominal wall is innervated by branches arising from the anterior rami of the
spinal nerve T7 to L1 which include the intercostal nerves (T7-T11), the subcostal nerve
(T12), and the iliohypogastric and ilioinguinal nerves (L1).
 Anatomy of Angle of Petit (Borders)
o Posterior - latissimus dorsi
o Anterior - external oblique muscle
o Inferior - illiac crest
o Floor – Transversus abdominis muscle

Figure 5.4: Surface landmark of Triangle of Petit

(McDonnell J.G et al. Anesth Analg 2007; 104:193-197)
 TAP block may be used for analgesia for the following types of surgery:
o Anterior abdominal wall surgery
o Appendicectomy
o Herniorraphy
o LSCS
o Abdominal hysterectomy
o Tenckhoff catheter insertion
o Retropubic prostatectomy
o Laparoscopic surgery
o Open Cholecystectomy

 For abdominal surgery, bilateral blocks may be given for midline incision. Here, care must
be taken not to exceed the maximum dose of local anaesthetic.
 15-20 mls of 0.375% ropivacaine or 0.25% levobupivacaine are deposited on either side to a
maximum of 30 mls. The success of the block depends on the spread of the local anaesthetic
rather than its concentration.
 The local anaesthetics deposited into the transversus abdominis neuro-fascial plane will
spread cephalad and caudad on each side, from the iliac crest to the costal margins, thus
blocking the nerves which lie between the fascial layers, providing the sensory block from
T7 to L1.
 The duration of the block ranges from 4-24 hours. If analgesia is required beyond the
duration of single injection, a catheter may be inserted into the TAP through a Tuohy needle
and analgesia maintained with infusion of local anaesthetic at 7 to 10 mls/h .
 This block provides effective postoperative analgesia in the first 24 hours after major
abdominal surgery, and has been found to reduce morphine requirement in post-operative
patients.
 Complications are uncommon, and include:
o Liver injury
o Intra-peritoneal injection
o Bowel hematoma
o Transient femoral nerve palsy
o Local anesthetic toxicity
Pain Management in Non-APS patient

 Analgesic drugs can be administered systemically through different routes. The

route of administration depend on various factors, including the severity, site and
type of pain, co-morbidity, ease of use, accessibility, onset of drugs, reliability of
effect, duration of action, patient acceptability, cost, staff education and
supervision available.
 Oral analgesic agents is simple, non‐invasive,good efficacy and high patient
acceptability.It is the route of choice for most analgesic drugs (refer to Appendix
6, Analgesic Ladder for Acute Pain Management)
 Paracetamol plus tramadol or oxycodone are effective analgesic for acute pain
 IV paracetamol has better analgesic effect after surgery with faster onset than the
same dose given orally but more expensive.
 NSAIDs and Coxibs can be used as sole therapy in various acute pain settings.
 Frequent pain assessment, response to treatment and side effects, is important to
achieved adequate analgesia.
 For those with severe pain, use IV morphine and titrate to comfort using
„Morphine Pain Protocol” to guide severe pain management (refer to Appendix 5)
References

1. Aguirre J. et al. 2012: The Role of Continuous Peripheral Nerve Blocks. Anaesthesiol
Res Pract 2012:560879
2. Ashok KS et al, 2004: Current Concepts in Neuraxial Administration of Opioids and
Non-Opioids: An Overview and Future Perspectives. Indian J.Anaesthesia;48(1):13-
24
3. Chelly J E, Ghisi D, Fanelli A. 2010: Continuous Peripheral Nerve Blocks in Acute
Pain Management. Br J Anaesth, 105(S1) : 186-196
4. Marret E et al, 2007: Meta-analysis of epidural analgesia versus parenteral opioid analgesia
after colorectal surgery. Br J Surg Jun: 94(6):665-673
5. Grass JA, 2005: Patient-Controlled Analgesia, Anaesthesia and Analgesia; 101:S44-
S61
6. Hindle A. 2008: Intrathecal Opioids in the Management of Acute Postoperative Pain.
Continuing Education in Anaesthesia, Critical Care & Pain, vol 8(3):81-85
7. Benzon H et al et al, 2008: Nerve Block Techniques,Raj‟s Practical Management of
Pain, 4th Edition, Mosby Elsevier,Philadephia
8. Hutchison RW, 2006: A Comparison of a Fentanyl, Morphine and Hydromorphone.
Patient-Controlled Intravenous Delivery for Acute Postoperative Analgesia: A
Multicenter Study of Opioid-Induced Adverse Reactions. Hospital Pharmacy; 41:659-
663
9. Ilfeld BM, 2011: Continuous Peripheral Nerve Blocks, A Review of the Published
Evidence. Anesth Analg 113(4):904-925
10. Rathmell JP et al, 2005: The role of Intrathecal Drugs in the Treatment of Acute Pain.
Anesth Analg 101
11. Macintyre PE et al, 2010: SE Working Group of the Australian and New Zealand
College of Anaesthetists and Faculty of Pain Medicine, Acute Pain Management:
Scientific Evidence (3rd edition), ANZCA & FPM, Melbourne
12. Macintyre PE et al, 2004: A Background Infusion of Morphine Enhances Patient-Controlled
Analgesia After Cardiac Surgery.Canadian Journal Anaesthesia, vol5 (7):718-722
13. Ministry of Health Malaysia 2008: Guidelines on Pain as 5th Vital Sign,
14. Stevensen C. 1995: Non-pharmacological Aspects of Acute Pain
Management.Complement Therapy Nursing Midwifery Jun;1(3):77-84
15. NYSORA - The New York School of Regional Anesthesia - Essentials of Regional
Anesthesia Anatomy. http://www.nysora.com/regional-anesthesia/3012-essentials-of-
regional-anesthesia-anatomy.html, accessed 4 November 2013
 CHAPTER 6
COMPLICATIONS AND MANAGEMENT

Complications associated with the provision of pain relief for acute pain may be related
to the drugs or the techniques used.
Complications related to drugs

Opioids:
 Nausea and vomiting
 Dizziness
 Pruritus
 Ileus/constipation
 Urinary retention
 Excessive drowsiness
 Respiratory depression

Local anaesthetics:
 Hypotension and bradycardia due to sympathetic block
 Systemic toxicity due to accidental intravascular injection
 Respiratory distress due to a high motor block.

Non-steroidal Anti-inflammatory Drugs:

 Gastro-intestinal (GIT) bleeding
 Renal impairment/failure
 Cardiovascular event (e.g. Myocardial ischaemia /stroke / uncontrolled hypertension)
 Platelet dysfunction
 Allergic reactions

Complications related to technique

PCA
 Superficial phlebitis at the I/V site

Central neuraxial block

 Post Dural Puncture Headache (PDPH)
 Neurological Complications
Transient Neurological Symptoms (TNS)
Epidural abscess,meningitis,encephalitis
Haematoma – Epidural or Subdural
Meningitis – septic or aseptic
Cauda equina syndrome
Adhesive arachnoiditis
Traumatic / Ischaemic injury to spinal cord and nerves roots
 Catheter problems; migration, knotting and snapping
 Persistent back pain - PBP after spinal anesthesia is almost exclusively associated
with pre-existing back pain, new onset of PBP is a rare event (K .Schwabe)
Subcutaneous morphine
 Cellulitis at the needle site

MANAGEMENT OF COMPLICATIONS
NAUSEA AND VOMITING
Incidence of postoperative nausea and vomiting (PONV) can be as high as 21% (National
Audit, 2007).
Factors contributing to the incidence of nausea and vomiting:
Surgical
 Laproscopic surgery
 Emergency surgery (full stomach)
 Gynaecological surgery
 Middle ear surgery
 Squint surgery
 Surgery involving the bowel, pharynx and spermatic cord

Patient
 Female patients
 Paediatric patients
 Obese patients
 Patients with history of motion sickness
 Patients with previous history of PONV

Prophylaxis and treatment

 Avoid excessive movement during transport back from OT

 Add a non-opioid analgesic to reduce opioid requirements
 Reduce bolus dose of opioid
 Administer one or more IV antiemetics as required:
i. Metoclopramide:10-20 mg TDS
ii. Haloperidol: 1-2 mg BD
iii. Dexamethasone:4-8 mg stat dose
iv. Granisetron: 1-3mg stat dose

EXCESSIVE DROWSINESS
Incidence is about 1% (National APS Audit 2007). Excessive drowsiness may be a sign
of opioid overdose.
RESPIRATORY DEPRESSION
Respiratory depression is an uncommon event but may be fatal. The incidence is about
0.9% (National APS Audit, 2007). It is always associated with excessive drowsiness
Clinical effects of opioids on respiration
 Decrease in respiratory rate then decrease in the tidal volume i.e. shallow breathing
 Decreased response to hypercarbia
 Blunted response to hypoxia

Conditions predisposing to opioid induced respiratory depression:

 Extremes of age (elderly or neonates)
 Chronic debilitation
 Poor pulmonary function
 Patient sensitivity to opioids and other CNS depressants
 Concomitant use of central nervous system depressant drugs e.g.benzodiazepines
 Morbid obesity and obstructive sleep apnoea
 Acute intoxication with alcohol or other drugs
 Renal impairment

Avoidance of complications
 Regular monitoring of the sedation score and respiratory rate by
trained personnel
 Oxygen therapy
 Availability of naloxone at the bedside.

Diagnosis
Sedation score of 2 AND respiratory rate less than 10/min
Sedation score of 3 irrespective of respiratory rate
Management
1) Confirm diagnosis; check for pin–point pupils
2) Stop the opioid
3) Call for help; ward doctor or APS team
4) Stimulate patient to breathe.
5) Oxygen at 10L/min via face mask
6) Naloxone 0.1 mg IV every 2-3 minutes up to a total of 0.4 mg or until patient is
breathing adequately.
7) Monitor patients in high dependency area

PRURITUS
This can occur with opioids especially morphine. The incidence is about 4% (National
APS Audit,
2007).
Management:
 Apply calamine lotion
 Antihistamine e.g. chlorpheniramine
 For severe cases: Low dose IV Naxolone as infusion 0.2-2 mcg/kg/hr for 24 hours
(caution: naloxone may also reverse the analgesic effect!)

ILEUS / CONSTIPATION
This may be a side effect of opioids but other causes, including inadequate pain relief and
surgical cause, must be ruled out as well.
Management
 Consider surgical problems and manage appropriately
 Use multimodal analgesia to reduce opioid requirements
 Consider changing opioid (e.g. morphine to fentanyl)
HYPOTENSION
Usually seen in patients on epidural analgesia and not in patients on PCA. It is almost
always contributed by hypovolaemia.
Management

1. Ward or APS doctor to attend to patient immediately

2. Administer oxygen via facemask
3. Rule out other causes:
 Inadequate fluid replacement (hypovolemia)
 Surgical problem (e.g. bleeding)
 Cardiac event
4. Rule out causes related to the epidural:
 Excessive sympathetic blockade
 High block associated with bradycardia
 Catheter migration into subarachnoid space causing a high block
5. Give fluids (200 – 500mls of Hartmann‟s solution)
6. Reduce the infusion rate if the cause is due to the epidural infusion.
7. Administer vasopressors if necessary e.g. ephedrine, phenylephrine.

URINARY RETENTION
Surgery, anaesthesia and postoperative analgesia are factors that contribute to
postoperative urinary retention. Urinary retention may occur with spinally administered
local anaesthetics and opioids or with systemic opioids.
In patients who have not passed urine in the postoperative period, it is important to
differentiate urinary retention from anuria due to other causes like acute renal failure,
dehydration etc.
Management
1. Confirm full bladder by clinical examination.
2. Reassurance.
3. If patient is still unable to void, insert an indwelling urinary catheter.

MOTOR BLOCKADE
Incidence during epidural analgesia
Lumbar epidural: 7-50%
Thoracic epidural: 1-4%
Management
 Regular neurological examination (Bromage scoring) and follow up.
 Reduce epidural infusion rate, adjust or remove epidural catheter.
 Further investigation if motor blockade persists after stopping the local
anaesthetic infusion.

POST DURAL PUNCTURE HEADACHE (PDPH)

It is thought to be due to leakage of cerebrospinal fluid (CSF) from the subarachnoid

space to the epidural space through the dural puncture site, resulting in traction on
meningeal vessels and nerves. Incidence is lower with a smaller gauge pencil point
needles and in the elderly.
Clinical Features:
 Dural puncture and postural component
 A postural component is the hallmark of PDPH, where the headache is worse on
sitting, standing, coughing or straining and relieved by lying down
 Onset may be within a few hours but more commonly present after 24-48 hours.
 Location is bi-frontal /occipital and may radiate to neck and shoulder.
 Severity ranges from mild to excruciating
 Associated symptoms are nausea, loss of appetite (LOA), photophobia, changes in
hearing acuity and tinnitus, diplopia, cranial nerve dysfunction/palsies
 Differential diagnoses include: tension headache, migraine, intracranial bleed or
thrombosis, meningitis or eclampsia (post partum female). Exclude by checking
for focal neurological deficit, neck stiffness, fever etc

Risk factors
1) Age <50 yr
• more frequently in young adults,
• incidence rate of 14% compared to 7% in individuals older than 70years

2) Obstetric patients
• Lowering intra-abdominal pressure after delivery lowers the epidural pressure
• Hormonal changes make cerebral vasculature more reactive

3) The incidence of PDPH depends on size, type and design of needle

25G Quincke = 10-15 %
27G Quincke = 8 %
27G pencil point = 0.02 %-1.5 %
Management
Up to 90% resolving within 10 days (Candido & Stevens, 2003).
Management includes:
Symptomatic:
1) *Bed rest-to avoid symptoms.
2) Support and reassurance
3) Adequate hydration
Pharmacotherapy:
1) Paracetamol (PCM),
2) NSAIDs
3) Weak opioid (Tramadol or DF 118)
4) Caffeine or caffeinated drinks
5) Sumatriptan

Intervention:
1) Epidural blood patch if conservative therapy fails. To be performed only by
experienced anaesthesiologist.

*Notes:
Bed rest delays the onset but does not prevent the occurrence of PDPH
NEUROLOGICAL COMPLICATIONS
Permanent neurological damage is the most feared complication of epidural analgesia,
but the incidence is extremely low.
Early diagnosis by monitoring patients for early signs of cord compression, such as
progressive numbness or weakness, bowel and bladder dysfunction, followed by
immediate decompression (less than 8 hours after the onset of neurological signs) results
in good neurological recovery.
Neurological injuries caused by neuraxial blockade include:
1) Transient Neurological Symptoms (TNS)
2) Epidural abscess
3) Haematoma – Epidural or Subdural
4) Meningitis – septic or aseptic
5) Cauda equina syndrome
6) Adhesive arachnoiditis
7) Traumatic / Ischaemic injury to spinal cord and nerves roots

Transient Neurological Symptoms

 Persistent pain in the back or in the lower limbs after recovery from neuraxial
block
 Symptoms usually resolve spontaneously within a few days
 Etiology is unclear
 Patient should be reassured and given symptomatic treatment with analgesics and
must be followed up in the Anaesthetic or Pain clinic until symptoms subside.

Epidural abscess
 Presence of severe or increasing back pain, even in the absence of a fever, may
indicate epidural space infection and should be investigated promptly, including
sending the patient for urgent MRI.
 If the diagnosis of epidural abscess can be made before the onset of any
neurological deficit, conservative treatment (antibiotics only) may be effective.

Cauda Equina syndrome

 Characterized by sensory deficit in the perineal area, urinary and fecal
incontinence and varying degree of motor deficit in the lower extremities which
persists after regression of neuraxial block
 May be permanent or may regress slowly over weeks or months
 Reported with the use of spinal microcatheters (<24 gauge) for postoperative
infusions of local anaesthetics.

Epidural Hematoma
Incidence varies from 1:150 000 (epidural) to 1:220 000(Spinal) (Tryba 1993).
Risk factors:
Difficult puncture/bleeding during catheter insertion
Peri-operative anti-coagulation therapy or thromboembolism prophylaxis
Perioperative coagulation disorder
Management:
 Early diagnosis, high index of suspicion in patient with risk factors.
 Presence of severe or increasing back pain, even in the absence of local swelling
may indicate epidural hematoma and should be investigated promptly, including
sending the patient for urgent MRI.
 Early decompression will result in better outcomes.

Subdural Hematoma
 Intracranial subdural haematoma is a rare complication of prolonged reduction of
CSF pressure resulting in high mortality and persistent neurological deficit.
 Prevention is by prompt diagnosis and treatment of Post dural puncture headache.

Spinal Cord Injury

 Traumatic injury to spinal cord and nerves roots is rare
 Anterior spinal artery syndrome giving rise to spinal cord ischemia and infarction
may occur after prolonged periods of arterial hypotension and/or the use of
adrenaline in the local anaesthetic solution.
References

1. Burke D and Wildsmith JA, 1997.Meningitis after Spinal Anaesthesia.Br J

Anaesth; 78 (6): 635-636.
2. Cashman JN and Dolin SJ, 2004: Respiratory and Haemodynamic Effects of
Acute Post-operative Pain Management: Evidence from Published Data,Br J
Anaesth,vol 93(2):212-223
3. Charney MA, 1995: Side Effects of Intrathecal/Epidural Opioids. Canadian J
Anesth vol 42(10) :891-903
4. Han IS et al, 2010: Spinal epidural hematoma after epidural anesthesia in a patient
receiving enoxaparin - A case report. Korean J Anesthesiol; 59(2): 119–122.
5. Hyderally H, 2002: Complications of Spinal Anesthesia, Mount Sinai J.Med.
69(1) 55-56
6. Candido KD, Stevens RA, 2003: Post-dural Puncture Headache: Pathophysiology,
Prevention and Treatment. Best Pract Clin Anesthesiol; 17(3):451-469
7. Li SL et al, 2010; Epidural Hematoma after Neuraxial Blockade: A Retrospective
Report from China. Anesth Analg 111(5):1322–1324
8. Macintyre PE et al, 2010: APM: SE Working Group of the Australian and New
Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain
Management Scientific Evidence: Third Edition,ANZCA & FPM,Melbourne
9. Ministry of Health Malaysia 2007.National APS Audit, MOH
10. Rathmell JP, 2005: The Role of Intrathecal Drugs in the Treatment of Acute Pain,
Anaesthesia Analgesia,101: S30-43
11. Ruan X, 2007: Drug-Related Side Effects of Long Term Intrathecal Morphine
Therapy.Pain Physician;10: 357-365
12. Schwabe K and Hopf H.B, 2001: Persistent Back Pain After Spinal Anaesthesia in
the Non-Obstetric Setting: Incidence and Prediposing Factors. Br J Anaesth
86(4):535-539.
13. Wheatley RG et al, 2001: Safety and efficacy of postoperative epidural analgesia.
Br J Anaesth; 87(1): 47–61
 CHAPTER 7
ACUTE NEUROPATHIC PAIN

Acute neuropathic pain (ANP) is a condition that is under-recognized, often difficult to

treat and one that may progress to persistent pain and disability. The incidence of acute
neuropathic pain has been reported as 1% - 3% primarily after surgery or trauma.

Neuropathic pain has been defined as “pain caused by a lesion or disease of the
somatosensory nervous system”.
Acute neuropathic pain is now recognized as one of the causes of post surgical and post
trauma pain. Early recognition of patients with acute neuropathic pain is essential
because of its high risk of progression to chronic pain.
Characteristics of neuropathic pain
 Sharp, burning, stabbing, stinging, shooting, or an electric shock like in quality.
 Allodynia and hyperalgesia.
 Superficial or deep
 Intermittent or constant.
 Spontaneous or triggered by various stimuli.
 It may be present preoperatively and can be worse after surgery.

Acute neuropathic pain can occur for the first time post operatively. This is usually due to
inflammation around nerve roots following surgery and may be temporary
For post surgical and post trauma patients in whom pain persists despite high doses of
strong opioids, acute pain neuropathic must be considered.
Severe, persistent neuropathic pain has to be investigated to exclude compression of
nerve roots for example by a haematoma or infection.
The prompt diagnosis of acute neuropathic pain is important as there is evidence that
specific early analgesic interventions may reduce the incidence of chronic pain which is
often neuropathic in nature.
Causes of acute neuropathic pain:
1. Post-operative: thoracotomy, Sternotomy, cholecystectomy, mastectomy,
amputation of a limb and other surgery associated with a risk of nerve injury
2. Post trauma: brachial plexus avulsion, lumbosacral plexus injury, spinal cord
injury and injury to peripheral nerves.
3. Infection:post herpetic neuralgia, Guillain-Barre syndrome
4. Neurological disorders: multiple sclerosis, trigeminal neuralgia and central post-
stroke pain
5. Nerve compression: Carpal Tunnel Syndrome, acute sciatica
Recommended treatments
1. Anticonvulsants
Gabapentin
Start at 300mg nocte and titrate to a maximum dose of 3600mg/day.
Side effects include dizziness, sedation, Gastro-Intestinal (GI) symptoms and mild
peripheral oedema.
Dose adjustment is recommended in renal impairment.
Pregabalin
Start at 75mg nocte and titrate up to twice daily to a maximum dose of 600mg daily.
Side effects similar to Gabapentin.
Dose adjustment needed in renal impairment.
2. Tricylic antidepressant
Amitriptyline
Start at10mg to 25 mg at bed time. Increase by 10 -25mg weekly up to a maximum of
75mg/day if tolerated
Side effects include dry mouth, sedation, disturbed vision, arrhythmia, palpitation,
postural hypotension, urinary retention and constipation.
Caution in elderly patients and cardiac disease.
Nortriptyline, desipramine
Start at10mg to 25 mg at bed time. Increase by 25mg every 3 -7 days up to a maximum
of 150mg/day if tolerated
Duloxetine
Start at 30mg/day. Increase to 60mg before bedtime after a week up to twice daily.
Nausea, vomiting, dry mouth, constipation, decreased appetite, insomnia, dizziness,
somnolence, blurred vision, increased sweating and fatigue.
Advise patients to take it with food to reduce the incidence of nausea.
3. Ketamine
The starting dose of ketamine is usually 10 -25mg intravenously over 30 minutes but this
is variable depending on effect. It is usually given with intravenous midazolam 2-5 mg to
prevent hallucinations occurring. Reduction of pain and dysaesthesia may last up to six
weeks following a single dose.
Continuous subcutaneous infusion
 Start with 1-2.5mg/kg/24hrs
 If necessary, increase by 50-100mg/24h
 Maximum reported dose is 3.6g/24h

Alternatively give as short term „burst‟ therapy

 Start with 100mg/24h
 If 100mg not effective, increase after 24h to 300mg/24h
 If 300mg not effective, increase after further 24h to 500mg/24h
 Stop 3 days after last dose increment

50% of patients respond and the regimen can be repeated prn: the duration of benefit
varies and undesirable effects are common. The use of prophylactic diazepam,
midazolam or haloperidol is recommended.

Side effects:
There is a very small therapeutic range between analgesia and side effects which include:
 20-30 per cent psychomimetic effects ( bizarre dreams or hallucinations )
 Nystagmus
 Sedation
 Euphoria
 Neurobehavioral and cognitive depression
 Tolerance
4. Lignocaine
 IV – 1 to 2 mg/kg
 Continuous IV infusion – 0.5 to 1 mg/kg/h
 Continuous subcutaneous infusion – 10 to 80 mg/h

Dose is titrated based on symptoms of local anesthetic toxicity such as lightheadedness,

dizziness, perioral numbness, slurring of speech, tinnitus, diplopia and convulsions.
Side effects are nausea, hypotension, bradycardia, hypertension, paraesthesia, dizziness
and vomiting.
Decrease the infusion rate or discontinue treatment if signs of toxicity are present.

References

1. Hayes C et al, 2002: Neuropathic Pain in the Acute Pain Service: A Prospective Study.
Acute Pain 4: 45–48.
2. Malaysian Guidelines on Management of Neuropathic Pain, Second Edition 2012:
Second Edition, Malaysian Association for Study of Pain (MASP)
3. Robert T and Wilcock A, 2007: Palliative Care Formulary, Third Edition
4. Treede RD et al, 2008: Redefinition of Neuropathic Pain and a Grading System for
Clinical Use: Consensus Statement on Clinical and Research Diagnostic Criteria.
Neurology; 70:1630–5.
 CHAPTER 8

ACUTE PAIN MANAGEMENT IN OPIOID TOLERANT PATIENTS

Opioids are commonly used for the management of cancer and non-cancer pain.
Exposure to opioids, whether recreational or therapeutic, may lead to the development of
opioid tolerance.
It is important to recognize opioid tolerant patients and plan their peri-operative
management as such patients will need higher opioid doses and may also require
additional analgesic techniques. Pain is often underestimated and under treated in opioid
tolerant patients.
The main goals in treating acute pain in the opioid tolerant patients are effective pain
relief and prevention of withdrawal symptoms.

Identification of opioid tolerant patients

There are 3 main groups of opioid tolerant patients
 Patients who have cancer pain treated with opioids
 Patients who have chronic non-cancer pain treated with opioids
 Patients who have an addiction disorder, or those with a previous disorder who
are on a maintanence programme.

Table 8.1: Terminology

Tolerance A predictable physiological decrease in the effect of a drug over time

so that a progressive increase in the amount of that drug is required to
achieve the same effect.
Tolerance develops to desired (eg analgesia) and undesired (eg
euphoria, opioid-related sedation, nausea or constipation) effects at
different rates.

Physical dependence A physiological adaptation to a drug whereby abrupt discontinuation or

reversal of that drug, or a sudden reduction in its dose, leads to a
withdrawal
(abstinence) syndrome.
Withdrawal can be terminated by administration of the same or similar
drug.
Addiction A disease that is characterized by aberrant drug seeking and
maladaptive
Drug taking behaviours that may include cravings, compulsive drug
use and
loss of control over drug use, despite the risk of physical, social and
psychological harm.
While psychoactive drugs have an addiction liability, psychological,
social,
environmental and genetic factors play an important role in the
development
of addiction.
Unlike tolerance and physical dependence, addiction is not a
predictable effect
of a drug.

Pseudoaddiction Behaviours that may seem inappropriately drug seeking but are a result
of undertreatment of pain and resolve when pain relief is adequate.

Physical withdrawal is a syndrome that occurs if an opioid is abruptly stopped, rapidly

reduced or reversed by administration of an antagonist.

Source: Adapted from Weissman & Haddox (1989), the Consensus statement from the American Academy
of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine (2001),
Alford et al (2006) and Ballantyne and LaForge (2007).

Table 8.2: Signs and symptoms of opioid withdrawal

Signs Symptoms
Sweating Restlessness
Pupillary dilatation Irritability
Tachycardia Nausea
Hypertension Abdominal cramps
Vomiting Increased sensitivity to pain
Diarrhoea Myalgia
Yawning Dysphoria
Fever / Chills Insomnia
Rhinorrhoea Anxiety
Lacrimation Craving for opioids
Pilierection

Adapted from Collett 1998

Acute pain management
It is important that an acute pain management plan is made. The plan should include the
following:
 Identification of opioid tolerant patients
 Effective pain control
 Prevention of withdrawal symptoms
 Avoidance of overdose
 Treatment of psychological disorders such as anxiety.
 A step down analgesic plan which is acceptable to the patient.

The provision of effective analgesia

A multimodal approach is recommended.
 continuation of their usual background opioid dose to prevent withdrawal
symptoms
 additional short acting opioids for acute pain.
 opioid sparing techniques such as:
o Paracetamol and NSAIDs / COX-2 inhibitors prescribed regularly
unless contraindicated.
o Local anaesthetic infiltration or using catheter techniques
o Ketamine at low doses for as a continuous intravenous infusion. Take
note about contraindications and side effects.

Low dose intravenous ketamine infusion

Make up 100mg ketamine to 50ml normal saline and infuse at 1ml / hour starting
dose. Then increase infusion rate by up to a maximum of 4mls/hr according to
response.

Midazolam may be added if required.

Continue dose of usual opioid to prevent withdrawal

If the patient normally takes oral medication but has to be nil by mouth, then an
equivalent parenteral replacement will be needed.
If a regional anaesthesia is planned, the baseline opioids may be continued in the
perioperative period with additional doses for acute pain.

Additional opioid for acute pain

 For minor procedures, short acting opioids can be administered as required. A
starting dose of one sixth of the patient‟s usual total 24 hour opioid dose,
given up to 4 hourly is recommended.
 The use of intravenous PCA is widely recommended as the treatment of
choice for administering short acting opioids as it allows dose titration and
 minimizes side effects. Patients will require increased bolus doses and may
require a background infusion if unable to take their usual dose of opioid.

Example A
Mr A has Ca Pancreas and is on 120mg sustained release morphine bd for pain
control. He is admitted with intestinal obstruction requiring an emergency laparotomy.
He is planned for PCA morphine postoperatively.
 To prevent withdrawal, the usual oral 24 hour opioid dose needs to be
maintained, i.e 240mg oral morphine.
 As he is nil by mouth this needs to be converted to an IV dose.
 Conversion ratio for oral morphine : IV morphine is 2.5 : 1 (see equianalgesic
doses )
 Total IV dose over 24 hours = 96mg, i.e a background infusion of 4mg / hour.
 The bolus dose should be started at 50% of the dose of the background
infusion (2mg), with a standard lock-out time of 5 mins.

A multimodal approach which includes the use of Paracetamol and NSAIDS should be
used if there are no contraindications.
Placement of an epidural catheter or other regional techniques wherever possible can be
used in combination with PCA which will help to reduce the overall consumption of
opioids and improve analgesia

Note that this PCA strategy is a guideline and may not be suitable for all patients in all
situations. Opioid tolerant patients need more frequent assessments and the initial PCA
regimen will need to be altered depending on the patient‟s response.

Example B
Mr B who is an ex IVDU is on a methadone maintanence program of 100mg daily. He is
admitted with PGU and requires a laparotomy for which he will be nil by mouth
postoperatively.
He is unable to take oral methadone, so we need to convert his dose of methadone to a
suitable dose of IV opioid to prevent withdrawal
 Need to convert his last 24 hours dose of methadone to oral morphine equivalents:
Oral methadone : oral morphine 1:2 or 1:3
 Using 1:2 ratio, 100mg oral methadone is equivalent to 200mg oral morphine
 200mg oral morphine is equivalent to 80mg IV morphine
 As there is incomplete cross tolerance between the different types of opioids we
reduce the equianalgesic dose of oral morphine by 50%.
 Dose of IV morphine required over 24 hours to prevent withdrawal is 40mg.
 So PCA should have morphine at 1.5mg / hr background infusion and starting
bolus dose at 50% of the background infusion ± 1mg bolus.
Example C

Miss C has Ca Stomach and is on Transdermal Fentanyl 100mcg/hour. She is unable to take
orally due to gastric outlet obstruction and has a feeding jejunostomy. She developed an
obstructed umbilical hernia that requires urgent surgery.

 The Transdermal Fentanyl should be continued at the baseline dose. (100mcg/hr)

 Additional opioids to cover for acute pain using PCA Fentanyl

Placement of an epidural catheter or other regional techniques wherever possible can be

used in combination with PCA which will help to reduce the overall consumption of
opioids and improve analgesia

Step down analgesia plan

To convert the patient from IV opioids to oral
 Calculate the patient‟s last 24 hour consumption of IV opioids and convert this
back to the oral equivalent
 Then administer 50% of this dose in a sustained release oral preparation and have
immediate release opioids prescribed on a regular basis
 The dose of immediate release opioids should be 1/6 of the calculated 24 hour
oral requirement.

Example D
An opioid tolerant patient recovering from major surgery is now able to take orally and the
plan is to convert him from his PCA morphine to oral morphine. He has used 50mg of IV
morphine in the last 24 hours
 Need to convert IV morphine dose to oral morphine equivalents – 50mg IV
morphine is equivalent to 125 mg oral morphine
 50% of the calculated oral equivalent (62.5mg) is given in a sustained release form e.g.
30mg of morphine sulphate sustained release twice daily.
 1/6 of 62.5mg is given in the immediate release form on a PRN basis e.g. oral
morphine 10mg up to 4 hourly.

Management of patients on buprenorphine

Buprenorphine is being increasingly used as a maintenance therapy in opioid addiction
disorder. It is usually used in doses ranging from 8 – 32mg. Its maximum effect at the µ
opioid receptor is less than that of a full agonist producing a ceiling effect for respiratory
depression and analgesia. It also has a very high opioid receptor affinity and its binding to
opioid receptors is not easily reversed by other opioids.
Perioperative pain management strategies for patients stabilized on buprenorphine

Minor procedures
 Continue the current buprenorphine regimen (and consider an increase by 25%)
 Maximise non-opioid treatments.

Major procedures
 Continue the usual dose of buprenorphine + 25% increase
 Maximise non-opioid analgesia
 Consider titration of intravenous opioids such as fentanyl or morphine. Patients
should be closely observed for adverse effects of sedation or respiratory
depression – HDU care is appropriate where available
Or
 Cease buprenorphine 72 hours preoperatively and commence a full opioid agonist
(sustained release morphine) 24 hours later, or earlier if opioid withdrawal is
noted.
 Additional doses of full agonist can be titrated to withdrawal symptoms
preoperatively and analgesic requirements postoperatively

Table 8.3: Comparison of oral morphine and transdermal patch dosage

Oral Morphine Buprenorphine patch Fentanyl patch

(mg in 24 hours) (mcg per hour) (mcg per hour)
10 5 -
15 10 -
30 20 -
45 - 12
60 35 -
90 52.5 25
120 70 -
180 - 50
270 - 75
360 - 100

Adapted from The British Pain Society, 2007

Summary

Guidelines for perioperative pain management in opioid tolerant patients

Preoperative
 Evaluation: Early recognition and high index of suspicion.
  Identification: Total opioid dose requirement, previous surgery/trauma resulting
in inadequate analgesia.
 Consultation: Anaesthesiologist/addiction specialist/pain specialist for
perioperative planning.
 Reassurance: Discuss concerns related to pain control and anxiety.
 Medication: Calculate opioid dose requirement and modes of administration;
provide anxiolytics and other medications as clinically indicated.
Intraoperative
 Maintain baseline opioid requirement (oral, transdermal, intravenous).
 Titrate intraoperative and postoperative opioids according to response.
 Provide peripheral nerve or plexus blockade and consider neuraxial analgesic
techniques when indicated.
 Use nonopioids as analgesic adjuncts
Postoperative
 Plan preoperatively for postoperative analgesia: Formulate a plan.
 Maintain baseline opioids.
 Use multimodal analgesic techniques.
 PCA: Use as primary therapy or as supplementation for epidural or regional
techniques.
 Continue neuraxial opioids: intrathecal or epidural analgesia
 Continue continuous neural blockade

Upon discharge
 If surgery provides complete pain relief, opioids should be slowly tapered, rather
than abruptly discontinued.
 Establish a pain management plan before discharge. Provide adequate doses of
opioid and non opioid analgesics.
 Arrange for a follow up appointment with patient‟s addictionologist./ pain
medicine specialist.
Adapted from Anaesthesiology 2004; 101:212-27: Perioperative Management of Acute Pain in the Opioid-
dependent Patient; Sukanya Mitra, Raymond Sinatra.
Table 8.4: Suggested dose conversion ratio (from Cancer Pain CPG 2010)

To Codeine Oral morphine SC morphine Oxycodone Fentanyl TD

From mg/day mg/day mg/day mg/day mcg/h
Oral codeine 8 20 12 24
mg/day

Oral morphine 8 2.5 1.5 3

mg/day
SC morphine 20 2.5 0.6 1.2
mg/day

Oxycodone 12 1.5 0.6 2

mg/day

Fentanyl TD 24 3 1.2 2
mcg/h

Notes: Yellow fill: Multiply

Pink fill: Divide

Additional conversion: Morphine 40mg/day PO = Tramadol 200mg/day PO

Methadone 100mg/day PO = Morphine 200-300mg/day PO
Table 8.5: Recommendations and Equianalgesic Dose Conversion Ratios for
Perioperative Pain Management

Commonly used opioids Recommendations Conversion ratio

Oral Methadone  Continue if allowed orally O.Methadone : O.Morphine
 Convert to oral morphine and 1: 2-3
then to IV if NBM When changing opioids, reduce
by 50% for cross tolerance/
NMDA activity
Oral Morphine  Continue if allowed orally O. Morphine : IV Morphine
 Convert to IV morphine and 2.5 : 1
maintain baseline if NBM
 Additional morphine as
indicated

Oral Oxycodone  Continue if allowed orally O.Oxycodone : IV Morphine

 Convert to IV morphine and 1: 0.6
maintain baseline if NBM
 Additional morphine as
indicated

Oral Tramadol  Continue if allowed orally O.Tramadol : O. Morphine

 Convert to IV morphine and 5:1
maintain baseline if NBM Convert oral morphine to
 Additional morphine as parenteral morphine (see above)
indicated

Oral Codeine  Continue if allowed orally O.Codeine to IV Morphine

 Convert to IV morphine and
maintain baseline if NBM O.Codeine
 Additional morphine as _________ = IV Morphine
indicated
20
Transdermal Fentanyl  Continue
patch  Additional morphine as
indicated

Transdermal  Continue
Buprenorphine patch  Additional morphine as
indicated
Please note:
There is incomplete cross-tolerance between different opioids, but the exact amount will
differ, thus equianalgesic dose are only approximations.
Depending on age, prior side effects, most experts recommend starting a new opioid at ½
-2/3 of the calculated equianalgesic dose.

References

1. Macintyre PE et al, 2010: APM:SE Working Group of the Australian and New
Zealand College of Anaesthetists and Faculty of Pain Medicine, Acute Pain
Management Scientific Evidence, 3rd Edition,ANZCA & FPM, Melbourne.
Chapter 11.7 The opioid tolerant patient.

2. Marshall S. and Jackson M, 2011: Acute Pain management for Opioid Tolerant
Patients. Updates in Anaesthesia: Vol 27(1)

3. Mitra S, Sinatra RS, 2004: Perioperative Management of Acute Pain in the Opioid
Dependant Patient. Anaesthesiology; 101:212-27

4. Ministry of Health Malaysia.Cancer Pain CPG,Putrajaya: MOH,2010

 CHAPTER 9
ANALGESIA FOR PROCEDURAL PAIN

Introduction
Pain is an important aspect of wound care. “Unresolved pain negatively affects wound
healing and has an impact on the quality of life. Pain at wound dressing procedures can
be managed by a combination of accurate assessment, suitable dressing choices, skilled
wound management and individualized analgesic regimens. For therapeutic as well as
humanitarian reasons, it is vital that clinicians know how to assess, evaluate and manage
pain.

Management of Procedural Pain

Non-pharmacological management:
 adequate preparation of the patient
 use of non-traumatic dressings
 to soak dressings before removal
 allowing patient control (e.g. allowing the patient to determine the time of the
dressing)
 relaxation / imagery

Pharmacological methods
All analgesics should be administered before a painful event. The type and route of
analgesia depends on the anticipated severity of pain, and should be modified according
to patient response.
Analgesia may be continued post-procedure, but if pain persists and is poorly controlled,
regular analgesics should be given.
It is recommended to monitor the vital signs of patients receiving intravenous or sub-
cutaneous opioids for at least 4 hours post –procedure.

Oral route

Mild to moderate pain:

Paracetamol and NSAIDs should be given at least 1 hour prior to the procedure. It can be
given together with oral weak opioids like Tramadol or DF118 (refer Appendix 6)

Moderate to severe pain:

Strong opioids like immediate release formulations of oxycodone (Oxynorm ) and
aqueous morphine - may also be administered orally half an hour prior to the procedure.

Subcutaneous route

Indications:
a) Unable to take orally
b) If patient has severe pain during the procedure despite oral analgesics.
c) If IV line is not available
S/C Morphine
 Will take at least 15 minutes to work
 Dose depends on age of patient and severity of pain
e.g. < 65yrs: 5mg -10mg
> 65yrs: 2.5mg -5mg

Intravenous route

IV morphine
Analgesia may be achieved using the Morphine Pain Protocol (Appendix 5). This
involves the administration of IV Morphine 0.5 -1 mg bolus, repeated every 5 minutes,
titrated to effect (i.e. a reduction in pain score) and monitoring for side effects
(drowsiness and respiratory depression) using the respiratory rate and the sedation score.
(Chapter 4).

Additional IV Analgesics
If the above analgesics techniques are not adequate, the following techniques may be
used. Caution: All the following should only be given by doctors who have been trained
in the administration of the analgesic.

 IV PCA Morphine with a bolus dose of 1-2 mg and a lockout interval

of 5 minutes may be used during the procedure, with the advice of the Acute Pain
Service anaesthetist.

 IV Fentanyl 0.5 mcg/kg slow bolus to be given 5-10 minutes before

the procedure, repeated during the procedure if necessary, up to a maximum of 2
mcg/kg (total dose).May be given as IV PCA Fentanyl with a bolus dose of 10-20
mcg and a lockout interval of 2-3 minutes, with the advice of the Acute Pain
Service anaesthetist.

Note:
The difference between IV Morphine and IV Fentanyl is in the onset and duration of
action, with IV Fentanyl having a faster onset but shorter duration of action. Fentanyl is
also more potent than Morphine and can rapidly cause profound sedation and respiratory
depression.

 IV Ketamine - 0.25 - 0.5 mg/kg titrated to effect.

Usually used in children, but may be used in adults in selected cases.

Note that the patient may have hallucinations with the use of this drug and IV Midazolam
1-2 mg may have to be used concomittently.

Topical local anaesthetics

Lignocaine 2% plain (max dose 3mg/kg body wt) or lignocaine 2% with adrenaline (max
dose is 7mg/kg body wt) diluted in Normal Saline. Soak gauze in LA Solution and place
on the wound for 3-5 mins before procedure.

Inhalationals
Methoxyflurane (Penthrox)
 used as an inhaler 5 mins prior to procedure
 each inhaler can be used multiple times by the same patient
 The maximum dose of methoxyflurane via the inhaler is:
 3mL to 6 mL for a single episode of severe pain
 15mL in any 7 day period (5 x 3mL bottles)
 Can only be used once in 48 hours (alternate day administration)

Contraindications
 Severe renal impairment with reduced glomerular infiltration rate (GFR) <30 mL
per minute
 Renal failure
 Hypersensitivity to fluorinated anaesthetics
 Cardiovascular instability
 A history of possible adverse reactions in either patient or relatives
 Patients unable to hold the inhaler due to impaired consciousness/cooperation
 Patients who are intoxicated with alcohol or illicit drugs
 Patients with respiratory depression, airway obstruction or airway burns
 Patients susceptible to or having a family history of Malignant Hyperthermia
 Concurrent use of tetracycline and other antibiotics of known nephrotoxic
potential are not recommended as it may result in fatal renal toxicity
 Precautions
 Diabetic patients
 Liver disease

Uncontrolled Pain

Patients whose pain is not controlled despite all the above methods should be referred to
the Acute Pain team (APS). There are other methods including the use of regional blocks
(e.g. epidural, peripheral nerve block) which can be used in selected cases but this can
only be done with the appropriate expertise and monitoring.

Patient Education

It is necessary to educate patients on their analgesics and how to take it.

They must understand that for the first 3-7 days, they will need to take their analgesics on
a regular basis and then as the wound heals, it can be on a PRN basis.

It should be emphasized that prior to any painful procedure , they will need to take their
analgesics 1 hour before the procedure as ordered.
References

1. Choiniere M et al. 1994: The Pain of Burns: Characteristics and

Correlates. Journal Trauma; 29(11): 1531-9.
2. Cousins MJ and Mazze RI, 1973: Methoxyflurane Nephrotoxicity. A
Study of Dose Response in Man. JAMA, 225 (13): 1611-1616
3. Ezike HA et al 2011: Oral Ketamine for Wound Care Procedures in Adult
Patients with Burns: South Africa Journal Anaesthesia Analgesia;17(3):
242-248
4. Grindlay J and Babl EF 2009: Efficacy and Safety of Methoxyflurane
Analgesia in the Emergency Department and Prehospital Setting.
Emergency Medicine Australasia, 21(1): 4–11.
5. Marshall MA and Ozoria HPL, 1972: Analgesia for Burns Dressing Using
Methoxyflurane. Br J Anaesth, 44:80-82
6. McGrath PG: 1990, Pain in Children, Guildford Press, New York
7. Ministry of Health Malaysia: 2008. Pain as the 5th Vital Sign Guidelines
for Doctors Management of Adult Patients, MOH
8. Principles of Best Practice, 2004: A World Union of Wound Healing
Societies Initiative – Minimising pain of wound dressing related
procedures. A concensus document. London MEP Ltd
9. Recommendations from the Prince of Wales Drug and Therapeutic
Committee, Dec 2005
10. Sussman C et al, 2007: Wound Care: a Collaborative Practical Manual:
Lippincott Williams and Wilkin.
11. Tomi K et al, 1993: Alterations in pain threshold and psychomotor
response associated with subanaesthetic concentrations of inhalation
anaesthetics in humans. Br J Anaesth; 70:684-686
 CHAPTER 10

PAEDIATRIC ACUTE PAIN MANAGEMENT

INTRODUCTION:

Significant advances have been made in the field of pain management in recent years.
The essential question is no longer whether children feel pain but how best to treat and
prevent it.
Acute pain is one of the most adverse stimuli experienced by children, occurring as a
result of injury, illness and necessary medical procedures. It is associated with increased
anxiety, avoidance, somatic symptoms and increased parent distress. Despite the
magnitude of effects that acute pain can have on children, it is often inadequately
assessed and treated.
Numerous myths and misconceptions, personal biases about pain, insufficient and
inadequate application of knowledge among caregivers contribute to the lack of effective
management. Misconceptions about pain and its management in children include the fear
of side effects like respiratory depression, cardiovascular collapse, addiction and the
notion that children especially infants and neonates have an immature nervous system
and do not feel or react to pain, and therefore do not require analgesic like adults.
It is now quite clear that the development of the physiologic mechanism and pathways for
pain perception take place during the late fetal and neonatal life. Children of all ages
including newborns feel and react to pain. There is mounting evidence that adequate pain
relief after surgery reduces period of recovery, lowers morbidity and improves outcome.
It is now widely accepted that for moral, ethical, humanitarian and physiological reasons,
pain should be anticipated and safely and effectively controlled in all children, whatever
their age, maturity or severity of illness.
This document has been prepared to give guidance to professionals involved in the acute
care of children undergoing pain management after surgery or for painful medical
procedures. This guidance is relevant to the management of children 0-12 years
undergoing surgery or painful procedures in hospital settings.
The procedures can be divided into two categories, painful diagnostic and therapeutic
(medical procedures) and surgical procedures (postoperative pain)

PRINCIPLES OF PAIN MANAGEMENT IN CHILDREN

There are some major differences between paediatric and adult pain relief.
1. For children, analgesics are calculated on mg/kg body weight basis.
2. Children do not like intramuscular (IM) injection. IM injection is unpredictable,
largely ineffective and children will deny having pain to avoid injection.
Intravenous, oral and rectal are the preferred methods of administration.
3. Pain is best prevented rather than treated. Requirements for analgesics are lower
if children are allowed to wake up comfortable and pain free following surgery or
are pretreated before painful procedures.
4. Severe pain is best treated with continuous methods of analgesic administration
(e.g. infusion, PCA).
 5. Neonates and some ex-premature infants (up to 60 weeks post-conceptual age)
may be sensitive to opioids. After administration of opioids, they must be closely
monitored in a high dependency unit or ICU.
6. Post-operative pain relief should be planned before the surgery. Preparing the
child and the family in advance with clear and simple information will help to
reduce fear and anxiety and correct misconceptions. Further some analgesic
techniques require preoperative explanation in order for the technique to be
optimally used eg. PCA.

PAIN ASSESSMENT IN CHILDREN

Assessment and management of pain are interdependent, for without adequate assessment
of pain, treatment is likely to be ineffective. Good pain assessment contributes to early
recognition, prevention as well as the effective management of pain.
It is a challenging task to obtain an objective, quantitative and accurate measurement of
pain in children, especially in young, pre-verbal children.
There are three fundamental approaches to pain assessment in children:
1. Self-report : measuring expressed experience of pain

2. Observational/behavioral : measuring behavioral distress associated with pain, or

measuring the perceived experience of pain by parent „s or carer‟s report
3. Physiological : measuring physiological arousal consequent to pain
Because pain is a subjective experience, a self assessment scale may be more preferable
and is considered the „gold standard‟ of measurement compared to an observer‟s
objective assessment and should be used wherever possible. Self report tools are
appropriate for most children aged 4 years and older and provide the most accurate
measure of the child‟s pain.
For older children and adolescents, self-report using the visual analogue scale, the
numerical rating scale is suitable while for younger children, facial expression, colour
analogue scales, pieces of hurt tool may be useful. By contrast, preverbal children and
infants must be assessed by an objective observer using objective scales such as FLACC,
modified Objective Pain Score and Objective Pain Score which relies on physiological
and behavioral observations.
In the Ministry of Health hospitals, the selection of pain measuring tools has been
standardized so as to allow a consistent approach towards pain management throughout
the country. FLACC scale is used for pain measurement in paediatric patients from age 1
month to 3 years. Wong-Baker Faces scale is used for paediatric patients from above 3
years to 7 years. For older children, the Visual Analogue / Numerical Rating Scale is
used.

METHODS OF PAIN MANAGEMENT IN CHILDREN

Preventive treatment is most effective in controlling postoperative pain. This approach

helps to minimize the emotional problems of fear and anxiety, prevents wind-up
phenomenon of CNS sensitization to noxious stimuli, ameliorates stress response and
reduces intra and post operative analgesic requirement.
Multimodal therapy is the mainstay of acute pain management. This technique uses
drugs or methods that modify nociceptive transmission at different points in the pain
pathway. By approaching the pain pathway at different points, analgesia can be produced
using minimal doses of drugs, thereby reducing side effects.

Figure 10.1: WHO Analgesic Ladder

NON-PHARMACOLOGICAL METHODS

There is increasing interest in the use of non-pharmacological techniques in the

management of acute pain. Most non-pharmacological techniques will not reduce the
intensity of pain but will help the child and family to cope better and give a sense of
being more in control. They should not be used solely but in combination with
appropriate pharmacological methods.
These techniques include distraction such as playing with favourite toys, watching
videos, video games, TV, music by head phones. Other techniques include breathing
techniques i.e. deep breathing (rhythmically with slow deep breathes) and blowing
(imaginary candles or take a deep breathe and „blow away the pain‟), hypnosis*, guided
and superhero imagery.
For infants and younger children, physical comfort measures such as cuddling, rocking,
swaddling, auditory and tactile stimulation, and suckling i.e. breast feeding and
nonnutritive sucking and/or the use of sucrose or other sweet solutions (only for
procedural acute pain) may reduce behavioral and physiological responses to acute
pain.
The environment should be made as child-friendly as possible and parental involvement
should be encouraged where possible. Preparation of the parent and child, anticipation of
and planning for each individual child‟s expected distress, and training of staff in coping
with the child and parent are methods to reduce pain and distress. Management of acute
pain in children should be individualized and tailored according to the child.
In this context, hypnosis is defined as a state of highly focused attention with a relative
diminution of peripheral awareness. In this state, it is possible to enhance control over
unwanted sensation, such as pain.

PHARMACOLOGICAL METHODS

1) Paracetamol
2) Non-steroidal anti-inflammatory drugs e.g. diclofenac,
3) Tramadol
4) Intravenous opioid infusion
5) Patient Controlled Analgesia (PCA)
6) Regional Analgesia
 Topical eg EMLA cream, lignocaine gel
 Local anaesthetic instillation
 Wound infiltration
 Peripheral nerve block


MANAGEMENT OF PROCEDURAL PAIN

Painful procedures are performed on children in order to diagnose and treat a wide
variety of disease, for example, lumbar puncture, bone marrow aspiration, intravenous
cannulation, change of dressing (Burns) and removal of drains.

Pain management for procedures should include both pharmacological and non-
pharmacological strategies whenever possible. Nonpharmacologic interventions should
be used to supplement, not to replace pharmacologic approaches. Individuals prescribing
and administering pharmacologic agents must be knowledgeable about the onset,
duration, and mechanism of action for these agents and be skilled in managing adverse
effects and complications should they occur.

Pharmacological Methods
Several factors should be considered when selecting appropriate pharmacologic agents
for patients undergoing procedures, including the type and length of the procedure, how
much pain is associated with the procedure, the setting in which the procedure will be
performed, age of the patient, accessibility to pharmacologic agents and techniques, and
availability of skilled personnel to administer and monitor the effects of the selected
pharmacologic intervention(s)

Common pharmacologic methods include:

 local anaesthetics,
  simple analgesic
 nonsteroidal antiinflammatory drugs (NSAIDs),
 Ketamine
 opioids,
 anxiolytics, and sedatives.
 Nitrous oxide (Entonox)

Some particularly invasive and painful procedures may benefit from the use of regional
(e.g., peripheral nerve block) or general anesthesia.

Local Anaesthetic
 commonly used for dermal procedures eg venepuncture, suture
 injected subcutaneously or intradermally
 applied topically to the skin eg EMLA cream. Lignocaine gel

EMLA Cream
EMLA cream consists of a eutetic mixture of 2.5% lignocaine base and 2.5% prilocaine
base in an emulsifier.
A blob of cream is placed over the chosen site and an occlusive dressing (eg Opsite,
Tegaderm) is applied to ensure skin contact and to speed up absorption.
It is effective in relieving pain associated with needling procedures such as venepuncture,
venous cannulation, arterial cannulation, vaccination and lumbar puncture.
The minimum effective application time is one hour. There is an initial phase of
vasoconstriction followed by vasodilatation. This initial vasoconstriction at site of
application sometimes make venepuncture difficult.
EMLA is not advisable for use in infants less than 3 months of age because of the
possibility of methaemoglobinaemia from the prilocaine component.

Ametop (Amethocaine)/ AnGEL

A 4% amethocaine gel is used as a percutaneous local anaesthesia. This formulation of
4% amethocaine (tetracaine) produces more rapid and prolong surface anaesthesia than
EMLA. It is used extensively for procedural pain including venepuncture, intravenous or
arterial cannulation, lumbar puncture, and others.

Lignocaine -Adrenaline -Tetracaine (LAT)

1-3ml of the solution is applied directly to the wound for 15-30 minutes using a cotton-
tipped applicator. The solution and gel have been used in children more than 1year of
age. The use of LAT should be avoided in highly vascular surfaces, mucous membrane
and wounds larger than 6 cm. Caution: If lignocaine is injected following LAT, the
maximum dose of lignocaine (5mg/kg) should not be exceeded.

Currently both Ametop and LAT are unavailable in this country. There are other topical
gels such as ELA-max (4% lignocaine) which is also unavailable. Vapo-coolant sprays,
ethyl chloride and fluoromethane, are available for intravenous cannulations and
venepunctures but may not be tolerated well by young children.
Infiltration of Local Anaesthetics
Infiltration of local anaesthetic eg lignocaine, bupivacaine or levobupivacaine into
subcutaneous area are effective for procedures like lumbar puncture, bone marrow
aspiration.

Safe maximum dose of LA

Lignocaine 7.0 (with adrenaline)
Bupivacaine 2-3
Ropivacaine 3
Levobupivacaine 2-3

Nitrous oxide (N2O) Analgesia

Nitrous oxide(N2O) can provide analgesia to facilitate diagnostic and therapeutic

procedures. It may be used in painful procedures. It is an anaesthetic agent with
significant analgesia and some amnesic and anxiolytic properties. It has a rapid onset and
predictable onset and offset and can safely be titrated to produce a state of „conscious
sedation‟.
Contraindications
 Closed head injury/raised ICP
 Respiratory distress
 Impending airway obstruction
 Pneumothorax
 Bowel obstruction
 Intoxicated/ drug overdose
 Impaired level of consciousness
 Known cobalamin-dependent inborn errors of metabolism
 Area without resuscitation and monitoring

Relative contraindications
 Infants*
 Facial/ airway burns
 Difficult airway
 Premedicated
 Ventilated in the PICU
 Extubated within the last 24 hours

* Requires an anaesthetist to be present

Fasting
 No food/ milk/ fluid or intragastric feeds for two hours prior to procedure.
 If an oral or IV premedication is to be given, the child must be fasted for 4 hours.

Pre-requisites for safe administration

 Parental consent for sedation and procedure
 Fasting
 N2O prescribed documented indicating % concentration administered
  No contra indications present
 Healthcare worker administering N2O and observing the child is allocated to this
task only
 Inability to provide N2O without oxygen
 Appropriate resuscitation equipment present
 Scavenging available

Delivery system and Administration

Premixed cylinders with 50% N2O in oxygen are available, but it is also occasionally
administered at inspired concentrations of up to 70% with oxygen.

Nitrous oxide inhalation is self-administered with a face mask or mouthpiece and

„demand valve‟ system is widely used for analgesia. It is also used in dentistry. The
system is suitable for children able to understand and operate the valve, generally those
above 5 years of age. Healthcare workers must be specifically trained in the safe and
correct technique of administration of N2O.

The self-administration demand flow system is operated by the child unaided such that
sedation leads to cessation of inhalation. Analgesia is usually achieved after 3 or 4
breaths. There must be an anti-viral, anti-bacterial filter attached to the system with
scavenging of exhaled gases. The child must have a pulse oximeter attached. Suction
equipment and resuscitation trolley must also be available. Recovery is rapid once the gas
is discontinued. 100% oxygen should be applied for 3 minutes, to prevent diffusion
hypoxia. Ensure that the child is returned safely to bed.

Continuous flow techniques of administration, where the face mask is held by a

healthcare worker rather than the child, is capable of producing deep sedation and
unconsciousness and therefore this method is not included in this document.

Safe delivery of N2O

 Provide 100% oxygen for 2-3 minutes before procedure
 Monitor HR, RR, O2 saturation, conscious state
 Administer N2O in oxygen
 Maintain verbal contact with the child at all times
 Provide 100% O2 for 3 minutes after the procedure
 Provide 100% O2 if child experiences adverse effects( desaturation, deeply
sedated)

Recovery
 Conscious level appropriate to age
 Stable vital signs
 Cough /gag reflex normal
 Absence of respiratory distress
 Absence of nausea/ vomiting
 Ambulation consistent with developmental age
Adverse effects of N2O
 Over sedation
 Airway obstruction
 Diffusion hypoxia
 Rapid expansion of air filled spaces
 Bone marrow suppression with chronic use
 Nausea
 Vomiting
 Dizziness

Repeated Exposure to NO
This may occur for children who require sedation to facilitate procedures such as
repeated dressing changes especially in burns. N2O is known to interfere with Vitamin
B12 and folate metabolism. Megaloblastic bone marrow changes can be detected
following exposures of several hours. Leucopenia, megaloblastic anaemia and sub-acute
combined degeneration of the cord are well recognized complications of prolonged
exposure to nitrous oxide.

The risks of repeated brief exposure to nitrous oxide are unknown.

 For all children requiring daily or second daily N2O for longer than two weeks
 For all children requiring N2O three times a week or more for a period of two
weeks or more:
o Add Folate 250mcg/kg (max 10mg) oral daily Add Vitamin B12 5mg/day
oral daily

KETAMINE
Ketamine is an N-methyl D-aspartate receptor antagonist that has a long history of use to
induce anaesthesia, analgesia and sedation. It can be administered orally, via the
intramuscular route or intravenously.

At low doses, it produces analgesia and in higher doses it produces a state of dissociative
anaesthesia. It somewhat preserves the pharyngeal/ laryngeal reflexes, cardiovascular
stability and less respiratory depression. However it increases secretions. When used as a
sole anaesthetic agent, it can cause hallucinations and emergence phenomenon.

Used in subanaesthetic doses (< 1mg/kg per dose IV or 1-2mg/kg per dose IM ), it is an
analgesic and amnesic agent. Ketamine has been used effectively for sedation and
analgesia for brief painful procedures and in combination with midazolam and fentanyl.

Indications
 Burns
 Repeated wound dressing
Recommended Dosage:
Oral: 2-10mg/kg (parenteral preparation can be given orally). Usually at 5mg/kg.
Intramuscular: 1-2mg/kg
Continuous infusion: as below

Preparation of solution for continuous ketamine infusion:

Add 5 mg/kg of Ketamine and make up to 50 mls with normal saline

1 ml of solution = 0.1 mg/kg of ketamine

A loading dose is usually not required. Bolus doses are not routinely given and must not
be given in the ward. Ketamine infusion must be run in an independent line.

Suggested Ketamine Infusion

Table 10.1: Suggested Ketamine Dose for Infusion

Dose mg/kg/hr Infusion rate ml/hr Max infusion rate ml/hr

0.02-0.4 mg/kg/hr 0.2 -2ml/hr 4ml/hr (20-

4ml/hr
(20-400mcg/kg/hr ) 200mcg/kg/hr )

STANDARD ORDERS for KETAMINE INFUSION

( FOR WARD NURSES AND DOCTORS )

1. Patient must be observed in the Acute Bay with pulse oximetry.

2. No opioid is to be given except on the order of the anaesthetist.
3. IV line for ketamine infusion is to be used only for infusion of ketamine
(dedicated line).
4. Monitoring:
Blood pressure, pulse rate, respiratory rate, pain score and sedation score hourly
for first 4 hours and then 4 hourly until the infusion is stopped.
5. The infusion rate must not be altered except on the order of the APS team. Bolus
administration can only be done by the APS team.
POSTOPERATIVE INSTRUCTIONS (FOR WARD NURSES)

NOTIFY APS DOCTOR IMMEDIATELY:

i) RR < 10/min (> 5 yr) or < 15/min (1-5 yrs) or < 20/min (< 1yr)

ii) Sedation score of 3 (unarousable )

iii) Inadequate analgesia (painscore>4)

iv) Hallucinations or bad dreams

MANAGEMENT OF MAJOR COMPLICATIONS

APS doctor should be notified immediately. STOP the ketamine infusion.

Hypoventilation or Unarousable :

1. Stop infusion
2. Oxygen12L/min.viaHudsonmask

NB: Hypoventilation if Respiratory rate < 10 / min. for > 5 years old

Respiratory rate < 15 / min. for 1 – 5 years old

Respiratory rate < 20 / min. for < 1 year old.

Apnoea :

1. Stop infusion
2. Ventilate with bag and mask(100%oxygen)

3. Check pulse, if absent start CPR

SUCROSE 24% /Glucose 25%

Sucrose/glucose solutions reduce physiological and behavioural indicators of stress and

pain in neonates. It may be used in painful procedures such as venepuncture, intravenous
cannulation, immunization, intramuscular injections and heel lancing. The effects of
sucrose/glucose appear to be directly related to the sweet taste of the solution with very
low volumes (0.05- 2ml), being effective within 2 minutes of administration.
Dosage and administration

Sucrose/glucose should be administered orally as a 24% or 25% solution, 1-2 minutes

before a painful stimulus, and may be repeated during a painful procedure if necessary. It
can be given using a pacifier or directly dripped (one drop at a time) on to the tongue
using a syringe, the number of applications is decided according to the child‟s response.

Upper volume limit per procedure according to gestational age:

27-31 weeks 0.5 ml maximum

32-36 weeks 1 ml maximum
> 37 weeks 2 ml maximum
Each „dip‟of the pacifier is estimated to be 0.2 ml

GUIDELINES FOR PAIN MANAGEMENT IN CHILDREN WITH BURNS

Basic Principles

1. Pain due to burn injury is complex. Other factors such as emotional distress,
traumatic memories, anticipatory fears about treatment, confinement in a new and
potentially frightening environment and discomfort may contribute to it.

2. It is better to prevent pain before it starts, because once it has begun, relief of pain is
much more difficult and the associated anxiety response complicates pain
management.

3. Optimal pain management involves treatment of the 2 main components of burn

pain: background pain and procedural pain.

Background Pain

Pain experienced by the patients while at rest, which is usually dull, continuous and
of low intensity.

Procedural Pain
Pain experienced during or after procedures like change of dressing, physiotherapy,
usually acute and short lasting, but of great intensity.
4. A multimodal approach is the mainstay in pain management of burn patients.

5. Frequent assessment of pain using a reliable pain assessment tool should be done
and analgesia adjusted to individual needs.

Management of Pain in Non-Ventilated Paediatric Patients with Burns

Initial stage (Resuscitation Phase)

During this phase, there is haemodynamic instability, the pharmacokinetics of drugs is

unpredictable and their absorption through non-intravenous routes uncertain. Therefore
intravenous administration is preferred AND drugs should be given with great care.
Use of small but frequent intravenous boluses of opioids is preferred.

 IV morphine 0.05 - 0.1 mg/kg bolus every 5 minutes till patient is comfortable.
 Pain should be evaluated before each bolus using an appropriate pain assessment
scale
 Heart rate, blood pressure, respiratory rate and oxygen saturation should be
monitored.
A) BACKGROUND PAIN

Major Burns

Options:

1). Intravenous Morphine Infusion

2). Patient Controlled Analgesia – for any child > 6 years old who is able to
use his/her hand

Minor Burns

Options:

1). Oral Opioids

Morphine sulphate: 0.3 mg/kg 4 hourly

Codeine: 0.5 - 1.0 mg/kg/dose 4 hourly
Oxycodone: 0.2 - 0.3 mg/kg/dose 4 hourly
2). Paracetamol

Oral
Loading dose – 20 mg/kg, then 15 mg/kg 4 hourly, maximum of 90
mg/kg/day
 Rectal
Loading dose – 40 mg/kg, then 20 mg/kg 8 hourly, maximum of 90
mg/kg/day.
NB: Paracetamol can be used as an adjunct to opioids if necessary

B) PROCEDURAL PAIN

Experienced during dressing changes, wound debridement, physiotherapy, lines insertion.

Can be very intense and often associated with anticipatory anxiety when previous
procedures have been painful.

General Anaesthesia
Indicated in patients:
 with extensive dressings changes and wound debridement
 with severe pain which cannot be adequately and safely controlled

Sedation
a). IV Morphine + IV Midazolam
Morphine
Initial bolus 0.1 mg/kg
Subsequent 0.05 mg/kg
Maximum 0.25 mg/kg in any 2 hour period
Wait 5 to 10 minutes between doses
Midazolam
Initial bolus 0.1 mg/kg
Subsequent 0.05 mg/kg
Maximum 0.3 mg/kg in any 2 hour period
Wait 2 to 5 minutes between doses

b). IV Ketamine + IV Midazolam

Midazolam
Initial bolus 0.1 mg/kg
Subsequent 0.05 mg/kg
Maximum 0.3 mg/kg in any 2 hour period
Wait 2 to 5 minutes between doses
Ketamine
To give glycopyrrolate 5 mcg/kg IV or atropine 0.02 mg/kg IV before initial
dose of
Ketamine

Initial dose 0.5-1 mg/kg over 30-60 sec

Subsequent 0.5 mg/kg every 5 min.

c). IV Fentanyl + IV Midazolam

 Midazolam
Initial bolus 0.1 mg/kg
Subsequent 0.05 mg/kg
Maximum 0.3 mg/kg in any 2 hour period
Wait 2 to 5 minutes between doses
Fentanyl
Initial bolus 0.5 mcg/kg over 30-60 sec
Subsequent 0.5 mcg/kg
Maximum 2 mcg/kg or total of 100 mcg

d). Oral morphine + oral midazolam

Morphine sulphate 0.3 mg/kg 1 hour before procedure supplemented by oral midazolam
0.5 mg/kg 30 min before

At end of procedure, no further opioids to be given by any route for next 4 hours.
Further analgesia can be provided by paracetamol.

Patients Already On PCA Morphine Or IV Morphine Infusion

For patients on IV morphine infusion:
 Give midazolam (for sedation)
Oral – 0.5 mg/kg 30 minutes before procedure
or
IV – 0.1 mg/kg bolus and then 0.05 mg/kg boluses

 Give a bolus of 2 ml (20g/kg) of morphine infusion every 5 min till desired

effect.

For patients on PCA morphine

 Give midazolam (for sedation)
Oral – 0.5 mg/kg 30 minutes before procedure
or
IV – 0.1 mg/kg bolus and then 0.05 mg/kg boluses
 Ask patient to press button of PCA machine for bolus doses of morphine (10
mcg/kg) every 5 min until desired effect.

MANAGEMENT OF POST-OPERATIVE PAIN

METHODS
1). Paracetamol
2). Non-steroidal anti-inflammatory drugs e.g. diclofenac,
3). Tramadol
4). Intravenous opioid infusion
5). Patient Controlled Analgesia (PCA)
6). Regional Analgesia
 Topical e.g. EMLA cream, lignocaine gel
 Local anaesthetic instillation
  Wound infiltration
 Peripheral nerve block
 Epidural infusion of local anaesthetic

PARACETAMOL

Paracetamol is a simple analgesic and antipyretic drug which is useful for all types of
mild to moderate pain. It is available for oral administration in syrup, tablet, and
dispersible form. Oral administration can be used in children from 6 months of age
onwards. Following oral administration, maximum serum concentration is reached in 30-
60 minutes.

For infants and children who do not tolerate oral medication, who are kept strictly “nil by
mouth” or who are nauseated and vomiting, paracetamol may be administered as a rectal
suppository. However, there is a wide variation of bioavailability following rectal
administration. To achieve an adequate plasma concentration, a loading dose of 40 mg/kg
rectally is recommended to achieve target plasma levels of 10-20mg/l, followed by
repetition doses every 6 h is recommended. Because of the slow onset of action, rectal
paracetamol suppository should be given after induction of anaesthesia for postoperative
pain relief. Rectal suppositories are available in doses of 125mg, 250mg and 500mg.
These suppositories should not be cut.

Table 10.2: Guidelines for Paracetamol dosing for analgesia in healthy children
(Morton & Arana)

Oral initial Dosing Max. daily Duration of

Age Rectal initial Maintenance dose
dose interval dose max dose
Group dose (mg/kg) oral / rectal (mg/kg)
(mg/kg) (hr)oral/ rectal (mg/kg/d) (hr)

28-32 O 8-12/
weeks 20 20 O 10-15/ R 15 30 48
PCA R 12

32-52
weeks 20 30 O 10-15/ R 20 O 6-8/ R8 60 48
PCA

>3
20 40 O 15/ R 20 O 4/ R6 90 72
months

PCA, - postconceptual age , O – oral, R - rectal

 Rectal administration should be avoided in neutropenic patient and in paediatric
patients undergoing anorectal surgeries.
 It is contraindicated in patients with severe liver disease.
 Caution should be exercised when prescribing paracetamol to children who are
malnourished or dehydrated.

INTRAVENOUS PARACETAMOL (PERFALGAN)

Intravenous paracetamol (Perfalgan) is now available. It provides higher effect site

concentration with higher analgesic potency. When administered intravenous, it should
be given as an infusion over 15 minutes. It is approved for the relief of mild to moderate
pain when an intravenous route is considered clinically necessary. Dosage guidelines are
based on lean body weight (LBW). For obese children, this is less than their measured
weight.

Formulation of IV Perfalgan
Aqueous solution: 10mg/ml paracetamol, 50 and 100ml vials.
Additive to this solution include: sodium phosphate dibasic dehydrate, hydrochloric acid,
sodium hydroxide, cysteine hydrochloride and mannitol.
Indications for IV Paracetamol (Perfalgan)

1. Older children who are fasting or NBM post-operatively and in whom PR

administration is contraindicated or too distressing for the paediatric patient.
Typically children undergoing laparotomy/ bowel surgery.

2. Intra-operative loading of paracetamol for children undergoing long surgical

procedures e.g. Neurosurgical, spinal surgery, craniofacial surgery, multiple
trauma orthopaedic surgery, children with mucositis where oral intake may be
likely be delayed.

 Short cases will be managed using oral paracetamol premedication or rectal

peri- operative (under GA) rectal suppositories.
 Intravenous paracetamol should not be used where alternative route of
administration (oral/ rectal) are available.
 Current recommendations for intravenous paracetamol use are limited to

 children over 1 year of age and weight > 10 kg.

 Only in anticipated short duration of therapy (72 hours)

 Table 10.3: Guidelines for Intravenous Paracetamol dosing

Weight (kg) Dose Interval (hr) Maximum daily dose

5 - <10 7.5mg/kg 4-6 30mg/kg

10-50 15mg/kg 4-6 60mg/kg

>50 1 gram 4-6 4grams

Side Effects

 Injection site pain

 Injection site reaction
 Nausea
 Vomiting
Risk Management Strategies

With the advent of a liquid product for infusion, there is potential for other (oral) liquid
Paracetamol formulation to inadvertently be injected into a drip. Individual hospital
policy documents should clearly identify safe prescribing and administration for IV
Paracetamol. The following are suggested:

 100 ml vials should be stored in pharmacy and the operating suites only.

 Perfalgan should not be stored in general paediatric wards.

 Perfalgan should be prescribed by anaesthetists, pain team and intensivists. In

general, Perfalgan may be prescribed on a regular basis (q 6 hourly) and must be
reviewed by the pain team.

 Prescriptions should clearly state the trade name of the drug (PERFALGAN) and
the generic name (Paracetamol), the route (IV), a fixed dose in mg and may also
state volume in ml. it should also state a maximum daily dose in mg.

 Perfalgan should be infused over 15 minutes using a paediatric chamber/infusion

burette. It should not be given via a syringe pump.

 Oral or rectal paracetamol should not be prescribed simultaneously with IV

paracetamol (Perfalgan)
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID)

NSAIDs are effective for mild or moderate pain. There have anti-inflammatory and
antipyretic effects. They inhibit peripheral cyclo-oxygenase and decrease prostaglandin
production, leading to possible side effects such as gastric ulcer, platelet and renal
dysfuction. NSAIDs may exacerbate asthma in a predisposed subset of asthmatics. Use
with caution in children with history of eczema, multiple allergies, and nasal polyps.
Avoid in children with liver failure.

Diclofenac ( Voltaren )

 It may be given via oral or rectal route.

 Oral: 1mg/kg
 Rectal : 1mg/kg
 Interval 8 -12 hourly
 Licensed from age of 6 months
 Suppositories should not be used in neutropenic paediatric patients or who are
severely immunocompromised.
 Particular attention should be paid to maintain hydration during the peri-
operative period.

Contraindications :

 bleeding tendencies
 renal impairment
 gastritis, ulcerative colitis, Crohn‟s disease
 liver failure
 history of allergy
 some orthopaedic procedures where bone healing may be compromised.
 Table 10.4: NSAIDs preparations, dose and route

Dose Interval Maximum daily dose

NSAID Route Licensed from age
mg/kg hours mg/kg/day

Ibuprofen 5 oral 6-8 20 3 months

Naproxen 7 oral 12 15

0.3 to 1 oral 8 3mg/kg/day for only a

Diclofenac 6 months
1 rectal 8 maximum of 2 days

TRAMADOL

Tramadol hydrochloride is a weak opioid analgesic with noradrenergic and serotonergic

properties that may contribute to its analgesic activity. It does not produce gastritis,
gastric ulcers or effect platelet aggregation. Tramadol can be given by oral route, as rectal
suppository or intravenously.

Tramadol has been shown to be effective against mild to moderate pain and may be used
in children more than 12years of age. It may produce fewer typical opioid adverse effects
such as respiratory depression, sedation, and constipation though demonstrates a
relatively high rate of nausea and vomiting. Initial slow titration of tramadol may
minimize side effects such as nausea and vomiting.

Care should be taken when prescribing tramadol if the child is on tricyclic

antidepressants, selective serotonin reuptake inhibitors, major tranquillisers, fentanyl and
pethidine. Tramadol is contraindicated in children who have taken MAO inhibitors within
the previous two weeks.

Dose oral, rectal or intravenous:

1 mg/kg 4-6 hourly
INTRAVENOUS OPIOID INFUSION

INTRODUCTION

Intravenous opioid infusion provides continuous analgesia that is consistent with rapidly
adjustable serum concentrations of opioids. They are suitable for children of all ages,
when regional analgesia is contraindicated and PCA is unsuitable. However, intravenous
opioid infusions need close observation as it is a continuous infusion and accumulation
may occur. The aim of this technique is to have a child free of pain with stable cardio
respiratory observations.

In general, Morphine is the preferred drug for children. Fentanyl is an alternative choice.
The use of Pethidine is not recommended in children because of its metabolic product
Norpethidine that can accumulate and cause central nervous system side-effects like
restlessness and convulsions.

Indications :
1. Post-operativepain
2. Burns
3. Oncology
4. Other painful conditions e.g. acute pancreatitis

Contraindications :
1. History of apnoea
2. Airway obstruction
3. Head injury, raised intracranial pressure

HOW TO PRESCRIBE AN INTRAVENOUS OPIOID INFUSION :

I. MORPHINE

1. Prior to commencing morphine infusion, the child should be titrated to comfort with
intravenous boluses of morphine. This should be administered and titrated
every 5 minutes until analgesia is achieved. The child must be continuously
monitored.

Titration of Morphine (100 mcg/ml i.e. 0.1mg diluted to 1ml in a 1ml syringe):

 < 12 months : 20 mcg/kg increments every 5 min x 5 (max)

over 25 min (40-100mcg/kg)
  12 months and under 50Kg: 50 mcg/kg increments every 5 min x 4 (max)

over 20 min. (100- 200mcg/kg)

2. Preparation of solution for infusion:

Dilute 0.5 mg/kg of Morphine in 50mls normal saline

1 ml of solution = 10 mcg/kg of morphine

3. Infusion rates will depend on the age of the patients:

Table 10.5: Suggested Morphine Infusion

Infusion rate Maximum infusion rate

Neonates 0.5-0.7 ml/hr 1ml/hr

1-3 months 0.5-1ml/hr 2ml/hr

Children > 3 months 1-2 ml/hr 4ml/hr

Bolus doses of 0.5ml – 1ml of the infusion can be given in 2 situations:

1. If pain relief is inadequate, then a prescribed bolus dose should be administered

followed by increasing the infusion rate by 0.5 – 1 ml/hr. Never leave the patient
unattended during the bolus administration.
2. To cover “incident pain“(e.g. pulling out drains, physiotherapy, dressing etc. )
A bolus dose should be given 10 – 15 minutes prior to the anticipated painful
procedure. It is extremely important to ensure that the original rate is resumed once
the bolus has been administered. Never leave the patient unattended during the bolus
administration.
Before bolus doses are given,
1. Alternative causes such as urinary retention, hunger etc. should be excluded.
2. The patient should be awake and coherent with appropriate respiratory rate for age.

2. FENTANYL

Fentanyl should only be used in the intensive care unit under close monitoring.
It should be used in children more than 1 year of age.
1. Prior to commencing fentanyl infusion, the patient should be titrated to comfort with
intravenous bolus of fentanyl. This should be administered and titrated every 5 - 10
minutes until analgesia is achieved. Fentanyl loading doses should only be given by
the Anaesthetic Team.

2. Preparationofsolution:

FENTANYL (Standard Strength)

Dilute 20mcg/kg of Fentanyl in 50mls normal saline

1 ml of solution = 0.4mcg/kg of fentanyl i.e. 1ml/hr = 0.4mcg/kg/hr

Loading Dose:
Initial bolus dose 0.4 mcg/kg (1ml)

Table 10.6: Suggested Fentanyl Infusion Fension

Only to be used > 1year of age

Infusion rate Maximum infusion rate

Children > 1 year 1-2 ml/hr 4ml/hr

STANDARD ORDERS for OPIOID INFUSION

( FOR WARD NURSES AND DOCTORS )

1. Patient must be observed in the Acute Bay with pulse oximetry.

2. No other opioid is to be given except on the order of the anaesthetist.
3. Naloxone (Narcan) must be available at the bedside.
4. IV line for opioid infusion is to be used only for infusion of opioid unless anti-reflux
valve is used.
5. Monitoring :
Blood pressure, pulse rate, respiratory rate, pain score and sedation score half-hourly
for the first 2 hours,hourly for the next 4 hours and then 4 hourly until the
infusion is stopped.
6. The infusion rate must not be altered except on the order of the APS team.
7. Bolus administration can only be done by the APS team.
POSTOPERATIVE INSTRUCTIONS (FOR WARD NURSES)

NOTIFY APS DOCTOR IMMEDIATELY :

 RR < 10/min (> 5 yr) or < 15/min (1-5 yrs) or < 20/min (< 1yr)

 Systolic BP< 80mmHg(>1yr)or<60mmHg(<1yr)

 Sedation score of 3 (unarousable )

 Inadequate analgesia (pain score >4)

 Severe vomiting or pruritus

MANAGEMENT OF MAJOR COMPLICATIONS

APS doctor should be notified immediately.

Hypoventilation or Unarousable :

1. Stop infusion
2 Oxygen12L/min.via Hudsonmask
3. Naloxone(Narcan) 0.01mg/kg
NB: Hypoventilation if Respiratory rate < 10 / min. for > 5 years old

Respiratory rate < 15 / min. for 1 – 5 years old

Respiratory rate < 20 / min. for < 1 year old.

Apnoea :

1. Stop infusion
2. Ventilate with bag and mask(100%oxygen)
3. Check pulse, if absent start CPR
4. Naloxone(Narcan) 0.01mg/kg
Severe Vomiting

1. Before any antiemetic, ensure always that patient is adequately hydrated, good
analgesia, and that hypoglycemia and hypotension are not causative factors.
2. Reduce or stop infusion if necessary.
3. Give Ondansetron 0.15mg/kg IV or Granisetron 0.05mg/kg IV over 10 min.
Recommendations for PONV Prophylaxis:

Children at increased risk of PONV

IV Ondansetron (Zofran) 0.15mg/kg OR IV Granisetron (Kytril) 0.05mg/kg over 10 min

For all children undergoing adenotonsillectomy, strabismus and laparoscopic surgery,

give IV Dexamethasone 0.15 mcg/kg (max: 4mg)

AND
IV Ondansetron (Zofran) 0.15mg/kg OR IV Granisetron (Kytril) 0.05mg/kg over 10
min

PATIENT CONTROLLED ANALGESIA (PCA)

INTRODUCTION

PCA is a technique of managing acute pain which uses a programmable pump to allow
patient to self administer their own intravenous opioid analgesia. It allows small
amounts of opioid to be given intravenously at frequent intervals, keeping the blood
levels of opioid within an effective range. This avoids having either excessive or
inadequate blood level of opioid and reduces the likelihood of ineffective analgesia or
side-effects such as excessive sedation, respiratory depression and nausea and vomiting.
The patient pushes a button if she / he feels pain. The PCA machine then delivers a small
amount of opioid into the blood stream. It can be used by any child who is able to
understand the concept of pushing a button when it hurts.
Morphine is the preferred drug for PCA.

Indications :

1. Post-operative pain
2. Burns
3. Oncology
4. Other painful conditions e.g.acute pancreatitis

Contraindications :

1. Inability to understand PCA e.g. preschool children, intellectually impaired.

2. Head injury
N.B. These contraindications are relative, and should be discussed with APS team if
doubt exists.
HOW TO PRESCRIBE PCA.

1 PCA is a specialised technique and must be commenced and supervised by anaesthetic

staff. All prescription and programming of the PCA machine are to be done by the
APS team.
2. Request for post-operative PCA should be made pre-operatively to allow for patient to
be familiar with the technique.
3. Patient starting on PCA should be titrated to comfort with intravenous boluses before
starting PCA
Preparation of solution for PCA Infusion

Morphine

1). 0.5 mg/kg of morphine make up to 50 mls with normal saline

1mlofsolution = 10mcg/kg

2 The PCA machine is programmed in mls.

Bolus dose : 1 ml (10 mcg/kg)

Lockout interval : 5 mins
Basal rate : 1 ml/hr (10 mcg/kg/hr ) – only for first 24 hours
1 hour limit : 13 mls

Fentanyl:
Caution: Only to be used if contraindication for Morphine. It must be prescribed by
an anaesthestist and monitored in intensive care or high dependency unit.

1) 20mcg/kg of fentanyl make up to 50 mls with normal saline

1 ml of solution = 0.4 mcg / kg

2) The PCA machine is programmed in mls.

Bolus dose : 1 ml (0.4 mcg/kg/ml )

Lockout interval : 5 mins

Basal rate : 0.5 ml/hr (0.2 mcg/kg/hr )

1 hour limit : 13 mls ( 5 microgram/kg in any hour)

A background infusion (basal rate) is recommended when Fentanyl is used because

of the short duration of a single bolus dose.
Other Modalities:

NCA (Nurse Controlled Analgesia) is appropriate for the control of pain infants and
pre- verbal children who cannot use a PCA. It is useful for moderate to severe pain that
has significant incident/movement component. The prescription is similar to the PCA
except that the lockout interval ranges from 10-30 minutes in any hour and it is usually
prescribed with a background infusion. It has been successfully used in hospitals overseas
but not commonly used in Malaysia.

STANDARD ORDERS (FOR WARD NURSES AND DOCTORS)

1. No other opioid is to be given except on the order of the anaesthetist / APS doctor
2. Naloxone (Narcan) is to be kept at the bedside.
3. IV line for PCA is to be used for PCA only unless anti-reflux valve is used.
4. Monitoring:
Record blood pressure, pulse rate, respiratory rate, pain score, sedation score and
vomiting score half-hourly for the first 2 hours,hourly for the next 4 hours and
then 4 hourly until the PCA is stopped.
5. Any change of PCA settings can only be made by the anaesthetic staff / APS team.
6. APS doctors to be notified if there are any problems with the PCA machine.
MANAGEMENT OF MAJOR COMPLICATIONS

APS doctor should be notified immediately.

Hypoventilation or Unarousable :

1. Stop infusion
2 Oxygen12L/min.via Hudsonmask
3. Naloxone(Narcan) 0.01mg/kg
NB: Hypoventilation if Respiratory rate < 10 / min. for > 5 years old

Respiratory rate < 15 / min. for 1 – 5 years old

Respiratory rate < 20 / min. for < 1 year old.

Apnoea :

1. Stop infusion
2. Ventilate with bag and mask(100%oxygen)
3. Check pulse, if absent start CPR
4. Naloxone(Narcan) 0.01mg/kg
Severe Vomiting

4. Before any antiemetic, ensure always that patient is adequately hydrated, good
analgesia, and that hypoglycemia and hypotension are not causative factors.
5. Reduce or stop infusion if necessary.
6. Give Ondansetron 0.15mg/kg IV or Granisetron 0.05mg/kg IV over 10 min.
Recommendations for PONV Prophylaxis:

Children at increased risk of PONV

IV Ondansetron (Zofran) 0.15mg/kg OR IV Granisetron (Kytril) 0.05mg/kg over 10 min

For all children undergoing adenotonsillectomy, strabismus and laparoscopic surgery,

give IV Dexamethasone 0.15 mcg/kg (max: 4mg) AND IV Ondansetron (Zofran)

0.15mg/kg OR IV Granisetron (Kytril) 0.05mg/kg over 10 min

LOCAL ANALGESIA

Instillation of LA

Local anaesthetics can be instilled onto small open wounds either by dropping solution
onto the wound or applying a soaked dressing to the wound. Irrigation of herniotomy
wound for 30 seconds has been shown to be as effective as nerve block.
Instillation of dilute local anaesthetics onto dressings is a useful simple method of
providing analgesia for split skin graft donor sites. Bupivacaine 0.125-0.25% with
adrenaline(1:400,000) up to a maximum of 2mg/kg of bupivacaine is placed on a foam
pad which is applied to the donor site once the graft has been taken. This provides
prolonged analgesia for this very painful site.
Pain relief can be prolonged by an infusion of the local anaesthetic solution at a rate of 1-
3ml/hr using an epidural catheter placed on the surface of the foam dressing. Care must
be taken not to exceed 0.5mg/kg/hour of bupivacaine.
Wound Infiltration

Infiltration techniques are widely used in children for providing analgesia for surface
wounds. Infiltration of the wound after inguinal herniotomy is as effective as caudal
analgesia or ilioinguinal nerve block. However analgesia is limited to the skin and
superficial tissues. Bupivacaine, Ropivacaine and Levobupivacaine provides much more
prolonged analgesia and is to be preferred than other local anaesthetics. The maximum
dose of is 2mg/kg.
Peripheral Nerve Blocks
Some of the common peripheral nerve blocks performed in children include:
 dorsal nerve block for circumcision

 ilioinguinal/ iliohypogastric nerve block for inguinal herniotomy

 femoral nerve and lateral cutaneous nerve blocks - useful in children for muscle
biopsies in the thigh, skin harvesting from anterior and lateral sides of the thigh.
It also provides analgesia for femoral shaft fracture and relieves muscle spasm.
 sciatic nerve block for surgery of the foot.

 brachial plexus block for surgery of shoulder, arm and hand.

EPIDURAL INFUSION

Introduction

Epidural infusion is the introduction of analgesic drug into the epidural space to provide
pain relief. Mixtures of local anaesthetic and opioid can be infused into the epidural space
via an indwelling catheter to provide post-operative pain relief for urological, abdominal
or thoracic surgery. The epidural catheter can be placed either in the caudal, lumbar or
thoracic areas at the time of surgery.

Contraindications :
1. Head injury or raised intracranial pressure.

2. Coagulopathy
3. Local or systemic infection.
4. Progressive neurological deficit.

HOW TO PRESCRIBE AN EPIDURAL INFUSION :

1. The epidural catheter is placed at the time of surgery, usually after induction before
surgery starts.
2. Once the epidural catheter is inserted, a bolus dose is given.
Bupivacaine 0.25% or Levobupivacaine 0.25% or Ropivacine 0.2%

0.5ml-0.75ml/kg titrated up to maximum of 2 mg/kg ++ Fentanyl 1 mcg/kg

via epidural catheter.

3. Infusion can be started ~ 1⁄2 hour after the bolus dose.

Preparation of infusion solution:

1. Levobupivacaine 0.1% / plain Bupivacaine 0.1%

10 mls Levobupivacaine 0.5% OR plain Bupivacaine 0.5%

+ 40 mls normal saline
(Total volume = 50 ml)

2.Levobupivacaine 0.125% / plain Bupivacaine 0.125%

10 mls Levobupivacaine 0.5% OR plain Bupivacaine 0.5%

+ 30 mls normal saline
(Total volume = 40 mls)

3. Ropivacaine 0.1%

25mls Ropivacaine 0.2%

+25mls normal saline
(Total volume = 50 mls)
OR

6.7mls Ropivacaine 0.75%

+ 43.3 mls normal saline
(Total volume = 50 mls)

Additive:
Fentanyl: 1-2 mcg/ml

Dosage for Infusion:

Neonates (< 5kg)

Bupivacaine 0.1% Rate: 0.1-0.2 ml/kg/hr
Levobupivacaine 0.125% Rate: 0.1-0.2 ml/kg/hr
Infants (< 1 year old / 5-10kg)

Bupivacaine 0.1% + Fentanyl 1 mcg/ ml Rate: 0.2-0.4ml/kg/hr

Ropivacaine 0.1% + Fentanyl 1mcg/ ml Rate: 0.2-0.4ml/kg/hr
Levobupivacaine 0.1% + Fentanyl 1mcg/ ml Rate: 0.2-0.4ml/kg/hr

Children > 1year old/ >10kg

Bupivacaine 0.1% + Fentanyl 2 mcg/ ml Rate: 0.2-0.4ml/kg/hr

Ropivacaine 0.1% + Fentanyl 2 mcg/ ml Rate: 0.2-0.4ml/kg/hr
Levobupivacaine 0.1% + Fentanyl 2 mcg/ ml Rate: 0.2-0.4ml/kg/hr
4. If analgesia is inadequate, a bolus dose of 0.5 ml/kg should be given followed by
increasing the rate of infusion by 0.05 – 0.1 ml / kg / hr. Do not exceed an infusion
rate of 0.4 ml/kg/hr. Following a bolus, observe the blood pressure, pulse and
respiratory rate every 15minutes for 1 hour. Pain score and motor tone should also be
observed every 15 minutes for 1 hour.
4. The catheter is usually kept for an average 48 – 72 hours post-operatively i.e. until the
patient can tolerate oral feeding and oral medication. The removal of the catheter is to
be done by the APS team.

Table 10.7: Suggested Maximum Dose Bupivacaine, Levobupivacaine and Ropivacaine

Single bolus dose Maximum Dosage

Neonates 2mg/kg

Children 2.5mg/kg

Continuous Postoperative Infusion Maximum infusion rate

Neonates 0.2mg/kg/hr

Children 0.4mg/kg/hr

STANDARD ORDERS (FOR WARD NURSES AND DOCTORS)

1. No other opioid is to be given except on the order of the anaesthetist / APS doctor.

2. Naloxone(Narcan) must be available at the bedside.

3. Monitoring
Record the blood pressure, pulse rate, respiratory rate, pain score, sedation score and
vomiting score half-hourly for the first 2 hours,hourly for the next 4 hours and
then 4 hourly until the epidural infusion is stopped.
Motor function of lower limb should be assessed 4 hourly using Bromage score (See
Appendix 3). This is important to detect the onset of complications e.g. epidural
haematoma or abscess.
To assess the motor function, ask the patient to flex their knees and ankles. For
younger or children who are unable to follow commands, try to elicit movement by
tickling the toes, or gentle knee or hip flexion. With thoracic epidural, upper limb
motor function should be assessed by testing bilateral hand and finger extension and
flexion.
The degree of motor block on both the left and right side should be assessed.
 To inform APS doctor if Bromage score is 2 - 3 or reduced hand or finger
motor function with a thoracic epidural
4. The infusion rate must not be altered except on the order of the anaesthetist / APS
doctor.
5. APS doctors are to be notified when the syringe finishes, or there are any problems
with the infusion.
POSTOPERATIVE INSTRUCTIONS (FOR WARD NURSES)

NOTIFY APS DOCTOR IMMEDIATELY:

i) RR < 10/min (> 5 yr) or < 15/min (1-5 yrs) or < 20/min (< 1yr)
ii) Systolic BP< 80 mmHg(>1yr)or< 60 mmHg(<1yr)
iii) Sedation score of 3 (unarousable)
iv) Inadequate analgesia
v) Severe vomiting or pruritus
vi) Profound weakness of lower limb (Bromage Score 2 – 3)
MANAGEMENT OF MAJOR COMPLICATIONS

NOTIFY APS DOCTORS IMMEDIATELY

Hypoventilation or unarousable
1. Stop infusion
2. Oxygen 12 L/min via Hudson mask
3. Naloxone 0.01 mg/kg IV stat

NB: Hypoventilation if respiratory rate < 10 / min. for > 5 years old
respiratory rate < 15 / min. for 1 – 5 years old
respiratory rate < 20 / min. for < 1 year old

Apnoea
1. Stop infusion
2. Ventilate with bag and mask (100 % oxygen )
3. Check pulse, if absent commence CPR
4. Naloxone 0.01 mg/kg IV stat

Convulsion
1. Stop infusion
2. Maintain airway and give 100 % oxygen
3. Ventilate if apnoeic
4. Check pulse, if absent commence CPR

High Epidural Block

(as evidenced by decreased sensation and/or motor block in the arms or respiratory
difficulty)
1. Stop infusion
2. Oxygen 12 L/min
3. Check ventilation and assist if required
4. Check pulse, if absent commence CPR
CAUTION:
Compartment Syndrome

Limb fractures and long hours in lithotomy position can sometimes be complicated by
compartment syndrome.

Cardinal signs
 Increasing pain at the site of surgery and injury (disproportionate pain)
 Pain remote to surgical site
 Increasing analgesia requirements
 Paraesthesia not attributable to analgesia
 Reduced perfusion of painful site
 Swelling
 Pain on passive movement of painful site
While it is important that analgesia does not mask these signs, analgesia should not be
withheld from children.

Unexpected increases in analgesia requirements should trigger clinical review. APS

team must be called.
 PAIN SCORING SYSTEM FOR PAEDIATRIC PATIENTS

FLACC Scale for 1 month-3 years

Category Scoring

0 1 2

Frequent to constant
No particular Occasional grimace or frown,
Face quivering chin, clenched
expression or smile withdrawn, disinterested
jaw

Normal position or Kicking or legs drawn

Legs Uneasy, restless, tense
relaxed up

Lying quietly,
Squirming, shifting back and
Activity normal position, Arched, rigid or jerking
forth, tense
moves easily

Crying steadily, screams

No cry (awake or Moans or whimpers; occasional
Cry or sobs, frequent
asleep) complaint
complaints

Reassured by occasional
Consolability Content, relaxed touching, hugging or being Difficult to console
talked to distractible

Each of the five categories (F)face, (L)legs, (A)activity, (C)cry and (C) consolability is scored from
0-2, resulting in total range of 0-10.

0 for no pain to 10 for the most severe pain.

FACES for 3-7years

Wong-Baker FACES pain rating scale

Ask the child to choose a face which best describes his or her pain. Then multiply the
score by 2 to get a maximum total score of 10. Be careful that some children might
confuse the faces as a happiness measure.
NUMERICAL SCALE for > 7 years

Refer to Chapter 4 (Assessment and Monitoring)

Explain to the child that he/she can rate the pain he/she is feeling on a scale from 0 to 10
by sliding the small bead, '0' being no pain and '10' being the worst pain that the child can
imagine. It is recorded in cm or by the faces.
Grading Severity for all three
Total Score Severity of Pain Pain Scores

0-3 Mild pain

4-6 Moderate Pain

7-10 Severe Pain

Sedation Score

0 awake alert

1 mild, wakes instantly to call

2 drowsy, arouses with shaking

3 very drowsy, difficult to arouse

S sleeping
Vomiting Score

0 Nil

1 Mild / infrequent (<2x)

2 Moderate / frequent

3 Severe

BROMAGE SCORE – ASSESSMENT OF MOTOR BLOCKADE

References

1. Anderson BJ and Allegaert K ,2009: Intravenous neonatal paracetamol dosing:

the magic of 10days.Paediatric Anaesthesia 19: 289- 295
2. Howard R et al, 2008: Good Practice in Postoperative and Procedural Pain
Management. Paed Anaesth, 18 (5) S1
3. Howard RF. 2003: Current status of pain management in children. JAMA, Vol
290 No 18, p2464-2469.
4. Jöhr M. 2000: Postoperative pain management in infants and children: New
developments. Current Opinion in Anaesthesiology; 13:285-89
5. Lonnqvist PA, Morton NS. Postoperative analgesia in infants and children: 2005B
J Anaesth; 95: 59-68
6. Neil S Morton. 1998: Acute Paediatric Pain Management – A Practical Guide.
WB Saunders
7. Paediatric and Child Health Division. The Royal College of Physicians, 2006:
Management of procedure-related pain in children. Journal of Paediatrics and
child Health; 42: S1-S29
8. Paediatric Nursing Practice Manual, 2005: Pain Assessment &
Management,Princess Margaret Hospital, Perth, Western Australia
9. Sümpelmann R & Münte S. 2003: Postoperative analgesia in infants and children.
Current Opinion in Anaesthesiology; 16:309-313
10. The Association of Paediatric Anaesthetists of Great Britain & Ireland, 2008:
Guidelines on the prevention of post-operative vomiting in children. Spring
11. The Children‟s Hospital at Westmead, Sydney. 2008: Pain Management Practice
Guideline, NSW, Australia
 CHAPTER 11

OBSTETRIC ANALGESIA AND ANAESTHESIA SERVICE (OAS)

Introduction
Labour and delivery result in severe pain in almost all women. Pain results in
physiological response that may harm the mother and the fetus. The provision of optimal
obstetric anaesthetic care of the parturient requires an appreciation of the
multidimensional nature of childbirth. It is essential for the anaesthetist to understand the
mechanisms of pain transmission during labour and delivery as well as other factors that
influence pain intensity, duration and quality. Rational pain management requires an
awareness of the underlying mechanisms involved and an understanding of how
pharmacological and non-pharmacological interventions can disrupt this mechanism.
The alleviation of pain and suffering is one of the fundamental principles guiding
medical practice, yet the amelioration of pain during childbirth has historically attracted
much controversy. In our country the methods of pain relief have been delayed by
superstition, religious beliefs and “old wives tales”, as well as opposition from some
members of the medical profession.
The three essentials of obstetric pain relief are simplicity, safety and preservation of
maternal and fetal homeostasis. With respect to the fetus, the most important is the
transfer of oxygen, which is dependent on the concentration of inhaled oxygen, uterine blood
flow, the oxygen gradient across the placenta, and the umbilical blood flow.

Principles of Pain Relief in the Obstetric patient

Pain relief in labour presents several unique problems. These may be best appreciated by
comparing several important differences between obstetrical and surgical analgesia and
anaesthesia.
1. Fetus-Infant
In surgical procedures, there is only one patient to consider, whereas during labour there
are two patients: mother and fetus. The respiratory center of the fetus is highly vulnerable
to sedative and anaesthetic drugs. Hence when these agents are given to the mother, they
rapidly cross the placenta and may cause neonatal respiratory depression.
2. Analgesia

Analgesia is essential to the safe, satisfactory and humane performance of surgical

performance and abnormal deliveries. Although analgesia is not absolutely necessary for
all spontaneous deliveries, it may relieve unnecessary suffering.

3. Duration
In most surgical procedures analgesia is required for only a few hours. Obstetric
analgesia maybe required for 12 hours or even longer.
4. Effect on Labour
Analgesic techniques used should exert little or no deleterious effect on uterine
contractions and voluntary expulsive efforts.
5. Timing
Surgical patients most often can be prepared for anaesthesia by withholding food and
fluid for several hours. Labour begins without warning and obstetrical anaesthesia maybe
required within a few hours to immediately after a full meal. During labour, aspiration of
gastric contents is a constant threat and often a major cause of serious maternal morbidity
and mortality.

Mechanisms of Pain Transmission in the Parturient

An understanding of the mechanisms of pain transmission during labour and many

factors that influence pain intensity, duration, distribution and quality is essential if
optimal labour analgesia is to be provided.

Most of these factors vary as labour progress; thus the stages of labour are considered
separately.
Figures. 11.1 and 11.2 are schematics of the peripheral nociceptive pathways involved in
the pain of childbirth.

Figure 11.1: Pain pathways in a parturient.

Figure 11.2: Dermatomes of the lower abdomen, perineal area, hips and thighs

Labour pain can be divided into the three stages of labour.

First stage of labour

Pain during the first stage of labour arises from the uterus and adnexae during
contractions.
 Pain results from dilatation of the cervix and lower uterine segment and their
subsequent mechanical distension, stretching and tearing during contractions.
 Pain intensity is related to the strength of the contractions and the pressure
generated. The minimal pressure required initiating dilatation of the cervix
and lower uterine segment is 15 mmHg. Typically intrauterine pressure must
exceed 25 mmHg before pain is experienced.
 Several chemical nociceptive mediators contribute to pain including
bradykinin, leukotrienes, prostaglandin, serotonin, lactic acid and substance P.
Pain is visceral in nature and it is poorly localized, diffuse, dull and vague. It is usually
referred often as periodic and builds to a peak.
The pain fibers are transmitted via T10, T11, T12 and L1 spinal nerves.

Second Stage of Labour

 Pain during second stage occurs when cervix is fully dilated, and continues from
the uterine body contractions and distension of the lower uterine segment.
 The progressively increasing pressure of the fetal presenting part on pelvic
structure gives rise to pain, with stretching and tearing of fascia and subcutaneous
 tissue of the lower birth canal, distension of the perineum and pressure on skeletal
muscle.
 The pain is transmitted via the pudendal nerve, a somatic derivative from the S2,
S3 and S4 sacral nerve roots.
 The pain is somatic in nature and is well localized, sharp definite, and intense.

Third Stage of Labour

The pain is associated with the expulsion of the placenta and is often not consciously
registered by the mother if placenta expulsion follows soon after delivery. However
if placenta expulsion is delayed or manually removed, pain relief is required.

Factors That May Influence the Pain of Childbirth

Table 11.1 Factors That Influence Pain

Physical Psychological and Proposed Neurohumoral

Ethnocultural Mechanism

1. Age and parity 1. Attitude towards labour 1. Endogenous opiods

2.Physical condition 2. Fear and anxiety 2.Hormones

3. Size of infant/birth canal 3. Expectation of pain 3. Placenta with or without amniotic

fluid substance

4. Abnormal fetal 4. Prior experience of pain 4. Substance P

presentation

5. Stages of Labour 5. Knowledge of childbirth 5. Nociceptin / ORL-1 receptor

system

6. Speed and Degree of 6. Support and environment 6. Spinal cord noradrenergic-

cervical dilatation cholinergic system

7. Frequency of contraction. 7. Confidence to cope with -

labour

8. Maternal position in 8. Education and social -

labour class

9. Menstrual history 9. Culture and Beliefs -

Physiological Changes in Labour
Labour is a physically demanding event that stresses the mother physiologically and
forces her to call on her cardiac, respiratory, renal, hepatic and other reserves. The mother
in whom these reserves are already compromised whether by congenital abnormalities,
disease or drug therapy may be stressed to the point that organ failure becomes a reality.
To identify and understand the pregnancy and labour induced stresses experienced by the
labouring woman, it is essential that the anesthesiologist providing obstetric pain relief
have an understanding of these physiological changes.

Respiratory System
As pain becomes severe, minute ventilation of the unmedicated parturient increases by
75-150% to 300% during the first and second stages of labour respectively. This results
in maternal hypocarbia (PaCO2 <=20 mmHg) and alkalemia (pH >7.55). Hypocarbia
may cause hypoventilation between contractions, which may result in maternal and fetal
hypoxia and loss of maternal consciousness.
Potential causes of fetal hypoxaemia during maternal hyperventilation are :
 Uteroplacental and fetoplacental vasoconstriction.
 A left shift of maternal oxyhemoglobin dissociation curve which causes O2 to
be bound tightly to maternal hemoglobin and compromises the transplacental
transfer of O2 to the fetus.

Cardiovascular System
Labour results in progressive increase in maternal cardiac output. Each uterine
contraction increases cardiac output by 10-25% and this is associated with a 5-20%
increase in blood pressure
The greatest increase in cardiac output occurs immediately after delivery due to increase
in venous return associated with relief of vena caval compression and autotransfusion that
results from uterine involution. Studies suggest that severe cardiovascular system stress
may result in adverse conditions for the fetus.
Maternal Endorphins
 Maternal concentration of beta-endorphins is increased during pregnancy.
 The increase is proportionate to the frequency and duration of uterine contractions.
 Caesarean section under general anaesthesia is associated with marked increase beta-
endorphins.
 The increase of endorphins during labour reflects the stress of labour.
 Lumbar epidural analgesia is associated with a minimal change in beta- endorphin
concentration during labour, vaginal delivery and caesarean section.

Adrenergic Response
 Pain, stress and anxiety increase maternal plasma concentration of catecholamines
during labour.
 High maternal concentration of catecholamines may be harmful for the mother and the
fetus. Pain resulted in a marked increase in circulating concentration of catecholamines
 as wall as a 50% decrease in uterine blood flow of the gravid uterus. After
administration of epidural analgesia there was a 55% decrease in plasma concentration
of epinephrine and a 25% decrease in plasma concentration of norepinephrine (Shnider
et.al).

Acid Base Balance

Pain, anxiety and increased skeletal muscle activity (eg. Hyperventilation) during labour
may result in both maternal and fetal metabolic acidosis. Woman who received effective
analgesia had less metabolic acidosis as did their fetuses than woman who delivered
without analgesia (Rooth et.al.).

Effect of Maternal Fear on the Fetus

Maternal fear during labour is a complex response and can be influence by many factors
including mother‟s expectations, her level of education, severity of pain, presence of a
support person and the labour room environment. The actions and words of physician and
nurses may promote or dispel fear during labour. Many studies have shown that maternal
fear results in a deterioration of fetal condition. Hence, effective labour analgesia
provided in a supportive and comforting environment can be one of the most effective
means of facilitating childbirth without fear.

GUIDELINES FOR REGIONAL TECHNIQUES FOR LABOUR ANALGESIA

A. Prior To Performance Of Regional Technique:

 Detailed pre-anaesthetic evaluation is performed, which includes an assessment of

patient‟s medical, surgical and anaesthetic history.
 Consent from patient taken, and risks of regional analgesia discussed.
 Establish intravenous access, minimum 18G cannula.
 Appropriate equipment and supplies for resuscitation should be checked and be
immediately available during administration of regional analgesia, including:
o Oxygen supply.
o Suction apparatus.
o Self-inflating bag and for positive-pressure ventilation.
o Face mask.
o Laryngoscope with different blades.
o Endotracheal tubes (sizes 6-7mm).
o Oropharyngeal airways.
o Drugs: Thiopentone, Suxamethonium, Atropine, Ephedrine, Phenylephrine,
Calcium chloride, Sodium bicarbonate, Naloxone, 20% lipid emulsion
(intralipid)
B. Criteria for Initiation of Epidural Analgesia for Labour
 No fetal distress (an assessment of fetal well being is performed in consultation with
the obstetrician).
 Established labour. (The patient is in labour and the obstetrician is committed in
delivering her).

Lumbar epidural analgesia is generally administered only when labour is well

established. It may however be advantageous to place an epidural catheter early when
the patient is comfortable and can be positioned easily. Patient request alone is a good
indication to provide epidural analgesia.

C. Monitoring (refer to nursing observation/pink chart)

 All patients should have CTG and non-invasive BP monitoring prior to performance
of the block.
 After the block has been performed, BP should be taken every 5 mins for the first 30
mins, then every 15 mins for the next 30 mins, after which hourly BP monitoring
should be instituted.
 Pain score should be documented before and 15 minutes after the initiation of
epidural. After that, pain score can be monitored hourly.
 Document lower limb weakness using Bromage score and level of sensory block (if
present).
 CTG should be continuous after performance of the block for continuous fetal heart
rate monitoring.
 Continual verbal communication.

D. Technique
This is a sterile procedure and full sterile precautions such as scrubbing, gown, gloves
and facemask are essential. The patient‟s skin should be appropriately prepared and
draped. A trained assistant is a prerequisite. Ensure that patient‟s hair is well kept by
using the OT cap.
 The patient is placed in a lateral decubitus or sitting position.
 The epidural space is identified under aseptic technique with a loss of resistance
technique.
 Epidural catheter is threaded 3-4 cm into the epidural space.
 Drug administration (according to protocol).
 The patient is cared for in any position comfortable to the patient. If in the supine
position, ensure left uterine displacement (LUD) to avoid aortocaval compression.
 The maternal blood pressure is measured and the fetal heart rate is monitored
continuously.
 The level of analgesia and intensity of sensory/ motor block is assessed initially after
establishing the block.
 The pain score is monitored hourly or more frequently as indicated.

PROTOCOLS FOR MANAGEMENT OF LABOUR PAIN

1. Lumbar Epidural

2. Combined Spinal-Epidural

3. PCA fentanyl

1. Lumbar Epidural

Patient Controlled Epidural Analgesia

 Insert epidural catheter

 Administer Test dose (see Table 11.2)
 5 mins after the test dose, if no complications occur, patient controlled epidural
analgesia (PCEA) is started, using either PCEA Regime 1 or 2 (see Table 11.2)
 The patient is cared for in any position comfortable to the patient. If in the supine
position, ensure left uterine displacement (LUD) to avoid aortocaval compression.
6. The patient is told that when she is nearing towards 2nd stage she will experience
perineum pain, she has to sit-up and bolus herself using the PCEA pump.

Continuous infusion technique

 Insert epidural catheter
 Administer Test dose (see Table 11.2)
 5 mins after the test dose, if no complications occur, administer a bolus dose followed
by the infusion (see Table 11.2)
7. The patient is told that when she is nearing towards 2nd stage she will experience
perineum pain, she has to sit-up and bolus herself using the PCEA pump.
 The patient is cared for in any position comfortable to the patient. If in the supine
position, ensure left uterine displacement (LUD) to avoid aortocaval compression.
8. If patient experiences pain during 2nd stage, sit patient up and top-up with 5 ml of
0.2% Ropivacaine OR 0.125% Levobupivacaine with Fentanyl 50 mcg as rescue
analgesia.
 Table 11.2 Labour Epidural Infusion Regimes

PCEA Regime 1 PCEA Regime 2 Continuous infusion

Drug 0.05% Ropivacaine + 0.1% Levobupivacaine 0.1% Ropivacaine or
Fentanyl 2 mcg /ml + Fentanyl 2 mcg /ml 0.1% Levobupivacaine +
Fentanyl 2 mcg/ml
Test dose 2ml Lignocaine 2% or
2ml Levobupivacaine 0.5% or
4ml Ropivacaine 0.2%

Initial dose Loading dose 15 mls Loading dose 10 mls 10-15 mls 0.1%
or loading Ropivacaine OR 0.1%
dose Levobupivacaine +
Fentanyl 50-100 mcg
PCEA Bolus 10 mls Bolus 5 mls Infusion rate 10 -15
Settings or Lockout interval 10 mins Lockout interval 10 mins ml/hr
Infusion Basal infusion 10 mls/hr Basal infusion 5 mls/hr
Rate One hour limit not set One hour limit not set

2nd Stage of Patient to sit up and Patient to sit up and Sit patient up and top-up
labour bolus herself using bolus herself using with 5 ml 0.2%
PCEA if perineal pain PCEA if perineal pain Ropivacaine OR 0.125%
experienced experienced Levobupivacaine +
Fentanyl 50 mcg

2. Combined Spinal-Epidural

The advantage of this technique is that pain relief is rapid. Patients who are having
frequent strong contractions will benefit from this technique.

CSE followed by Continuous infusion technique

 Once the epidural space is identified, the spinal needle is introduced through the
Tuohy needle and CSF backflow is confirmed.
o 15-25 mcg of undiluted Fentanyl +/- 0.5 mls of 0.5% Plain Bupivacaine is
injected intrathecally, after which the spinal needle is removed. The effect may
last about an hour.
o The epidural catheter is inserted and connected to the PCEA pump or infusion
pump
 No bolus is needed through the epidural.
 o The patient is cared for in any position comfortable to the patient. If in the
supine position, ensure left uterine displacement (LUD) to avoid aorto-caval
compression.

CSE followed by PCEA

PCEA may also be used, following the PCEA Regime 1 or 2 (see Table 11.2)

CSE followed by continuous infusion

A continuous infusion may also be used via the epidural catheter (see Table 11.2)

Ambulation
 Ambulation should only be considered 45 minutes after initiation of block and more
than 15 minutes after the last top-up, and only if maternal and fetal observations are
satisfactory.
 Assessment of sympathetic block and postural hypotension:
o BP to be taken both lying and sitting on edge of bed.
o Patient not to ambulate if:
 Reports any feelings of light-headedness or giddiness or nausea.
 Systolic BP whilst sitting is less than 100 mmHg or there is postural
drop in systolic BP of 20 mmHg or more.
 Assessment of motor block:
a. Patient able to sustain straight leg raise for ≥ 5 sec. on each side.
b. Patient able to weight bear - this must be tested with the help of two staff
members.
c. Patient should only ambulate within the Labour room and must be
accompanied by a nurse at all times.

3. PCA Fentanyl

 This is suitable for patients with IUD, mid-trimester termination of pregnancy or

when there are absolute or relative contraindications to neuraxial block such as,
platelet dysfunction (e.g. ITP), coagulation disorders, anticoagulant therapy, sepsis,
spinal anomaly/ history of spinal trauma/injury, high intracranial pressure (ICP).
 Fentanyl PCA is not as effective as, but is a useful substitute for regional analgesia.
 No difference in APGAR scores and the need for naloxone in newborn when
compared with epidural technique2. Nevertheless, paediatricians should be informed
and have Naloxone ready if needed.
PCA fentanyl regime:

Loading dose : 1 mcg/kg

PCA bolus : 10 – 20 mcg
Lock out interval : 5 min
Basal infusion : none
MANAGEMENT OF COMPLICATIONS OF REGIONAL ANALGESIA
Hypotension

Hypotension is defined as a 20-30% decrease in systolic blood pressure (compared with

baseline) or Systolic blood pressure of less than 100mmHg.
Maternal hypotension and its complication can be minimized or avoided in many cases if
the anaesthesiologist appropriately assess the mother‟s fluid and cardiovascular status
before proceeding with regional anaesthesia, and treats the hypotension promptly.
Management:
a. Administer only as much local anaesthetic to relieve maternal pain, as this will
reduce the extent of sympathetic block and hence reduce the risk of hypotension.
Dose should be titrated to the minimum dose necessary to achieve sensory
analgesia.
b. Position patient to ensure Left Uterine Displacement (LUD).

c. Administer IV fluids and supplement oxygen.

d. Administer IV Phenylephrine 50-100 mcg or Ephedrine (6-30mg) if the above

measures do not result in prompt increased BP.
e. If maternal bradycardia is observed, administer IV Atropine (0.4-1 mg) to block
any untoward vagal overactivity that may be contributing to the hypotension.
f. If there is profound hypotension, further investigation should be made to
determine whether an accidental intrathecal injection has occurred.

Unintentional Dural Puncture

If recognized, thread the catheter about 4 cm into the intrathecal space. The catheter will
now be managed as an intrathecal catheter. Administer 15 -25 mcg of Fentanyl +/- 0.5
mls of 0.5% plain Bupivacaine. Label the catheter clearly as “SPINAL CATHETER -
DO NOT INJECT”. Cover the filter and the injection port with transparent dressing. All
subsequent top-ups via the catheter must be given by the anaesthetic medical officer only.
Inform the staff-midwife to let the anaesthetic medical officer know when the pain score
is 4 and above. Similar top-up with fentanyl+/- plain Bupivacaine should be
administered.
Both anaesthetisiologist and obstetric specialist should be informed of the incident and
consideration given to an instrumental delivery to avoid straining. The catheter should be
left in-situ for at least 24 hours and should be removed only by the OAS team.3 The
patient should be told about the complication so as to be aware of the possible post-dural
puncture headache later. The patient should be followed-up for 3 days.
Post Dural Puncture Headache (PDPH)

 Definition: Severe postural headache thought to be due to an acute

reduction in CSF volume and pressure consequent to leakage of CSF via a dural tear.
Possibly contributed to by reflex cerebral vasodilatation

 Significance: Headache may be debilitating. The obstetric population is

especially at risk of developing PDPH. Rarely intra-, extra- or subdural haematoma
can occur. Hence severe PDPH must be treated as more than just an inconvenience to
the patient.

 Recognition: Suspect whenever subarachnoid or epidural block has been

performed. Expect in up to 80% following inadvertent dural puncture with 18G
Tuohy needle. Of those patients with headache, 50% will be mild and need no
treatment, 35% will be moderate and may require treatment and 15% will be severe,
incapacitating and always require treatment.

 Characteristics: Severe, typical occipital and bifrontal headache,

occurring when patient sits or stands and relieved by lying flat. Onset is usually 24 to
48 hours following the dural puncture. Associated symptoms include visual and
auditory disturbance, nausea and vomiting.
Differential Diagnosis for PDPH

 Meningitis

 Cerebral infarction

 Cerebral haemorrhage

 Migraine

 Pre-eclampsia

 Metabolic (hypoglycaemia, electrolyte imbalance)

Management of PDPH

 Explanation and reassurance to the patient.

 Daily (at least once) review and record, by anaesthesiology medical officer and
patient alerted to the specialist/consultant in-charge of obstetrics of the day.
 Trial of conservative management.
 Bed rest for symptomatic relief. Patient must be informed not to care for her
newborn. This responsibility has to be taken over by the ward nurse.
 Adequate (not over) hydration, oral or intravenous. At least 2.5L over 24 hours.
Analgesia: Use regular paracetamol and NSAID, providing the latter is not
contraindicated. Supplemental parenteral opioids are frequently required.
  Suggested regime:
o T. PCM 1g QID
o T. Diclofenac 50 mg TDS
o T. Tramadol 50 mg TDS
o Oral caffeine 300mg to start. Repeat 12 hourly prn. (if available)
o A cup of instant coffee contains approx 70 mg caffeine, fresh coffee 100 -
150 mg, and a can of cola 40 mg. Note this may be a cause of irritability in
breastfed babies.
o Patient should be primed for possibility of an epidural blood patch on the
first visit.

 Offer epidural blood patch from Day 2 for unrelenting or disabling headache
causing inability to care for infant and delay in discharge. Epidural blood patch is
the definitive treatment of PDPH, but if performed within 24 hours of dural
puncture has a much higher failure rate than after 24 hours.
 Prophylactic blood patching for accidental dural puncture is not widely accepted
and carries potential risks for patients who may not develop headache.
 Ensure the patient does not have local or systemic sepsis (examination, white cell
count, temperature).

Management of a blood patch procedure.

 Explain procedure and obtain consent.
 IV access and infusion of crystalloid.
 Appropriate location and skilled assistant. The ideal location is usually the
operation theatre.
 Position the patient and identify vertebral level one below that of the dural
puncture.
 Identify epidural space in the usual manner.
 Withdraw 20ml of venous blood from non-drip arm under aseptic conditions.
 Slowly inject blood into the epidural space via the Tuohy needle. Stop once 15-20
mls has been given or sooner if back pain or cessation of headache occurs.
 Send remaining blood for culture.
 Bed rest for 1-2 hours + routine observations.
 Inform obstetrician that patient will need to rest in ward for at least 24 hours
before discharge.
 Avoid straining or lifting for 4 days.
 Repeat blood patching is required in 25% of patients

Contraindications to Epidural Blood Patch

 Patient refusal e.g. Jehovah Witness
 Systemic or local sepsis.
 Blood dyscrasias.
 Anticoagulation.
 Active central axis neurological disease.
Follow-up
 All patients must be given a phone call follow-up on the day after discharge
 An appointment to the anaesthetic clinic must be given at 2 weeks after discharge
together with a discharge note

Unintentional Intravascular Injection of Local Anaesthetic

Intravenous injection of large doses of local anaesthetic causes CNS symptoms (e.g.
restlessness, dizziness, tinnitus, confusion, seizures and loss of consciousness).
Convulsions result in serious damage to mother and fetus. It also causes serious CVS
effects (e.g. bradycardia, arrhythmias, depressed ventricular function, ventricular
tachycardia and fibrillation and cardiac arrest). Bupivacaine cardiotoxicity may be fatal in
pregnant women.

Management of Unintentional Intravenous injection of Local Anaesthetic:

 Stop convulsions with a barbiturate or benzodiazepine

 Maintain Airway and Breathing by administrating 100% oxygen to maintain
maternal oxygenation. Use positive pressure ventilation if necessary. Tracheal
intubation will facilitate ventilation and help protect airway.
 Maintain Circulation by intravenous fluid and vasopressors (Ephedrine 6-30 mg).
 Monitor maternal blood pressure, ECG and oxygenation and fetal heart rate.
 Provide cardiopulmonary resuscitation (CPR) if necessary with uterine
displacement. Delivery of fetus may facilitate successful resuscitation of
mother.
 Provide Advanced Life Support as necessary.
 Intralipid 20% according to Appendix 8: Management of Severe LA Toxicity
 Prevent maternal respiratory and metabolic acidosis.

Unexpected High Block

Etiology:
 A high or total spinal block results after unintentional placement of either the
subarachnoid or subdural space, followed by injection of an epidural dose of local
anaesthetic through the catheter, or
 The epidural catheter may migrate into the subarachnoid or subdural space during
the course of labor and delivery.

Precautions:

 Aspiration alone is an inadequate method of excluding subarachnoid placement of

the catheter.
  Administration of an appropriate Test Dose and careful assessment of the
patient‟s response to the Test Dose should minimize the chance of a large dose of
local anaesthetic into the subarachnoid space.

Symptoms:

 Hypotension, dyspnoea, inability to speak and loss of consciousness.

Management of Total Spinal:
 High spinal anaesthesia may occur several minutes after an epidural injection of
local anaesthetic.
 Communicate with the patient. Agitation, dyspnoea, and difficulty may herald the
onset of total spinal anaesthesia.
 Avoid aorto-caval compression.
 Maintain Airway and Breathing by administrating 100% oxygen to maintain
maternal oxygenation.Use positive pressure ventilation if necessary. Tracheal
intubation will facilitate ventilation and help protect airway.
 Maintain Circulation by intravenous fluid and vasopressors (Phenylephrine 50-
100mcg or Ephedrine 6-30 mg ) as needed. Do not hesitate to give Adrenaline if
needed
 Monitor maternal blood pressure, ECG, oxygenation and fetal heart rate

Inadequate Analgesia
The failure rate of epidural analgesia ranges from 1.5 to 5.0%. Successful location of
epidural space is not always possible and satisfactory analgesia does not always occur
even when the epidural space has been identified correctly. Patient factors (e.g. obesity,
abnormal lumbar spine anatomy, depth of epidural space, longitudinal connective tissue
band between the dura) increase the likelihood of an unsatisfactory result.

Management of an inadequate epidural block:

a. Perform an honest evaluation of the anaesthetic. Is the catheter really in the epidural
space? If in doubt, replace the catheter.
b. If catheter is in the epidural space but block is asymmetric:
 Withdraw the catheter 0.5 to 1.0cm, place the less-blocked side in the
dependent position and administer 10 mls of local anaesthetic cocktail
 Additional 50-100 mcg of Fentanyl may be given
 If these maneuvers are unsuccessful, replace the catheter.

c. If the patient feels a change in the nature of her pain;

 ask the obstetrician to evaluate the progress of labor
 check for bladder distention
 increase the volume and/or concentration of local anaesthetic, or add an opioid
to the local anaesthetic
Pruritus

Pruritus is the most common side effect of intrathecal opioid administration. It may be
related to disturbance of sensory input, which results from rostral spread of the opioid
within the CSF to the level of the trigeminal nucleus or subnucleus caudalis. It is not due
to histamine release.

Management of Pruritus:

 Reassurance, as effects are normally transient and self limiting

 In severe cases, titration of IV Naloxone 40 mcg every 5 minutes up to 400 mcg
or intravenous Nalbuphine 2.5 – 5mg
 Avoid antihistamines as it may cause more sedation and increase the risk of
respiratory depression

POST-OPERATIVE ANALGESIA

Objectives:

 To provide an appropriate management plan for analgesia following a routine

caesarean section using a multimodal approach.
 To provide safe and effective post-operative analgesia that is safe for both mother
and baby

Options:
 Intrathecal Morphine

 Epidural Morphine

 Epidural cocktail

 Patient Controlled Analgesia (PCA) using morphine

All the techniques above should be supplemented with oral or suppository Paracetamol
and/or NSAIDs.

Intrathecal morphine
Introduction

 Onset of action is slow, up to 45 minutes and has a prolonged duration of action after
a single bolus dose (up to 24 hours of analgesic benefit) following administration.
Indication
Analgesia following caesarean section in a woman having spinal anaesthesia for
caesarean section

Anaesthetic Problems (dose-dependent side-effects)

 Pruritus: incidence of 60%; 1/6 need specific treatment

 Nausea and vomiting: incidence of 40-50%; severe cyclical form for 10-12 hours in
2-3%
 Herpes labialis reactivation; a clear association after intrathecal Morphine has not
been established but avoid Morphine if there is strong history of herpes.
 Late respiratory depression (up to 24 hours after administration) - clinically
significant depression or arrest has not been reported in this population within the
usual clinical dose range of up to 0.25 mg when intrathecal Morphine is used in
isolation, i.e. with no other parenteral or intrathecal opioids
 Potential for significant opioid side-effects when other parenteral opioids or sedatives
administered within the first 24 hours after administration
 There is increased risk of sedation or respiratory depression for up to 24 hours in the
presence of morbid obesity or when additional sedative drugs are used.

Contraindications

 Allergy to Morphine
 Sensitivity to opioids, e.g. previous severe nausea/vomiting
 Morbid obesity
 Previous herpes labialis infection

Preparation

 Given intraoperatively with spinal anaesthesia for LSCS itself

 Dose 0.1 – 0.2 mg (100 - 200 mcg)
 Example : To prepare 0.15mg :
o Take 1 mg (0.1ml) of Morphine in 1 ml syringe. Add 0.9ml 0.5% Heavy
Bupivacaine and discard 0.85 ml. Administer the remaining 0.15ml (150 mcg)
morphine with the desired amount of 0.5% heavy Bupivacaine +/- Fentanyl

A typical patient may be given 1.8 ml heavy Bupivacaine + 22.5 mcg Fentanyl (0.45ml)
+ 150 mcg morphine (0.15ml) = total volume 2.4 mls. Please adjust the dose at your
discretion.
Post-operative Management

 Routine post-caesarean section observations - hourly pulse, respiratory rate and blood
pressure for four hours and then 4-hourly.
 No other sedative or parenteral opioids in the first 24 hours.

Management of Side Effects

Pruritus

 Face, nose and upper extremities are the areas involved

 Possible mechanism – μ receptor mediated, stimulation of trigeminal nerve,
oestrogen, itch centre in the brain
 Usually requires no treatment. Reassure patient that the presence of this side
effect indicates that the morphine is working and it should subside within a day
 Administer IV Naloxone 40 mcg boluses to effect if required (maximum 400
mcg total) in extreme cases.
 Avoid Antihistamines – this will cause sedation and is not the proper antidote as
this side effect is not an allergic reaction

Nausea and vomiting

See “Prevention and management of postoperative nausea and vomiting associated with
caesarean section"

Inadequate analgesia
 This is extremely uncommon, particularly if combined with NSAIDs and
women encouraged to take oral analgesics as soon as tolerated.
 IV patient-controlled analgesia (PCA) is appropriate if there is complete
failure of therapy. Hourly RR observation is mandatory if initiated within
the first 24 hours following intrathecal morphine

Respiratory depression (RR < 8)

 Call OAS team / anaesthetisiologist.
 Administer high-flow oxygen via face-mask
 Administer Naloxone 0.1mg IV or subcutaneous and titrate to
effect up to 0.4mg
Epidural morphine

Introduction
Its onset of action is slow, up to 45 minutes and has a prolonged duration of action after a
single bolus dose (up to 24 hours of analgesic benefit) following administration.
Indications

 Analgesia following caesarean section in a woman who has an epidural catheter in

situ
Contraindications:

 Allergy to Morphine
 Sensitivity to opioids, e.g. previous severe nausea/vomiting
 Morbid obesity
Technique

- Administered at the end of surgery

- Dose: 3 mg
- To prepare: Take 10 mg (1 ml) of Morphine in 10 ml syringe. Add 9 ml normal saline
and discard 7 ml. Administer the remaining 3 ml (3 mg) Morphine and flush the
catheter with 2 mls normal saline.
- Epidural catheter to be removed in OR before discharge to the ward. Document
complete removal of catheter.

Post-operative Management

- Routine post-caesarean section observations - hourly pulse, respiratory rate and blood
pressure for four hours and then 4-hourly.
- No other sedative or parenteral opioids in the first 24 hours.

Management of Side Effects

Refer to “management of side effects of intrathecal morphine”

N.B. Alert stickers attached to the patients medication chart to remind ward doctors not to
prescribe additional opioids.
SPINAL / EPIDURAL MORPHINE ADMINISTERED

DATE: TIME:

No opioids/sedatives to be given within first 24 hours.

If pain relief is inadequate, please inform the APS team.

If RR < 8, give oxygen via high-flow mask @ 15L/m.

Give naloxone IV 0.1mg stat and titrate to effect up

to a maximum of 0.4mg. Call APS team or ICU MO

Epidural cocktail

When neuraxial morphine is contraindicated, epidural cocktail of 0.1% Ropivacaine +

Fentanyl 2mcg/ml can be administered during the postoperative period as part of a CSE
or epidural technique.

Patient controlled analgesia

 Following LSCS done under GA or when regional technique is contraindicated.

 Morphine is the drug most commonly used.
 If patient is allergic to Morphine --> Fentanyl or Tramadol would be the alternatives
 Anaesthetic MO need to fill-up relevant forms and arrange for PCA pump as for any
other post-op patient on PCA
 No opioids / sedatives should be given while PCA is in progress. If pain relief
inadequate, please inform the OAS team.

Supplemental analgesia

To be given to all patients unless contraindicated

Paracetamol (PCM)

1 gram suppository at the end of surgery

Tab PCM 1 gram 6 hourly strictly for 3 days to be written in patient medication chart
Contraindication:
o Allergy to paracetamol
o Liver disease (use with caution or in reduced dose)
o Suppositories are contraindicated in proctitis
Diclofenac

 50-100 mg suppository at the end of surgery

 To be started 18 hours after initial 100mg suppository: Tab Diclofenac 50 mg 8
hourly (with food) strictly for 3 days to be written in patient medication chart
 Contraindication
o Allergy to aspirin or other NSAIDs
o History of gastric or duodenal ulcer or gastrointestinal bleeding
o NSAID induced asthma
o Pre-eclampsia/HELLP Syndrome
o Coagulation disorder
o Major haemorrhage (until review the following day)
o Hypovolaemia
o Renal impairment
o Suppositories are contraindicated in proctitis

Note:

Paracetamol and diclofenac may be regarded as mild-moderate analgesic agents.

However, it is still useful as part of the multimodal approach of pain management.

Tramadol (50-100 mg tds) can be used as an alternative if there are contraindications for
the use of Diclofenac or paracetamol but can only be initiated 24 hours after
spinal/epidural Morphine (will cause more PONV). Tramadol also interacts with 5HT3
antagonists (Ondansetron, Granisetron) making both drugs less effective.

Prevention of Post-operative Nausea and Vomiting (PONV) Associated with

Caesarean Section

 Higher incidence following spinal, epidural and PCA Morphine

 The risk assessment for PONV based upon the following 4 factors:
1. Female sex
2. Non-smoking status
3. History of PONV or motion sickness
4. Post-operative opioid use

Table 11.3: Incidence of PONV by Number of Risk Factors

Number of Risks Incidence of PONV (%)

0 10

1 20
 2 40

3 60

4 80

 Prophylaxis to be given in OT after clamping of the umbilical cord

 All patients : IV Dexamethasone 8 mg + IV Ondansetron 4mg or Granisetron 1
mg
 For treatment of PONV in ward if the above measures failed (to be ordered by
anaesthetic MO):
 IV Metoclopramide 10mg 8 hourly/PRN or repeat IV Ondansetron 4 mg or
Granisetron 1 mg stat dose for severe PONV

Other Issues:

 Please do not keep the bladder catheter (CBD) and IV drip in-situ merely because
OAS techniques are being used. The bladder catheter and IV drip may be
discontinued once the obstetric team is satisfied, regardless of OAS techniques.
Please however leave the IV cannula in-situ and use a stopper.
 Our aim is to have a pain-free, ambulatory patient. The OAS infusion pumps may be
attached to a drip stand, and the patient may walk around, pushing the drip stand.
Once the patient is able to tolerate fluids orally, oral analgesia (Paracetamol,
NSAIDs) should be given strictly as ordered.
 Epidural Catheter
o If catheter is disconnected from filter, the catheter is to be removed by OAS
doctor/nurse immediately.
o The OAS nurse and doctor are the only personnel allowed to inject drugs or other
solutions through the epidural catheter.
References

1. Abboud TK, Shnider SM, Dailey PA, et al. 1984: Intrathecal administration of
hyperbaric morphine for the relief of pain in labour. Br J Anaesth; 56: 1351-
60.
2. Association of Anaesthetists of Great Britain and Ireland, 2008,
http://www.aagbi.org/publications/guidelines/docs/latoxicity07.pdf (accessed
13 October 2008).
3. Apfel CC et al, 1999: A Simplified Risk Score for Predicting Postoperative
Nausea and Vomiting. Conclusions from Cross-validations between Two
Centers. Anesthesiology; 91:693–700

4. Nikkola EM et al, 1997: Intravenous PCA during labour. Can J Anaesth;

44(12):1248-1255

5. Camorcia M et al, 2004: Epidural Test Dose with Levobupivacaine and

Ropivacaine: Determination of ED50 Motor Block after Spinal
Administration. Br J Anaesth; 92(6): 850-853.

6. Melzack R. The Myth of Painless Childbirth, Pain 1984;19:321–337

7. Rutter SV et al, 2001: Management of accidental dural puncture in labour

with intrathecal catheters: an analysis of 10 years experience. Int J Obs
Anaesth; 10:177-181
8. Sah W et al, 2007: Efficacy of ropivacaine, bupivacaine and levobupivacaine
for labour epidural analgesia. J Clin Anaesth; 19(3): 214-217.

9. Yang T et al, 1999: Comparison of 0.25mg and 0.1mg intrathecal morphine

for analgesia after Cesarean section. Can J Anaesth; 46: 856-860.
 CHAPTER 12
MANAGEMENT OF PAIN IN ADULT DAY SURGERY PATIENTS

Introduction
Pain is the most common problem after discharge of day surgery patients. A survey of
more than 5000 patients published in 2004 found that 30% of patient had moderate to
severe pain after ambulatory surgery (McGrath 2004). Uncontrolled pain can lead of
prolonged stay in the day surgery unit and is a major cause of nausea and vomiting,
which further delays discharge. Pain also limits early mobilisation and early return to
normal function, is the most common reason for unanticipated hospital admission and
leads to patient dissatisfaction and increased healthcare costs.

Effective management of acute postoperative pain in day surgery should include the
following:

 Education and training of all staff

 Education of patients and their carers regarding analgesic options that are
available (pharmacological and non-pharmacological)
 Identification of at risk groups
 Having an established formal protocol and guidelines covering acute pain
management which are relevant to each institution
 Having a formal quality assurance program to regularly evaluate the effectiveness
of acute pain management

General Principles

 Optimal postoperative pain control for day surgery should be effective and safe,
produce minimal side-effects, facilitate recovery and be easily managed by
patients at home.

 Analgesics should be prescribed on a regular schedule, not on a “PRN” basis.

 Analgesics should provide a general background level of analgesia sufficient to

permit normal activities.

 Additional analgesic supplements should be provided to cover any painful

activity.

 The use of pre-packaged take-home analgesics specific to the type of surgery and
breakthrough medication can lead to improved pain control and sleep.
  Regular monitoring and recording of each patient's pain intensity and treatment
efficacy should be done. (refer to Chapter 4)

 To improve the effectiveness of acute pain management in day surgery,

multimodal or balanced analgesia is strongly recommended.

 To ensure that patients are comfortable and relatively pain-free after the operation,
postoperative pain control must be started pre-emptively.

 Cases done under regional anaesthesia alone should be started on

supplemental analgesics (NSAIDs, COX-2 inhibitors and/or opioids) before
the block wears off.

 Prior planning of analgesic therapy is necessary and can be done according to

the anticipated level of pain according to surgery.

Techniques for Intraoperative analgesia

A. Regional Analgesia

1. Wound infiltration with local anaesthetics (LA) has been shown to be a simple and
effective method for immediate postoperative pain relief and is highly recommended.
Bupivacaine or Levo-bupivacaine 0.25% or Ropivacaine 0.375% are preferable as
they have a longer effect than lignocaine 2.0%.

2. Peripheral nerve blocks are useful in day surgery because they provide site specific
anaesthesia and analgesia with little systemic and hemodynamic effects.

 The type of blocks varies according to the surgery. Although many peripheral
nerve blocks are feasible, only a few are regularly practiced in day surgery, as listed
below. With the increasing use of ultrasound-guided nerve blocks as well as the
availability of peripheral nerve catheters, the trend is to use more blocks in day
surgery patients.

 Continuous peripheral nerve block (CPNB) with perineural catheters and

continuous infusions of local anaesthetics result in sustained postoperative analgesia,
earlier discharge, less sleep disturbance and improved rehabilitation of patients at
home. In addition, they also have an opioid sparing effect. CPNB have increased the
scope of ambulatory surgery cases, as patients may be sent home with infusions of
LA for 24-48 hours by continuous infusion or by patient-controlled devices which
allow intermittent bolus doses of LA.

 If patients are sent home with CPNB, we need to provide extensive oral and
written instructions to the patients as well as relatives and 24-hour telephone access
 to the anaesthesiologist during the period of block. In Malaysia, this has not been
practiced yet but is expected to catch on in the near future.

 Ropivacaine and levo-bupivacaine are usually the agents of choice due to their
improved safety profile, particularly with respect to cardiovascular toxicity.

 Blocks should only be performed by experienced anaesthesiologists or under the

direct supervision of an expert.

 Examples of commonly used peripheral nerve blocks:

o Interscalene nerve block for proximal humerus and shoulder surgery. This
may be done with a catheter technique and patients can be sent home with LA
infusions through disposable infusion devices. 
o Infraclavicular block for surgery to the elbow, forearm and hand. 
o Axillary nerve block for procedures on the forearm and hand. This is
preferred to supraclavicular block because of the risk of pneumothorax with the latter
block.
o Ankle block for foot surgery.
o Ilioinguinal, iliohypogastric and genitofemoral nerve block for inguinal
hernia surgery. 
o Sciatic and femoral nerve block or popliteal nerve block for knee surgery.

3. Central neural block

 Intrathecal (spinal) anaesthesia may be performed for operations such as knee

arthroscopy, and other lower limb surgery.

 As with all regional blocks, supplementation with other forms of analgesia should
started before the block effect wears off.

 Epidural or combined spinal-epidural (CSE) anaesthesia are not commonly done

for day surgery cases, as the operations done here are relatively short in duration.

 Low dose low concentration local anaesthetic given spinally with the addition of a
short acting opioid (fentanyl) gives good postoperative analgesia and a smooth
transition to oral analgesia.

 CNB is not frequently done in day surgery patients unless it is done for the first
patient on the list. This is because the patiens cannot be discharged until the block
is fully worn off, and this may take some hours.
B. Parenteral and oral analgesics

Paracetamol (PCM)
1. May be used
 Orally as premedication or postoperatively in the day surgery ward.
 Rectally after induction of anaesthesia. Note that patients and/or parents
should be informed of the intention to use rectal administration of drugs.

2. It is often used in combination with other drugs, such as weak opioids and
NSAIDs, as part of balanced analgesia.

3. Paracetamol may be given in doses limited to 4 g/day in adults. It should be

used with caution in patients with liver disease.

Non-steroidal anti-inflammatory drugs (NSAIDs) & Cyclo-oxygenase2 inhibitors

(Coxibs)
1. NSAIDs or Coxibs are the drugs of choice and form the basis of most day
surgery analgesic regimes, in patients with no contraindications.
2. NSAIDs or Coxibs may be used:
 Orally as premedication or postoperatively in the day surgery ward.
 Rectally after induction of anaesthesia. Note that patients and/or parents
should be informed of the intention to use rectal administration of drugs.
 Intravenously at or after induction of anaesthesia.
 Intramuscular NSAIDs should be avoided. Diclofenac given IM can lead
to haematoma and abscess formation.

(For doses of the different NSAIDs and Coxibs, please refer to the Drug Formulary,
Appendix 9)

Morphine
The routine use of morphine is not advisable for day surgery as it causes significant
nausea and vomiting and excessive sedation.

Fentanyl
1. Fentanyl is more useful for day surgery analgesia as it is highly potent, has a rapid
onset and a short initial half-life.
2. It may be used:
 for intra-operative analgesia at doses of 1-2 ug/kg
 as a rescue analgesic for treatment of severe pain in the Post-Anaesthesia Care
Unit (PACU)
3. High dose fentanyl should be avoided as it can lead to postoperative nausea and
vomiting (PONV) and somnolence.
Oxycodone

1. Oxycodone is available as IV or oral preparations. IV oxycodone may be used for

intraoperative analgesia or in the PACU.
2. Oral oxycodone (immediate release (IR) formation) may also be used for
postoperative analgesia in the PACU and continued at home.

Remifentanil
1. Remifentanil has limited use in day surgery because of its extremely short duration of
action.

Tramadol
1. Tramadol is useful for postoperative analgesia in patients whose pain is expected to
be moderate to severe. It can be administered IV or orally.
2. Its main disadvantage is a high incidence of nausea and vomiting.
3. The commonly used dose of Tramadol is 50 mg 6-8 hourly.
4. Ultracet ®, a combination of Tramadol 37.5 mg and Paracetamol 325 mg, may also
be used for postoperative analgesia.

Codeine / Dihydrocodeine
1. Dihydrocodeine is safe and is effective for postoperative analgesia in patients with
moderate pain. Only oral Dihydrocodeine is available (DF118).
2. Codeine is only available in combination with paracetamol, as an oral preparation
(Panadeine ®)

Pain management in the Post-Anaesthesia Care Unit (PACU)

 Whatever the intraoperative analgesia used, additional analgesia is necessary for

those patients with moderate to severe pain (pain score ≥4) in the RR.
 Rapid and short-acting IV opioids may be titrated to the desired effect. Fentanyl is
the opioid of choice in the immediate recovery period. IV fentanyl 10-20 mcg boluses
can be given repeatedly at 3 to 5 minute intervals while closely monitoring the
patient‟s sedation score, respiratory rate and haemodynamics.
 Supplementary analgesics should also be given, to take effect as the short-acting
opioid wears off or to take effect before any regional block wears off.
 Any unexplained pain must be evaluated by the surgical team.

Pain management in the Day Surgery Unit before discharge

1. There should be a smooth transition to oral medications in the Day Surgery Unit and
patients are allowed to take them as soon as they can tolerate orally.
2. For mild to moderate pain, oral analgesics are usually sufficient. Paracetamol,
NSAIDs or COX-2 inhibitors are the first line of treatment if not given intra- or pre-
operatively.

3. For moderate to severe pain requiring rapid relief, parenteral opioids such as IV
Tramadol 0.5-1mg/kg or IV Oxycodone 2-5 mg in titrated doses, may be used.
Alternatively, oral drugs such as Tramadol 50 mg or IR oxycodone (Oxynorm ®) 5-
10 mg may be used.

Non-pharmacological methods of pain management

Non pharmacological techniques are useful in Day Surgery patients and include the
following:

1. Physical methods (RICE - Rest, Ice, Compression, Elevation)

a. Ice packs help reduce oedema, reduce muscle spasm and alter the patient‟s pain
threshold.

b. Bandages immobilize and reduce pain but if applied too tightly, they can increase
postoperative pain and local oedema, impede the patient‟s ability to mobilize and
early return to function.

c. Elevation of the affected part (e.g. above the heart level for upper limbs) reduces
oedema which is a significant cause of pain immediately after surgery.

2. Transcutaneous electric nerve stimulation (TENS) has been shown to be useful in

allowing an increased range of function in patients postoperatively, reducing
their pain scores and requirements for analgesia.

3. Reassurance, relaxation and distraction, hypnotherapy, aromatherapy, yoga

acupressure and music therapies may reduce pain and anxiety postoperatively.

Analgesic therapy on discharge

1. The clinician should review the patient prior to discharge, assess the efficacy of pain
relief and provide specific drugs and discharge instructions.

2. Patients should be comfortable and their pain controllable with oral analgesics before
they are discharged from the day surgery unit.

3. Patients must be provided with an adequate supply of analgesics to take home.

4. Comprehensive written information about when and how often to take the analgesic
medications must be given to the patient as well as the carer, because of the amnesic
effects of certain anaesthetic agents.

5. An emergency telephone number (depending on your hospital protocol) should be

given to the patient in case problems persist.

6. It is important to encourage patients to take analgesics pre-emptively and regularly,

starting before the effect of the local anaesthetic has worn off.

7. Before going to bed, oral analgesia should be taken so that the patient does not wake
up in severe pain.

8. Postoperative telephone calls should be made to check on patients at home. After

discharge, patient follow-up is essential to monitor the effectiveness of pain treatment.

Analgesia according to the anticipated severity of pain

1. The degree of postoperative pain can be anticipated by the surgery type and the pain
managed accordingly. As far as possible, all pain should be treated, whether it is mild,
moderate or severe.
2. Table 12.1 lists the anticipated severity of pain for common day surgery procedures
together with the recommended perioperative analgesia. As different patients may
experience different levels of pain perioperatively, the analgesia will still have to be
titrated to the patient‟s needs.
3. Before discharge from the Day Care Unit, the patient should not experience more
than mild pain (i.e. pain score ≤3)
4. Table 12.2 gives the suggested analgesic regimes for take-home analgesia according
to the anticipated severity of pain. The amount of analgesia required in the PACU can
be used as an indicator for the analgesic requirements at home.

Special considerations

Groups of patients requiring special considerations include the following:

1. Elderly patients
a. May develop oversedation disproportionate to the amount of opiate administered,
and dosages should be reduced appropriately.
b. Problems of dementia, deafness and visual disturbances may make pain assessment
difficult.
c. Be careful of renal toxicity and gastric irritation with the use of NSAIDs.
2. Cognitively impaired, emotionally disturbed and non-English/non-BM speaking
patients require extra explanation, attention and time with interpreters or specialized
health care workers.

3. Patients with chronic pain on opioids prior to surgery may require higher starting and
maintenance doses postoperatively.

4. Patients who receive central neural blockade (e.g. spinal anaesthesia) for the
surgery should have return of their motor and sensory function and preferably void
before discharge. Those who have residual numbness after limb anaesthesia should be
advised about limb protection. Supplementary analgesics should be given before the
block wears off.

Conclusion
 Satisfactory pain control is pivotal to the success and popularity of day surgery.
As more extensive and painful procedures are being performed as day surgery,
there will be a pressing need to introduce better drug combinations and newer
pain relief methods to alleviate pain.

 Pain management guidelines can standardize and simplify a safe and effective
analgesic regime. Nevertheless, each patient should be further individualized and
his or her pain treatment tailored to produce excellent pain relief after day
surgery.
Table 12.1: Anticipated Postoperative Pain by Surgery and Selection of Peri-
operative Analgesia

Severity of Pain
MILD PAIN MODERATE PAIN SEVERE PAIN
Type of Surgery Myringotomy Reduction of nasal fracture Wisdom teeth extraction
Submucous resection Tonsillectomy Wide excision of breast lump with
Excision of nasal or aural Adenoidectomy axillary clearance
polyps Removal of dental bone plates and Open hernia repair
Biopsy of oral lesions wires Laparoscopic hernia repair
Surgical removal of wisdom tooth Laparoscopic cholecystectomy
Excision of tongue tie
Cone biopsy of cervix Haemorrhoidectomy
Dilatation and Currettage
Termination of pregnancy Varicose vein surgery
Hysteroscopy
Laparoscopic tubal ligation Anal fissure dilatation or excision
0ther minor gynaecological
Marsupialisation Arthroscopic surgery
surgery
Cystoscopy Removal of orthopaedic implants
Excision of breast lump
Herniotomy
Removal of other lumps and
Ligation of Varicose veins
bumps
Ligation of Hydrocoele
Orchidopexy
Vasectomy
Circumcision
Excision of thyroid nodule
Lymph node biopsy
Bunion surgery
Toenail surgery
Dupuytren‟s contracture surgery
Cataract surgery
Carpel tunnel surgery
Excision of ganglion
Excision of chalazion
Correction of squint

Preop analgesia Oral NSAIDs/Coxibs + Oral NSAIDs/Coxibs + Oral NSAIDs/Coxibs +

Paracetamol Paracetamol Paracetamol

Intraop Wound infiltration with LA Wound infiltration with LA and/or Wound infiltration with LA and/or
analgesia Peripheral Nerve/plexus block or Peripheral Nerve/plexus block or
+/- IV fentanyl* Single shot spinal Single shot spinal
+/- IV fentanyl* +/- IV fentanyl*

Postop Oral NSAIDs/Coxibs + Oral NSAIDs/Coxibs Oral NSAIDs/Coxibs

analgesia Paracetamol (if not given preop) (if not given preop) (if not given preop)
In Recovery Oral or IV Tramadol Oral or IV Tramadol
Room Oral Oxynorm Oral Oxynorm
IV fentanyl (titrated to effect) IV fentanyl (titrated to effect)

*For cases done by anaesthesiologists

Table 12.2: Suggested Regime for Home Analgesia in Adult Day Surgery Patients
according to Pain Severity **

MILD PAIN MODERATE PAIN SEVERE PAIN

Non-drug techniques Non-drug techniques Non-drug techniques

RICE (Rest, Ice, Compression, RICE (Rest, Ice, Compression, RICE (Rest, Ice, Compression,
Elevation), Relaxation, Distraction, Elevation), Relaxation, Distraction, Elevation), Relaxation, Distraction,
etc. etc. etc.

Regular Oral Paracetamol Regular Oral Paracetamol Regular Oral Paracetamol

OR / AND OR / AND OR / AND
Regular / PRN Oral NSAIDs or Regular / PRN Oral NSAIDs or Regular / PRN Oral NSAIDs or
Oral COX2 inhibitors Oral COX2 inhibitors Oral COX2 inhibitors

PRN Regular and PRN

Oral Tramadol Oral Tramadol
or or
Oral Oxycodone (Oxynorm) Oral Oxycodone (Oxynorm)

**Patients with contraindications to NSAIDs / PCM are excluded from this regime.
Reference

1. Amata A. 2010: Pain Management in Ambulatory/Day Surgery in Guide to Pain

Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel.
IASP, Seattle

2. Gramke HF, de Rijke JM, van Kleef M et al, 2009: Predictive Factors of
Postoperative Pain After Day Case Surgery. Clin J Pain 25(6): 455–60.

3. Kopp SL and Horlocker TT. 2010: Regional anaesthesia in day-stay and short-
stay surgery. Anaesthesia, 65 (Suppl. 1): 84–96.

4. Ilfeld BM.2011: Continuous Peripheral Nerve Blocks in the Hospital and at

Home. in Anesthesiology Clin 29:193–211

5. Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM; 2010: APM:SE
Working Group of the Australian and New Zealand College of Anaesthetists and
Faculty of Pain Medicine, Acute Pain Management: Scientific Evidence (3rd edition),
ANZCA & FPM, Melbourne.

6. Ministry of Health Malaysia 2012: Protocols for Day Care Anaesthesia

7. Pavlin DJ, Chen C, Penaloza DA et al, 2002: Pain as a factor complicating

recovery and discharge after ambulatory surgery. Anesth Analg 95(3): 627–34
 CHAPTER 13

CHRONIC NON-CANCER PAIN

Introduction

 It is estimated that about 20% of individuals worldwide have some degree of

chronic pain.
 Chronic non-cancer pain is typically defined as pain lasting longer than 3 months
or beyond the expected period of healing of tissue pathology.

 Mechanisms underlying chronic pain include a complex interaction of

physiological, emotional, cognitive, social, and environmental factors.
 Table 13.1: Differences between Acute and Chronic pain

ACUTE PAIN CHRONIC PAIN

General A symptom of underlying damage or disease A chronic disease of the nervous system

Onset Acute pain begins suddenly, usually due to an injury Chronic pain might have originated with an initial
trauma/injury or infection, or there might be an ongoing
cause of pain.
However, onset may be insidious and many people
suffer chronic pain in the absence of any past injury or
evidence of body damage.

Types of pain Usually nociceptive (somatic or visceral) May be nociceptive(somatic or visceral) or neuropathic.
Acute neuropathic pain may occur but is much less Nociceptive somatic pain is that arising from skin, soft
common tissue and bones while visceral pain is that arising from
viscera e.g. liver,pancreas,intestines.Neuropathic pain
is pain resulting from damage to the central or
peripheral nervous system.

Characteristics of Somatic pain is sharp in quality and well localized, Nociceptive pain may be sharp or dull, throbbing or
pain and is worse on movement, while visceral pain is dull, aching. Neuropathic pain is usually burning, shooting or
aching and poorly localized. stabbing. Neuropathic pain may be associated with the
Psychological effect when present is usually anxiety. following sensory symptoms:
 Numbness or Paraesthesia
 Allodynia: (pain in response to a non-painful
stimulus,e.g touch)
 Hyperalgesia: (pain out of proportion to a
painful stimulus)
 Dysasthaesia: (unpleasant abnormal
sensations)
Often has a psychosocial impact e:g depression/anxiety,
anger, fear, family and relationship stresses, sleep
disturbances.

Meaning of pain Acute pain serves as a warning sign of damage e:g Chronic pain does not single damage. The nature of the
injury, disease or a threat to the body. disease is that the pain level may be worse on some
days and better on others so that patients have „bad
days‟ and „good days‟. Often associated with fear of re-
injury resulting in „fear avoidance‟

Pain Duration Acute pain resolves when the injury heals and/or when Chronic pain persists despite the fact that the injury has
the underlying cause of pain has been treated. healed. Duration of pain is usually more than 3 months.
Unrelieved severe acute pain, however, might lead Patients often present to hospital with „acute‟ episodes
to chronic pain. which are actually „flare-ups‟ of pain.
Common Causes Acute pain might be caused by many events or Common chronic pain conditions include:
circumstances, including: Headache
Surgery Low back pain
Fracture Cancer pain
Burns or cuts Arthritis pain
Labour and childbirth Chronic pancreatitis
Myocardial infarction Chronic abdominal pain from „adhesion colic‟
Inflammation e:g abscess, appendicitis Neuropathic pain e:g
a. Post-herpetic neuralgia
b. Diabetic peripheral neuropathy
c. Post spinal cord injury pain
d. Central post-stroke pain

Table 13.2: Summary of Differences between Acute and Chronic Pain

Acute pain Chronic Pain

Symptom Disease
Tissue injury/inflammation Tissue injury may not be present OR pain
persists even after tissues have healed
Onset recognizable Gradual onset
Short-term-resolves when tissue heal Long term-does not resolve despite healing/no
injury
Warning sign False alarm
Psychological impact(anxiety)is usually short Associated with psychological problems e.g.
term depression,anger,fear

Making a diagnosis of chronic pain

 History of the presenting complaint in detail including a past medical and

surgical history, family, social and psychological evaluation
 A thorough physical examination
 A review of available records, investigations, previous treatments and
current medications
 A working diagnosis

Principles of management of chronic non-cancer pain

 Make a diagnosis - differentiate between acute and chronic pain.

 The patient may already be known to have chronic pain e.g. in emergency
department where s/he is a “regular visitor” or in the surgical or orthopaedic ward
where the patient gets admitted every few weeks or months. You need to re-
investigate the patient only if the pain is in a different site or if the patient has new
symptoms e.g. vomiting, loss of weight.
 All patients with chronic pain who are coming for repeated admissions or
treatment because of pain should be referred to a Pain Service.

 Analgesic management of patients with chronic non-cancer pain in the ward:

o Avoid Inj. Pethidine and other injections (e.g. IM Diclofenac).

Pethidine is not recommended in chronic pain conditions because
of its high addiction potential.

o Give regular oral analgesics e.g. Tramadol 100 mg QID +

Paracetamol 1 gram QID

o If you suspect neuropathic pain, add antineuropathic agents like

amitriptyline (refer appendix 8, drug formulary).

o Do not use NSAIDs / COX2 inhibitors longer than 1-2 weeks. You
may use them for a few days to get control of a flare up of chronic
pain, but they should never be given for long term as the patient
will have a risk of developing renal failure and have a higher risk
of cardiovascular events.

 Other management of the patients with chronic non-cancer pain in the ward:

o Refer to a physiotherapist for an exercise program (tailored to the

patient‟s current physical abilities) that he/she can do at home.

o Discharge the patient on a regime of regular analgesics (as

described in no. 4 above).

o Refer to a pain clinic for assessment and follow-up.

 Management of chronic pain patients at the Pain Clinic:

o Multidisciplinary Assessment of the patient, which includes

 Medical assessment, which includes making a diagnosis and

deciding whether any further investigations are indicated, as well
as reviewing current treatment. This is done by a doctor.

 Physical assessment to look for primary and secondary

musculoskeletal effects of chronic pain. This is usually done by a
physiotherapist.
  Psychological assessment which includes looking at the
psychological impact of the pain, level of anxiety and depression,
how the patient copes with the pain, effect on family and work, etc.
This is usually done by a clinical psychologist or psychiatrist.

o Multidisciplinary multimodal management, which includes

 Review of current treatment

 Making a management plan (short term and long-term). This usually

- pharmacotherapy, using appropriate drugs

- nerve blocks and other interventions,
- active physiotherapy, including exercises and activities that patients can do at
home
- psychological therapy, including relaxation training and other pain management
strategies
 In the management of chronic pain, emphasis is on self-management (what the
patient can do for him/herself) and achieving long-term changes (e.g. from
exercise) rather than short-term gains (e.g. from short acting analgesic
medications).
Reference:

1. Gureje O. 1998: Persistent pain and well-being: a World Health

Organization Study in Primary Care. JAMA; 280: 147–51.

2. Practice guidelines for chronic pain management. An updated report b the

ASA task force on chronic pain management and the American Society of
Regional anaesthesia and Pain Medicine.Anaesthesiology 210; 112:1-1

3. Turk DC, Okifuji A. 2009: Pain terms and taxonomies of pain. In:Fishman
SM, Ballantyne JC, Rathmell JP, eds. Bonica‟s Management of Pain, 4th
edn. New York, NY, USA: Lippincott Williams & Wilkins: 13–23

4. Turk DC, Wilson HD, A Cahana. 2011: Treatment of chronic non-cancer

pain, Lancet; 377: 2226–35
 APPENDIX 1: Acute Pain Service

Instructions for Medical Officers and APS nurse

Acute Pain Service (APS)

Department of Anaesthesiology & Intensive Care, Kementerian Kesihatan Malaysia

I. Selection of patients for APS

 Technique selected should be explained to the patient prior to surgery during the
pre-operative assessment.
 If you are unsure about what analgesic technique to use please discuss it with your
specialist before informing the patient.
 Patient should be well informed and educated regarding mode, benefits of
analgesia and possible complications.
 The choice of analgesia explained to the patient should be documented in the
anaesthetic record (GA form).

II. Responsibility of Medical Officers in the Operating Theatre

 To fill up the APS Audit Form and place it in the APS file.
 To fill up the APS Nursing Observation Chart and place it in patient‟s BHT.
 To inform the surgeon on the choice of analgesia prescribed to avoid duplication
of orders.
**Surgeon should not order any opioids or sedative drug if patient is under
the APS team.
**Oral analgesics without opioids are allowed e.g: Paracetamol, NSAIDs or
COX-2 inhibitors.
 To ensure medications prescribed are available.
 To fill up the prescription slip in patient‟s BHT.
 To start PCA or epidural in the recovery bay and re-educate patients on how to
use the PCA machine.
**Please make sure pain score ≤ 4/10 before discharging patient to the ward.

III: Preparation of Epidural Infusion Cocktail Solutions

Levobupivacaine 0.1% / plain Bupivacaine 0.1% + Fentanyl 2 mcg/ml

10 mls Levobupivacaine 0.5% OR plain Bupivacaine 0.5%

+ 100 mcg Fentanyl (2 mls)
+ 38 mls normal saline
(Total volume = 50 mls)

Levobupivacaine 0.125% / plain Bupivacaine 0.125% + Fentanyl 2 mcg/ml

10 mls Levobupivacaine 0.5% OR plain Bupivacaine 0.5%

+ 100 mcg Fentanyl (2 mls)
+ 28 mls normal saline
(Total volume = 40 mls)

Ropivacaine 0.2% + Fentanyl 2 mcg/ml

48 mls 0.2% Ropivacaine

+ 100 mcg Fentanyl (2 mls)
(Total volume = 50 mls)
Note: Ropivacaine concentration is slightly less than 0.2%

Drug Used and Dosages

1. Patients on epidural cocktail

Levobupivacaine 0.1% + Fentanyl 2 mcg/ml

OR
Plain bupivacaine 0.1% + Fentanyl 2 mcg/ml
OR
Ropivacaine 0.2% + Fentanyl 2 mcg/ml

Lumbar epidural: Run at 6-12 ml/h

Thoracic epidural: Run at 4-10 ml/h

2. Patients on PCA

PCA Morphine
Concentration = 1mg/ml,
Bolus (Demand) dose : <60 years = 1 mg; >60 years = 0.5 mg
Lockout interval = 5 min
If patient has severe pain before started on PCA, give a loading dose of 2-3mg

PCA Tramadol
Concentration = 10 mg/ml,
Bolus (Demand) dose = 10 mg
Lockout interval = 5 min

PCA Fentanyl
Concentration = 10 mcg/ml,
Bolus (Demand) dose = 10 mcg
Lockout interval = 3 min

3 Patients on Subcutaneous morphine

<60 years: 5 - 10mg 4 hourly
>60 years: 2.5 - 5mg 4 hourly
IV. Responsibility of the APS team

1. Ward rounds

1.1. All APS patients should be reviewed 2-3 times a day and when pain score is > 4/10
or complications/side effects arise.
1.2. All patients started on APS should be reviewed as following:

A. Assess the patient

 Ensure patient is comfortable. Assess the pain score. Aim for pain score at rest
and on movement ≤4/10.
 Ensure patient knows how to use the PCA machine.
 Look for and treat side effects from the APS technique.

B. Check the pump

 Ensure the tubing is connected correctly (Epidural or PCA)

 Ensure there is enough morphine / epidural solution in the syringe / cassette to last
till the next morning.
 Record the drug used and dose delivered to the patient.

C. Check the nursing observation form

 Ensure that the ward nurse in charge of the patient understands the technique and
the observations that are required (Pain Score, Sedation Score, Respiratory Rate
and Bromage score)
 Point out to the ward nurse and/or sister if observations are not done.
 Note pain score, sedation score and respiratory rate and take appropriate
action if values are abnormal.

D. Check the Medication Chart

 Make sure no opioids or sedative drugs are given; inform the ward doctor or your
specialist if these drugs were given to the patient.
 Make sure the following sticker is attached to the patient‟s medication chart.
 PATIENT ON APS DATE: TIME:

No opioids/sedatives to be given within first 24 hours.

If pain relief is inadequate, please inform the APS team.

If RR < 8, give oxygen via high-flow mask @ 15L/m.

Give naloxone IV 0.1mg stat and titrate to effect up

to a maximum of 0.4mg. Call APS team or ICU MO

E. Documentation
 Record your findings in the patient‟s file and APS form.
 Record your decision on whether to continue or to stop the APS technique.
 Record your step down analgesia plan after ruling out contraindications.

1.3. All problems should be discussed. Consult your specialist and pass over to the on-
call team.

2. Other Responsibilities

2.1. Education: To motivate and educate the ward staff and junior doctors and help in
conducting APS course.

2.2. Medication and the pump

 Prepare the medication as documented in APS audit form.

 Make sure all drugs prepared are clearly labeled, including name of drug and
patient‟s particulars.
 Check the function of the pump and send for repair if necessary.

2.3. This APS protocol should be available in the APS file at all times.

2.4. Audit- daily/monthly census to be done.

2.5. Research

V. Monitoring in the ward

 All patients should be monitored hourly for the first 4 hours then 4 hourly (Blood
Pressure, Pulse, RR, Sedation Score, Pain Score at rest and movement, Bromage
Score)
  Ward staff to notify the APS team according to Standard Orders in Nursing
Observation Chart
 Make sure the primary team does not order any opioids or sedative medication.

VI. Taking a patient off the APS

We can stop the analgesic technique when

 The patient is taking orally and can take oral analgesics.

 The patient on PCA requires less than 10 mg/day of morphine.
 The epidural has been in situ for 3-5 days, remove the epidural catheter as risk of
infections increases.

When you stop the analgesic technique, please make sure that the patient has oral
analgesia ordered (usually Paracetamol +/- NSAID/COX-2 inhibitor or a weak opioid
depending on the WHO analgesic ladder)

Oral analgesics available and standard dose for adult are in the drug formulary (Appendix
9)

VII. Trouble shooting

1) Inadequate analgesia, e.g.: Pain score at rest and on movement is more than 4/10.

See the patient as soon as possible and check for the following:

i) Patients on Epidural

 Check that the epidural catheter is still in place and the marking is as noted in the
anaesthetic notes.
 Give a bolus dose (either 3-5mls of the solution that is running, or 5 mls of 1-2%
lignocaine) through the epidural catheter.
 If patient still complains of pain after the bolus dose of lignocaine, check the level
of the block and give an additional bolus if the level is not high enough to cover
the incision.
 Rule out neuropathic pain (spontaneous burning, shooting).
 If patient is comfortable after the bolus dose, increase infusion rate by 2-3
mls/hour. Review the patient in an hour to ensure patient is still comfortable.
 If there is a unilateral block, pull out catheter by 1-2 cm and give a bolus of 1-2%
lignocaine. Make sure at least 2-3cm of catheter is left in epidural space.
 Please recheck BP after each epidural bolus dose.

ii) Patients on PCA

 Check patency of IV line and tubing.

 Check that the patient knows how to use the PCA pump.
  Check the number of demands, successful and unsuccessful.
 If the patient understands how to use the PCA pump, and the number of
unsuccessful demands is high, you may want to increase the bolus dose. You
may add a background infusion dose if patient is in ICU/HDW.
 If the patient does not understand how to use the PCA pump, you may need to re-
educate the patient and stay with the patient until she is comfortable or at least
until there is a downward trend in the pain scores.
 Make sure the tubing is connected correctly and there is no leakage at all
connecting points

2) Hypotension for patient on epidural cocktail infusion (BP 20% lower than baseline)

 Run 250ml crystalloid

 Rule out other causes e.g. surgical bleed or cardiac event
 Assess adequacy of analgesia and level of block
 If it is due to the epidural technique, give IV Ephedrine 6mg stat/PRN and IV
fluids till BP is stable, then reduce the epidural infusion by 2ml/hr. Review 1 hour
after changing the infusion rate.
 Withhold epidural and change to another modality of pain control if hypotension
persists.
 If due to surgical bleed or cardiac event, call the surgeon or physician, stop the
epidural cocktail temporarily and restart the cocktail at a reduced dose when BP is
stable. Give a bolus dose if patient is in pain.
 Epidural opioids alone DO NOT cause hypotension but be careful of respiratory
depression.

3) Nausea/vomiting

 IV/PO Metoclopromide 10-20mg tds

 IV/PO Ondansteron 4 mg tds
 IV Granisteron 1-3 mg od/bd

4) Pruritus

 Reassurance
 Calamine Lotion
 Naloxone 40 mcg titrating to a max of 400mcg
 Ondansetron 4-8mg IV or Granisetron 3mg IV
 T. Chlorpheniramine 4mg tds/prn. Sedative properties of antihistamines may be
helpful in interrupting the itch-scratch cycle. However caution is necessary
because the sedative effect of antihistamine may worsen opioid-induced sedation.

5) Respiratory Depression

Diagnosis
  Sedation Score =2 and Respiratory Rate < 8/min
 Sedation Score =3 regardless of Respiratory Rate
 pin point pupils

Management

 Stop APS technique

 Oxygen at 3L/min via nasal prong/face mask where necessary
 Stimulate and encourage patient to breath
 IV Naloxone 0.1mg boluses every 1-2mins until patient wakes up or RR >10
 Monitor SaO2, RR, BP,PR, Pain Score hourly
 If respiratory depression recurs:
o Give another dose of Naloxone.
o Consider airway protection if indicated
o Admit patient to ICU / HDU for close monitoring. May require Naloxone
infusion.

6) Numbness and muscle weakness

 Check and document the level of numbness and muscle weakness to exclude
nerve injury
 Reassure the patient
 Reduce the infusion rate and add oral analgesic if tolerating orally
 Change to epidural opioid or use PCA morphine.
 Inform specialist if Bromage score ≥ 2; it is absolutely essential to rule out other
causes such as epidural haematoma and CNS infections

VIII: Recommendations on Neural Blockade and Anticoagulant Refer to Appendix7

 APPENDIX 2:NURSING OBSERVATION CHART

PCA EPIDURAL PCEA NERVE BLOCK OTHERS

MORPHINE ⌂ COCKTAIL COCKTAIL * UPPER LIMB INTRATHECAL OPIOID

FENTANYL ⌂ -Bupivacaine ⌂ -Bupivacaine ⌂ BRACHIAL - fentanyl ⌂

OXYCODONE ⌂ -Ropivacaine ⌂ -Ropivacaine ⌂ PLEXUS - morphine ⌂

OTHERS ⌂ -Levo- bupivacaine ⌂ -Levo- bupivacaine ⌂ BLOCK - others ⌂

⌂ ⌂
Conc…….mg/ml PETHIDINE ⌂ OTHERS ⌂ - interscalene ⌂ Dose………mg

Bolus Dose OTHERS ⌂ Conc… + Fentanyl - supraclavicular ⌂ INTRAVENOUS OPIOID

………….mg Conc……+ Fentanyl ……… mcg/ml - infraclavicular ⌂ INFUSION ⌂

………mcg/ml
Lockout……mins Bolus dose………ml - axillary ⌂ Drug……………..….
Infusion
Background Rate………ml/hr Lockout……..mins * LOWER LIMB Bolus Dose……...mg

………….ml/hr Epidural inserted Background…..ml/hr FEMORAL BLOCK ⌂ Conc……… mg/ml

by………………
Loading Dose Loading Dose SCIATIC NERVE BLOCK ⌂ Infusion Rate…..…ml/hr
Level: ……..…..
…………mg at …… ml at………..hr 3 in 1-BLOCK ⌂ SUBCUTANEOUS
Anchored at MORPHINE ⌂
…………hr skin………cm Epidural inserted OTHERS ⌂
OTHER TECHNIQUES ⌂
By………………….. Drug……………………………
……………………...……
Level: …………. infusion………...ml/hr

Anchored at skin………cm

STANDARD ORDERS
1. No Opioids or sedatives to be given other than that ordered by Acute Pain Service (APS).
2. Naloxone (Narcan) 0.4mg to be available in the ward.
3. Oxygen at 2L/min via nasal cannula /face mask where necessary
4. Monitoring
Record HR,BP,RR,Pain score,sedation and Bromage score hourly for the first 4 hours, then 4 hourly.
5. Management of Complications
i. Respiratory Depression
Sedation Score = 2 and Respiratory Rate less than 10 per minute OR
Sedation Score = 3 regardless of Respiratory Rate
Give Naloxone (Narcan) 0.1mg IV stat and repeat up to total of 0.4mg
Call APS Team/Anaesthesia MO immediately.
ii. Hypotension
If systolic BP drops to less than 90mmHg, stop epidural infusion (if any).Call the ward doctor
Run in 250mls Normal Saline or Hartmann‟s solution
Call the APS Team/Anaesthesia MO for additional assistance if required
iii.Nausea and vomiting
Give the patient IV Metoclopramide (Maxolon) 10mg 8hrly PRN, if still no relief, call APS Team
iv. Any persistent numbness or weakness (Bromage score>2), call APS Team
v. Other Problems
For inadequate analgesia (Pain Score>4), call the APS Team immediately.
For mild pruritus, treat with calamine lotion. For severe pruritus, inform APS Team.
For other problems like urinary retention, call the ward doctor.
 NURSING OBSERVATION CHART
TECHNIQUE: PCA  EPIDURAL  PCEA  OTHERS 

PAIN SCORE SEDATION SCORE

VISUAL ANALOGUE SCORE 0 = Patient is awake

1 = Mild (occasionally drowsy)

2 = Moderate (frequently drowsy,

easily rousable)

0 5 10 3 = Severe (difficult to rouse)

No Pain Worst Pain S = Sleeping (easy to rouse)

BROMAGE
SCORE NAUSEA/
PAIN SED
DATE TIME DRUG DOSE RR BP HR COMMENTS
SCORE SCORE
VOMITING

Name: RN :
 APS No.

APPENDIX 3: Acute Pain Audit Form

Name: …………………………………………. R/N: ……………………………….

Age/Sex: ……………. Unit/Ward: …………… Weight: ………kg BMI:…………

Medical problems: ……………………………………………………. ASA: …………

Diagnosis: …………………………………………Operation: ………………………..

Technique 1) ………………… Ordered by: …………… Date started/end: …………

2) ………………… Ordered by: …………… Date started/end: …..............

PCA EPIDURAL PCEA NERVE BLOCK OTHERS

MORPHINE ⌂ COCKTAIL COCKTAIL * UPPER LIMB INTRATHECAL OPIOID

FENTANYL ⌂ -Bupivacaine ⌂ -Bupivacaine ⌂ BRACHIAL - fentanyl ⌂

OXYCODONE ⌂ -Ropivacaine ⌂ -Ropivacaine ⌂ PLEXUS - morphine ⌂

OTHERS ⌂ -Levo- bupivacaine ⌂ -Levo- bupivacaine ⌂ BLOCK - others ⌂

Conc…….mg/ml MORPHINE ⌂ OTHERS ⌂ -interscalene ⌂ Dose………mg

Bolus Dose…….mg PETHIDINE ⌂ Conc……+ Fentany…mcg/ml -supraclavicular ⌂ INTRAVENOUS OPIOID

Lockout……mins OTHERS ⌂ Loading Dose -infraclavicular ⌂ INFUSION ⌂

Background…….ml/hr Conc…+ …… ml at………..hr -axillary ⌂ Drug……………….

Loading Dose Fentanyl ………mcg/ml Bolus dose………ml * LOWER LIMB Bolus Dose……...mg

……mg at……hr Infusion Rate…ml/hr Lockout……..mins FEMORAL BLOCK ⌂ Conc……… mg/ml

Epidural inserted Background…..ml/hr SCIATIC NERVE BLOCK ⌂ Infusion Rate…ml/hr

by………………
Epidural inserted 3 in 1-BLOCK ⌂ SUBCUT. MORPHINE ⌂
Level: ………..
By………………… OTHERS ⌂ OTHER TECHNIQUES
Skin to space ………cm
Level: …………. Drug……………………… ……………….
Anchored at skin ……cm
Skin to space ………cm Bolus…………. mls
Length of catheter in space
Anchored at skin………cm given at ………(time)
………cm
Length of catheter in Infusion…...ml/hr
space………cm
 PCA □ EPIDURAL □ PCEA □ NERVE BLOCK □ OTHERS □
Drug Used: ……………………… ………………… Anticoagulant: …………………

DATE

TIME

Seen by

Dose used

Pain score at rest

Pain score with activities

Heart Rate ( HR)

Blood Pressure (BP)

Sedation score

Respiratory Rate (RR)

Nausea /vomiting(Worst score)

Pruritus (Worst score)

Numbness(dermatome)

Motor weakness (Bromage

Score)

Urinary retention

(Y /N), CBD present?

Able to sleep? (Y/N)

Ambulation (Y/N)

Epidural site

Plan

Level of Satisfaction: Excellent Good Satisfactory Poor

Complication score: 0 = none

since last review 1 = mild, no treatment needed
2 = moderate, helped by treatment
3 = severe, despite treatment
 APPENDIX 4: GUIDELINE FOR USE OF OXYNORM®
USE OF OXYNORM® IN PATIENT WEANED OFF PCA MORPHINE

Patient allow orally (at least with clear fluid)

Total PCA Morphine used

>30mg mg/last 24 hours < 30mg/last 24 hour

Start Oxynorm Start Tramadol

< 60 yr > 60 yr

Give Oxynorm 5mg stat & stop PCAM Give Oxynorm 5mg stat & stop PCAM

Prescribe Oxynorm in ward: Prescribe Oxynorm in ward:

Regular dose for 2 days Regular dose for 2 days

C. Oxynorm 5mg 4 hourly & C. Oxynorm 5mg 6 hourly &

C. Oxynorm 5mg PRN C. Oxynorm 5mg PRN

(to give 1hr after regular dose) (to give 1hr after regular dose)

**Continue/combine with regular Paracetamol ± NSAID/Cox II unless

contraindicated

**May consider Oxynorm for those who cannot tolerate Tramadol

**ALL post-operative patients on Oxynorm will be followed-up by the APS

Team.

Please fill up the APS form for these patients

APPENDIX 5: MORPHINE PAIN PROTOCOL (ADAPTED FROM THE ACUTE
PAIN SERVICE, ROYAL ADELAIDE HOSPITAL, SOUTH AUSTRALIA)
 APPENDIX 6: ANALGESIC LADDER OF ACUTE PAIN MANAGEMENT

Oxynorm
1-3 5-10 mg
4-6 hrly

DF118
30-60mg
6 -8 hrly

Notes:

1. Dihydrocodeine (DF118) may be used as an alternative to Tramadol

2. In NBM patients oral drugs may be replaced by
a. Tramadol SC or IV
b. PCM rectal
c. Diclofenac rectal or Parecoxib IV
NSAIDs should be used with caution in patients with asthma, thrombocytopenia,
coagulopathies, and renal, hepatic or cardiac impairment.
NSAIDs are contraindicated in patients with hypovolemia, active peptic ulceration
and those with a history of hypersensitivity, e.g. wheezing to aspirin or any other
NSAIDs.
In the elderly (over 65 years),avoid or consider using a lower dose of NSAID
Those at risk of Gl problems or with symptoms (epigastric pain) may be “buffered”
with Proton Pump Inhibitors.
For those with severe pain, use SC or IV morphine and titrate to comfort (see
appendix 5 Morphine Pain Protocol)
Used of Oxynorm only for APS team
Refer to APS team for uncontrollable severe pain
 APPENDIX 7: Neural Blockade and Anticoagulant

Drug Time to peak Elimination Acceptable Acceptable Acceptable Acceptable

effect Half-life time after time for next time after time after
drug for drug dose drug for catheter
block after block catheter removal for
performance removal next drug
dose

Heparin

UFH s.c. <30 min 1‐2 h 4 h and normal 1h 4 h and normal 1h

prophylactic APTT APTT

UFH i.v. <5 min 1‐2 h 4 h and normal 4h 4 h and normal 4h

treatment APTT APTT

LMWH s.c. 3-4 h 3‐7 h 12h 4h 12h 4h

prophylactic

LMWH s.c. 3-4 h 3‐7 h 24h 4h 24h 4h

treatment

Heparin alternatives

Fondaparinux 1‐2 h 17‐20 h >36 h 12 h 42 h 12 h

Antiplatelet Drugs

NSAIDs 1-12 h 1-12h No additional precautions

Aspirin 12‐24 h Not relevant No additional precautions

irreversible
effect
Clopidogrel 12-24 h 7days Contraindicated while catheter 6h
in place

Ticlopidine 8‐11 days 24-32 h but 90 10 days 6h

h in chronic
use
 Drug Time to peak Elimination Acceptable Acceptable Acceptable Acceptable
effect Half-life time after time for next time after time after
drug for drug dose drug for catheter
block after block catheter removal for
performance removal next drug
dose

Dipyridamole 75 min 10 h No additional 6h

precautions

Oral Anticoagulants

Warfarin 3‐5 days 4‐5 days INR ≤1.4 After catheter INR ≤1.4 1h
removal

Rivaroxaban 3h 7‐9 h 21 h 5h Manufacturer recommends

caution with use of neuraxial
catheters

Dabigatran† 0.5--‐2.0 h 12-17 h 36 h 6h

Thrombolytic drugs

Streptokinase <5 min 4‐24 min Contraindicated Not applicable 10 days

Abbreviations

UFH = unfractionated heparin, APTT = activated partial thromboplastin time, LMWH =

low molecular weight heparin, s.c. = subcutaneous, i.v. = intravenous, NSAIDs = non-
steroidal anti-inflammatory drugs, INR = international normalised ratio

Adapted from “Regional Anaesthesia in Patients with Abnormalities in Coagulation” by

the Joint Working Party of the Association of Anaesthetists of Great Britain & Ireland
(AAGBI), Obstetric Anaesthetists‟ Association (OAA) and Regional Anaesthesia UK
(RA-UK), 2011 and University of Washington Medical Center (UWMC) Anti-coagulation Guidelines on
Neuraxial Procedures,2011

Please note: All patients should be informed and monitored for motor block (spinal/epidural
hematoma) for 24 hrs after removal of the catheter
APPENDIX 8: MANAGEMENT OF SEVERE LOCAL ANAESTHESTIC
TOXICITY

Management of Severe Local Anaesthetic Toxicity

Signs of severe toxicity:

1 • Sudden alteration in mental status, severe agitation or loss of consciousness,

with or without tonic-clonic convulsions
• Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and
Recognition ventricular tachyarrhythmias may all occur
• Local anaesthetic (LA) toxicity may occur some time after an initial injection
• Stop injecting the LA

2 • Call for help

• Maintain the airway and, if necessary, secure it with a tracheal tube
• Give 100% oxygen and ensure adequate lung ventilation (hyperventilation
Immediate may help by increasing plasma pH in the presence of metabolic acidosis)
management • Confirm or establish intravenous access
• Control seizures: give a benzodiazepine, thiopental or propofol in small
incremental doses
• Assess cardiovascular status throughout
• Consider drawing blood for analysis, but do not delay definitive treatment to
do this
In circulatory arrest Without circulatory arrest

3 • Start cardiopulmonary resuscitation

(CPR) using standard protocols
• Manage arrhythmias using the same
Use conventional therapies to treat:
• hypotension,
• bradycardia,
Treatment protocols, recognising that • tachyarrhythmia
arrhythmias may be very refractory to
treatment Consider intravenous lipid emulsion
• Consider the use of cardiopulmonary (following the regimen overleaf)
by pass if available • Propofol is not a suitable substitute for
Give intravenous lipid emulsion lipid emulsion
(following the regimen overleaf) • Lignocaine should not be used as an
• Continue CPR throughout treatment anti-arrhythmic therapy
with lipid emulsion
• Recovery from LA-induced cardiac
arrest may take >1 h
• Propofol is not a suitable substitute
for lipid emulsion
• Lignocaine should not be used as an
anti-arrhythmic therapy

• Arrange safe transfer to a clinical area with appropriate equipment and suitable staff

4 until sustained recovery is achieved

• Exclude pancreatitis by regular clinical review, including daily amylase or lipase assays
for two days
Follow-up
 IMMEDIATELY

Give an initial intravenous bolus

Start an intravenous infusion of
injection of 20% lipid emulsion AND 20% lipid emulsion at 15 ml/kg/h
1.5 ml/kg over 1 min

AFTER 5 MIN
Continue infusion at same rate,
but:
Give a maximum of two repeat
boluses (same dose) if: Double the rate to 30 ml/kg/h at
• cardiovascular stability has not any time after 5 min, if:
been restored ● cardiovascular stability has not
or been restored or
• an adequate circulation
deteriorates
AND ● an adequate circulation
deteriorates
Leave 5 min between boluses
Continue infusion until stable and
A maximum of three boluses can adequate circulation restored or
be given(including the initial bolus) maximum dose of lipid emulsion
given

Do not exceed a maximum cumulative does of 12 ml/kg

Adapted from The Association of Anaesthetists of Great Britian & Ireland 2010
 APPENDIX 9: Drug Formulary

SUGGESTED MEDICATION DOSAGES AND SIDE EFFECTS

Drug Drug Recommended Side Cautions and Comments

Class Dosages Effects Contraindications
Simple Paracetamol 0.5 - 1gm, 6 - 8 Rare Hepatic impairment Preferred
analgesic hourly drug in
Max: 4g/day elderly.
Reduce Liver damage
maximum dose following
50%-70% in over dosage.
patients with Maximum
hepatic dose 4 g daily
impairment

Perfalgan >50 kg, 1 g 6 Hepatic impairment Important to

(IV) hourly up to max consider the
Aqueous 4g/day total dosage
solution: 10-50 kg, 15
of
10mg/ml mg/kg/dose
max 60mg/kg in paracetamol
paracetamol, used i.e. to
4 divided doses
available in Administration: include
50ml and Infusion over 15 dosage of.
100ml vials minutes. suppositories
and oral
Renal & hepatic
preparations
impairement:
minimum
interval between
doses should not
be less than 6
hours.
 Drug Drug Recommended Side Effects Cautions and Comments
Class Dosages Contraindications
Non- Peptic ulcer, Gastroduodenal Current data
Selective Diclofenac 50 - 150 mg GI bleed, ulcer suggest that
Sodium daily,
NSAIDs increased CVS
8 - 12 hourly
Max: 200 Platelet Asthma risk may be an
mg/day dysfunction, effect of the
Bleeding disorder NSAIDs/Coxib
Renal failure, class.
Renal dysfunction
Hypertension Physicians and
Mefenemic 250-500 mg 8
Acid hourly
Ischaemic heart patients should
Allergic disease weigh the
reaction in benefits and
susceptible Cerebrovascular risks of
individuals, disease NSAIDs/Coxib
Ibuprofen 200-400 mg, 8 therapy.
hourly Increase in Inflammatory
Max: 2400 CVS events bowel disease
mg/day Concurrent use
Elderly patients: with aspirin
200 mg 3 x a day inhibits aspirin‟s
antiplatelet
effect
500-550mg BD
Naproxen Elderly patients; (mechanism
220 mg BD unclear)

Patch: 30 -60 mg
Ketoprofen BD
Topical; PRN

IV: 10-20 mg BD
Ketolorac ( max 3days)

7.5-15 mg daily
Meloxicam Max: 15 mg /day
 Drug Drug Recommended Side Effects Cautions and Comments
Class Dosages Contraindications
Selective Celecoxib 400mg BD in Renal Ischaemic heart
Cox-2 acute pain (48 impairment disease
Inhibitors hours only)
Allergy Cerebrovascular
200-400 mg reaction in disease
daily (for susceptible
longer term individuals Hypersensitivity to
use) sulfonamides
Increase in Associated
<18 years : not CVS events Higher doses with lower
recommended associated with risk of serious
Hypertension higher incidence of upper
Elderly GIT, CVS side gastrointestinal
patients: effects side effects
100 mg daily compared to
Patients with traditional
indications for NSAIDs
Etoricoxib 120 mg daily in cardioprotection
acute pain (48 require aspirin
hours only) supplement Use the lowest
60 - 90 mg effective dose
daily (for Uncontrolled for the shortest
longer term Hypertension duration
use) necessary
Elderly patients
30 mg daily

Parecoxib 20-40mg 6-12

hourly (max
80mg/day for
max duration
of 48 hours )
Elderly (>65
years & <50kg)
reduce to half
the dose with a
maximum daily
dose of 40mg.
Renal &
hepatic
impairment :
Do not use
Drug Class Drug Recommended Side Effects Cautions and Comments
Dosages Contraindications
Weak opioids Tramadol 50 - 100 mg, 6 Dizziness Risk of seizures in Interaction
- 8 hourly Nausea patients with with TCA,
Max: 400 Vomitting history of seizures SSRI and
mg/day Constipation and with high SNRI
Drowsiness doses

In elderly, start at
lowest dose (50
mg) and maximum
300 mg daily
Dihydrocodeine 30 - 60 mg, Nausea Respiratory Metabolites
tartrate 6 - 8 hourly Vomiting depression can
(DF118) Max: 240 Constipation accumulate
mg/day Drowsiness Acute alcoholism causing
adverse
Paralytic ileus effects
Renal
dysfunction Raised intracranial In severe
&:dialysis pressure hepatic
patient: do not impairment,
use codeine
may not be
Hepatic converted
dysfunction: to the
do not use active
metabolite-
morphine.
Combinations Paracetamol 1 - 2 tablets, 6 - Constipation Hepatic Decrease in
of opioids 500 mg + 8 hourly impairment, side effect
and Codeine 8 mg Max: 8 profile of
paracetamol tablets/day tramadol
and
paracetamol
while
maintaining
efficacy
Paracetamol 1 - 2 tablets, 6 - Nausea Hepatic
325 mg + 8 hourly impairment,
Tramadol 37.5 Vomiting Epilepsy
mg Max: 8
tablets/day Drowsiness
(Ultracet®)
Drug Drug Recommended Side Cautions and Comments
Class Dosages Effects Contraindications
Strong Morphine SC (Adults): Nausea Acute bronchial asthma
opioids
<65 yrs: 5mg-10 mg Vomiting Respiratory depression Metabolites can
4 hrly accumulate
>65 yrs: 2.5 mg- Pruritus Head injuries,Renal and causing increased
5mg 4hrly hepatic dysfunction: therapeutic and
Sedation needs dose adjustment adverse effects
IV: Follow
(refer Chapter 3)
morphine pain Constipation
protocol
(Appendix5) Respiratory Both parent drug
depression and metabolites
Oral: Starting dose can be removed
5- 10 mg, Myoclonus
with dialysis,
4 hourly of IR watch for
Elderly: 2.5 - 5 mg, “rebound” pain
4 - 6 hourly of IR effect

IV to be prescribed by Nausea No active

Fentanyl APS team only metabolites and
Vomiting appears to have
Renal dysfunction : no added risk of
appears safe, Sedation
adverse effects;
however, a dose monitor with
Constipation
reduction is high long term
necessary Respiratory user
depression
Dialysis patients : Metabolites are
appears safe inactive, but use
caution because
Hepatic dysfunction
fentanyl is poorly
: appears safe,
dialysable
generally no dose
adjustment Decrease hepatic
necessary blood flow
affects
metabolism more
than hepatic
failure.
Drug Class Drug Recommended Side Caution Comments
Dosages Effects and
Contra-
indication
Oxycodone IR Starting dose (oral): Nausea Acute Metabolites and parent
(oxynorm) 5 -10 mg 4 - 6 bronchial drug can accumulate
hourly Vomiting asthma causing toxic and CNS-
depressant effects
Renal dysfunction : Sedation Respiratory
Use cautiously with depression In severe hepatic
careful monitoring, Constipation
impairment, the parent
adjust dose if Con- drug may not be readily
Respiratory
necessary comittent converted to
depression
used of metabolites
Dialysis patients: sedative
do not use
drugs
Hepatic dysfunction:
Head
Use cautiously and
injuries,Ren
monitor patient
al and
carefully for
hepatic
symptoms of opioid
dysfunction:
overdose
needs dose
Decrease initial dose
adjustment
by 1/2 to 1/3 of the (refer
usual amount Chapter 3)

Elderly patients : 2.5-

5 mg every 4-6 h
 Drug Class Drug Recommended Side Effects Cautions and Comments
Dosages Contraindications
Antidepressant Amitriptyline Start with 10 - Anticholinergic Not recommended Nortriptyline
25 mg nocte. effects in elderly patients may be a
e.g. dry mouth, with cardiac suitable
Increase weekly drowsiness,
disease, glaucoma, alternative and
by 25 mg/day to urinary
retention, renal disease better tolerated
a max of 150 in elderly at
arrhythmias
mg/day similar doses

Interaction
with Tramadol

Elderly patients: Significant

10 mg ON risk of adverse
effects for the
elderly

Duloxetine 30 - 60 mg/day Gastrointestinal Narrow-angle Interaction

disorder glaucoma with Tramadol
Max: 120
mg/day Excessive Potent CYP1A2
sweating CNS inhibitors
disorder
Concomitant use of
MAOIs

Hypertension

Anticonvulsants Carbamazepine 100 - 1600 Dizziness Increased ocular Well tolerated.

mg/day pressure Serious
Ataxia adverse events
Latent psychosis are rare
Fatigue
Elderly patients: Confusion
100 mg daily Leucopenia
Agitation
Nausea

Vomiting

Drowsiness
Drug Class Drug Recommended Side Effects Cautions and Comments
Dosages Contra-
indications
Gabapentin Day 1: start at Drowsiness Dose adjustment
300mg needed in renal However,
dizziness impairment need to
Day 2: 300 mg monitor
12 hourly GI symptoms sedation,
ataxia,
Day 3: 300 mg Mild peripheral oedema,
8 hourly oedema hepatic trans-
aminases,
Thereafter, blood count ,
increase by 300
serum
mg/day every
1- 7 days creatinine,
blood urea
Max: 3600 and
mg/day electrolytes

Elderly patients
: 100mg daily

Pregabalin Start with 150

mg/day (in 2
divided doses).
If needed,
increase to 300
mg/day after 3
- 7 days
intervals,
then if needed,
increase to 600
mg/day after 7
days interval
Max: 600
mg/day

Elderly patients
: 50 mg at
bedtime

Sodium Initially 400 Fatigue Avoid Swallow

Valproate mg/day in 2 concomitant use whole,do not
divided doses. Loss of appetite of salicylates in chew / crush
Maybe increase children < 3
by 200 mg at 3 Vomiting year old due to
day intervals risk of liver
Dizziness toxicity.
Max: 1600 Monitor
mg/day prothrombin
time when used
 with Warfarin
Drug Class Drug Recommended Side Effects Cautions and Comments
Dosages Contra-
indications
Bisphosphonates Pamidronate 60 - 90 mg as a Asymptomatic Hypersensitivity Rehydrate
single infusion hypocalcemia, to patients with
over 2 - 4 hrs hypophosphata biphosphonates. normal saline
every 4 weeks emia, Hyperparathyroi before or
hypomagnaese dism during
mia treatment.
Flu-like In renal
symptoms impairment, Not to be
Mild fever reduce dose and given as bolus
Local injection increase injection.
-site reactions infusion
Malaise duration
Rigor required
Zoledronate 4 mg as 15 min Rise in body
Acid IV infusion temperature In patients with
every 3 - 4 poor dental
Flu-like hygiene, there is
weeks
symptoms higher risk of
Headache ONJ. Dental
referral is
Hypersensitivit advised.
y reactions

Osteonecrosis
of the jaw

Clodronate 800-3200 mg Gatrointestinal Should not be

daily (oral) irritation taken within 1
Renal
hour before or
Max: 3200 dysfunction
2 hours after
mg/day meals
 Drug Class Drug Recommended Side Cautions and Comments
Dosages Effects Contra-
indications
Corticosteroid Dexamethasone Oral/ IV/SC: Increased Peptic ulcer Should be
or disease given before
8 - 16 mg daily decreased Concomitant 6 pm to
or divided appetite NSAIDs use reduce risk of
doses (initial insomnia
dose), then to Insomnia Liver or
reduce to cardiac Efficacy may
lowest possible Indigestion impairment reduce over 2
dose (usually 2 Nervousness - 4 weeks
mg/day)
Myopathy Use lowest
possible dose
Oral to prevent
candidiasis side effects.

Adrenal Anticipate
suppression fluid retention
and glycemic
effects in
short-term
use and CV
and bone
demineralizati
on with long-
term use

Monitor for
rash or skin
irritation

Elderly patients
:5 mg daily and
taper as soon as
feasible
Drug Class Drug Recommended Side Effects Cautions and Comments
Dosages Contraindications
Lignocaine Lignocaine Elderly patients Monitor muscle
(topical) 5% : 1-3 patches weakness,
for 12 hours per urinary
day function,
cognitive
effects,
sedation
Muscle Baclofen 5 mg -15 mg Avoid abrupt
relaxant daily discontinuation
because of CNS
irritability

Laxatives Lactulose 15 - 45 ml orally Bloating Hypersensitivity to May be mixed

6 - 8 hourly lactulose products with fruit juice,
Epigastric water or milk
pain Galactosemia
Patients requiring a Reasonable
Flatulence galactose free diet fluid intake is
required for
Nausea efficacy

Vomiting

Cramping
Bisacodyl 5 - 10 mg orally, Atony of Intestinal
1 - 2 times daily colon obstruction
Max: 30 mg/day
Senna 2 - 4 tablets Diarrhoea Allergies especially
daily in divided to Tartrazine
dose Nausea

Vomiting

Rectal
irritation

Stomach
cramps

Bloating
Macrogols 1 - 2 sachets/day Abdominal Severe
distension inflammatory bowel
disease,
Nausea Fructose
intolerance,
Diarrhoea
Drug Class Drug Recommended Side Effects Cautions and Comments
Dosages Contraindications
Antiemetic Metoclopramide 10 - 20 mg Extrapyramidal Epileptic patients
6 - 8 hourly reactions Gastrointestinal
hemorrhage
Dizziness

Drowsiness
Haloperidol 0.5-3 mg ON Extrapyramidal Concomitant use
Syndromes with other
psychotropic drugs
Dystonia may increase Extra-
pyramidal
Prolonged QT Syndromes
interval

Neuroleptic
Malignant
Syndrome
Granisetron 1 mg 12 hourly Constipation Progressive ileus Should not be
and/or gastric used as first line.
distension may be
masked Not for long term
use.
Ondansetron 8 mg 12 hourly Headache Pregnancy and
Sensation of lactation
flushing or
warmth in the Hepatic impairment
head and
epigastrium
Constipation
Prochlorperazine 10 - 30 mg daily Extrapyramidal May increased risk
in divided doses symptoms of seizure with
Tramadol
Severe nausea Dry mouth
and vomiting:
20 mg stat
followed by 10
mg after 2 hours

For prevention:
5 - 10 mg 8 - 12
hourly