South African Acute Pain Guidelines Offi cial publication of SAJAA The South African Society of Anaesthesiologists 2009;15(6):1-120 (SASA) DRUGS AT A GLANCE (Bold=paediatric) A Diclofenac misoprostol, 29 Local anaesthetics, 36 Pentazocine, 26 Alfentanil, 43, 111 Dihydrocodeine tartrate, 25, 43 Lorazepam, 44 Pethidine, 24, 43 Alpha-2- agonists, 35, 43, 52 Dipipanone HCl (10 mg) + Lornoxicam, 31 Piroxicam, 31 Amethocaine, 61 cyclizine (30 mg), 25 Pregnancy, 109 Amitryptiline, 52 Doxylamine succinate, 33 M Propofol, 43, 89 Anticoagulation and neuroaxial Dothiepin, 52 Magnesium, 34 Propoxyphene, 25 drugs, 80 Diphenhydramine, 33 Meprobamate, 33 Propoxyphene napsylate, 33 Antidote to benzodiazepines, Droperidol, 71 Mefenamic acid, 30, 42 Promethazine, 33 44 Meloxicam, 32 Puerperium, 112 Antidote paracetamol, 42 E Midazolam, 44 Anti-platelet GP IIb/IIIa EMLA, 61 Morphine, 24, 42, 51, 77, 78, 84 R antagonists, 81 Epidural, 77 Morphine and cyclizine, 24 Rectal, 52 Aspirin, 28 Remifentanyl, 43, 71, 89 Atypical opioid, 27 F N Ropivacaine, 36, 41, 61, 73, 77 Fentanyl, 43, 71, 77, 78 Naloxone, 26, 43 B Flumazenil, 44 Naproxen, 31 S Bupivacaine, 36, 41, 61, 73, 77 Neuroaxial analgesia, 80 Salicylic acid, 28 Buprenorphine, 26 H Nitrous oxide, 34 Selective COX-2-inhibitors, 32 Heparin, 80 N-acetylcysteine, 42 Specific cyclo-oxygenase-2 C N-methyl-D-aspartic acid inhibitors (COXIBs), 32 Caesarean section, 111 I (NMDA) receptor antagonists, Sublingual, 53 Caffeine hydrate, 33 Ibuprofen, 29, 42 34 Subcutaneous, 55 Celecoxib, 32 Indomethacin, 30 NSAIDs, 28, 51, 84 Sufentanil, 71, 77, 78 Chirocaine, 61 Intra-muscular, 56 Sulindac, 31 Clonidine, 35, 43, 52 Intra-nasal, 53 O Clopidogrel, 81 Intra-osseous, 57 Odansetron, 71 T Codeine, 25, 51, 84 Intra-thecal, 78 Opioids, 23 Tenoxicam, 32 Combination analgesics, 33 Opioid antagonists, 26, 43 Thrombin-inhibitors, 80 COX-2 inhibitors, 32 K Opioid dualist, 26 Ticlopidine, 81 COXIBs, 32, 51 Ketamine, 34, 43, 87, 120 Orphenadrine, 33 Tilidine, 43 Ketoprofen, 30 Tramadol, 27, 43, 51, 71, 84 D Ketorolac, 30, 42 P Transdermal, 54 Dexmedetomidine, 35, 71, Paracetamol, 27, 51, 84 90, 120 L Parecoxib, 32 V Dextrometorphan, 34 Lactation, 112 Papaveratum, 25 Vaginal delivery, 110 Dextropropoxyphene HCl, L-bupivacaine, 36, 61, 73, 77 Patient controlled analgesia 33, 51 Lignocaine 2%, 36, 41, 61, 73 (PCA), 69, 71 W Diclofenac, 29, 43 Warfarin, 80 LOCAL ANAESTHETIC DOSES AND INFUSION RATES FOR PERIPHERAL NERVE BLOCKS IN ADULTS (From Table II, page 61) Technique Drugs Adult dose Considerations Plexus block Bupivacaine *LD: 0,25–0,5%, 20–40 ml Maximum 2 mg/kg or 6 mg/kg/24h; *CI: 0,125–0,25%, 5–10 ml/h maximum 150 mg or 1 ml/kg bolus Levobupivacaine As for bupivacaine As for bupivacaine Ropivacaine *LD: 0,5–,75%, 10–40 ml Maximum 800 mg/24 h or 28 mg/h. *CI: 0,2%, 0,1 ml/kg/h Maximum 1 ml/kg bolus Minor nerve Bupivacaine 0,25–0,5% Maximum 2,5 mg/kg blocks or 5–10 ml/nerve or 150 mg infiltration Levobupivacaine 0,25–0,5% Maximum 2,5 mg/kg 1–60 ml or 150 mg Ropivacaine 0,2% Maximum dose 200 mg 1–100 ml *LD = Loading dose *CI = Continuous infusion SA Acute Pain Guidelines: Contents 1. Acute pain management – Foreword 4 2. Introduction 6 3. Physiology of acute pain 8 4. Measurement and assessment of acute pain 16 4.1 Pain assessment tools 16 4.2 Regular assessment and the 5th vital sign 20 4.3 How to adjust treatment according to intensity of pain 21 4.4 The pain team and the need to document and evaluate the service 22 5. Drug listings – Enteral and Parenteral 23 5.1 OPIOIDS – mainly for SEVERE pain 23 5.2 OPIOID DUALISTS 26 5.3 OPIOID ANTAGONISTS 26 5.4 ATYPICAL OPIOID 27 5.5 PARACETAMOL 27 5.6 NSAIDs (for MILD to MODERATE Pain Relief) 28 5.7 N-methyl-D-aspartic acid (NMDA) receptor antagonists 34 5.8 α- AGONISTS 35 2 5.9 LOCAL ANAESTHETICS 36 6. Paediatric guidelines 37 7. Routes of systemic drug administration 49 7.1 Enteral administration 50 7.1.1 Oral route 50 7.1.2 Rectal route 52 7.1.3 Sublingual route 53 7.1.4 Feeding tubes; nasogastric, post-pyloric, gastrostomy, enterostomy 53 7.2 Parenteral administration 53 7.2.1 Non-invasive systemic drug administration 53 7.2.2 Invasive systemic drug delivery 55 7.2.3 Regional (plexus) 57 7.2.4 Neuraxial 57 8. Locally and regionally administered analgesic drugs 58 8.1 Local anaesthetics 58 8.1.1 Short-duration local anaesthetics 58 8.1.2 Long-duration local anaesthetics 58 8.2 Opioids 59 8.3 Adjuvant drugs 59 8.4 Anti-infl ammatory drugs 60 8.4.1 Corticosteroids 60 8.4.2 Non-steroidal anti-infl ammatory drugs 60 8.5 Regional and local analgesic techniques 60 SAJAA 1 2009;15(6) SA Acute Pain Guidelines: 9. Techniques of drug administration 65 9.1 Clinical guidelines on the use of patient-controlled analgesia (PCA) 65 9.1.1 Rationale for use 65 9.1.2 Standards of care 66 9.1.3 Equipment 68 9.1.4 Medication 69 Acknowledgements 9.1.5 Method 70 9.2 Epidural and spinal drug administration for acute pain 72 9.2.1 Epidural analgesia 72 9.2.2 Spinal (intrathecal) analgesia 78 9.2.3 Regional analgesia and concurrent anticoagulant medications 79 10. Non-pharmacological techniques 82 11. Management of acute pain in specifi c scenarios 84 11.1 Acute pain as an outpatient 84 11.2 The casualty department 85 11.3 The Intensive Care Unit (ICU) 88 11.4 Postoperative pain 90 The South African Society of Anaesthesiologists (SASA) 11.4.1 General surgery 91 11.4.2 Vascular surgery 92 wishes to acknowledge with gratitude the unrestricted educational grants 11.4.3 Cardiothoracic surgery 92 provided by the following two companies that made the development, 11.4.4 Neurosurgery 93 publishing, distribution and web hosting of this guideline possible. 11.4.5 Orthopaedic surgery 93 11.5 Acute spinal cord injury 94 11.6 Acute burns injury 94 11.7 Acute back pain 95 11.8 Acute musculoskeletal pain 95 11.9 Post-trauma pain 95 11.10 Acute pain management in sports medicine 96 11.11 Acute abdominal pain 98 and 11.12 Acute cardiac pain 100 11.13 Acute headache 100 11.13.1 Migraine 101 11.13.2 Tension headache 103 11.13.3 Cluster headache 103 11.13.4 Post-dural puncture headache 103 11.14 Neurological disorders 104 11.15 Acute orofacial pain 104 11.16 Herpes zoster infection 105 11.17 Acute pain in patients with HIV infection 105 11.18 Cancer acute pain 107 11.19 The pregnant patient 108 11.20 Specifi c patients with medical conditions 112 11.20.1 Respiratory patients, including asthmatics 112 11.20.2 Cardiac patients 114 11.20.3 Analgesia in the presence of liver and kidney dysfunction 115 11.21 Acute pain management in the patient with obstructive sleep apnoea 118 11.22 Analgesic options for patients with opioid tolerance 118 SAJAA 2 2009;15(6) Acknowledgements The South African Society of Anaesthesiologists (SASA) wishes to acknowledge with gratitude the unrestricted educational grants provided by the following two companies that made the development, publishing, distribution and web hosting of this guideline possible. and SA Acute Pain Guidelines: Acute pain management – Foreword 1. Acute pain management – Foreword Acute pain management is not a luxury, it is a human right! We as the South African consensus group tasked with making recommendations for the management of acute pain agree with every other international body that the management of acute pain is still less than optimal. Under ideal circumstances patient rights should include; the right to be believed; to be properly assessed; to access appropriate effective pain management strategies; to have education about effective pain management options; and to be cared for by health professionals with training and experience in the management of pain. In order to provide better acute pain therapy an understanding of pain physiology, analgesic drugs, and the techniques of drug delivery are essential. All clinical staff dealing with the management of acute pain should understand the principles of pain management and the methods and techniques of providing analgesia so that they can make informed therapeutic decisions. The development of this guideline refl ects the current emphasis on delivering care that is patient- centred, cost-effective, and fair. This will endeavour to facilitate comparable standards of acute pain therapy for patients regardless of where they access services. Key principles of best practice statements A best practice statement describes best and achievable practice in a specifi c area of care. Such statements are based on a number of universally acceptable principles: • Best practice statements are intended to guide practice and promote a consistent and cohesive approach to care. • Best practice statements are primarily intended for use by medical practitioners, registered nurses, midwives and support staff. • Statements are derived from the best available current evidence. • Language use must be accessible and meaningful. • Consultation with relevant role-players must take place. • Statements will be regularly reviewed and updated. The aim of this publication is to combine all of the above principles, summarise all the data and present it in a concise and easily readable form. The recommendations contained in this document have resulted from a multidisciplinary committee evaluating the information available and considering the scientifi c merit and evidence of this information. SAJAA 4 2009;15(6) SA Acute Pain Guidelines: Acute pain management – Foreword How can these guidelines be used? This information on acute pain management can be used in a variety of ways. It is primarily intended to serve as a guide to good practice and to promote a consistent and cohesive approach to care. The document is intended to be realistic and practical. It is a basis for • Developing and improving acute pain management. • Stimulating learning among medical teams. • Promoting effective interdisciplinary team working. • Measuring quality in acute pain management. This document must be considered as an aid to any health care professional managing acute pain, rather than a “recommended’ regimen. It remains the prerogative of the practitioner to evaluate the patient and to adapt any of the suggestions to the circumstances surrounding that particular patient. It is hoped that by using the information provided in this publication that there will be meaningful benefi t for both the medical professional and the patient. The use of the principles provided will ensure that the right of all patients to adequate and effective pain management will be fulfi lled. Dr Milton Raff President SA Society of Anaesthesiologists, 2010 SAJAA 5 2009;15(6) SA Acute Pain Guidelines: Introduction 2. Introduction This is the fi rst edition of the South African Acute Pain Guidelines. It has been compiled in response to recognition of the need for guidelines to assist practitioners in acute pain management at ALL levels of medical care and in all types of practices. The guidelines are being published in two versions – this hard copy bedside reference, as well as a more comprehensive web-based version. The latter will also contain the references for these guidelines. Both of these versions need to be seen as “works in progress”, and the guidelines committee of the South African Society of Anaesthesiologists would appreciate inputs from colleagues from all sectors of medical practice over the next few years. Address your contributions and opinions to the SASA Councillor responsible for Practice Guidelines, currently Dr Hyla Kluyts through email: sasa@uiplay. com. A formal review of these guidelines is due in 2015, at the discretion of the South African Society of Anaesthesiologists. The South African Society of Anaesthesiologists appointed a consensus group of practitioners from varying specialities, with varying areas of expertise and interest, to write these guidelines, which cover a wide range of clinical topics. It is by no means comprehensive, and will be expanded in the next edition, as needs dictate. Acknowledgements The authors acknowledge the very generous and constructive input of Prof Stephan Schug, who has shared his extensive knowledge with us, and given generously of his time, during two recent visits to South Africa. The authors also acknowledge the following document as one of the primary references for these guidelines: Acute Pain Management: Scientifi c Evidence 2nd Edition, as published by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. And fi nally, the publication would not have been possible without the very generous sponsorship by Bristol Myers Squibb and Pfi zer Pharmaceuticals. Christina Lundgren (editor) and Werner Mohr (SASA Council) SAJAA 6 2009;15(6) SA Acute Pain Guidelines: Introduction On behalf of the consensus group: • Prof Wayne Derman • Prof Eva Frohlich • Dr David Grolman • Dr Sonia Hitchcock • Dr Eric Hodgson • Dr Hyla Kluyts • Prof Christina Lundgren • Prof Analee Milner • Dr Werner Mohr • Dr Phillipa Penfold • Dr Milton Raff • Prof Jenny Thomas • Dr Anthony Travers © Copyright 2009: Contents: The South African Society for Anaesthesiologists (SASA). © Copyright 2009: Design: Medpharm Publications (Pty) Ltd. All rights reserved. No part of the South African Acute Pain Guidelines may be reproduced or transmitted in any form, by any means, electronic or mechanical, including photocopying, recording or any information storage or retrieval system, without written permission from The South African Society of Anaesthesiologists and Medpharm Publications (Pty) Ltd. Reprint enquiries may be directed to: [email protected] and [email protected] or SASA, PO Box 1105, Cramerview, 2060 and Medpharm, PO Box 14804, Lyttelton, 0140 Disclaimer This is a condensed version of a more comprehensive guideline and is an offi cial consensus document of The South African Society for Anaesthesiologists. While every effort has been made to ensure scientifi c accuracy, SASA and Medpharm shall not be responsible or in any way liable for errors, omissions or inaccuracies in this publication, whether arising from negligence or otherwise or for any consequences arising therefrom. Published by Medpharm Publications for The South African Society for Anaesthesiologists (SASA) www.medpharm.co.za SAJAA 7 2009;15(6) SA Acute Pain Guidelines: Physiology of acute pain 3. Physiology of acute pain Pain is a complex interaction of sensory, emotional and behavioural factors. There are no pain pathways only nociception pathways. Nociception is modulated at the level of the spinal cord and interpreted by the cortex, resulting in varying degrees of discomfort and pain. • Pain is defi ned by the International Association for the Study of Pain (IASP) as an “unpleasant sensory and emotional experience, associated with actual or potential tissue damage or described in terms of such damage.” (Mersky 1979). • Acute pain is defi ned as pain of short and limited duration. The pain is related to an identifi able cause (trauma, surgery, infl ammation etc). Acute and chronic pain, represent a continuum of a process where infl ammatory neuropathic visceral and somatic pain play a role. The CNS is not a hard-wired system, it allows for peripheral, central, intra- cellular and synaptic modifi cations. Acute pain can result in long-term changes and a subsequently modifi ed response to sensory input (neuroplasticity). Pain is divided into physiological pain and pathophysiological or clinical pain. • Physiological pain is the activation of nociceptors in response to a noxious stimulus whereas the clinical pain includes tissue and/or nerve injury and the infl ammatory response. Physiological pain serves as a protective mechanism, is well localised, is transient and is well differentiated from touch. • Clinical pain outlasts the stimulus and spreads to non damaged areas leading to primary hyperalgesia. Peripheral sensitisation occurs as part of the infl ammatory response and results in activation of the high threshold A beta fi bres. This leads to the sensation of touch not being differentiated from pain. Antidromic impulses result in the release of neurotransmitters from nerve endings of a primary afferent in response to noxious stimulation. Understanding nociceptive pathways Primary afferent fi bres and the dorsal horn Peripheral nociceptors are organs that respond to pressure, temperature and chemical stimuli. The nociceptor cells are located in the Dorsa Root Ganglia except for the fi bres innervating the head and SAJAA 8 2009;15(6)