Analgesic Modalities

There is no one correct way to treat a patient in pain, but a multimodal approach is always better than using a single modality to its "limit"; this can include both pharmacologic and

N. Vadivelu et al. (eds.), Essentials of Pain Management,

DOI 10.1007/978-0-387-87579-8_18, © Springer Science+Business Media, LLC 2011

Table 18.1 Mechanisms of pain.

Pain mechanism

Character

Examples

Treatment options

Somatic

• Usually well localized

• Laceration

• Heat/cold

• Constant

• Fracture

• Acetaminophen

• Aching, sharp,

• Burn

• NSAIDs

stabbing

• Abrasion

• Opioids

• Localized infection or inflammation

• Local anesthetics (topical or

infiltrate)

Visceral

• Not well localized

• Muscle spasm

• NSAIDs

• Constant or intermittent

• Colic or obstruction (GI or renal)

• Opioids

• Ache, pressure, cramping,

• Sickle cell crisis

• Muscle relaxants

sharp

• Internal organ infection or

Local anesthetics (nerve blocks)

inflammation

Neuropathic

• Localized (i.e., dermatomal) or

• Trigeminal

• Anticonvulsants

radiating, can also be diffuse

• Post-herpetic

• Antidepressants

• Burning, tingling, electric

• Post-amputation

• NMDA antagonists

shock, lancinating

• Peripheral neuropathy

• Neural/neuraxial blockade

• Nerve infiltration

NSAIDs, non-steroidal anti-inflammatory drugs; GI,gastrointestinal; NMDA, N-methyl-D-aspartate.

NSAIDs, non-steroidal anti-inflammatory drugs; GI,gastrointestinal; NMDA, N-methyl-D-aspartate.

non-pharmacologic measures. It is best to individualize therapy for each patient with the addition or alteration of agents when pain control is inadequate and an adjustment or diminishing of agents as the pain resolves. In terms of pharmacologic measures, there are many different agents available that can be divided into three basic categories: non-opioid analgesics, opioids, and adjuvant analgesics (American Pain Society 2008). Most of these agents can be administered through a variety of routes including enteral, parenteral, and neurax-ial. The neuraxial, specifically epidural, route will be discussed specifically in the sections on patient-controlled epidural analgesia below. Always discuss the analgesic plan with the patient and family, understand the patient's expectations for pain management, and offer reasonable goals for the therapy. If pain is present most of the time or expected to last for an extended period of time (e.g., greater than a few weeks), order standing analgesics or use long-acting agents. As needed (prn) dosing of immediate release agents is also needed for breakthrough pain. If pain is intermittent or expected to last a short time (e.g., less than a couple weeks) then prn dosing of immediate release agents can be used.

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