Acutely ill deteriorating patients are often in acute pain, and sometimes poorly controlled pain can be the primary cause of the deterioration. Many patients still experience acute pain in hospital and studies show that nurses and doctors often lack knowledge about pain management. Pain is particularly under-recognised and under-treated in older people. In order to try and prevent deterioration it is essential that you have some understanding of the following:

• The negative physiological effects of acute pain, and the complications of poorly controlled pain

• How to accurately and consistently assess pain

• A systematic approach to acute pain management using the analgesic ladder approach

• How to recognise and manage common complications of epidural and PCA using the ABCDE approach

• What resources are available to help you assess and manage acute pain

Good pain control begins with effective assessment. Patients often don't want to bother busy staff and will not always volunteer that they are in pain. They rely on you asking them regularly about their pain.

The use of the term, "pain is the fifth vital sign" has been criticised because it can lead to a uni-dimensional assessment of pain which may not enable effective pain management (Scher et al 2018). Hospitals use a verbal descriptor pain assessment tool as part of the NEWS2 scoring system which requires patients to report the level of severity. This is usually on a scale of 0-3. Further questioning will be required to assess a patient's level of pain, its nature and the effectiveness of interventions.

Sometimes patients may say they don't have pain but ‘it's just sore' or ‘it aches', or they are unable to choose one of the options of mild moderate and severe and say instead something more vague such as ‘its not too bad'.

This can make assessment difficult but you can reasonably assume that if they say its sore that is pain. Sometimes the patient will say they have no pain but more subtle signs may dispute this, for example the patient may be grimacing when they move or are reluctant or unable to cough and deep breathe. Pain should be assessed on movement. Ask them to take a deep breathe and observe them. Pain assessment also includes assessment of the sedation score and nausea and vomiting score.

There are lots of myths concerning pain that are held by patients and nurses and doctors.

Patients often think:

• They should be in pain as they have had an operation

• They will get addicted to the morphine or using too much will impede their progress

Amongst doctors and nurses you may hear:

• They can't be in pain they only had some morphine 1 hour ago

• They can't be in severe pain they are watching TV and talking to relatives

• If they have any more morphine they stop breathing

• Pain relief will mask the surgical signs when the doctor examines the abdomen

The same principles apply if you are requesting a medical review for poorly controlled pain as for communicating a clinical deterioration. Gather all the information before making the call (observations chart and pain scores, prescription etc). Think about what you want the outcome of the call or conversation to be (a prompt medical review to relieve the patient's pain).

Be specific: “he has an epidural running at maximum rate of 15 ml/hr, and has had regular paracetamol but his pain score is 3 and he is unable to cough or deep breathe. I would like you to review him urgently please..” The communication tools discussed in the communication chapter RSVP and SBAR can also be used for acute pain problems.

This tool promotes a systematic approach which stresses the use of analgesics in a sequential order according to the patient's response. Steps in the ladder are only ascended when pain persists or is increasing. The first step is non-opioid drugs like paracetamol or NSAIDs. If pain persists then the second step on the ladder introduces weak opioids like codeine. Step 3 introduces strong opioids such as morphine if pain persists. Many doctors / nurses and patients themselves do not realise just how effective paracetamol can be as an analgesic in combination with opioids.

Paracetamol can be given orally, rectally or IV. Ensure it is prescribed regularly and not PRN.

NSAIDs are very effective but there are some circumstances in which they should not be used or should be used with caution:

NSAIDs should not be used if patient has moderate to severe renal impairment, has a previous history of gastro intestinal ulceration, or is receiving anticoagulation therapy.

They should be used with caution if the patient is asthmatic, is elderly, or if the patient is dehydrated or has a low urine output.

Opioids: Anti-emetics should always be prescribed with opioids as they cause nausea and vomiting. Adjuvant therapies are non-pharmacological methods of controlling pain that can be used in addition to drugs and include the following:

• Distraction

• Reassurance

• Position

• TENS machine

Complications of Epidural and PCA

Respiratory depression as a result of opioids. This is usually defined or recognised as respiratory rate of less than 8 breaths/minute. As with any deterioration take an ABCDE approach and call for urgent medical help.

• Call for urgent medical help

• Assess airway

• Give oxygen

Hypotension: This is usually defined as BP of 90mmHg Systolic or significantly lower than the patients norm. Opiates can cause hypotension as they have a vasodilating effect. The Bupivicaine in epidurals blocks the sympathetic nerves that normally constrict the muscles in the blood vessel walls. This block leads to vasodilation and low blood pressure. Treatment is with the ABCDE approach as follows:

• Inform medical staff urgently.

• Consider other possible causes for hypotension (most likely surgical bleeding and hypovolaemia).

• Check level of block. If too high stop the epidural.

• Lie patient flat (NOT head down).

• Give oxygen ASAP.

• Monitoring.

• Treatment will be administration of fluid boluses to improve blood pressure.

Epidural boluses: sometimes the Anaesthetist may give a bolus dose of the epidural infusion to a patient in severe pain. Please be aware that this can result in hypotension which will sometimes not occur for up to 5- 10 minutes after the bolus. Monitor BP carefully post epidural bolus doses.

The above are general principles of management and individual hospitals may do things slightly differently. Please make yourself familiar with local policies and guidelines for managing respiratory depression, over sedation and hypotension for epidural and PCA in the Trust where you are working.

Resources to help you manage acute pain

If you need advice and support with regard to acute pain there is a Pain Team in most hospitals within office hours. There are also lots of experienced senior staff in the areas where you are working who can help. There is also the Critical Care Outreach Team and out of hours there will be a Night Practitioner / Sister or a Hospital Out of Hours Team. There is always an Anaesthetist on call via switchboard who will be able to help with post operative pain problems particularly with epidurals and PCAs. Most hospitals also have acute pain guidelines and guidelines for epidural and PCA which are easily available.

• Lynch (2001) Pain as the fifth vital sign. Journal of Intravenous Nursing 24: 85 - 94

• Scher, C. Meador, L. Van Cleave, J.H. a Carrington Reid, M. (2018) Moving Beyond Pain as the Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21^st Century. Pain Manag Nurs. 2018 Apr; 19(2): 125–129.

• British National Formulary - see section on Analgesics

• British Pain Society

• Faculty of Pain Medicine (2010) Good Practice in the management of epidural analgesia in the hospital setting. London, Faculty of Pain Medicine.

• Faculty of Pain Medicine - Opioids Aware resource

• Schofield, P. (2018) The assessment of pain in older people: UK national guidelines. Age and Ageing. 2018; 47: i1–i22.