PreEmpt Pain App. Exercise 1. Demographics.

This is the first of several exercises to introduce you to the clinical decision tool I am developing for the non-pain provider. PreEmpt Pain is a smartphone app to guide you in the development of a pain management plan for the hospitalized patient after a surgery, physical trauma, or medical condition.

One of the first pages of the decision tool is a demographic page where you consciously acknowledge the factors that play a role in your pain management decisions.

Let's go through these one by one.

The Plan date refers to the date for which you are making the plan.

The Sx / adm date (surgery or admission date) refers to the date of the surgical procedure or admission for a physical trauma or medical condition. These dates are important because as one gets further away in time from the acute event, pain levels and healing should be improving. This provides a good context for just how acute the condition is on a given day. One may need to consider that numerous procedures could be performed during a hospitalization and this will affect the pain management regimen.

Patient age - for adults there is usually a fixed dose range for medication prescription (mg per dose). For children however, below the age of 13 / under the weight of 50kg) many the medications may be dosed on a milligram per kilogram (mg / kg) basis. Age is also important to understanding the developmental aspects of hospitalization and pain that change through childhood.

Weight in kg - as mentioned above, weight of pediatric patients is particularly important as often medications are dosed on a mg / kg basis, rather than a fixed dose range per se. In addition, it may sometimes be necessary to decrease the dose of a sedating medication in those patients with comorbid conditions that put them at risk for increased sensitivity to these medications.

Surgical procedure / Medical condition - pain management is ideally based on the expected intensity of pain associated with a given procedure or medical condition rather than the self-report score of pain at any given time. For example, spine surgery, or posterior spinal instrumentation, is usually associated with more tissue trauma and therefore increased (intense) pain. Compare this to the expected pain after central line ('port') placement, which is usually mild in nature. These different degrees of tissue trauma require different pain management regimens. We'll explore this concept below.

Disposition - or expected location of the patient after the procedure, trauma, or ER visit.

Some patients with pain will be admitted to the hospital floor (ward); others may be admitted to a monitored setting such as an intensive care unit. Location of stay will often dictate the services and medications available for pain and we should be aware of the capabilities and limitations of the various settings. For example, some medications, such as opioids, ketamine, or other sedating medications, require a higher level of monitoring as the risk of respiratory depression is increased.

Other patients may be anticipated to be discharged home, and will therefore be more reliant on their ability to follow instructions regarding pain medication administration. A good pain management plan involves consideration of the patients' and families' ability to care for them.

Diet and nutrition - the ability to take in food and nutrition and the mode in which nutrition is obtained may have a direct relationship to the acceptable forms of medications prescribed and the ability of the patient to tolerate them. There are several options:

NPO bowel rest - oral medications may not be allowed, such as opioids, with which we often rely on gut motility for metabolism.

NPO nausea / vomiting - the patient may not absorb any medications given via the oral route and to assure proper treatment, alternative routes may need to be considered (and / or additional treatment to minimize nausea / abolish vomiting)

Clear liquids - the patient may be on the verge of having diet advanced but for the time being is being tested with clear liquids. It is best to avoid any oral medication that is 'difficult on the stomach' such as opioids, NSAIDs. Individual practices may vary so check in with what is the norm.

Clear liquids G-tube - similar to clear liquids by mouth but emphasizes the gastrostomy tube; the reason I make this distinction has to do with passive versus active consumption of water. The patient taking fluids in by mouth can be encouraged to pay attention to hydration and having a water bottle readily available while the patient receiving gastrostomy tube fluids often needs to rely on another individual to provide free water to them.

Advance diet ad lib / PO - this allows us to consider administration of meds by mouth if appropriate. There is an old adage 'If the gut works, use it'. In other words, we should provide medications by mouth rather than through a more complicated method such as the intravenous, intramuscular, or rectal route. Using the mouth as the route for medications relies to a greater degree on the patient's innate ability to care for themselves and perhaps puts them in a better position for hospital discharge.

Advance diet G-tube - allows a greater number of options as noted above. Consider the need to prescribe these in liquid form or crushed tablets if appropriate and consider potential of these medications to block the gastrostomy tube.

Knowing the patient's NPO / nutrition status is also important in returning them to their baseline state of nutrition. Good nutrition (meaning eating at breakfast, lunch, and dinner times, and maybe some snacks) provides the calories and glucose individuals need to recover. Many patients will state they lack appetite and therefore avoid oral intake. This is a common scenario related to anesthetic agents, unfamiliar environment, stress, different foods. However, if nausea or vomiting is not present and oral intake is allowed, the patient should be encouraged to eat something at every meal time, even if it is a cracker, a piece of toast, etc. As one starts to tolerate food in the stomach, this can have a positive impact on gastric motility and improved appetite. In this situation, one should rely on 'eating by the clock' rather than by the presence of appetite.

Allergies - especially allergies or sensitivities to pain medications and the like should be indicated here

Expected pain intensity - procedures and conditions can often be classified as being associated with mild, moderate, or intense pain.

In the app, if you tap on the 'Expected pain intensity' link, you will be brought to another page providing examples of those procedures associated with mild, moderate and intense pain. You can use this as reference and return to the previous screen by tapping the 'back' button on the far left of the footer.

Chronic pain at baseline - it is important to determine if your patient has chronic pain at baseline or pain associated with a condition prior to a surgical procedure. This allows you to have a realistic expectation regarding how much you can impact procedural pain with a pain medication regimen. It is important to communicate these expectations to the patient.

Tapping the Chronic Pain at Baseline link within the app will bring you to another page to gain better understanding of their pain in general.

The first is a simple yes / no question. You can ask, 'Prior to this procedure / hospitalization, did you have pain on a daily basis?'

The second question allows you to gain insight into their pre-existing pain. This assumes use of the numeric rating scale (NRS) for older children and adults. As a surrogate, you may ask how much the pain is interfering with the activities of daily living. In the next version of PreEmpt Pain, I will have some additional resources addressing chronic pain's impact on an acute medical condition, surgical procedure, or physical trauma.

Home pain regimen. Finally, it is important to identify any medications the individual may be taking to manage chronic pain symptoms so these medications can be continued in the hospital, if appropriate. It is important to avoid any potential withdrawal symptoms that might occur should the medications be abruptly discontinued by oversight. These would include medications such as the tricyclic antidepressants, amitriptyline and nortriptyline, or the anticonvulsant medications such as gabapentin or pregabalin. If the patient is taking an opioid medication for pain, the regularity with which these medications are taken should be determined. It is to be recognized that, should an opioid be needed due to the expected intensity of pain, doses above that taken at baseline might need to be considered. Opioid withdrawal symptoms and contribute to morbidity in some circumstances but can be mitigated with proper treatment. One may want to consider consulting a pain management expert to assist in these situations, particularly if expected pain is anticipated to be of high intensity.

Procedure associated with nerve pain - it is also important to identify those procedures in which nerve pain, or neuropathic pain, might be possible. For example, procedures that involve correction of chest wall deformities, such as the Nuss repair (or minimally-invasive correction of pectus excavatum) may result in stretching of the nerves of the chest wall and increased chance of pain originating from those stretched nerves. These patients may have pain that increases a few days after the surgical procedure. Preventative measures are often put into place involving multimodal analgesia to better manage postoperative pain and minimize the chance of acute pain developing into a chronic pain condition.

Pain scale - the business of how to measure pain is a complex undertaking. Choosing a measure that will follow the trends in the pain experience is an important step. Consistency amongst providers in using these scales is important, although there may be two different scales used to gain a better understanding of the patient experience. There are numerous scales available for different patient populations based on age and ability to interact with the healthcare provider. The two types of scales are observational and self-report.

Here is a quick summary of the various scales.

Premature Infant Pain Profile (PIPP) - observational

Neonatal Infant Pain Scale (NIPS) - observational

Bieri FACES pain scale - self-report

Faces Legs Activity Cry Consolability (FLACC-R) - observational

Numeric Rating Scale (NRS) -self-report

Youth Acute Pain Functional Activity Profile (YAPFAQ) - self-report

This topic is a very important one and therefore warrants its own post. Stay in touch for further exploration in my next post.

Demographic header - The above entries will be summarized in a header present in several of the subsequent screens. This serves as a reminder of the specifics regarding your patient so you can make appropriate selections regarding the pain regimen.

Now, if you haven't done so already, submit your email and name on the home page to gain access to the PreEmpt Pain app. Try out this exercise with the Demographics page and see for yourself how this can help you better understand your patients. Leave a comment for discussion.