Guide to Pain Management in Low-Resource Settings

Why must practice guidelines 
consider regional resources?
Developing countries have limited access to expensive 
drugs or procedures. Th
 erefore, PGs must consider 
regional resources for their feasibility and routine ap-
plication, often making it impossible to simply copy 
international PGs. It may be inevitable to make certain 
evidence-based approaches to diagnosis and treatment 
optional, e.g., by including phrases like “if available.” Ex-
isting PGs have to be adapted if possible according to 
the national “essential drug list.” If no reasonable alter-
native drug choice is available, no further compromise 
for a national PG is recommended. Instead, the essen-
tial drug list should be targeted. Th
 e eff ort should be 
made to encourage all stakeholders to change the drug 
list accordingly. To give an example, the introduction 
of basic palliative care in East African Uganda was only 
possible when the essential drug list was amended by 
adding morphine.
Another fact to be respected when introducing 
PGs in low-resource settings is the disparity regarding 
access to medical services depending on geographic 
factors, such as the diff erence between the capital and 
rural regions or the diff erence between underfunded 
national health system institutions and high-standard 
private ones.
On the one hand, PGs have to be adapted in a 
stepwise structure to be used depending on the resourc-
es available, and on the other hand, PGs may be used as 
an instrument to optimize resources and the quality of 
delivery of health care.
Also, certain national diff erences exist, due to 
cultural, ethnic/genetic, and traditional reasons, regard-
ing the use of certain drugs and procedures. In Mexico, 
for example, 80% of the population use herbal medi-
cine, and 3,500 registered medical plants with medicinal 
properties are available. For that reason, phytotherapy 
or other complementary medicine could be considered 
for inclusion in locally adapted PGs.
Finally, potentially eff ective dissemination and 
education techniques developed in high-resource set-
tings may also have to undergo some changes to be fea-
sible in a specifi c low-resource setting. It is understood 
that such an initiative will mean a considerable eff ort, 
although the work of local PGs could at least be based 
on international accepted PGs. It will be necessary to 
get all stakeholders at one table: rural and academic 
practitioners, other health providers, patients and their 
families, local organizations, and academic institutions. 
Th
  is sounds like a lot of work, but the gain in safety and 
economy following the publication and implementation 
of (adapted) PGs will justify the eff ort.
Pearls of wisdom
•  Practice guidelines (PGs) are “a systematically de-
veloped statement to assist the practitioner’s and 
patient’s decisions about appropriate health care 
for specifi c clinical circumstances.” Guidelines are 
not rules or standards, but they are a helpful, fl ex-
ible synthesis of all the available, relevant, high-
quality information applicable to a particular 
clinical situation, so that the clinician and patient 
may make a good decision.

334
Uriah Guevara-Lopez and Alfredo Covarrubias-Gomez
• Th
 e evolution of medicine has complicated 
medical decision making; for that reason, PGs 
may be used as an instrument to assist the clini-
cian in medical decision making. Th
 is objective 
is possible because PGs summarize the collec-
tive experience and establish easy access to sci-
entifi c knowledge.
•  PGs must be easy to comprehend, inclusive, and 
manageable. Th
  e method for evidence selection 
must be explained, and the criteria used to grade 
each recommendation must be included.
• A wide variety of methods for “grading” the 
strength of the evidence on which recommen-
dations are made have been developed. Grading 
methods take into account the study design, ben-
efi ts and harms, and outcome.
• Th
  e acceptance of PGs requires extensive educa-
tion among clinicians, health care administration, 
policy makers, benefi t managers, and patients 
and their families. Th
  erefore, PG must introduce 
a comprehensive and integrating strategy for its 
implementation.
•  Physician adherence to guidelines may be hin-
dered by a variety of barriers, which include: (i) 
awareness, (ii) familiarity, (iii) agreement, (iv) 
self-effi
  cacy, (v) outcome expectancy, (vi) ability 
to overcome the inertia of previous practice, and 
(vii) absence of external barriers to perform rec-
ommendations.
•  Developing countries may have limited access to 
(expensive) drugs or procedures. Th
 erefore, PGs 
must consider regional resources for their feasi-
bility and routine application.
•  PGs must take into account local resources and 
traditions and make available the evidence re-
garding the risk-benefi t ratio and the cost-eff ec-
tiveness. If local resources lack proper evidence 
or local resources ignore essential evidence, PGs 
may be used as an instrument to draw the atten-
tion of policy makers and health administrators 
to provide the most benefi cial management or 
intervention to the aff ected population.
References
[1]  Carter A. Clinical practice guidelines. CMAJ 1992;147:1649–50.
[2]  Frances A, Kahn D, Carpenter D, Frances C, Docherty J. A new method 
of developing expert consensus practice guidelines. Am J Manag Care 
1998;4:1023–9.
[3]  Guevara-López U, Covarrubias-Gómez A, Rodríguez-Cabrera R, 
Carrasco-Rojas A, Aragón G, Ayón-Villanueva H. Practice guidelines 
for pain management in Mexico. Cir Cir 2007;74:385–407.
[4]  Henning JM. Th
  e role of clinical practice guidelines in disease manage-
ment. Am J Managed Care 1998;4:1715–22.
[5]  Palda VA, Davis D, Goldman J. A guide to the Canadian Medical Asso-
ciation handbook on clinical practice guidelines. CMAJ 2007;177:1221–
6.
[6]  Walker RD, Howard MO, Lambert MD, Suchinsky R. Medical practice 
guidelines. West J Med 1994;161:39–44.
Websites
NICE: National Institute for Health and Clinical Excellence (UK). www.nice.
org.uk
AGREE: Appraisal of Guidelines Research and Evaluation Collaboration. 
www.agreecollaboration.org

Pearls of Wisdom

337
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Corrie Avenant
Chapter 45
Techniques for Commonly Used Nerve Blocks
Why recommend                     
regional anesthesia?
• Th
  e patient remains conscious or mildly sedated.
•  Airways and respiration are not aff ected.
• Th
 e incidence of postoperative thromboembo-
lism is reduced.
•  Regional anesthesia techniques are less expensive 
compared to general anesthesia.
What are the disadvantages             
of regional anesthesia?
•  Special skills are required to do a nerve block suc-
cessfully.
•  Analgesia may not always be eff ective, so conver-
sion to general anesthesia might be necessary.
•  Immediate complications can occur, such as tox-
icity or hypotension.
What assessment must be done 
before performing a block?
Th
  ere are no diff erences regarding the assessment of a 
patient between a general anesthesia or a regional an-
esthesia technique. Th
  e same care and considerations 
must be taken into account, with a history and relevant 
clinical examination. Special drug history is necessary 
with regards to anticoagulant and antiplatelet drugs, 
such as the type, dose, and the time when the antico-
agulants were taken.
It is necessary to explain to the patient what he/she 
will experience:
•  Some paresthesias and involuntary movements 
during needle insertion.
•  Intraoperatively, the patient may feel movement, 
touch, and pressure while having adequate anal-
gesia, and he or she will have to be reassured that 
if the analgesia is inadequate, there is a strong 
possibility of being given general anesthesia.
•  Postoperatively the patient will have to wait for a 
few hours for movement and sensation to return 
completely, but he or she can eat a meal straight 
away.
What are the contraindications    
for regional anesthesia?
• Patient refusal
• Coagulation disorders
•  Infections at the site of injection
•  Pre-existing neurological defi cits: check previ-
ous documentation and make your own brief ex-
amination before planning regional anesthesia to 
avoid being blamed for any undocumented neu-
rological defi cits

338
Corrie Avenant 
What is the structure and 
characteristics of a typical          
local anesthetic drug?
•  Local anesthetics have a three-part structure
• Th
  e three parts of the structure consist of an aro-
matic ring, an intermediate chain, and an amino-
group
• Th
  e intermediate chain has either a ester or an 
amide linkage
• Th
  e ester linkage gets broken down by hydrolysis, 
has a short shelf-life, and is relatively nontoxic
• Th
  e amide linkage is metabolized by the liver
• Th
  e mode of action is a reversible block of nerve 
conduction by blocking the sodium channels 
(from the intracellular site)
How is toxicity avoided               
when using local anesthetics?
•  Always respect maximum doses: for bupivacaine 
the maximum dose is 2 mg/kg for a single injec-
tion technique (daily maximum 8 mg/kg for con-
tinuous techniques).
•  In case of toxicity symptoms (slurred speech, 
tingling in the ear, loss of consciousness, convul-
sions, or arrhythmias), stop the injection, and ad-
minister oxygen and support ventilation to avoid 
acidosis.
•  Stop seizures with intravenous pentothal, benzo-
diazepines, or propofol.
•  If cardiac symptoms are present, give circulatory 
support (antiarrhythmics such as amiodarone or 
amrinone); if arrhythmias persist, use direct-cur-
rent (DC) cardioversion and cardiopulmonary re-
suscitation (CPR) for as long as needed (which may 
be much longer than for other causes of arrest).
•  If available, use lipid infusion (Intralipid) to “an-
tagonize” local anesthetic toxicity (a bolus of 1.5 
mL/kg body weight of Intralipid 20%, followed by 
0.25 mL/kg body weight/minute for 1 hour).
What types of nerve blocks            
are easy to perform?
Finger block
Indications are fractures and lacerations. Th
  e two digi-
tal nerves run on each side of the fi nger. Th
 erefore, the 
technique would be as follows:
• Th
  e landmark is the base of the fi nger.
•  Insert the needle and make contact with the bone 
(the proximal phalanx at its lateral point).
•  Withdraw the needle a bit and deposit 0.5–1 mL 
of 0.5% bupivacaine.
•  Redirect the needle dorsally and inject another 
1 mL.
•  Repeat this on the other side as well.
Toe block
Indications would be fractures and amputations. As in 
the fi nger, two nerves run on either side of each toe. 
Th
  erefore the technique is the same as in fi nger blocks.
Always use plain local anesthetics for digi-
tal blocks; NEVER use mixtures with epinephrine 
(adrenaline).
Intravenous regional anesthesia (Bier’s block)
Bier’s block may be a very eff ective block for upper and 
lower limb manipulation, such as manipulation of sim-
ple fractures and suturing of lacerations.
Th
  e method is as follows:
•  Secure venous access on both sides.
•  Have a full resuscitation trolley available (in case 
of cuff  failure).
•  The inflatable tourniquet is placed around the 
upper arm over a wool bandage to protect the 
skin.
•  A double cuff  may be used for prolonged surgery 
(>15 minutes).
•  Drain venous blood from the aff ected limb.
• Infl ate the blood pressure cuff  to 100 mm Hg 
above systolic blood pressure.
•  Inject local anesthetic.
•  Anesthesia is achieved after 10–15 minutes (the 
blood pressure cuff  should not be defl ated within 
20 minutes).
•  Use 0.5 mL/kg of 0.5% lidocaine (plain) solution
Intercostal nerve block
A typical indication would be postoperative pain relief 
after cholecystectomy or thoracotomy, as well as pain 
relief from fractured ribs. Remember that the intercos-
tal nerves derive from the ventral ramus of the spinal 
nerves and that they run along the inferior border of 
the ribs. To block the intercostal nerves, use the fol-
lowing technique:
•  Position the patient in a supine position.

Techniques for Commonly Used Nerve Blocks
339
•  Have the patient’s arm raised with the hand be-
hind the head.
• Confi rm the rib by palpation or adequate land-
marks.
•  Identify the midaxillary line.
•  To avoid pneumothorax, the needle point should 
be in close proximity to the rib.
• Th
  e rib is held between the second and third fi n-
gers.
•  Insert the needle between the second and third 
fi nger and advance to make contact with the rib.
•  Direct the needle downward (caudally) and walk 
the needle until it slides off .
•  Advance the needle not more than 5 mm to pre-
vent pneumothorax.
•  Finally, inject 2–3 mL of 0.5% bupivacaine at each 
level, after careful aspiration, as the intercostal ar-
tery and nerve are very close by.
Wrist block
Wrist blocks may be used if a plexus block is incom-
plete, as a diagnostic block, or for pain therapy. Be 
familiar with the anatomy. The median nerve is lo-
cated on the radial site of the palmaris longus tendon 
(better visible when flexing the wrist), and the ulnar 
nerve is located on its other (ulnar) side. The radial 
nerve is superficially located at the lateral aspect of 
the wrist.
To block the median nerve:
•  Insert the needle on the fl exor side between the 
tendons of the fl exor carpi radialis and palmaris 
longus tendon.
•  After eliciting paresthesias, withdraw slightly and 
inject 3–5 mL.
To block the ulnar nerve:
•  Have the arm stretched out and the hand supi-
nated.
•  Insert the needle approx 3–4 cm proximal to the 
crease between the fl exor carpi ulnaris tendon 
and the ulnar artery.
•  After eliciting a light paresthesia, withdraw the 
needle slightly and inject 3–5 mL of the local an-
esthetic.
To block the radial nerve:
•  Have the arm stretched out and the hand supi-
nated.
• Infi ltrate subcutaneously on the radial side of the 
wrist 3–5 cm proximal to the radial head point.
Ankle block
Indications would be all kinds of foot surgery, includ-
ing amputations. For an eff ective ankle block, proceed 
as follows:
•  Position the patient supine.
•  Block the superfi cial peroneal nerve with subcu-
taneous infi ltration between the anterior edge of 
the tibia and the upper edge of the lateral malleo-
lus with 5–10 mL anesthetic solution.
•  Block the sural nerve by subcutaneous infi ltra-
tion of 5 mL local anesthetic between the Achilles 
tendon and the lateral malleolus.
• Infi ltrate the saphenous nerve with of 5 mL of 
subcutaneous local anesthetic from the anterior 
edge of the tibia to the Achilles tendon.
•  Block the deep peroneal nerve by inserting the 
needle between the tendon of the extensor pol-
licis muscle and the dorsalis pedis artery on the 
dorsum of the foot. Th
  e needle is inserted per-
pendicularly to the skin and advanced slightly 
under the artery. Following negative aspiration 
inject 5 mL local anesthetic.
•  Tibial nerve block can be obtained with the nee-
dle inserted directly dorsal to the posterior tibial 
artery on the medial side of the joint, or alterna-
tively, directly anterior to the Achilles tendon be-
hind the medial malleolus.
Pearls of wisdom
•  Some peripheral nerve blocks are very easy to 
perform and very eff ective.
• Th
  ey can be performed with minimum training.
• Nevertheless, anatomical details have to be 
known and memorized (see webpage).
•  Peripheral nerve blocks will work better if there is 
no local infl ammation.
•  Toxicity of local anesthetics can be prevented (al-
most always) by respecting maximum doses and 
avoiding intravascular injection with careful aspi-
ration.
•  In case of local anesthetic toxicity have all neces-
sary instruments and drugs ready for treatment, 
otherwise refrain from performing blocks.
•  In case of paresthesias, withdraw the needle to 
avoid injury to the nerve.
•  Do not use blocks if the patient is not willing.

340
Corrie Avenant 
References
[1]  Enneking FK, Chan V, Greger J, Hadzić A, Lang SA, Horlocker TT. 
Lower-extremity peripheral nerve blockade: essentials of our current 
understanding. Reg Anesth Pain Med 2005;30:4–35.
[2]  Klein SM, Evans H, Nielsen KC, Tucker MS, Warner DS, Steele SM. Pe-
ripheral nerve block techniques for ambulatory surgery. Anesth Analg 
2005;101:1663–76.
Websites
http://www.painclinic.org/treatment-peripheralnerveblocks.htm (including 
anatomical images for each block)
http://www.nysora.com/ (including real life photos for all relevant blocks)
http://www.nda.ox.ac.uk/wfsa (World Anaesthesia Online educational mate-
rial on diff erent relevant blocks to be used in low-resource settings)

341
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Chapter 46
Psychological Principles in Pain Management
Claudia Schulz-Gibbins
What can we use for acute pain?
Acute pain occurs mainly in connection with an illness 
or injury or as an eff ect of a treatment of an illness (e.g., 
postsurgical pain). In contrast to chronic pain, acute 
pain is an alarm signal to the body. Normally, the cause 
is noticeable, and the treatment is mostly rest and man-
agement of the cause of pain. Th
  e psychological eff ect is 
the hope that the treatment will be successful and the 
pain will be over soon. It is possible that anxiety and ap-
prehension may appear within the period of acute pain, 
for example, the fear of surgery and anesthesia that 
could form part of the treatment.
Practical consequences
As part of preparation for surgery, interventions such as 
relaxation techniques, a good explanation of the proce-
dure and possible outcomes, and an optimistic outlook 
have been proven to be helpful. It is possible to reduce 
postoperative pain experience through such knowledge. 
Knowledge about the treatment can often reduce one’s 
anxiety. Relaxation techniques can minimize psycho-
logical agitation patterns such as a high heart rate and 
inner restlessness.
What can we use for cancer          
and HIV/AIDS pain?
In the treatment of chronic pain, it is important to dif-
ferentiate between benign and malignant pain. However, 
for cancer pain as well as for pain caused by HIV, there 
is the same relationship, in the framework of the biopsy-
chosocial concept, as with other chronic pain models.
Th
  e prevalence of comorbidities such as anxiety and 
depression is common, as in other pain syndromes, and 
should be taken into consideration and treated. Often 
these disorders are ignored. Additionally, patients have 
to cope with pain due to a tumor, as well as pain that 
may arise during the course of the treatment. Overcom-
ing the consequences of chronic diseases diff ers signifi -
cantly in developed countries in contrast to developing 
countries. Caring for the ill person is often very diffi
  cult 
for the family because of fi nancial problems. A diffi
  cult 
fi nancial situation and poor access to medical, nursing, 
or other social services can aff ect the process of healing 
negatively. At the time of diagnosis, there is often a loss 
of control and helplessness in the face of possible physi-
cal disfi gurement, accompanying pain, and possible fi -
nancial implications for adequate treatment, not least 
the fear and uncertainty surrounding the prospect of an 
untimely death. Additionally, questions of guilt can lead 
to psychological strain because of trying to own up to 
one’s own responsibility for a disease, for example: “It’s 
my own fault that I have a tumor, because I have been 
smoking too much,” or “Being infected by HIV is be-
cause of my irresponsible sex life.”