Together we stop the pandemic #COVID-19
Together we stop the pandemic #COVID-19

Pain Management in COVID-19 Patient

Kamaruddin Ibrahim, Shamsul Kamalrujan Hassan, Mohd Zulfakar Mazlan, Sanihah Che Omar
Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan.
Pengarang Koresponden:
Dr Kamaruddin bin Ibrahim
Anaesthesiologist and Pain Specialist,
Department of Anaesthesiology and Intensive Care, School of Medical Sciences,
Universiti Sains Malaysia, Health Campus,
16150 Kubang Kerian, Kelantan.

COVID-19 affects different people in different ways. The most common presentations are fever, cough and shortness of breath. However, COVID-19 has been reported to present with abdominal pain, sore throat, headache, myalgia, back pain, testicular pain and arthralgia1-5. It is prudent for paramedics to obtain pain intensity that patient might has. Pain as a fifth vital sign has been introduced in Malaysia since 2008. Therefore, paramedics are required to chart the Pain Score (PS) together with other common vital signs such as Blood Pressure (BP), Heart Rate (HR), Temperature (T) and Respiratory Rate (RR) in a vital signs chart.

Pain Score is measured by using Visual Numerical Rating Scale (VNRS) as shown in figure 1. Number 1-10 represent the level of pain intensity6. Number 1 is for the pain with minimum intensity while the number 10 is for the pain with maximum intensity. As the number increases, the pain also increases up to the most severe pain that patient can imagine.


Figure 1: Visual Numerical Rating Scale

Faces Pain Scale (Figure 2) is used whenever patient has difficulties to understand the numerical scale. Generally, Faces Pain Scale is applied for a preschool kids aged above 4 years old. Patient is required to point which face is identical to their pain now. Different face indicates certain pain scale number.


Figure 2: Faces Pain Scale

For children below 4 years old, FLACC (Face Leg Activity Cry Consolability) scale is used (Figure 3). It is being used for demented patient or cognitive impaired patient for example in Down syndrome. Paramedics and doctors need to sum up each score for each category. The maximum point for each scale is 10. Thus, documentation of Pain Score (PS) is per 10. Remember to chart the PS together with 4 other vital signs include BP, HR, T and RR.







No particular expression or smile

Occasional grimace or frown, withdrawn, disinterested

Frequent to constant quivering chin, clenched jaw


Normal position or relaxed

Uneasy, restless, tense

Kicking or legs drawn up


Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tens

Arched, rigid or jerking


No cry (awake or asleep)

Moans or whimpers; occasional complain

Crying steadily, screams or sobs, frequent complaints


Content, relaxed

Reassured by occasional touching, hugging or being talked to, distractible

Difficult to console

Each of the five categories (F) face, (L) legs, (A) activity, (C) cry and (C) consolability is scored from 0-2, resulting in total range of 0-10.



Doctors need to differentiate between acute pain and chronic pain. Most of COVID-19 patients suffer from acute pain1. Acute pain is a pain that occurs during tissue healing or less than 3 months, whereas chronic pain is a pain that persist beyond tissue healing or more than 3 months. Managing chronic pain is challenging and it is not discussed here.

Acute pain is managed by pharmacological and non-pharmacological approach. Treatments are always started with explanation of a diagnosis and reassurance. Later the treating doctor need to educate patient on deep breathing exercise therapy, Distraction technique, rest, hot or cold appliances, massage etc. Pharmacological therapy is guided by using WHO (World Health Organization) analgesic ladder6 (Figure 4).


FIGURE 4: WHO Analgesic Ladder for Acute Pain Management.

The main objective of treating acute pain is to reduce the pain score to 3 or below or to make patients comfortable with the current tolerating pain. The pharmacological pain treatment is divided according to the severity of pain; mild, moderate and severe. Patient with mild pain (PS 1-3) is treated using Paracetamol or NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) or combination of both. Currently there are still no evidence suggesting NSAIDs worsen COVID-19 infection7.  The usual NSAIDs that have been used are mefenemic acid (ponstan), diclofenec sodium (voltaren), Ibuprufen (brufen), celecoxib (celebrex) and etoricoxib (ancoxia).

For moderate pain (PS 4-6), weak opiod like tramadol or dehydrocodeine is usually added together with paracetamol and NSAIDs. Dehydrocodeine is usually well tolerated comparing to tramadol. Doctors should be well versed on indication, dosage and contraindication for individual analgesic. The problem arises when PS is more than 6 which is severe (PS 7-10). This type of severe pain requires strong opiod; morphine, oxycontin or fentanyl. If the treating doctor is not familiar with the strong opiod use, it is advisable to refer or consult the Acute Pain Service team.

As far as we concern, there is no single case report mentioning the COVID-19 patient suffers from uncontrolled severe pain. However, the treating doctor should know how to treat acute pain as patient with COVID-19 can present with any kind of body pain.


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