Post Operative Pain Management

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There is evidence that patients benefit from the use of multimodal, or balanced, analgesia after surgery. NSAIDs, paracetamol, local anaesthetics, adjuvant drugs, and opioids are employed in combination to improve pain relief (Table 1). Multimodal analgesia employs a variety of drugs, given by different routes, to achieve analgesia, with a reduction in the incidence and severity of side effects. NSAIDs contribute significantly to multimodal analgesia and postoperative recovery of the patient by minimizing opioid side effects including the inevitable opioid-induced gastrointestinal stasis that delays the resumption of normal enteral nutrition after surgery. However, the effect on morbidity and mortality has been disappointing in some studies, demonstrating that very good pain control is not automatically associated with an improvement in outcome. Recent studies have suggested

Table 1. Scientific Evidence for Pharmacological Interventions to Manage Postoperative Pain in Adult Patients

Intervention Level of Comments evidence

NSAIDs

Oral (alone) I

Oral (adjunct to opioid) Parenteral (Ketorolac)

Opioids Oral

Route of choice Intramuscular

Subcutaneous

Intravenous

PCA (systemic)

Epidural and intrathecal

Effective for mild to moderate pain. Relatively contraindicated in patients with renal disease and risk or actual coagulopathy. Risk of coagulopathy, gastrointestinal bleeding and other risk factors should be carefully sought

Potentiating effect resulting in opioid sparing. Caution as above

Effective for moderate to severe pain. Useful where opioids contraindicated or to produce "opioid sparing'', especially to minimize respiratory depression, sedation, and gastrointestinal stasis. Best used as part of a multimodal analgesia regimen

As effective as parenteral in appropriate doses. Use as soon as oral medication tolerated.

Has been the standard parenteral route, but injections painful and absorption unreliable. Hence, avoid this route when possible.

Preferable to intramuscular because of patient comfort and a reduced risk of needlestick injury

Parenteral route of choice after major surgery. Suitable for titrated bolus or continuous administration. Significant risk of respiratory depression with inappropriate dosing

Intravenous or subcutaneous routes recommended. Good steady level of analgesia. Popular with patients but requires special infusion pumps and staff education.

When suitable, provides good analgesia. Risk of respiratory depression (as with opioids by other routes), but (as with opioids by other routes), but sometimes delayed in onset. Requires careful monitoring. Use of infusion pumps requires additional equipment and staff education. Expensive if infusion pumps are employed

Table 1. (Continued)

Intervention

Level of Comments evidence

Local anaesthetics Epidural and I

intrathecal

Peripheral nerve block

Indications in particular settings. Effective regional analgesia. May blunt "stress response'' and aid recovery. Opioid sparing. Addition of opioid to local anaesthetic may improve analgesia. Risks of hypotension, weakness, numbness. Requires careful monitoring. Use of infusion pumps requires additional equipment and staff education. Expensive if infusion pumps are employed Plexus block, peripheral nerve block and infiltration. Effective regional analgesia. Opioid sparing

that the use of multimodal analgesia after major surgery may improve recovery and thus reduce costs of hospital stay. Several authors have proposed that the ''pain-free state'' should be employed as a fundamental component of an aggressive regimen of postoperative mobilization and early oral feeding in a process of acute rehabilitation after surgery. Multimodal analgesia employing NSAIDs to minimize opioid requirements has the particular advantage over unimodal systemic opioid administration. In addition, by using non-opioid drugs as part of a balanced analgesic plan, the patient can return to normal enteral nutrition much more quickly by avoiding the undesiderable opioid problems of gastrointestinal stasis, nausea and vomiting. The best approach to post-operative pain therapy is based on pharmacologic protocols, using all drugs involved in postoperative pain relief (Table 1). In fact, a correct use of drugs for pain should control symptoms and achieve a good outcome. As the World Health Organization guidelines support there are two main goals to consider [25]: Pain therapy must be assessed ''By the Patient'' and ''By the Ladder''.

By the Patient

Different factors may alter the amount of pain suffered by the individual patient. The general conditions, the patient himself, his disease and psychological factors are important factors to consider in order to start an adequate pain management (Box 5a, 5b). Severe pain can cause a number of changes in an individual behaviour, including increased self absorption

a. Psychological factors affecting pain response

- Cultural differences

- Cognitive appraisal

- Fear and anxiety

- Neuroticism and extroversion

- Perceived control of events

- Coping style

- Attention/distraction b. Psychological methods for reducing pain

- Placebo and expectation

- Psychological support

- Sensory information

- Relaxation training

- Cognitive coping strategies and withdrawal from interpersonal contact. Fear and anxiety are the major emotional concomitants of acute pain and are especially pronounced when associated with fear of death. Severe acute pain that remains unrelieved for days may lead to depression and helplessness as a result of patients experiencing a loss of control over their environment. It is now generally agreed that unrelieved severe acute pain exacerbates premorbid tendencies for anxiety, hostility, depression, or preoccupation with health. In a few cases, the inability to cope with pain may create an acute psychotic reaction. However, acute pain is one of the important factors contributing to the development of delirium in intensive care units. For all these reasons psychological approaches are an integral part of the medical care of the patient with pain (Box 5b). All patients can benefit from psychological assessment and support and some are good candidates for specific psychological therapy. Cognitive-behavioural interventions can help some patients decrease the perception of distress engendered by the pain through the development of new coping skills and the modification of thoughts, feelings and behaviours. Relaxation methods may be able to reduce muscular tension and emotional arousal or enhance pain tolerance. Other approaches reduce anticipatory anxiety that may lead to avoidant behaviours or lessen the distress associated with the pain. Approaches that give patients more control are likely to be successful in reducing anxiety and decreasing the requirement for pain and medication. Patient-controlled analgesia (PCA) is a highly successful example (see below). Successful implementation of these approaches in the postoperative patients requires a cognitively intact patient and a dedicated, well-trained clinician.

By the Ladder

Analgesic pharmacotherapy is the mainstay of postoperative pain management. Although concurrent use of other interventions is valuable in many patients and essential in some, analgesic drugs are needed in almost every case. The guiding principle of analgesic management is the individ-ualization of therapy. Through a process of repeated evaluations, drug selection and administration is individualized so that a favourable balance between pain relief and adverse pharmacological effects is achieved and maintained (Table 1). An expert committee convened by the World Health Organization (WHO) has proposed a useful approach to drug selection for acute and chronic pain states, which has become known as the 'analgesic ladder' (World Health Organization 1986) (Fig. 5). The World Federation of Societies of Anaesthesiologist (WFSA) has been developed to treat acute and post-operative pain. Initially, pain can be expected to be severe and may need strong analgesics in combination with local anaesthetic blocks and peripherally acting drugs to be controlled (Fig. 6). When combined with appropriate dosing guidelines, this approach is capable of providing adequate pain relief to patients. Emphasizing that pain intensity

Freed om from cancer pain

Opioid for modéraie-

to-severe pain

± nonopidd í adjuvant therapy

Pain persisting or increasing

Opioid for mild-to-moderate pain

+ nonopicid ± adjuvant therapy

Opioid for mild-to-moderate pain

+ nonopicid ± adjuvant therapy

Pain persisting or increasing

Nortopioid

- adjuvant therapy

Pain persisting or increasing

Nortopioid

- adjuvant therapy

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