What type of pain management regimen would you suggest in the postoperative period?
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Post-operative pain management is a key responsibility of the junior doctor and is one of the most common “bleeps” to receive. Indeed with the careful applications of a few core principles, it can often prove a simple and rewarding management. Pain can be divided into acute or chronic types. This article will predominantly focus on the assessment and management of acute pain. Clinical Assessment of PainPost-operative pain can be assessed subjectively and objectively:
Each patient should be assessed when mobile, when taking a deep breath, and when in bed (a pain-free patient in bed may well be in severe pain when they walk to the toilet). Remember that pain itself may be a marker of underlying pathology (not always just “routine post-operative pain”), therefore it is important to assess for any underlying (and potentially treatable) causes for the pain. Consequences of Poor Pain Control Inadequate control of post-operative pain results in a slower recovery
WHO Analgesic LadderThe World Health Organisation Analgesic Ladder (Fig. 1) is the best-known method for approaching pain relief. It provides a strategy for titrating analgesia, starting with simple analgesics and working upwards to strong opioids. After implementing a regime, the patient should always be reviewed shortly after to assess adequacy. Initially starting with simple analgesics (such as paracetamol or NSAIDs), if the pain is not well controlled, move up to the next stage of the ladder and consider prescribing weak opiates, such as codeine or tramadol. Again, assess the response and if this is still inadequate, move to the next step and prescribe morphine or other strong opiates. Consider alternatives to the oral route, such as topical, intravenous, or subcutaneous. If this fails and sinister causes of pain have been ruled out, consider specialist help and/or a patient-controlled analgesia pump. Any neuropathic pain may respond better to alternative analgesics (see appendix), such as amitriptyline or gabapentin. As patients recover, it is important to move down the ladder, and wean down the analgesia to a more simple regime. It is always preferable to not send patients home with strong opiates. World Health Organisation Figure 1 – The WHO pain relief ladder, commonly used in the management of pain due to cancer. Types of AnalgesiaSimple AnalgesicsNon-opioid analgesia consists of paracetamol and/or NSAIDs (e.g ibuprofen or diclofenac). NSAIDs work by inhibiting the synthesis of prostaglandins, thereby reducing the potential inflammatory response causing the pain. These anti-inflammatory properties mean such analgesics are often used in musculoskeletal conditions. They are also frequently used intra-operatively. The side effects of NSAIDs include (a useful mnemonic is I-GRAB):
Opiate AnalgesicsOpiates are divided into weak opiates, such as codeine, or strong opiates, such as morphine, oxycodone, or fentanyl. They work by activating opioid receptors (MOP, DOP, and KOP), which are distributed throughout the central nervous system. These medications have a significant side effect profile; most patients will experience a degree of constipation and nausea. Thus, laxatives and anti-emetics should be prescribed concurrently. Other side effects include sedation or confusion, respiratory depression, pruritus, and tolerance and dependence (both of the latter are relatively rare). Prescribing Tips
Patient Controlled AnalgesiaPost-operatively, many patients require more intense or immediate analgesia and their requirements exceed the capacity of nursing staff to provide. In such situations, patient controlled analgesia (PCA) can be used. PCA involves the use of intravenous pumps that provide a bolus dose of an analgesic when the patient presses a button. These are started in theatre (based on clinical experience of analgesia requirements of the specific operation by the surgical staff) or on the wards (often when strong opiates are inadequate).
Key Points
Appendix – Neuropathic painNeuropathic pain results from irritation or injury directly to the nerves, either peripherally or centrally. It often presents with shooting or stabbing pains, and can be described as like an electrical shock. Following surgery, the prevalence of neuropathic pain is as high as 10%. It is frequently encountered in orthopaedic or vascular surgery, such as following limb amputation (due to the nerve damage sustained when the limb is severed). The management of neuropathic pain can be split into pharmacological and non-pharmacological methods. In many cases a combination of both approaches offers the best results:
What methods can be used to manage pain postoperatively?Postoperative pain also can be managed by other prescription and over-the-counter medications such as ibuprofen (Motrin), acetaminophen (Tylenol), and aspirin (Bayer). Medications like ibuprofen also help reduce inflammation and swelling.
Why is pain management so important in postoperative patients?Post-surgical pain control helps speed your recovery and reduces chances of complications, such as pneumonia and blood clots. Pain needs to be managed carefully, with you and your healthcare provider working together to come up with the right plan.
What type of pain is post surgery?Postoperative pain is considered a form of acute pain due to surgical trauma with an inflammatory reaction and initiation of an afferent neuronal barrage.
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