Murtaza Asif Ali

Queen’s Hospital
Burton upon Trent

POST-OPERATIVE PAIN
MANAGEMENT.
Definitions of Pain:

Oxford dictionary definition:

Highly unpleasant physical sensation caused by illness or injury.

IASP definition of pain (1962)

An unpleasant sensory and emotional experience associated with actual

or potential tissue damage, or described in terms of such damage.

Emotional components of pain

‘Pain is whatever the experiencing person says it is,
existing whenever the experiencing person says it
does’
Margo McCaffery 1968

Evidence suggests that less than half of patients who undergo

surgery report adequate postoperative pain relief.
Apfelbaum JL, Chen C, Mehta SS, Gan TJ: Postoperative pain experience: Results from a national survey suggest postoperative pain
continues to be undermanaged. Anesth Analg 97:534-540, 2003
Why treat
pain?
 Basic human right

 Decrease pain and suffering

 Decrease complications of unrelieved pain

 Prevent development of chronic pain

 Increased patient satisfaction

 Faster recovery

 Decreased length of stay and cost reduction

 Increased productivity and quality of life

Assessment of pain
 The Abbey Pain Scale
For assessment of pain in
patients who cannot verbalise i.e.
patients with dementia or
communication difficulties .
Pain management
 Ideally should begin preoperatively with the preparation
of the Patient

 Adjustment or Continuation of Medications.

 Treatment to Reduce Preexisting Pain and Anxiety

 Patient and Family Education

 Preventative Analgesia has replaced Pre-emptive
analgesia

Establishing an effective analgesic state prior to

surgical trauma and continuing postoperatively.

ALL NOCICEPTION PRODUCES PAIN BUT NOT

ALL PAIN RESULTS FROM NOCICEPTION

The World Federation of Societies of Anaesthesiologists analgesic
ladder

Strong Opioids
by injection.
Opioids by Local
Anaesthetics
mouth
Paracetamol
NSAIDS
Uses and characteristics of commonly used analgesic drugs

Simple analgesics

Paracetamol
Mild pain
1g qds, maximum 60mg/kg in 24hours
Potential hepatotoxicity in overdose
Good antipyretic, not anti-inflammatory
Can be given PO, PR, IV

NSAIDS
Mild to moderate pain, especially superficial,
muculoskeletal and with inflammatory component.
Ibuprofen (200-400mg tds), Diclofenac (50mg tds)
Risk of renal failure.
Increased bleeding tendency
Can be given PO, PR or IV
Weak opioids
Codeine
Moderate pain and for minor surgical procedures
15–60 mg qds (max 240 mg/24hours)
Good in combination with paracetamol
s/e constipation, N/V dizziness
Can be given oral or IM (avoid if possible)

Tramadol
Moderate pain
50–100 mg qds
Avoid giving with other opioids.
Less addictive therefore very useful in problem drug users
s/e dizziness, dysphoria esp. in elderly
Can be given oral, IV or IM
Strong Opioids

Morphine Sulphate
Severe, visceral pain and for deep structural
procedures.
0.05–0.1 mg/kg IV
0.1–0.2 mg/kg IM
0.2–0.4 mg/kg PO

IV route best for immediate pain relief

s/e respiratory depression, N/V constipation,

confusion and decreased consciousness

Oral, sublingual (buprenorphrine), IM, IV,

patient-controlled analgesia cont IV/bolus)
Epidural and spinal
 Alternative pain medicines

 IV Lignocaine
 Ketamine
 MgSo4
 Clonidine
 Anticonvulsant
 Antidepressant
 Corticosteroid
 Botulinum toxin
Patient-controlled analgesia

Effective way of providing opioid analgesia where the patient

titrates the dose to his/ her need by pressing a button that
delivers a small bolus (e.g. 1 mg morphine).

It is safe, has a high patient satisfaction and is usually set up in

theatre.

Used postoperatively until the patient can tolerate oral

analgesia.

For safety, a separate IV line is required with a non-return

valve and crystalloid infusion at 30 ml/hour to keep the line
patent.
Interventional pain management

Neuraxial analgesia (Spinal, Epidural)

Peripheral nerve blocks

Multimodal Analgesia

Administration of two or more analgesic agents by one or

more routes

Exert their effects via different analgesic mechanisms and

ideally act synergistically at different sites in the nervous
system, thereby providing superior analgesia

Decrease side effects.

 A fit and well 25 year-old woman.

 Has had an inguinal hernia repair in

day surgery.

 She is unable to be discharged

because of her pain, and so has to
stay in overnight.

 What analgesia is appropriate?

May need PCA morphine.

Oral morphine every 3–4

hours

Titrate IV morphine in 1–2

mg every 5 mins.

Regular Paracetamol
+NSAID
An 87-year-old woman.

Admitted with a fractured femur.

A history of dementia, hypertension

and type 2 diabetes. She is mildly
confused.

What pain relief can you offer?

Potential Approach
 Regular paracetamol.

 Check her renal function before prescribing NSAIDs. If within

normal range can prescribe ibuprofen 200-400 mg three times a day.

 Ensure IV fluids prescribed and urinary output monitored.

 Prescribe a mucoprotective agent, e.g. omeprazole 20 mg once

daily.

 Oral morphine can be given every 3–4 hours.

 PCA is probably not the best option as she is confused and may not
be able to use it effectively(could use nurse-controlled analgesia).

 She may benefit from a local nerve block by an anaesthetist

 45 years old male

 IVDU

 On methadone programme

 Admitted for incision and drainage of

abscess.

 Says he is in a lot of pain

 What analgesia should be used?

 Patient on long term opioids
 Opioid induced hyperalgesia
 Increased sensitivity to pain
 Need for optimal multimodal analgesia
 Ketamine

 Opioid tolerance
 Decreased opioid effectiveness
 Higher doses of opioids are needed
 Gabapentin, Pregabalin

 Risk of Opioid withdrawal if unable to take usual medications

(eg.methadone, buprenorphine)
 Continue baseline opioids.
 Clonidine, Gabapentin, Pregabalin
 Clonidine reduces opioid withdrawal symptoms

 Gabapentin and pregabalin attenuate opioid induced

hyperalgesia and tolerance and reduce opioid withdrawal
symptoms

 Ketamine improves pain relief after surgery and may

reduce opioid requirements

 Opioid tolerant patients report higher pain scores, have

slower pain resolution with a longer hospital stay and increased
readmissions

 Also have higher opioid requirements and higher

interpatient variation in the doses needed
Acute pain management: scientific evidence, fourth edition, 2015.
Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J.
 Potential Approach

Regular oral (or rectal) paracetamol and NSAIDs can still

be taken up to 2 hours preoperatively.

The patient is on methadone –check the dose with his GP

– write up regularly. Be sure about the dose. If the dose
cannot be confirmed contact the drug dependency unit or
pain team.

Try tramadol 100 mg qds (can be given IV or oral) or

morphine (avoid giving IV) for breakthrough pain.

Contact the pain team for advice – PCA may be

appropriate. Be aware of withdrawal symptoms. Consider
background infusion.

Local anaesthetics may be an option.

 Take home message

 Its our duty to treat pain

 Trust your patient

 Multimodal analgesia provides best pain relief.