Dr Suleman Mumtaz PG Ward 2

• The purpose of this presentation is to review Common methods of relieving acute postoperative pain • In this we will discuss how to use Common peripherally-acting analgesics (like nonsteroidal anti-inflammatory drugs(NSAIDS), centrally-acting agents (such as opioids) and also local anaesthetics . • This review is not comprehensive but is intended to summarise current thought about the practical management of postoperative pain in most hospital of our Country like JPMC • Finally WHO recomendation

• • Respiratory - if patient is unable to cough and expand lung bases it increases risk of chest infection/pneumonia. • Urinary – Urinary retention • Psychological – Pain can lead to anxiety, sleep deprivation,patient:s unsatisfaction towards treatment

Adverse pathophysiological consequences of poor pain management(What if not considered) Cardiovascular – Hypertension, tachycardia

• Generally, if patient’s pain is well controlled they will recover quicker and be discharged sooner.

Misconceptions about postoperative pain
• Doctor believe that they, rather than the patient, are the authority on the patient’s pain • Post-operative pain can not be prevented • Patients will become addicted • Side effects of analgesics can not be controlled • Opioids must not be given as primary treatment • The same operation produces comparable severity of pain in different people

 Pain Assessment
  Pain must be assessed regularly by asking the patient.  Pain can not be assessed accurately by observers Believe the patient! (pain is the patients own experience) Ask them to rate their pain as ‘none’, ‘mild’, ‘moderate’ or ‘severe’ – PAIN SCORE Ask the patient to assess their pain on movement (eg. deep breathing) Pain should be assessed for at least 4 days to 1½ week postoperatively.  Level of sedation and respiratory rate must also be observed (in case of OPIODS) Surgeon should assess by using PAIN SCORE • • • • •

 Pain Assessment Cont: Pain Score

  • • • • • •

 Principles of good pain management

Involve the patient in the management of their pain Aim to predict and prevent pain if possible Analgesics should be used regularly for continuous pain Always use the IM/IV route If patient is requiring regular Opiod injections consider PCA Dose and frequency must be individualised.  Opioids (IM) can be given safely 6 hourly if patient is stable • Next dose of analgesia should be given before previous dose has completely worn off • Use multi-modal approach.  Combine use of compound analgesics with NSAID.  The addition of an NSAID or paracetamol will reduce need for opioids by 30%.Also known as COMPOUND ANALGESIA

 Recommended Analgesics
• Paracetamol (use for mild pain)

analgesia • Compoundto opioid receptors (use for mild-moderate pain) Action: Contain mild opioid which binds in dorsal horn

Dose: 1g DONOT USE in hepatic disorders

• Buprenorphine

Preparation of choice : TRAMAL 100mg and DICLOFENAC Na 75mg Stronger alternative : KINZ and DICLOFENAC Na 75mg Soluble preparation : KINZ and PARACETAMOL 1g Side effects : Constipation, nausea and vomiting and drowsiness (treat with ant-emetics and laxatives DO NOT WITHDRAW ANALGESIA) can be used as an alternative for moderate to severe pain.  It has less incidence of respiratory depression and constipation.  But can cause more nausea and vomiting. Dose: 0.3mg IM or Slow IV Push every 6hrly Rarely used

 Recommended Analgesics Cont: NSAIDs (use with compound analgesia) Action : Inhibits •

inflammation (prostaglandin synthesis) that causes pain after surgery Drug of Choice:DiclofenacNa 75mg IM Ketorolac(Toradol) 30mg IV/IM 6h Contraindications : NSAIDs should not be given to patients with poor renal function, dyspepsia or peptic ulcer. • Opioids (use for moderate – severe pain with NSAID/paracetamol) Action: Binds to opioid receptors in dorsal horn Drug of choice: Morphine/Nalbuphine(Kinz 10mg)

• TRAMAL. agent

 Recommended Analgesics Cont:
Is TRAMADOL –Non 0piod 100mg IV/IM 4-6hrly Max dose 400mg/day Singal Regime/Compound


Management of pain
• Pain score mild/no pain - consider change to oral analgesia • Pain score moderate-severe - Repeat morphine/Nalbuphine/Tramal for up to 2 doses and consider NSAID/paracetamol • Pain score still remains moderatesevere - Clinical review (look for Hematoma/Wound Infection) If not then consider 3 doses rather then 2

Guidelines for administration of all opioids via any route
• All patients must have an anti-emetic administered • Patients over 60 years old should have oxygen • Do not give other sedatives with opioids • If sedation is there , respiratory rate<10 or BP<90mmHg STOP ALL OPIOIDS AND REVIEW IN 15 MINS • If sedation is Unarousable, respiratory rate <8 or BP<90mmHg STOP ALL OPIOIDS, TRY TO WAKE PATIENT, ADMINISTER OXYGEN, NEED TO CONSIDER NALOXONE

Contraindications and side effects:
• Liver disease and renal impairment (action of opioids is prolonged) • Causes respiratory depression which may further elevate intracranial pressure for patients with head injury –Opiods given • Nausea and vomiting (treat with anti-emetics) Always DO That • Sedation • Dependence is not likely to occur when used appropriately for the treatment of acute pain • Slowing of gastric emptying and GI motility (treat with metoclopramide)

Guidelines for postoperative IV/IM analgesia
• Age Weight Morphine/KinzDose <70yrs  >65Kg  <70yrs  <65Kg  7.5mg  >70yrs  >65Kg  7.5mg  >70yrs  <65Kg 



• Frequency : every 5-6 hours providing that: • Pain is mild to moderate Sedation is there Systolic BP >100mmHg Resp rate >10/min

Guidelines for postoperative intramuscular analgesia Cont:

Other methods of treating Postop pain

• Patient Controlled Analgesia (PCA)

PCAs are usually set up in theatre for patients undergoing major surgery.  PCAs can also be set up for patients that are having regular injections of an opioid .  This system allows the patient to self-administer a small IV bolus of an opioid analgesic.  An IV loading dose needs to be given to establish analgesia before PCA is started.  The system has a lockout period built into it to allow the patient to re-assess their pain before administering a further dose.  The safety mechanism of the pump is that the patient MUST be the only person to press the button so if they become sedated they will not be able to press the button and avoid overdose.

Patient Controlled Analgesia (PCA) Cont:
• Advantages: Patients experience less anxiety and discomfort.  The delay associated with nurse administered IM analgesia does not occur • Disadvantages: Potential for malfunction and user error.  Continuous training is essential.  Needs patient cooperation.

Patient Controlled Analgesia (PCA) Cont:

A photo of the PCA pump that a patient may use for their own pain management.

Local Anaesthesia
• Action: Blocks transmission of nerve impulses • Advantages: Profound analgesia without opioid-like side effects • Disadvantages: Local anaesthetics are toxic in large quantities and short duration of action.techniques require specialist skills.

Local Anaesthesia Cont:
• Local Infiltration of wound site at the end of operation provides short term analgesia. local anaesthetic to be injected around peripheral nerves , gives excellent pain relief .Definately applicable • Commonly used drugs LIDOCAIN,BUPIVACAIN. • Either can be used • These can also used for SPINAL ANASTHESIA • Spinal anaesthesia blocks the nerves as they leave the spinal canal and before they separate into branches, resulting in analgesia in deep tissues as well as around the wound.  Hypotension may occur .

IV opioid infusions
• A continuous infusion of opioid can be effectively used post-operatively, especially if patient is unable to use PCA.  Doses can be altered but it is not as safe as PCA and serious respiratory depression, regular monitoring required and may not be appropriate for general ward • NOT applicable in our system

Inhalation analgesia
  • Entonox (50% nitrous oxide and 50% oxygen) may be useful during short periods of post-operative pain (e.g.removal of drains/dressings).  It cannot be used continuously because nitrous oxide causes bone marrow depression. • Should apply this.

WHO Recomendation

WHO Recommendation Cont:

Epidural analgesia
  • A catheter can be left in place in the epidural space post-operatively.  A combination of continuous local anaesthetic and opioid is used. • Advantages: Excellent analgesia allowing early mobilisation.  Reduction in stress response and post-operative complications. A reduction of opioid-like side effects has been shown. • Disadvantages: Hypotension .  Risk of epidural abcess, haematoma or nerve damage (very rare). • RARELY USED

Epidural analgesia Cont:

  • Reassurance. • Education / Information. • Relaxation.(muscle relaxents) • Hypnosis. (Alprazolam)

Complementary Therapies (to be used with analgesics)


• Proper postop pain control is key feature in postop management. • Patient realize that he is been treated by good doctor • Pain Score should be used as a Scale • Recommended Postop Regimes • Choices in case of Comorbidities • Usage of Local Anesthesia and PCA • Other Modalities like Epidural • Clinical importance of Pain management

SUMMARY: What is commonly accepted

MCQs 1
• The local infiltration anesthetic drug ineffective if introduced into an area of infection. contraindicated in any clotting disorder. free from toxic effects. 4.with adrenaline is contraindicated if the patient is taking tricyclic antidepresant. 5.usually used with adrenaline.

MCQs Cont: 2
• Morphine is given for injured primarily because it is 1.a sedative analgesic 3.a diaphoretic emetic 5.a mood stimulant

MCQs Cont: 3
• Pt underwent Pyelolithotomy,postop analgesia 1.Morphine 2.Morphine +Diclofenac Na 3.Tramal+DiclofenacNa 4.Ketorolac 5.Nalbuphine+Paracetamol

MCQs Cont: 4
• Pt underwent Tube Thoracostomy,analgesia should be 1.Oral DiclofenacNa 2.Oral preparation of Tramadol 3.IM DiclofenacNa 4.IV Paracetamol(PROVAS) 5.Local Anesthetic agent

MCQs Cont: 5
• Pt is operated for Esophageal varices with Sclerotherapy,postop analgesia 1.IM Paracetamol(Detamol) 2.IV Paracetamol(Provas) 1g 3.Tramal+Provas 4.IM Morphine 5.Tramal+DiclofenacNA

MCQs Cont: 6
• Pt is a case of Warfare injuries,one leg and one arm amputated,and one deep wound on another leg,postop analgesia 1.IV Morphine 10mg TDS 2.Nalbuphine 10mg IV TDS 3.Nalbuphine 10mg IV BD+DiclofenacNa 75mg IM TDS 4.Nalbuphine 10mg IV BD+Provas IV 1g TDS 5.PCA with nalbuphine

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