Această

conferinţă e
închinată
amintirii
neuitatului
meu prieten,
Prof. Dr.
Şerban
Marinescu
Could postoperative pain kill the
patient?
A short glance on the principles of
postoperative analgesia
Gabriel M. Gurman, M.D.
Ben Gurion University of the Negev and Mayney
Hayesuah Medical Center, Israel

gurman@bgu.ac.il
 A warning word!!
• Pathophysiology of the
acute pain

• Various mechanisms of This

drug influence on acute
pain presentation
is not a
• Description of various
methods for postoperative cookbook!!
pain management

• Dosage
 First, why the CEEA organizers
included this topic in the syllabus??!!
A survey of 56 anesthesiologists How much money a patient is ready
Mario O et al, Anesth Analg 1999;88:1085 to ”invest” in order to avoid bad
What is the most dreadful fear of the outcome in the six postoperative
patient in the postop period? hours?!
Mario O et al Can J Anaesth
2001;46:6

• Postop pain • PAIN $ 110

• Nausea and vomiting • Vomiting $ 100
• Anxiety • Difficult voiding $ 60
• Discomfort produced by the • Hangover $ 50
i-v access • Shivering $50
 You are the anesthesiologist in case
with this case……
• 66 yr old man
• COPD , moderate, no O2 at
home
• PaCO2 43
• PaO2 room air 69
• Hypertensive treated
• BMI 33
• Subtotal colectomy 120 minutes
• General anesthesia: propofol,
rocuronium, isoflurane,
fentanyl in incremental doses
up to a total of 375 mico
• Intraoperative epidural
catheter by the end of surgery,
no drug through it, yet.
• Perfectly alert and stable in the
recovery room.
 Now you have to tell me…..
• What would happen • The patient would develop
shock because of high
if you do not take catecholamine discharge
care of his • The patient would become
postoperative pain agitated, crying, yelling
and leave it to the and jumping out of bed
• The family would
decision of the complain to the hospital
surgical ward team ? administration
• The patient would
eventually develop a
Please, select myocardial infarction,
one of these: cardiogenic shock and die.
 I have some good news for you!!
• Most probable nothing • Continuous severe
of the above would postoperative pain
happen!! would produce :

• But, for sure, patient’s *psychological distress

condition would be
bad, his life in the next AND
48-72 hours miserable *physiological
complications
Why?!
 ACUTE
PAIN

Reduced Sympathetic activity

respiratory ability

Atelectasis Tachycardia

Hypoxia Increased O2
consumption
Hypercapnia
Myocardial
Pneumonia ischemia

Above everything: anxiety, sleepiness,

confusion, agitation, depression
 How come that this patient has not
been taken care properly?
• Lack of knowledge

• Fear of secondary effects

• Patient’s fear of addiction

• Lack of enough personnel

The bottom line: PAIN IS
SUBJECTIVE!!!!!
 Sometimes, the intentions are good,
but the results not so…..
• It happened in my hospital in
the year of 1995
• I had a patient, a radiologist,
scheduled for a right
nephrectomy for a malignant
kidney tumor
• Uneventful surgery and
general anesthesia
• An epidural catheter was
inserted for postop analgesia
• An order to prepare 0.25%
bupivacaine for continuous
epidural infusion
• Patient transferred to
Recovery Room and then to
the Urology Department
• Some four hours later I was
asked by the ward nurse to
come and see the patient,
since he had some very odd
complains
• The patient (remember, a
physician!!!( that is not able
to move or feel his…..
tongue!!
• Beside he felt weak arms and
hypoanalgesia on both hands
• A short glance on the infusion
pump attached to the
epidural catheter showed
that………..
Instead
of 08
drops/
minute The patient
got….
80
drops/min
 The patient survived but ……
What was the basic mistake in this very case?
• The nurse’s lack of understanding and
knowledge
• The absence of an organized system for on
site education regarding acute pain
management
• The absence of medical supervision of the
postoperative analgesic management
In other words, the
absence of an
ACUTE PAIN
SERVICE (APS)!!!
 The ideology behind the acute pain
service
• A goal:
*provide optimal analgesia
*to individualize pain management
*to be responsive to patient’demands
• A team of dedicated individuals, which would
provide :
*pain management for each patient
*24 hrs a day presence
*daily rounds and consultations

• A continuous education plan, for each nurse and

physician in every single surgical department
 It is evident that…..
• Only an anesthesia • No anesthesia
department could take department can
the responsibility of efficiently manage an
creating and acute pain service
maintaining an acute without the help and
pain service which understanding of :
would respond to each *surgeons
patient demands and
*nurses
needs
*administration
*pharmacy
 If so, an APS team is supposed to…
• Include: • A question of:
*a dedicated
anesthesiologist in charge
with the service
TIME
*a nurse coordinator
*one anesthesiologist per
MONEY
unit of time who would
answer the calls
*a physican-teacher who MOTIVATION
would be responsible for a
course for medical staff in UNDERSTANDING
every department ( to be
repeated periodically)
 Now, back to our patient, that one
after subtotal colectomy
• Let’s decide what would • to go on with the old
be the postoperative system of parenteral
pain management opiates, given in
options in this very fractionated doses,
case? according to patient’s
complains, offered by
the nurse, after being
ordered by the surgeon
on call, provided they
would have time to
dedicate to each newly
operated patient
Or…….
Or….
 To select one of the following
techniques:
• Each of these methods
• Patient controlled demands:
analgesia (PCA) *patient education
• Patient controlled *patient’s alertness
epidural analgesia *ward’s team
(PCEA) indoctrination and
• Single-dose spinal teaching
morphine *no known allergy to any
(preservative-free) analgesic drug
And above all, an acute
pain service !!!!
So, let’s see the flowchart of postop
pain management
The patient is seen at the
preanesthesia outpatient clinic

Surgical procedure is done under

general/regional anesthesia

A decision is taken regarding his

postop pain management

Information is passed to :
*the ward team
*the APS team
 And then…..
• Postop analgesia starts in the Recovery Room
• Ward team is informed about the patient reaction and
his vital signs situation
• A ward nurse will take care of the patient
• She/he will:
*fill all the forms
*keep the MD in charge informed about patient
condition
*check and monitors patient’s condition at least
every 2H
*inform the APS team member about any worrying
change in patient situation
 Clinical and instrumental
monitoring for postop analgesia
• Respiratory rate Q 2H
• Level of alertness
• Level of analgesia Q 4H
• Blood pressure and pulse
• Secondary effects :
*pruritus
*urinary retention
*nausea and
vomiting
• Functionality of the
catheter
How do you feel till
now?!
Confident?
Isn’t it that
postoperative
analgesia is a very
simple procedure
and one does not
have to know too
much about it?!
 Here is the disappointment!!!
• What about the kind of
patient fit for postop
analgesia?
• And what are the patients
at risk?

• And how much you have

to give in order that you
will not give too much or
too less?
• And how to weigh the risk
and benefit for every
single patient?
• Before you decide to put a patient on a postop analgesia
protocol, please be sure that :
*the patient is completely alert
before you start it
*he/she fully understood your plan
*he/she has no known allergy to
any analgesic drug
*he/she is stable hemodynamically
*there is no surgical bleeding
*the surgical ward is prepared and
ready to accept the patient and his postop
analgesia protocol!!
Here are just a couple of examples of
high risk patients
• Age above 65, with
some postop cognitive
problems
• ASA III or IV
• Epidural or parenteral
opoids during surgery
and anesthesia
• Thoracic surgery
• COPD
• Obesity
 Finally, in order to weigh the risk and
benefit one has to pay attention to the
following:
The risks of postop The benefit of postop
analgesia analgesia
• The invasivness of the • Lack of pain
procedure may be accompanied • Patient’s good feeling
by technical and anatomical • Partially blunting of the
complications
neuroendocrine response to
• Respiratory depression is not pain and stress, more
infrequent cardiovascular stability
• Neural trauma can happen • Family satisfaction
• Hypotension is not unusual • Enlarging the anesthesiologist
• Urinary retention is very activities outside the operating
unpleasant, as well as pruritus room
 Here is an example-continuous
epidural analgesia
• An efficient way to treat
postop pain BUT...
• Facilitates the return of •It is invasive
gastrointestinal function
• Decreases the incidence of •Could be
postoperative pulmonary accompanied by
complications
• Reduces the incidence of
neurological
thrombo-embolic damage
accidents
•Infection is a real
• Improves the
cardiovascular stability possibility
•Needs continuous
monitoring
 Do you still remember our patient?
• 66 yr old man
• COPD , moderate, no O2 at
home
• PaCO2 43
• PaO2 room air 69
• Hypertensive treated
• BMI 33
• Subtotal colectomy 120 minutes
• General anesthesia: propofol,
rocuronium, isoflurane,
fentanyl in incremental doses
up to a total of 375 mico
• Intraoperative epidural
catheter by the end of surgery,
no drug through it, yet.
• Perfectly alert and stable in the
recovery room.
Let’s create a plan for taking care
of his postoperative pain
(PCEA= patient controlled
epidural analgesia)
*The epidural catheter is tested
and a postop analgesia form is
filled up to be signed by the
anesthesiologist and the nurse
on the ward
*A solution of Saline 500 ml
containing bupivacaine 0.065%
(330 mg) + 1000 microgram of
fentanyl (2 micro/cc)- 8
ml/hour- is started
*the patient has a possibility of
adding 5 ml Q 20 minutes
The result: pain level around 2-3
on a scale to 10
 One has to add some more
techniques for postop analgesia
• Peripheral nerve blockade • All these proposed
(Cervical, brachial, intercostal,
sciatic, femoral, etc.)
methods need:
• Intrapleural *knowledge
• Transdermal drug
*experience and
delivery (Fentanyl)
expertise
• Transcutaneous
electrical nerve *sometimes special
stimulation (TENS) equipment
• Cryoanalgesia
 Nevertheless, some key points
towards the end:
• Postop pain is dangerous also
because may result in rapid
neuronal sensitization and chronic
pain
• Individual titration (PCA, PCEA) is
much better than any other drug
regimen
• Monitoring is the key for success
• Use of adjuvant drugs (NSAIDs)
may improve the results and
diminish the side effects
• A well built up acute pain service
could solve most of the problems and
avoid most of the dangers
 One more interesting point (and
a personal contribution)
The list of factors which influence the postop
pain (Bonica, the 90s)
• Site, duration and nature of surgery
• Physiological and psychological patterns of the patient
• Pre-operative psychological preparation of the surgical
patient
• Use of pre-emptive analgesia
• Presence of surgical complications
• Quality of intra-operative analgesia
• Quality of postoperative care and pain management
Gurman , Popescu M et al Acta Anaesth Scand
2003;47:804-808

• 72 morbid obese patients, scheduled for

laparoscopic gastric banding
• BMI > 35
• Spectral Edge Frequency (SEF) continuously
monitored, but screen kept hidden
• Cutting point : SEF > 80% of maintenance
time “in range”
 SEF 8-12 Hz < SEF 8-12 Hz > Parameter
p 80% of time, 80% of time,
n=33 n=38
0.005 6.9 6.3 VAS at RR
admission
0.05 6.1 5.5 VAS RR
30 minutes
0.06 6.6 4.7 VAS RR
60 minutes
0.05 4.2 3.8 VAS RR
discharge
0.03 7.4 11.9 Lag time to 1st
dose of MO –
minutes
0.02 6.1 mg 3.94 mg Total dose MO in
 So, BE SURE THAT :
• the patient is well
anesthetized during surgery
• he/she is fit for a postop
analgesia plan
• He/she understood the
meaning of your plan
• all the human factors
involved in the postop care
agree with your proposals
• everything is prepared to
monitor patient conditions
• You get a fair and quick
report on every single case
who did not go according to
your initial plan
 “There is no failure,
except no longer
trying. There is no
defeat except from
within and no really
insurmountable
barrier save our
inherent weakness of
purpose “
(Ken Hubbard, a preacher
and Christian leader, 1933-
2010)