Advance Pain management modalities

for Pre & Post Surgery

Pain
ACUTE
 Pain is the 5th Vital Sign PAIN
MIXED CHRONIC
PAIN PAIN
 Unpleasant sensory
NOCICEPTIVE
NOCIPLA PAIN PAIN
STIC PAIN
 Emotional experience
SOMATIC NEUROPATHIC
PAIN
PAIN
 Tissue damage (Actual or Potential) VISCERAL
PAIN

 The IASP defines pain as "an unpleasant sensory and emotional experience associated
with, or resembling that associated with, actual or potential tissue damage.”
 Pain may be localized, affecting a specific part of your body or it may be generalized.
Pain has complex nature

Pain is a perceptual experience Linear in nature

Circular in nature

Melzack and Casy Model Loeser’s Model of Pain

 Prevalence of pain
Lifetime prevalence in general population:
 Approaches 100% for acute pain leading to use of analgesics1
Emergency room patients:
 Pain accounts for >2/3 of emergency visits2
Hospitalized patients:
 >50% report pain3

https://www.physio-pedia.com/Epidemiology_of_Pain
 The Pain Continuum

Insult Time to resolution

Acute pain Chronic pain

Normal, time-limited response Pain that has persisted beyond

to ‘noxious’ experience normal tissue healing time
(less than 3 months) (usually more than 3 months)
• Usually obvious tissue damage • Usually has no protective function
• Serves a protective function • Degrades health and function
• Pain resolves upon healing
Acute pain may become chronic

Chapman CR, Stillman M. In: Kruger L (ed). Pain and Touch. Academic Press; New York, NY: 1996; Cole BE. Hosp Physician 2002; 38(6):23-30;
International Association for the Study of Pain. Unrelieved Pain Is a Major Global Healthcare Problem.
Available at: http://www.iasp-pain.org/AM/Template.cfm?Section=Press_Release&Template=/CM/ContentDisplay.cfm&ContentID=2908. Accessed: July 24: 2013;
National Pain Summit Initiative. National Pain Strategy: Pain Management for All Australians.
Available at: http://www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf. Accessed: July 24, 2013;
Turk DC, Okifuji A. In: Loeser D et al (eds.). Bonica’s Management of Pain. 3rd ed. Lippincott Williams & Wilkins; Hagerstown, MD: 2001.
Pain Pathways
Impact of Pain
PHYSICAL

SUFFERING
PSYCHOSOCIAL EMOTIONAL

SPIRITUAL
Why is rapid & effective treatment of acute
pain important

Autonomic instability with tachycardia, hypertension, and

increased myocardial oxygen consumption

Under- Depression, anxiety, insomnia, irritability, or phobias

treatment of Chronic fatigue

acute or
traumatic pain Atelectasis, pneumonia, hypoxia
may lead to:
Immobility with risk for DVT

Muscle spasms
Assessment of Pain

9
 International Pain Rating Scales
Western Ontario and McMaster Universities Arthritis
Index (WOMAC):
 It is widely used, proprietary site of standardized
questionnaires used by health professionals to
evaluate the condition of patients with all types of
chronic and acute painful conditions
 The WOMAC is among the most widely used
assessments in arthritis research
 The WOMAC measures:
 Pain
 Stiffness
 Functional limitation
International Pain Rating Scales

Visual Analogue Scale (VAS):

 It is a psychometric response scale which is used in questionnaires
 When responding to a VAS item, respondents specify their level of agreement to a statement by
indicating a position along a continuous line between two end-points
 The amount of pain that feels ranges across a continuum from none to an extreme amount of
pain
Pain Management modalities for Pre &
Post Surgery
Goals in Pain Management

 Involve the patient in the decision-making

process
 Agree on realistic treatment goals before
starting a treatment plan

Optimized pain relief Minimized

Improved function adverse effects

Farrar JT et al. Pain 2001; 94(2):149-58; Gilron I et al. CMAJ 2006; 175(3):265-75.
 Pre – operative Pain Management
 Aims to Control Pain and Decrease Likelihood of Developing Chronic Pain

Acute Persistent
post- post-
May lead to development of operative
operative
pain pain

Use of pharmacological agents

before, during and after surgery may:
 acute pain
 subsequent development of chronic pain
 morbidity, costs and other consequences of chronic pain

Joshi GP et al. Anesthesiol Clin N Am 2005; 23(1):21-36; Kehlet H et al. Lancet 2006; 367(9522):1618-25.
 Importance of Post-operative Pain Management

Consequences of the failure to Proper pain management

adequately relieve pain: may lead to:
 Pneumonia  Earlier mobilization
 Delayed readiness  Decreased hospital stay
for discharge  Reduced hospital cost
 Increased patient  Decreased likelihood of
monitoring/nursing time developing chronic pain
 Delayed ambulation

Dunwoody CJ et al. J Perianesth Nurs 2008; 23(1 Suppl):S15-27; Joshi GP et al. Anesthesiol Clin N Am 2005; 23(1):21-36; Kehlet H et al. Lancet 2006; 367(9522):1618-25;
Liu LL et al. Drugs 2003; 63(8):755-67; Shang AB et al. Drugs 2003; 63(9):855-67.
 Controlling Post-operative Physiology

Supportive
Enteral agents/therapy
Pre-operative Attenuation of
information intra-operative Pain Exercise nutrition in high-risk
+ teaching stress relief patients

Reduced morbidity and accelerated convalescence

Kehlet H. Br J Anaesth 1997; 78(5):606-17.
 Multimodal Treatment of Pain Based on
Biopsychosocial Approach

Lifestyle management

Sleep hygiene Stress management

Interventional pain
Physical therapy Pharmacotherapy management

Occupational therapy

Education
Complementary therapies Biofeedback

Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.; National Academies Press; Washington, DC: 2011;
Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo Clinic; Rochester, MN: 2006.
Non-pharmacological Treatment
 Pre-operative Management Issues

Pre-operative preparation may help minimize post-operative pain.

 Comprehensive plan to treat post-operative nausea

and vomiting
 Patient and caregiver education
 Assuring the patient that his or her pain level will
be monitored
 Familiarizing the patient with the pain scales
 Counseling the patient to overcome fears of addiction

Iverson RE et al. Plast Reconstr Surg 2006; 118(4):1060-9;

Miaskowski C et al. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 6th ed. American Pain Society; Chicago, IL: 2008.
 Pre-operative Assessment

 Underlying medical conditions  Previous or ongoing pain

 Peri-operative pain and/or post-  Ineffective and effective methods of
operative nausea and vomiting treatment
experience  Patient attitude to
 Current medications pain medications
 Reactions/allergies  History of substance abuse
to analgesics  Psychological history
 Smoking history
 Perceived barriers to  Patient expectations of pain level
pain management  Patient’s expression of pain
 Pain management preferences

American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012; 116(2):248-73;
Iverson RE et al. Plast Reconstr Surg 2006; 118(4):1060-9; Krenzischek DA et al. J Perianesth Nurs 2003; 18(4):228-36;
Niraj G et al. Br J Anaesth 2011; 107(1):25-9; Miaskowski C et al. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain.
6th ed. American Pain Society; Chicago, IL: 2008.
 Non-pharmacological Management of
Sports Injuries

}
 Rest
 Ice Important elements of patient
management in the first
 Compression 48 hours following musculoskeletal
 Elevation injury

Physiotherapy, including therapeutic ultrasound, followed by

rehabilitation form an essential part of treatment from 24 hours after
injury.

South African Society of Anaesthesiologists. SAJAA 2009; 15(6):1-120.

 Non-pharmacological Treatment of Acute Neck
Pain

Recommended
• Exercise/advice to stay active
• Multimodal therapy
• Pulsed electromagnetic therapy

Not recommended
• Collars

Insufficient evidence
• Acupuncture • Gymnastics • Patient education
• Cervical manipulation • Biopsychosocial • Traction
• Cervical passive mobilisation rehabilitation • TENS
• Electrotherapy • Neck school

TENS = transcutaneous electrical nerve stimulation

Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians.
Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.
Non-pharmacological Treatment of Acute
Shoulder Pain

Recommended
• Exercise
• Therapeutic ultrasound

Conflicting/insufficient evidence
• Acupuncture
• Extracorporeal shock wave treatment
• Manual therapy
• Surgery
• Transcutaneous electrical nerve stimulation

Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians.
Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.
 Non-pharmacological Treatment of Acute Knee
Pain

Recommended
• Exercise/advice to stay active
• Foot orthoses
• Injection therapy

Not recommended
• Laser therapy

Insufficient evidence
• Patellofemoral orthoses • Patellar taping
• Acupuncture • Progressive resistance braces
• Electrical stimulation • Therapeutic ultrasound

Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians.
Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.
Pharmacological Treatment
 Ideal Characteristics for Acute Analgesic Therapy

Rapid onset Limited

Long duration adverse
Effective analgesia effects

Baumann TJ. In: DiPiro JT et al (eds). Pharmacotherapy: A Pathophysiologic Approach. 5th ed. McGraw-Hill; New York, NY: 2002.
 Patients Prefer Avoiding Side Effects to
Complete Pain Control

Relative Importance Placed by Patients on Different Attributes

of Acute Pain Therapy

47%

Gan TJ et al. Br J Anaesth 2004; 92(5):681-8.

 So how do we Treat acute pain?

Treat according to pain

mechanisms involved

Multimodal analgesia

Voscopoulos C, Lema M. Br J Anaesth 2010; 105(Suppl 1):i69-85.

 Multimodal or Balanced Analgesia

Opioid • Improved analgesia

•  doses of
Potentiation each analgesic
•  severity of side
Acetaminophen effects of each drug
nsNSAIDs/coxibs
α2δ ligands
Ketamine
Clonidine
Nerve blocks

Coxib = COX-2 inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug

Kehlet H, Dahl JB. Anesth Analg 1993; 77(5):1048-56.
 Synergistic or Additive Effects of Analgesics
Used Together
 Agents with different mechanisms of action can potentially have
additive or
synergistic effects:
 Acetaminophen/NSAIDS + opioids
 Opioids + local anesthetics
 Centrally acting agents + NSAIDS
 Opioids + 2δ ligands (e.g., dexamethatomidine)

NSAID = non-steroidal anti-inflammatory drug

Bader P et al. Guidelines on Pain Management. European Association of Urology; Arnhem, The Netherlands: 2010;
Kehlet H et al. Acta Anaesthesiol Scand 2010; 55(7):778-84; Paul S et al. Ceylon Med J 2010; 55(4):111-5; Robert B et al. J Pain 2010; 11(8):701-9;
Starks I et al. ISRN Anesthesiology 2011; 2011:742927; Vadivelu N et al. Yale J Biol Med 2010; 83(1):11-25.
 American Society of Anesthesiologists Task Force
on Acute Pain Management Recommendations

 Advocate the use of multimodal analgesia

 “Unless contraindicated, all patients should receive around-the-clock
regimen of NSAIDs, COX-2 inhibitors, or acetaminophen”

NSAID = non-steroidal anti-inflammatory drug

American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004; 100(6):1573-81.
 Improved Outcomes with Aadapted Post-
operative Pain Management
 Incidence of pulmonary complications:
 Surgery lower limbs: 12% vs. 28%
 Abdominal and vascular: 10% vs. 17%
 Thoracic surgery: 15% vs. 31%
 Incidence of cardiac complications:
 Abdominal surgery: 15% vs. 24%
 Better gastrointestinal function
 Duration of paralytic ileus: 56 h vs. 103 h
(8 randomized controlled trials)
 Fewer thromboembolic complications
 DVT incidence: 29% vs. 62%
 4 randomized controlled trials: hip, knee, prostatectomy, peripheral vascular
surgery

Kehlet H et al. Br J Anaesth 2001; 87(1):62-72.

 Analgesics Should Be Given at Regular Intervals
During Acute Pain Episodes

Sutters KA et al. Clin J Pain 2010; 26(2):95-103.

 Analgesia for Post-operative Pain Based
on Type of Surgery

Surgical procedures Major surgery

Moderate surgery - Acetaminophen

- nsNSAIDs/coxibs*
- Wound infiltration
Minor surgery - Acetaminophen - Epidural or major
- nsNSAIDs/coxibs* peripheral nerve or
- Wound infiltration plexus block or
- Acetaminophen - Peripheral nerve block IV opioid
- nsNSAIDs/coxibs* or IV opioid
- Wound infiltration
- Regional block analgesia
- Weak opioid or rescue
Treatment modalities
analgesic, if necessary

*Unless contraindicated
Coxib = COX-2-specific inhibitor; IV = intravenous; nsNSAID = non-selective non-steroidal anti-inflammatory drug
Sivrikaya GU. In: Racz G (ed). Pain Management – Current Issues and Opinions. InTech; Rijeka, Croatia: 2012.
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Post-operative Pain

Moderate-
High-intensity Low-intensity
intensity pain
pain (VAS ≥50) pain (VAS ≤30)
(VAS 30–50)

nsNSAID/coxib nsNSAID/coxib nsNSAID/coxib

+ + +
acetaminophen acetaminophen acetaminophen
± ± ±
strong opioid weak opioid weak opioid

*Note: specific recommendations vary depending on type of surgery

Coxib = COX-2-specific inhibitor; nsNSAID = non-selective non-steroidal anti-inflammatory drug;
PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Abdominal Hysterectomy
Postoperative Pain

Expected Expected Expected

high-intensity pain moderate-intensity low-intensity pain
(VAS ≥50) pain (VAS 30-50) (VAS ≤30)

Low risk: All:

Low risk:
coxib/nsNSAID + coxib/nsNSAID +
strong opioid (IV PCA)
acetaminophen ± acetaminophen ±
+ coxib/NSAID
weak opioid weak opioid

High risk:
High risk: consider step-down to
strong opioid + coxib/nsNSAID +
epidural LA acetaminophen ±
weak opioid

Coxib = COX-2-specific inhibitor; IV = intravenous; LA = local anesthetic; nsNSAID = non-selective non-steroidal anti-inflammatory drug;
PCA = patient-controlled analgesia; PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Colonic Resection Post-
operative Pain

Patients
undergoing
open surgery
All patients
Expected
Multimodal Expected
moderate-
rehabilitation high-intensity pain
intensity pain (VAS
Expected
protocols + 30-50): consider
(VAS ≥50): low-intensity pain
thoracic epidural strong opioid
step-down to
(VAS ≤30)
analgesia (if not coxib/nsNSAID +
(IV PCA) +
contraindicated) acetaminophen ±
coxib/nsNSAID
weak opioid

Coxib = COX-2-specific inhibitor; IV = intravenous; nsNSAID = non-selective non-steroidal anti-inflammatory drug;

PCA = patient-controlled analgesia; PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog
scale
 Management of Hemorrhoid Surgery Post-
operative Pain

Coxibs/nsNSAIDs
+ acetaminophen

Moderate- to Low- to Laxatives

high-intensity moderate- Oral
pain intensity pain metronidazole

Oral strong Oral weak

opioids opioids

Coxib = COX-2-specific inhibitor; nsNSAID = non-selective non-steroidal anti-inflammatory drug;

PROSPECT = Procedure Specific Postoperative Pain Management
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Herniorrhaphy
Post-operative Pain

Coxibs/nsNSAIDs*
+ acetaminophen

Moderate-
High-intensity
intensity pain
pain (VAS ≥50)
(VAS 30-50)

Add strong opioid Add weak opioids

*Use weak opioids when nsNSAIDs/coxibs are contraindicated

Coxib = COX-2-specific inhibitor; nsNSAID = non-selective non-steroidal anti-inflammatory drug;
PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Laparoscopic Cholecystectomy
Post-operative Pain

High-risk
pulmonary Routine surgery
patients

Epidural analgesia Coxib/nsNSAID +

+ strong opioids (in acetaminophen;
early postoperative opioid for rescue
period) analgesia

Early discharge
(<24 hours)

Coxib = COX-2-specific inhibitor; nsNSAID = non-selective non-steroidal anti-inflammatory drug;

PROSPECT = Procedure Specific Postoperative Pain Management
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Non-cosmetic Breast Surgery Post-
operative Pain

High-intensity Moderate or low-

pain intensity pain For major breast
surgery, consider
(VAS ≥50) (VAS <50) continuing
paravertebral
block from
Coxib/nsNSAID +
Coxib/nsNSAID + intra-operative
acetaminophen +
acetaminophen + period
strong opioids
weak opioids
(titrated to effect)

Coxib = COX-2-specific inhibitor; nsNSAID = non-selective non-steroidal anti-inflammatory drug;

PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Radical Prostatectomy Post-
operative Pain

High-intensity Moderate or
pain low-intensity
(VAS ≥50) pain (VAS <50)
Coxib + Coxib +
acetaminophen ± acetaminophen ±

α2δ ligands + α2δ ligands ±

IV PCA opioid weak opioid
Note: the above recommendations are based on evidence from unimodal interventions.
The optimal combinations of these interventions remain unknown at present time.
Coxib = COX-2-specific inhibitor; IV = intravenous; PCA = patient-controlled analgesia;
PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Thoracotomy
Post-operative Pain

Continue intra-operative
analgesia* 2–3 days
post-operatively

Expected high-intensity Expected moderate- Expected low-intensity

pain (VAS ≥50) intensity pain (VAS 30–50) pain (VAS ≤30)

IV PCA strong opioid ± Acetaminophen +

Acetaminophen +
coxib/nsNSAID/acetamino coxib/nsNSAID ± weak
coxib/nsNSAID
phen opioids

*Either thoracic epidural LA + opioid + epinephrine or paravertebral block with LA is recommended as the primary analgesic approach
Coxib = COX-2-specific inhibitor; IV = intravenous; LA = local anesthetic; nsNSAID = non-specific non-steroidal anti-inflammatory drug;
PCA = patient-controlled analgesia; PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Total Hip Arthroplasty
Post-operative Pain
Continue peripheral nerve block*
or epidural analgesia**
(if used)

High-intensity pain Moderate- or low-intensity

(VAS ≥50) pain (VAS <50)

Systemic analgesia
Coxib/nsNSAID +
acetaminophen ± Coxib/nsNSAID +
IV PCA strong opioids acetaminophen ±
(titrated to effect) weak opioids
(titrated to effect)

*By cathether techniques, using patient-controlled regional analgesia; **Establish epidural infusion as the nerve block regresses using
patient-controlled epidural analgesia
Coxib = COX-2-specific inhibitor; IV = intravenous; nsNSAID = non-specific non-steroidal anti-inflammatory drug;
PCA = patient-controlled analgesia; PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Management of Total Knee Arthroplasty
Post-operative Pain

Continue femoral
nerve block (if used)

Moderate- or low-
High-intensity pain
intensity pain
(VAS ≥50) For all:
(VAS <50)
cooling and
compression
techniques
Coxib/nsNSAID + Coxib/nsNSAID +
acetaminophen + acetaminophen ±
IV PCA strong opioids weak opioids
(titrated to effect) (titrated to effect)

Coxib = COX-2-specific inhibitor; IV = intravenous; nsNSAID = non-specific non-steroidal anti-inflammatory drug;

PCA = patient-controlled analgesia; PROSPECT = Procedure Specific Postoperative Pain Management; VAS = visual analog scale
PROSPECT Working Group. Procedure Specific Postoperative Pain Management. Available at: http://www.postoppain.org/frameset.htm. Accessed: July 24, 2013.
 Pain Measuring and Monitoring Protocol

Chose appropriate
unidimensional scale

}
Monitor pain every 15 minutes and
If pain intensity
adjust analgesic treatment
increases to >5/10:
accordingly, until patient is pain free
1. Contact In the meantime:
relevant 1. Look for
physician complication
2. Adjust pain that might
Monitor pain hour for 6 hours treatment cause pain
3. Go back to 2. Monitor
15-minute and medication’s
then hourly side effects
monitoring
Continue with 4-hourly assessment schedule

South African Society of Anaesthesiologists. SAJAA 2009; 15(6):1-120.

 Strategies to Improve Adherence

 Simplify regimen
 Impart knowledge
 Modify patient beliefs and human behavior
 Provide communication and trust
 Leave the bias
 Evaluate adherence

Atreja A et al. Medacapt Gen Med 2005; 7(1):4.

 Simplifying Medication Regimen

 If possible, adjust regimen to minimize:

 Number of pills taken
 Number of doses per day
 Special requirements (e.g, bedtime dosing,
avoiding taking medication with food, etc.)
• Recommend all medications be taken
at the same time of day (if possible)
• Link taking medication to daily activities,
such as brushing teeth or eating
• Encourage use of adherence aids such as
medication organizers and alarms

American College of Preventive Medicine. Medication Adherence Clinical Reference. Available at: http://www.acpm.org/?
MedAdherTT_ClinRef. Accessed: October 8, 2013; van Dulmen S et al. BMC Health Serv Res 2008; 8:47.
Conclusion
 Pharmacotherapy remains the mainstay of most acute pain
conditions
 However, analgesics, including opioids and nsNSAIDs/cpxobs, can
be associated with
adverse effects
 Individual patient risk profile should be considered when
selecting pain management therapies
 Agents with different mechanisms of action can potentially have
additive or synergistic effects
 Multimodal therapy is generally recommended for acute pain
conditions
Thank you

50