Anesthesia Department
Post-Operative Pain Management
Raafat Abdel-Azim
Professor of Anesthesia, Intensive Care and Pain Management
Intended Learning Outcomes
By the end of this lecture, the student will be able to:
1. Understand the importance of POP relief
2. Assess the severity of POP
3. Plan for POP management
4. Identify the appropriate way of POP
management for different cases
2
Raafat Abdel-Azim
OR
(Operating Room)
PACU
(Post-Anesthesia Care Unit)
=RR
(Recovery Room)
ICU
(Intensive Care Unit)
3
Surgical Ward
Raafat Abdel-Azim
Importance of
Postoperative Pain (POP)
Management
4
Raafat Abdel-Azim
Goals of Postoperative Care
Significant pain relief
Patient satisfaction
Improved mobility
Postoperative complications
Fatigue
Earlier return to bowel function
Earlier hospital discharge
5
Raafat Abdel-Azim
Consequences of Unrelieved POP
•
•
•
•
•
•
•
•
Undesirable effects on vital functions
 Morbidity & mortality
 Risk of acute postoperative stress syndrome
 Risk of mental & psychological stress
Delayed return to normal activity
Prolonged hospital stay
Readmission to hospital
Potential development of chronic pain & long-term
effects on quality of life
•  Patient satisfaction
•  Costs associated with staffing & resources
6
Raafat Abdel-Azim
Benefits of Effective POP Management
•  Hormonal & metabolic stress
– SNS response: hypertension, tachycardia &
dysrhythmias
•
•
•
•
7
 Morbidity & postoperative complications
Earlier discharge from hospital
Cost-effectiveness
Quality of life scores & patient satisfaction
Raafat Abdel-Azim
Key Elements for POP
Management
8
Raafat Abdel-Azim
Recommendations for POP
Management
• Adequate medical & nursing staff training
• Adequate patient information
• Use of balanced analgesia, patientcontrolled analgesia (PCA) & epidural drug
administration
• Use of written protocols
• Regular assessment of pain intensity
9
Raafat Abdel-Azim
Assessment of POP
• Inexperienced nurses overestimate a patient's
pain, whereas more experienced nurses tend to
underestimate. Either error leads to
inappropriate treatment
• POP should be assessed several times a day in
every patient, at rest and in dynamic conditions
(cough, movement).
• Assessment should be recorded in a clear and
concise manner to serve as a guide to
intervention
10
Raafat Abdel-Azim
The CNS signs of
oHypoxemia
oAcidemia
oCerebral hypoperfusion
often mimic those of pain, especially during
emergence.
Evaluating
oOrientation
oThe level of arousal
oCardiovascular or pulmonary status
usually identifies such patients.
Fear, anxiety, and confusion often  POP,
especially after general anesthesia.
11
Raafat Abdel-Azim
To avoid masking signs of an unrelated
condition or a surgical complication, ascertain
that the nature and intensity of pain are
appropriate for the surgical procedure before
analgesics or sedatives are administered
Administration of parenteral analgesics or
sedatives can acutely worsen hypoventilation,
airway obstruction, or hypotension, causing
sudden deterioration and arrest
12
Raafat Abdel-Azim
Commonly Used Pain Scales
• Visual analogue scale (VAS)
• Numerical rating scale (NRS)
• Verbal rating scale (VRS)
• Other methods
The choice of the pain scale depends on the
patient’s age, ability to communicate, or
other factors
13
Raafat Abdel-Azim
Visual Analogue Scale (VAS)
From 0 to 100 mm
0 = no pain at all
100 = the worst possible pain
0
No pain
14
10
20
30
40
50
60
70
80
90
100
The worst possible pain
Raafat Abdel-Azim
Numerical Rating Scale (NRS)
From 0 to 10
0 = no pain
10 = the worst possible pain
Verbal rating scale (NRS)
4-point scale
0 = no pain
1 = mild pain
2 = moderate pain
3 = severe pain
15
Raafat Abdel-Azim
The Multidisciplinary Team
(The Multidisciplinary Approach)
OR
Surgeon
PACU
Anesthesiologist
ICU
Nurse
Ward
Home
16
Improved pain relief, patient satisfaction &
outcome
Raafat Abdel-Azim
Treatment of POP
17
Raafat Abdel-Azim
Pharmacological Treatments of POP
Classification
• Non-opioids
– Non-steroidal antiinflammatory drugs (NSAIDs)
– Paracetamol
• Opioids
– Strong opioids: morphine, pethidine, fentanyl,
nalbuphine
– Weak opioids: tramadol
• Local anesthetics: lidocaine, bupivacaine, …
18
Raafat Abdel-Azim
19
Raafat Abdel-Azim
Dose Schedule
Administration on a
regular basis
Prevents inadequate pain
control
Administration only
when the patient
complains of pain
Analgesic gaps as patients wait for
drug administration
20
Raafat Abdel-Azim
Precautions for Use
Paracetamol
•Liver disease
•Severe renal
insufficiency
•Chronic alcoholism
•Chronic malnutrition,
dehydration
21
NSAIDs
•H/O Peptic ulcer
•Renal insufficiency
•Liver insufficiency
•Cardiac insufficiency
•Asthma
•Elderly
•Drug interactions
Opioids
•Renal insufficiency
•Liver insufficiency
•Respiratory insufficiency
•Elderly
•Infants < 3 months
Raafat Abdel-Azim
Contraindications
Paracetamol
Allergy to paracetamol
Severe liver disease
22
NSAIDs
Allergy to NSAIDs
Active peptic ulcer
Renal insufficiency
Liver insufficiency
Asthma (aspirin or
NSAID-related)
Drug interactions
3rd trimester pregnancy
Opioids
Allergy to opioids
Severe liver insufficiency
Respiratory insufficiency
 ICP or head injury
Raafat Abdel-Azim
Side Effects
Paracetamol
NSAIDs
Opioids
Malaise
Hypotension
Transaminases
Hypersensitivity reactions
Hematologic disorders
(rare or very rare)
GI disorders (nausea,
vomiting, constipation,
bleeding)
Nephrotoxicity
Hepatotoxicity
Hypersensitivity reactions
Hematologic disorders
Prolonged bleeding
GI disorders (nausea,
vomiting, constipation)
CNS effects: sedation,
hallucinations, confusion)
Itching
Urinary retention
Respiratory depression
23
Raafat Abdel-Azim
Route of Administration
Paracetamol
Oral (PO)
Intravenous (IV)
Rectal
24
NSAIDs
PO
IV infusion
IM
Rectal
Opioids
PO
IV
IM
SC
Epidural
Raafat Abdel-Azim
The IV route:
During iv titration of opioids, analgesia is
achieved while incremental respiratory or
cardiovascular depression is assessed.
Sufficient analgesia is the end point, even if
large doses of opioids are necessary in tolerant
patients
25
Raafat Abdel-Azim
Disadvantages of the IM route include
olarger dose requirements
odelayed onset
ounpredictable uptake in hypothermic patients
Oral and transdermal analgesics have a limited
role in the PACU but are helpful for ambulatory
patients.
Rectal analgesics are useful in children.
26
Raafat Abdel-Azim
Delivery Techniques of POP Treatment
Patient Controlled Analgesia (PCA)
Self-administration of analgesics using a computerized pump by either the IV or
epidural route
Advantages
•Gold standard of POP therapies
•Enables the patients to titrate their
own analgesia
•No analgesic gaps
•High level of patient satisfaction
27
Disadvantages
•Significant time and resources
needed
•Staff programming of the PCA pump
 the potential for medication errors
•Potential for device malfunction
Raafat Abdel-Azim
Epidural Analgesia
Injection of analgesics into the epidural space close to the spinal cord and
spinal nerves where they exert a powerful analgesic effect
Advantages
Disadvantages
•Very effective pain relief
•Invasive
•Low doses of opioids   side effects •Staff time and training
• Stress response to surgery
•High catheter failure rate (25%)
•Post-dural puncture headache
•Risk of spinal hematoma
28
Raafat Abdel-Azim
Peripheral Nerve Blockade
Injection of local analgesics close to peripheral nerves to produce analgesia by
blocking pain impulses from the nerve
Advantages
•Excellent analgesia
•Tergeted analgesia
• Systemic exposure to opioids
• Adverse effects
29
Disadvantages
•Staff time and training
•Potential for infection, hematoma &
local anesthetic toxicity
•Not useful for abdominal and
cardiothoracic procedures
Raafat Abdel-Azim
Balanced or Multimodal Analgesia
Combination of various analgesic agents
and/or delivery techniques with different
mechanism of action
Potential to enhance analgesia (additive or
synergistic effects) and to  side effects
30
Raafat Abdel-Azim
31
Raafat Abdel-Azim
Benefits of Balanced Analgesia
•
•
•
•
•
•
•
32
Improved pain control & patient satisfaction
 morbidity
 length of stay
 adverse events
Earlier mobilization
Earlier return to bowel function
 cost of care
Raafat Abdel-Azim
Treatment of “At Risk” Patients
• Elderly
–  opioid sensitivity
–  ability to metabolize & eliminate analgesics
– polymedication
• Patient with cardiovascular disease
–  ability to tolerate sympathetic/hemodynamic
responses to severe pain or certain
analgesics
33
Raafat Abdel-Azim
• Patient with hepatic/renal disease
–  ability to metabolize analgesics,  risk of analgesic
toxicity
• Patient with severe pulmonary disease
–  risk of atelectasis & pneumonia by incident pain
• Neonates
– Immaturity of enzyme systems involved in drug
metabolism
–  GFR
–  ventilatory response to hypoxia
34
Raafat Abdel-Azim
At risk patients are more sensitive to adverse
effects of opioid and non-opioid analgesics
• Opioids
–  risk of respiratory depression
–  sedation & confusion
– Metabolite toxicity
• NSAIDs
–  risk of bleeding
–  risk of renal impairment
–  risk of hypertension & CHF
35
Raafat Abdel-Azim
Patient Information about POP
Increasing patient education and awareness
of the postoperative experience is one way
to improve POP management
36
Raafat Abdel-Azim
1. Pain can follow surgery but there are effective
treatments to relieve it.
2. Your pain will be assessed regularly after
surgery. (Patient must be trained on pain
assessment before surgery).
3. Always alert your healthcare team when you
feel pain.
4. You will receive treatment for your pain.
5. You may experience side effects as a
consequence of surgery, anesthesia or from
your pain treatment (e.g. nausea, drowsiness,
constipation, itching, …)
37
Raafat Abdel-Azim
6. Specific information related to the different
techniques (PCA, epidural analgesia, nerve
blocks, …)
38
Raafat Abdel-Azim
Summary of important points
•Benefits of effective POP management
•Recommendations for POP management
•Evaluation of POP
•The multidisciplinary team & approach
•Pharmacological treatments of POP
•Balanced or multimodal analgesia
•Treatment of at risk patients
•Patient information about POP
39
Raafat Abdel-Azim
Anesthesia lectures are available at:
http://telemed.shams.edu.eg/moodle6
http://telemed.shams.edu.eg/moodle
40
Raafat Abdel-Azim
Thank You
41
Raafat Abdel-Azim