Post operative Pain Relief

Dr U I Hapuarachchi
Department of Surgery Faculty of Medicine, Galle

Learning objectives
At the end of this lecture, you should be able to demonstrate the;

Advantages of relief of pain WFSA pain ladder Treatment options available Side effects of the options mentioned Management of common side effects

Content

Definition of Pain Advantages of relief of pain Assessment of Pain Systemic drugs Regional techniques

Definition

An unpleasant sensory & emotional experience resulting from a stimulus causing, or likely to cause, tissue damage (nociception), or expressed in terms of that damage

Advantages of pain relief

Humanitarian reasons Reduced cardiovascular complications Reduced respiratory complications Reduced gastro-intestinal effects Less salt/water retention Less impairment of sleep/mental function Early hospital discharge Economical

Assessment of Pain

Visual Analogue Scale

10 cm line Worst pain experienced

0_______________________________10
No pain

Numerical Scale
10 cm line Worst pain experienced

0__ 1__ 2__3__ 4__5__ 6__7__8__9__10

No pain

Assessment of Pain

Descriptive Scale
No pain - mild - moderate - severe - excruciating

McGill Pain Questionnaire

Check list of words describing symptoms Psychological questionnaires for analysis of personality & pain

Assessment of Pain

Wong-Baker FACES Pain Rating Scale

Is used in children

Management of Pain

Multimodal Approach

According to the WFSA ladder Systemic analgesics Regional techniques

WFSA Pain Ladder

Systemic analgesics

Opioids Morphine, pethidine, fentanyl, remifentanyl, NSAIDs Diclofenac sodium, ibuprofen, ketorolac Others Paracetamol, Tramadol

Opioids

Strong analgesic for moderate to severe pain Can be given as im, iv, sc, oral, Patient controlled analgesia (PCA), transdermal, spinal/epidural

PCA bolus dose, lockout interval +/- background infusion

Opioids
Dose

Morphine 0.1 mg/kg

Pethidine 1 mg/kg
Fentanyl 1-3 g/kg Remifentanyl 0.025-0.1 g/kg/min

Opioids

Respiratory depression Hypotension Tachy / bradycardia Sedation Euphoria / dysphoria Nausea / vomiting Uriticaria Urine retention

Opioids
Respiratory depression

If RR < 10 /min Awaken the patient If RR < 8 /min O2 via face mask Naloxone 40 g iv boluses

Urticaria

Chlopheniramine 5-10 mg Naloxone 40 g iv

Opioids
Nausea & vomiting

Promethazine -12.5-25 mg im / iv Metoclopramide 5-10 mg slow iv / im Ondansetrone 4-8 mg iv

Urine retention

General measures

catheterization

NSAIDs

Can be given as oral, suppositories, iv Potent analgesic for mild to moderate pain
Can cause renal toxicity Precipitate bronchial asthma Peptic ulceration Fluid retention

NSAIDs
Dose

Diclofenac sodium 1 mg/kg tds (maximum 3 mg/kg/day) - > 1 yr

Ibuprofen 5-10 mg/kg tds

Other drugs
Paracetamol

Analgesic for mild to moderate pain Liver damage in overdose Can be given as oral, suppositories, iv Dose 20 mg/kg & then 15 mg/kg 4 hrly Maximum dose 90 mg/kg

Other drugs
Tramadol

Has opioid & non-opioid mechanism of action Has less respiratory depression, constipation, euphoria than other opioids Causes nausea, dizziness, dry mouth Increased S/E in conjunction with other opioids Can be given as oral, slow iv / im 50-100 mg 4 hrly

Regional techniques

Epidural Continuous infusion / boluses

PCEA, Caudal

Nerve plexus blocks Supraclavicular,

axillary, lumber plexus

Individual nerve blocks median, ulnar,

sciatic, femoral

Intra-pleural analgesia Infiltration

Regional techniques

Less stress response Less bleeding Better organ perfusion Better gut motility Less DVT

Motor block CVS instability Hypotension Urine retention with spinal/epidural opioids

Regional techniques
Epidural / PCEA 0.1250.1% Bupivacaine
+ /- opioid

Other blocks 0.25-0.5% Bupivacaine

PCEA better pain relief less overdose

Regional techniques
Hypotension

Rapid iv fluid infusion Vasoconstrictors ephedrine 5-10 mg iv Inform the Pain relief team

References

Management of Acute pain

National Guidelines-Anaesthesiology, Ministry of Healthcare & nutrition, Sri Lanka. Pg70-91

Atkinson RS, Rushman GB, Davies NJH. Acute pain

Lees Synopsis of Anaesthesia 11th Edition Chapter 26

Kirk RM, Ribbans WJ. Management of Post-operative pain

Clinical Surgery in General-RCS Course Manual 4th Edition

Pg 357-369

http://www.frca.co.uk Resources>Clinical Anaesthesia>Acute pain

Thank you