POST-OPERATIVE

PAIN MANAGEMENT

Dr Suleman Mumtaz
PG Ward 2
 OBJECTIVE
• The purpose of this presentation is to review
Common methods of relieving acute post-
operative pain
• In this we will discuss how to use Common
peripherally-acting analgesics (like non-
steroidal 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
 Adverse pathophysiological
consequences of poor pain
management(What if not
• Cardiovascular –considered)
Hypertension, tachycardia
• 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

• Generally, if patient’s pain is well controlled they will

recover quicker and be discharged sooner.
Misconceptions about post-
operative 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 post-
operatively.  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) Dose: 1g
DONOT USE in hepatic disorders

• Compound analgesia (use for mild-moderate pain) Action: Contain mild

opioid which binds to opioid receptors in dorsal horn
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)
• Buprenorphine
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
• NSAIDs (use with
Cont:
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)
 Recommended Analgesics
Cont:
• TRAMAL.
Is TRAMADOL –Non 0piod
agent
100mg IV/IM 4-6hrly
Max dose 400mg/day
Singal Regime/Compound
Analgesia
 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 moderate-
severe - 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 post-
operative IV/IM analgesia

• Age Weight
Morphine/KinzDose
<70yrs  >65Kg  10mg 
<70yrs  <65Kg 
7.5mg 
>70yrs  >65Kg 
7.5mg 
>70yrs  <65Kg  5mg
 Guidelines for post-
operative intramuscular
analgesia Cont:
• Frequency : every 5-6 hours
providing that:

• Pain is mild to moderate

Sedation is there
Systolic BP >100mmHg
Resp rate >10/min
 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 co-
operation.
 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:
 Complementary Therapies
(to be used with
analgesics)
 
• Reassurance.
• Education / Information.
• Relaxation.(muscle relaxents)
• Hypnosis. (Alprazolam)

 
SUMMARY:
What is commonly
accepted
• 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
 MCQs 1

• The local infiltration anesthetic drug

1.is ineffective if introduced into an area of
infection.
2.is contraindicated in any clotting disorder.
3.is 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
2.an analgesic
3.a diaphoretic
4.an 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
Thank You