Post Operative Pain

2. POST-OPERATIVE PAINMANAGEMENT
Dr. Kamal Ahmed
Asst. Registrar, SURGERY

3.  Derived from Greek “Poin”; meaning “Penalty”
 Derived from Latin “Poena”; meaning “Punishment from God”
 Homer - Arrows Shot by the Gods
 Aristotle – Distinguish five senses, considered pain to be Passionof the Soul
 Plato – Pain and pleasure arose from within and considered pain to be an emotional
experience than a localized body sensation
 Hippocrates – Imbalance of body fluids
 Bible - Anguish of the Soul
 Freud - Solution to Emotional Conflicts

4. Pain is……….
Protective mechanism
Localized sensation as a result of noxious stimulation
Now recognized as being more of an experience than a sensation

5. An unpleasant emotional experience
associated with actual or potentialtissue
damage or described in terms of such
damage.
Source: International Association for the Study of Pain (IASP) (WHO)

6. TRANSIENT PAIN
Short duration
Severe
Self limiting
PERSISTENT
 Long term duration
 Eg.: Cancer & neurogenic pain
 Pharmacological
assistance(analgesics) andcognitive
approach

7. ACUTE
 Associated with postoperative, post
injury
 Requires pharmacological
assistance(analgesics)
CHRONIC/DISABLING
 Continue beyond expectation for
diseaseprocess
 Pain and pain therapy dominate the
life
 Depression, anxiety

8. PHYSICAL CONDITIONS
 SOMATIC PAIN
 NEUROPATHIC PAIN
PSYCHOLOGICAL CONDITIONS
 MOOD DISORDERS
 ANXIETY DISORDERS
 SOMATOFORM DISORDERS
 OTHER CONDITIONS

10. PAIN INVOLVES FOUR PHYSIOLOGICAL
PROCESSES:
1. TRANSDUCTION
2. TRANSMISSION
3. PERCEPTION
4. MODULATION

12. Np : Neuro-peptides, BV : Blood Vessels

13. Biological
• Genetic variations leads differences in amount & type of neurotransmitters.
• Previous pain experience
• Gender
Cognitive
• Younger –report greater level of pain
• Older children understand the meaning of pain
• Up to 3 months- no understanding of pain but memory is present
• By 6 month respond to pain by anger
• By 20 months anger becomes more dominant

14.  Psychological
• Feeling of lack of control - intensify pain perception
 Sociocultural
• Difference in perception exist among different cultural group
• Parents perception & response to their child’s pain strongly
influence child’s
• perception & his reaction to pain

16.  Incisional
 Skin
Subcutaneoustissue
 Deep
 Cutting
 Coagulation
 I/V site
 Needle trauma
 Extravasation
Irritation
 Tube
Drain
Nasogastric
Endotrachialtube
 Operative site
 Cast
 Tight dressing
 Others
 Urinary retention
 Ambulation

17. ⚫Surgery
Tissue trauma
or nerve injury
Inflammation
due to release of
inflammatory
mediators
Hyperalgesia
and Allodynia

18. Sensory receptors Spinal cord
Spinothalamic
pathway
Thalamus
& cortex Muscle

19.  Pain lasting form more than 1 month after surgery
 Risk factors for CPSP
Repeat surgery
Catastrophizing
Anxiety
Genetic predisposition
Radiation therapy to that area
Moderate to severe post-operative pain
Surgical approach with risk of nerve damage
Neurotoxic chemotherapy
Depression

21. Complete pain free post –operative period but alongwith:
Early mobilization
Enhanced recovery
Maintained muscle power
Minimal complications

22. The Patient may suffer from:
CVS: Tachycardias, Ischemia
Hypercoagulable state: DVT
Diminished range of joint motion andArthrofibrosis are closely related to the degree of postoperative
pain
Psychological:Anxiety, Depression, Sleep Deprivation
Prolonged hospital stays, increased hospitalreadmissions and increased opioid use
For The Healthcare professional:
 Low Morale
 Complaints to/towards/against Institute
 Litigation

24. Oral medications whenever possible
Dose “by the clock” – but always have “as needed” medications for
breakthrough pain
Titrate the dose
Use appropriate dosing intervals
Be aware of relative potencies
Treat side effects

27.  PRE-PROCEDURE
EVALUATION
 PATIENT
EDUCATION
 PRE-EMPTIVE AND
PREVENTATIVE
ANALGESIAPLAN
The preparation for
Post-Operative
Analgesia should
start in the Pre-
Operative.

28. I.V MEDICATIONS
NEURAXIAL TECHNIQUES
TRANSVERSEABDOMINIS PLANEBLOCKS
PERIPHERAL NERVE BLOCKS
WOUND INFILTRATIONANESTHESIA
TUMESCENTANAESTHESIA
TOPICAL LOCALANAESHTESIA

29. ⚫Pharmacologic
Acetaminophen
(Paracetamol)
NSAIDs
Opioids
Alpha-2 agonists
⚫Pharmacologic
Regional
Anesthesia
LA infiltration at
incision site
⚫Nonpharmacologic
Approaches
Music and Audio
analgesia
Transcutaneous
electrical nerve
stimulation (TENS)

30. WEAK OPIOIDS
 Codeine phosphate 30-
60mg 4h
 Dihydrocodeine 30mg 4-6hpo
or 50mg 4-6h im
 Buprenorphine 200-
400mcg sl 4-6h
 Tramadol weak agonist 50-
100mg 4h
STRONG OPIOIDS
 Nalbuphine
 Morphine
 Diamorphine
 Pethidine: max1.2g daily

31.  Paracetamol: Acetaminophen
centrally acting 500mg-1g 6h
or 15- 20mg/kg for children
 Diclofenac sodium:50mg TDS
orally
 Aspirin: 300-900mg4h
 NSAIDs: Analgesic,
antipyretic, anti-
inflammatory
 Opioid sparing
 SE: Prostaglandin and
prostacyclin effect
 Ibuprofen, diclofenac,
naproxen, piroxicam

33. Using more than one drug for pain control
• Different drugs with different mechanisms/sites
of action along pain pathway
• Each with a lower dose than if used alone
• Can provide additive or synergistic effects
• Provides better analgesia with less side
effects (mainly opiate related S/E)
Always consider multimodal analgesia when treating pain

34. The
administration of
analgesic agents
prior to an injury
in order to
prevent
development of
central nervous
system
hyperexcitability

35. First-line treatment if no contraindication
Mechanism: thought to inhibit
prostaglandinsynthesis in CNS →
analgesia, antipyretic
Typical dose: 650 to 1000 mg PO every 6H
Max dose: 4 g / 24 hrs from all sources
Warning: ↓ dose / avoid in those with liver
damage

36.  First-line treatment
 Mechanism
⚫ Block cyclooxygenase (COX) enzyme → ↓prostaglandin synthesis
⚫ COX-2 → Prostaglandins → pain, inflammation,fever
⚫ COX-1 → Prostaglandins → gastric protection,
hemostasis
 No physical dependence
 No tolerance

37.  Diclofenac
 Piroxicam
 Ibuprofen
 Ketorolac
 Ketoprofen
50 mg PO bd/tds
20 mg OD
200-800 mg q 6 hr.
3x 30-40 mg/day
(only IV form)
4 x 50 mg/day
200 mg
40 mg
3200 mg
Cox-2
inhibitor
 Celecoxib
 Parecoxib
100-200 mg PO bid40
mg followed by
1-2x 40 mg/day(IV
form)
400 mg

38. Warnings: ↓dose / avoid if
⚫ GI ulceration
⚫ Bleeding disorders / Coagulopathy
⚫ Renal dysfunction
⚫ High cardiac risk – COX IIinhibitors
⚫ Asthma
⚫ Allergy

39. ⚫Multiple
Mechanism
Weak µ-
receptor
agonist
Inhibit
serotonin &
NE
reuptake
Application
Mild to
Moderate
Post-op
pain
Dose
50-100 mg
PO q 4-6
hr.
Max.- 400
mg/d
Side effect
Nausea
and
Vomiting

40.  Essential element of pain management
 Mechanism
 Action on opioid receptor
 Located mainly in spinal cord & brain stem, some
inperipheral tissue

41. RECEPTORS
Mu (μ or OP3)
μ1
μ2
Kappa (κ or OP2)Delta (δ
orOP1) Sigma(σ)
CLINICAL EFFECT
Analgesia, sedation, euphoria
Resp. depression, physical
dependenceSpinal analgesia,
resp. depression Analgesia,
resp. depression
Dysphoria, hallucination,
tachycardiahypertension

42. 1. Agonists
 Stimulate receptor
 No ceiling effect ( no limit mg/kg)
 Moderate to severe pain
 Codiene, morphine, pethidine,
fentanyl, methadone
2. Partial Agonists
 Ceiling effects eg. Buprenorphine
3. Agonists-antagonists
 Agonist-κ or σ receptor but antagonist
to μ receptor
 Can used in mild to moderate pain
 Ceiling effects
 Precipitate withdrawal in opioids
dependent
E.g: Pentazocine, Nalbuphine,
Nalorphine

43. Side Effects
Nausea / Vomiting,
Pruritus, Constipation,
Urinary Retention, Ileus,
Sedation, Respiratory
Depression,Tolerance
Opioid Overdose
Manifests as Somnilence,
respiratory depression,
bradycardia, miosis.
⚫ Management:
 Stimulate patient
 Attach Monitors/ IV Lines
and record Vitals
 Airway, Breathing,
Circulation
 Shift to ICU

44. LA bind sodium channels preventing propagationof action
potentials along nerves
Wide variety of LA with different
characteristics:
⚫ Lidocaine – fast onset, short duration ofaction
⚫ Bupivacaine – slow onset, longer duration
⚫ Ropivacaine: longer duration, less cardiotoxic

45. All local anesthetics drugs can cause toxic effects if
given in large doses or if accidentalintravascular
injection occurs. Central nervous system and
cardiovascular toxicity can result in restlessness,
hypotension, convulsions, cardiacarrhythmias and
even cardiorespiratory arrest.
Drug Safe Dose
Bupivacaine 2 mg/kg
Lignocaine 3 mg/kg
Lignocaine (with adrenaline) 7 mg/kg

46. - Residual motor weakness
- Peripheral nerve irritation
- Cardiac arrhythmias
- Allergic reactions
- Sympathomimetic effects (due to
vasoconstrictors)

47. Non-Opioid Drugs:
⚫ Antineuropathic : Pregablin 150 mg or Gabapentin 1200 mg PO
⚫ COX 2 inhibitors: Celecoxib 400mg or Valdecoxib 40mg PO
⚫ NSAIDS: Ketorolac 15-30mg PO/IV; Ibuprofen 400- 800 mg
-Reduce excess intra-operative opioid usage
-Reduce the possible effect of opioid-induced hyperalgesia post-operatively

48. Using rofecoxib 24 hours and 1 hour beforesurgery with
continued postoperative drug administration for 14
days had better outcomes in total knee arthroplasty.
These patients showed reduced opioid requirements,
faster time to physical rehabilitation, reduced nausea
and vomiting, better sleep patterns and greater
patient satisfaction after surgery.

49.  Spinal anesthesia is administered using
10-15mgbupivacaine.
 Addition of Fentanyl 20-25 ug increases
the postoperative analgesia for 2-3 hours.
 Addition of Clonidine 25-50 ug increases
the postoperative analgesia for 6-8 hours.
 Addition of Morphine 0.2-0.3 mg extends
the postoperative analgesia for 12-15
hours.

50.  Epidural Catheter placed in lumbar or thoracic segments.
 LA+ Opioids given via bolus dosing, Infusion pump orPatient
Controlled Analgesia pump
 Superior analgesia compared to Intravenous drugs inthoracic/ abdominal
procedures
 Reduced systemic opiate requirements
 Improves GI bloodsupply

52. TYPE NERVES
BLOCKED
PROCEDURE SITE CONTRAINDICATION
INTERSCALENE
BRACHIALPLEXUS
C5-7 SHOULDER AND
UPPERARM SEVERE PULMONARY
DISEASE PREEXISTING
CONTRALATERALPHRENIC
NERVE PALSY
SUPRACLAVICULAR BRACHIA
LPLEXUS
AT OR BELOW THE
ELBOW SEVERE PULMONARY
DISEASE PREEXISTING
CONTRALATERALPHRENIC
NERVE PALSY
INFRACLAVICULAR BRACHIA
LPLEXUS
DISTAL TO ELBOW
VASCULAR CATHETERS IN
THIS
REGION.IPSILATERAL
PACEMAKERS
AXILLARY BRACHIAL
PLEXUS
DISTAL TO ELBOW

53. TYPE NERVES BLOCKED PROCEDURESITE C/I
LUMBAR PLEXUS
SACRAL PLEXUS
FEMORAL
LATERAL FEMORAL
CUTANEOUS
OBTURATOR
SAPHENOUS
SCIATIC
ANKLE
SAPHENOUS NERVE,
DEEPPERONEAL,SUP
PERONEAL,
POST TIBIAL,SURAL
L4-5 AND S1-3
MOST MEDIAL BRANCH OFTHE
FEMORALNERVE
L2-3
L4-5 AND s1-4
L1-4
ANTTHIGHANDMEDIAL
LEG
POST THIGH AND MOST
OF LEG ANDFOOT
HIP,THIGH,KNEE AND
SAPHENOUS NERVE OF THE
ANKLE
LATERALTHIGH
COMPLETE ANAESTHESIA
OF THEKNEE
MEDIAL LEG ANDANKLE
HIP
,THIGH,KNEE,LOWER
LEGAND FOOT
FOOT
PREVIOUS VASCULARGRAFTING

55. o Allows patient participation and gives
themautonomy in their treatment
o Rapid titration
o Precise Analgesic calculations for
scientificstudies
o Reduced analgesic requirements
o Reduced incidence of breakthrough pain
o Less staffing and monitoring concerns

56. • Anxiolytic drugs
• Anticonvulsants
• Antidepressants
• Ketamine

57. • Potent analgesic effect
• Small doses in combination of opioids
substantially improve pain control
• Bolus dose of 100 mcg/kg followed by a continuous
drip of 1-3 mcg/kg/min is idealfor chronic opioid
users postoperatively

58. Every surgical incisional pain has Neuropathic component
studies showed giving 1200 mg of Gaba pentin 1 h prior to
surgery decreases the opioids requirement post-op and results
in better pain control without increasedsedation combining
Gabapentin with opioids is ideal for re-do back surgery cases
with chronic opioids usage. These class of drugs are also mode
stabilizers.

59. Psychological Treatments: Relaxation,
hypnosis cognitive therapyetc…
TENS Units
Physiotherapy

60. ACUTE
PAIN
TEAM
SURGEON
NURSE
ANESTHETI
ST
PSYCHOLOGIST
PHYSIOTHERAPIS
T
PHARMACIS
T

63. ⚫ Preoperative: Gabapentin 300mg PO + Celecoxib 200mgPO +
Acetaminophen 1g PO (2hrs before procedure)
⚫ Intraoperative: Spinal anesthesia using 10-15mgbupivacaine
⚫ Postoperative: Continuous Femoral nerve or adductor canal block infusion
– 0.2% Ropivacaine @ 8-10mls/hr incase of Knee arthroplasty.
⚫ Single shot Lumbar plexus or Fascia Iliaca block in case ofHip Joint
arthroplasty.
⚫ Gabapentin 300mg PO Q8 for 7 Days .
⚫ Celecoxib 200mg PO for 72 hrs.
⚫ Acetaminophen 1g PO for 72 hrs.
⚫ Oxyodone PO

64. Prefer Multi-modal approach for an excellent Post
Operative analgesia thus leading to:
⚫Improved patient satisfaction and Doctor-Patient
relationship.
⚫Early Mobilization
⚫Early Discharge
⚫Reduced Complications
⚫↓ likelihood of chronic pain