Dr. Sudheer Dara is a consultant anesthesiologist and pain specialist at Yashoda Hospital Secunderabad. He is the honorary treasurer of ISSP AP Chapter and founder of YAPM. His special interests include interventional pain management, ultrasound regional anesthesia, postoperative pain, acute pain services, and oral and injectable drugs. He discusses the need for improved postoperative pain management, highlighting issues like suboptimal analgesia, myths about pain relief, and inadequate assessment. He emphasizes the importance of multimodal analgesia using combinations of opioids, NSAIDs, paracetamol, nerve blocks, and the need for acute pain services with protocols and staff training to optimize postoperative pain management.

1. Dr Sudheer Dara
• Consultant Anaesthesiologist & Pain specialist,
Yashoda Hospital Secunderabad.
• Hon. Treasurer of ISSP (AP Chapter)
• Faculty for “Traveling pain school” started by ISSP (AP Chapter)
• Founder of YAPM (Yashoda Academy of Pain Medicine)
• Special Interests:
Interventional Pain Management
Ultrasound Regional Anaesthesia

2. Post operative pain & acute pain services
DR.SUDHEER DARA
ANAESTHESIOLOGIST
PAIN SPECIALIST
YASHODA HOSPITAL
SECUNDERABAD

3. Drugs
(oral & injectable)

4. Epidural analgesia

5. Periphral nerve blocks

6. Where are we ?

7. Questionnaire
1)The % of your patients comfortable in post
operative ward?
2)Are you satisfied with your post operative
rounds?
3)How frequently you use opioids in
postoperative period?
4) Do you have acute pain services?

8. Sub optimal analgesia
? lack of knowledge about drugs
?
? many myths associate with pain
? pain is not harmful to patient
? pain relief obscures signs of complications
?
? patient will become addicted to opioids
? risk of respiratory depression is high
? PRN: means
?
give as infrequently as possible’

9. Sources of postoperative pain
•Acute nociceptive pain from incision.
• Musculoskeletal pain from abnormal
body positioning and immobility during and
after surgery
• Neuropathic pain from excessive
stretching or direct trauma to peripheral
nerves

10. Postoperative pain is nociceptive
Perception
Modulation
Is responsive to NSAID’s,coxibs, paracetamol and
opiates
Transmission
Transduction
Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.

11. Pain pathway and modulation1
Ascending nociceptive pathways
Interpretation in
cerebral cortex:
pain
Stimulation of nociceptors
(A and C fibers) /
Release of
neurotransmitters and
neuromodulators (i.e. PG)
Descending inhibitory controls /
Diffuse noxious inhibitory controls
Activation of serotoninergic
and noradrenergic pathways
Release of
serotonin, noradrenalin and
enkephalins at spinal level
Injury
1. Adapted from: Bonica JJ. Postoperative pain. In Bonica JJ, ed. The management of pain. Philadelphia: Lea
and Febiger;1990:461-80.

12. Post operative pain- effects

13. Adverse Effects of Poor Pain Control
“… it remains a common misconception
amongst clinicians that acute
postoperative pain is a transient condition
involving physiological nociceptive
stimulation, with a variable affective
component, that differs markedly in its
pathophysiological basis from chronic pain
syndromes.”
Cousins MJ, Power I, and Smith G.
Regional Analgesia and Pain Medicine, 25 (2000) 6-21

14. No one likes it

17. Consequences of Unrelieved Pain
Acute Pain
Increased
sympathetic
activity
GI effects
Splinting,
shallow
breathing
Increased
catabolic
demands
Anxiety
and fear
Peripheral/
central
sensitization
Myocardial
O2
consumption
GI motility
Atelectasis,
hypoxemia,
hypercarbia
Poor wound
healing/muscle
breakdown
Sleeplessness,
helplessness
Available
drugs
Myocardial
ischemia
Delayed
recovery
Pneumonia
Weakness
and impaired
rehabilitation
Psychological
Chronic
pain
Courtesy of Sunil J Panchal, MD

19. Pain is subjective
Pain is subjective

21. Pain Assessment
Visual Analogue Scale

22. Different modalities of pain
control
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Drugs- oral,intramuscular,intravenous,rectal,
Epiduralanalgesia
Nerve blocks
Skin infiltration
Accessory methods: TENS, ACUPUNCTURE
COGNITVE THERAPIES

23. Modes of action of analgesics1,2,3,4
Paracetamol

Inhibition of central Cox-3 (?)
(Inhibition of PG synthesis)
Opioids

Activation of
opioid receptors
Paracetamol

Interaction with
serotoninergic descending
inhibitory pathway
NSAIDs / Coxibs

Inhibition of peripheral and
central Cox-1 / Cox-2
(Inhibition of PG synthesis)
1. D’Amours RH et al. JOSPT 1996;24(4):227-36.
2. Piguet V et al. Eur J Clin Pharmacol 1998;53:321-4.
3. Pini LA et al. JPET 1997;280(2):934-40.
4. Chandrasekharan NV et al. PNAS 2002;99(21):13926-31.

24.  How much we are successful?

25. Where is the problem?

26. First contact (PAC)
 Explaining about the nature of surgery
 Explaining about the expected amount of
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pain
Explaining the self assessment of pain
Explaining about the management offered
Explaining about the reassessment
Clearing the faulty thoughts (spiritual)

27. Operation theatre
 Preemptive analgesia
 Pre incision infiltration
 Epidural analgesia (continous)
 Parentral medication continuing into post
operative period (dosing)
 Peripheral nerve blocks (technique ?)
 Neuropathic pain
 Patches ( fancy but questionable)

28. Epidural analgesia(failures)
 Technical difficulties

29. Epidural analgesia
(failures)

30. Epidural failures (guess?)

31. Epidural failures
 Loss of resistance

34. Catheter placement
 Cervical – 1cm
 Thoracic-1.5 cm
 Lumbar – 2 cm

35.  Dermatomal involvement
 Calculation

37. Drug concentration & dosages
(epidural)
 Bupivacaine hydrochloride ( 0.125% to 0.5%)
 Ropivacaine ( 0.2%)
Additives : fentanyl citrate, morphine,clonidine
Precise and strict monitoring
Bolus dosage:

38. Post operative room
Pain assessment:
rarely done

39. Pain Assessment
Visual Analogue Scale

41. Principles of assessment of
pain
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At rest and on movement
Evaluate before and after therapy
Character of the pain
Severe the pain more the evaluation
Document the response and adverse effects
Attention towards those unable to express
Family members are involved

42. Post operative pain
(guess??)

43.  Isolated

44. Be compassionate
 Pp


45. Assurance
 Done by a nurse or the physician
 Explain the measures and administer
 Reassess the pain
 Multimodal approach

46. Treat according to the scale
 Upto 4/10 ---- NSAID AND PARACETOMOL
 4/10 and above ---- NSAID AND OPIOID

47. Epidural is not the sole
saviour
Combination therapy
WHO LADDER

48. Combination analgesia
 Epidural drug(opioid) + Nsaid
 Nsaid and paracetomol
 Nsaid and opioid
 Do not add opioid to opioid
 Paracetomol--- ?????( alone)

49. “Real World”: Multimodal Analgesia
 Reduced doses
Opioids
 Improved pain relief
Potentiation
 Reduce severity
of AEs
 Earlier discharge
NSAIDs, coxibs,
paracetamol,
nerve blocks
Kehlet et al. Anesth Analg. 1993;77:1048-1056 (B).
 Decreased costs

50. BJA 2002
Comparative effect of
paracetomol(pct),NSAID,or their
combination
Systematic review of literature in medline
1996 to 2001

51. Bja 2002
Major abdominal surgeries:
Nsaid are superior to pct
Gynaecological :
Nsaid superior to pct
ENT:
pct = Nsaid
Dental: Nsaid superior to pct

52. Result
Paracetomol is additive to
nsaids and opioids

53. Assessment of pain in
critically ill ( non verbal)
 Critical care pain observation tool (CPOT)
 Adult non verbal pain scale(NVPS)
 Faces legs activity cry consolibility
scale(FLACC)

55. Assessment
CPOT
. Facial description
. Body movements
.muscle tension
. Compliance with ventilator
.vocalization

56. Assessment
 NVPS
. Face
. Activity
. Guarding
. Physiology
. Respiration

57. Precise dosing and timing

59. PRN based monotherapy
 Analgesic gaps
 Break through pains

60.  Failure of NSAID and paracetomol
 Failure of epidural analgesia

61. Opioids!!!!!!!!!!!

62. Opioid !!!!
 Gold standard
 Needs understanding
 Side effects
 Antidote

63. Opioid intravenous infusions
 Morphine sulphate infusions
30 to 50 mics per kg per hour
 Fentanyl citrate infusions
1 mic/kg/hour

64. Yashoda opioid infusion
protocol
Opioid infusion protocol in post-operative pain
Morphine : 30 µg/kg/hour
Add 2.5 cc(2.5 amp)- inj morphine in 50 ml N.S
1cc = 0.5 mg
50 kg ----------------1.5mg/hour--------------3cc/hour
60kg -----------------1.8mg/hour--------------3.6cc/hour
70kg -----------------2.1mg/hour---------------4.3cc/hour
80kg ---------------- 2.4mg/hour---------------4.8cc/hour
90kg-----------------2.7mg/hour---------------5.6cc/hour
100kg---------------3.0mg/hour----------------6cc/hour
Initial bolus:
Dose: 50 µg/kg
50 kg----------------------2.5 mg---------------5cc
60kg----------------------3.0 mg---------------6cc
70kg---------------------3.5 mg----------------7cc
80 kg--------------------4.0 mg----------------8cc
90 kg--------------------4.5 mg----------------9cc

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Painful procedures:
Physiotherapy,dressing,shifting:
Dose: 20 µg/kg
50 kg----------------1.0mg----------------2cc
60 kg----------------1.2mg----------------2.4cc
70 kg----------------1.4mg----------------2.8cc
80 kg---------------1.6mg-----------------3.2cc
90 kg---------------1.8mg---------------- 3.8cc
100kg--------------2.0 mg---------------4.0 cc
Keep Nalaxone ready
Dilute: NALAXONE 0.4 mg (1 amp) + 20 cc N.S
1cc = 20µg
Pruritis
Excess sedation
C.P ARREST
1µg/kg
2µg/kg(5 dose)
10µg/kg(5 dose)
Rpt after 2 hours
Rpt after 1-2 min
rpt 1-2 min

66. Transdermal patches??
 Buprigesic patches
 Fentanyl patches

67. Patches for acute pain????
 Delayed onset
 Respiratory complications

68. Transdermal fentanyl. A review of its pharmacological properties and therapeutic
efficacy in pain control.
Jeal W, Benfield P.
Source
Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

69. Initially, much of the clinical experience with fentanyl TTS was obtained in
patients with acute postoperative pain. However, because of the increased risk
of respiratory complications, fentanyl TTS is contraindicated in this setting.
 The most serious adverse event was hypoventilation, which occurred more
frequently in postoperative (4%) than in cancer patients (2%).

70. Opioid adverse effects
Common
Uncommon
Constipation
Bad dreams / hallucination
Dry mouth
Dysphoria / delirium
Nausea / vomiting
Myoclonus / seizures
Sedation
Pruritus / urticaria
Sweats
Respiratory depression
Urinary retention

71. POST OP ANALGESIA????

72.  Opioid infusion
 Combination with others

73. Peripheral nerve blocks

74. Anatomy

78. CONTINOUS CATHETER TECHNIQUE

79. patient-controlled analgesia (PCA)
negative feed back loop
microprocessor-controlled pump
basal (infusion) rate
incremental (bolus) dose
lockout interval
4-hour limit
monitoring: pain score, sedation score,
RR, other side effects

80. SO!!!!!
 WHAT’S THE SOLUTION

81. Acute pain services

82. The important components of APS are as
follows:
(a)
Multidisciplinary committee comprising
anesthetists, surgeons, nurses and
pharmacists, supported by the secretarial
staff. The committee should define the needs
and suggest the equipments and
infrastructure besides providing guidance to
develop and manage the APS.
(b)
Acute pain management protocols and
modalities of APS.
(c)
Regular pain assessment methods and
guidelines to control pain within a defined
time scale.
(d)
Continuous professional development and
teaching programs.
(e)
Regular meetings, cooperation and
networking amongst the members

83. Guidelines for optimising
POP management1,2,3,4,5,6

Adequate and thorough patient information2,3,4,5,6

Use of written protocols1,3,4,5,6

Regular assessment of pain intensity1,2,3,4,5,6

Adequate medical and nursing staff training1,3,4,5,6
Use of balanced analgesia, PCA, and epidural drug
administration1,2,3,4,5,6

1. The Royal College of Surgeons of England and the College of Anaesthetists. Commission on the provision
of surgical services, report of the working party on pain after surgery. London, UK, HMSO.1990.
2. Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. Acute Pain Management in
Adults: Operative Procedures. Quick Reference Guide for Clinicians. AHCPR Pub. No. 92-0019. Rockville, MD.1992.
3. International Association for the Study of Pain, Management of acute pain: a practical guide. In: Ready LB, Edwards WT, eds. Seattle, 1992.
4. Wulf H et al. Die Behandlung akuter perioperativer und posttraumatischer Schmerzen Empfehlungen einer
interdisziplinaeren Expertenkommision. G. Thieme, Stuttgart, New York. 1997.
5. EuroPain. European Minimum Standards for the Management of Postoperative Pain.1998.
6. SFAR. Conférence de consensus. Prise en charge de la douleur postopératoire chez l’adulte et l’enfant.
Ann Fr Anesth Réanim 1998;17:445-61.

85. Thanks for your patient
hearing
DR.SUDHEER DARA
ANAESTHESIOLOGIST & PAIN SPECIALIST
YASHODA HOSPITAL
SECUNDERABAD