Postoperative pain is harmful and leads to both acute and chronic negative effects if poorly controlled. A multimodal approach to pain management is recommended, utilizing both pharmacological and non-pharmacological techniques. This includes the use of opioids, non-opioid analgesics like NSAIDs and gabapentinoids, and regional analgesic techniques such as epidurals, peripheral nerve blocks, and trigger point injections to provide superior pain relief with fewer side effects than systemic opioids alone. The goal is to control pain and facilitate early recovery after surgery.

1. Moderator : Dr Alok Basu Roy
Presenter: Dr Saurabh Kakkar

2. 
 Postoperative pain, especially when poorly
controlled, results in harmful acute effects and
chronic effects
 Widespread recognition of the under treatment of
acute pain by clinicians, economists, and health
policy experts has led to the development of a
national clinical practice guideline for management
of acute pain by a agency of U.S.
Introduction

3.  Anesthesiologists have developed the concept of
acute postoperative pain services application of
evidence based practice to acute postoperative pain,
and creation of innovative approaches to acute pain
medicine
 Anesthesiologists functions as a “perioperative
physician” consultant, and therapist throughout an
institution, as well as a highly skilled expert in the
operating room
 Postoperative pain management should be tailored
to the needs of special populations who may have
different anatomic, physiologic, pharmacologic, or
psychosocial issues

4.  Surgery produces tissue injury with consequent
release of histamine and inflammatory mediators
 Release of inflammatory mediators activates
peripheral nociceptors, which initiate transduction
and transmission of nociceptive information to the
central nervous system
 Noxious stimuli are transduced by peripheral
nociceptors and transmitted by A-delta and C nerve
fibers from peripheral visceral and somatic sites to
the dorsal horn of the spinal cord, where integration
of peripheral nociceptive and descending
modulatory input occurs
Pain pathway

5.  Some impulses pass to the ventral and ventrolateral
horns to initiate segmental (spinal) reflex responses,
which may be associated with increased skeletal
muscle tone, inhibition of phrenic nerve function, or
even decreased gastrointestinal motility
 Others are transmitted to higher centers through the
spinothalamic and spinoreticular tracts, where they
induce supra segmental and cortical responses to
ultimately produce the perception of and affective
component of pain
 Continuous release of inflammatory mediators
causes Sensitization of peripheral nociceptors may
occur and is marked by a decreased threshold for
activation, increased rate of discharge with
activation, and increased rate of basal discharge

6. 
 Intense noxious input from the periphery may also
result in central sensitization ( hypersensitivity) and
hyperexcitability.
 Nociception is a dynamic process (i.e.,
neuroplasticity) with multiple points of modulation.
 Persistent noxious input may result in relatively
rapid neuronal sensitization and possibly persistent
pain
 The intensity of acute postoperative pain is a
significant predictor of chronic postoperative pain

7. 
 Patient dis-satisfaction
 Decreased Respiratory function
 Myocardial ischemia
 Sodium and water retention
 Increased catabolic state
 Postoperative hypercoagulable state
 Immunosuppression
 Poor wound healing
 Prolonged paralytic ileus
Acute effects of postoperative pain

8. 
 Delayed recovery
 Inability to participate in rehabilitation
 Chronic postsurgical pain ( CPSP )
 Financial expenses
Chronic effects of postoperative pain

9. 
 Previously called “ preemptive analgesia ”
 It refers to an analgesic intervention that preceded a
surgical injury and was more effective in relieving
acute postoperative pain than the same treatment
following surgery
 The rationale for preemptive analgesia was based on
the inhibition of the development of central
sensitization
 An intervention administered before the surgical
incision is not preventative if it is incomplete or
insufficient
Preventive Analgesia

10. 
Principles of a multimodal strategy include:
 Control of postoperative pain to allow early mobilization
 early enteral nutrition
 education, and attenuation of the perioperative stress response
through the use of regional anesthetic techniques
 combination of analgesic drugs (i.e., multimodal analgesia)
The multimodal approach integrates the most recent data and
techniques from surgery, anesthesiology, nociceptive neurobiology,
and pain treatment, making it an extension of clinical pathways
(Enhanced Recovery After Surgery, or ERAS) or fast tracks
MULTIMODAL APPROACH TO
PERIOPERATIVE RECOVERY

11. 
 Systemic
1. Opioid analgesics
2. Non-opioid analgesics
 Regional
1. Neuraxial techniques
2. Peripheral techniques
Treatment Methods

12. 
 Cornerstone for postoperative pain treatment
 Opioids may be administered by the subcutaneous,
transcutaneous, transmucosal, or intramuscular
route, oral and intravenous
 Prescribed on an as-needed (PRN) basis
 Intravenous Patient-Controlled Analgesia (PCA)
Opioids

13. 
 PCA optimizes delivery of analgesic opioids and
minimizes the effects of pharmacokinetic and
pharmacodynamic variability in individual patients
 When pain is experienced, analgesic medication is
self-administered, and when pain is reduced
 PCA device can be programmed for several
variables, including the demand (bolus) dose,
lockout interval, and background infusion
Intravenous Patient-Controlled
Analgesia

14. 

15. 
 NSAID’S :
 Inhibition of cyclooxygenase (COX) and synthesis of
prostaglandins
 COX-1 is constitutive and COX-2 is inducible
 COX-1 participates in platelet aggregation, hemostasis,
and gastric mucosal protection, whereas COX-2
participates in pain, inflammation, and fever
 provide effective analgesia for mild to moderate pain
 side effects include decreased hemostasis, renal
dysfunction, and gastrointestinal hemorrhage
 Diclofenac, Acetaminophen , Ketorolac
Non - Opioids

16. 
 Gabapentanoids
 Gabapentin and pregabalin, antiepileptic drugs
 used in the treatment of neuropathic pain
 interact with calcium channel α2-δ ligands to inhibit
calcium influx and subsequent release of excitatory
neurotransmitters
 meta-analysis demonstrated use of pregabalin was
associated with a decrease in opioid consumption and
opioid-related side effects, but no difference in pain
intensity
 perioperative administration of gabapentin and
pregabalin may reduce the incidence of CPSP
Non - Opioids

17. 
 Ketamine
 Traditionally recognized as an intraoperatively
anesthetic induction agent
 Small analgesic dose ketamine can facilitate
postoperative analgesia because of its NMDA-
antagonistic properties, which may be important in
attenuating central sensitization and opioid tolerance
 can be administered orally, intravenously,
subcutaneously, or intramuscularly
Non - Opioids

18. 

19. 
 Single-Dose Neuraxial Opioids
 Administration of a single dose of opioid may be
efficacious as a sole or adjuvant analgesic drug when
administered intrathecally or epidurally
 One of the most important factors in determining the
clinical pharmacology for a particular opioid is its
degree of lipophilicity
 Continuous Epidural Analgesia
 Analgesia delivered through an indwelling epidural
catheter is a safe and effective method for
management of acute postoperative pain
REGIONAL ANALGESIC TECHNIQUES

20. 

21. 
DRUG INTRATHECAL
SINGLE DOSE
EPIDURAL
SINGLE DOSE
EPIDURAL
CONTINUOUS
INFUSION
FENTANYL 5 – 25 µg 50 – 100 µg 25 – 100 µg/hr
MORPHINE 0.1 – 0.3 µg 1 – 5 µg 0.1 – 0.2 µg/hr
REGIONAL ANALGESIC TECHNIQUES

22. 
 Local anesthetics
 Opioids
 Local anesthetics + Opioids
 Adjuvants – Clonidine , Ketamine , Dexmedtomidine
Analgesic drugs for regional
techniques

23. 

24. 
 Hypotension
 Motor block
 Pruritus
 Respiratory depression
 Nausea and vomiting
 Urinary retention
 Migration of catheter
Side Effects of Neuraxial Analgesic
Drugs

25. 
Patient Controlled Epidural Analgesia

26. 
 Reduction in mortality and morbidity
 Postoperative thoracic epidural analgesia can facilitate
return of gastrointestinal motility without contributing to
anastomotic bowel dehiscence
 Preserving postoperative pulmonary function through
providing superior analgesia and thus reducing splinting
behavior and attenuating the spinal reflex inhibition of
diaphragmatic function
 Decreases the incidence of postoperative myocardial
infarction by attenuating the stress response and
hypercoagulability
Benefits of Epidural Analgesia

27. 
 Epidural hematoma
 Epidural abscess
 Infections like meningitis
 Intrathecal or intravascular migration
Risks With Epidural Analgesia

28. 
 Analgesia superior to that with systemic opioids
 Brachial plexus, Lumbar plexus, Femoral, Sciatic-
popliteal, and Scalp nerve blocks
 one-time injection used primarily for intraoperative
anesthesia
 Continuous infusions of local anesthetics is
administered through peripheral nerve catheters
 Techniques like nerve stimulation, ultrasound
guidance, and paresthesia elicitation are used
Peripheral Regional Analgesia

29. 
 Paravertebral blocks
 Intercostal blocks
 Transversus abdominis plane blocks
 Interpleural (intrapleural) analgesia
 Cryoanalgesia
 Intra – articular analgesia
Nonepidural Analgesia

30. 
 Transcutaneous electrical nerve stimulation (TENS)
 Acupuncture
 Exercise/activity
 Psychological approaches
 All of these approaches to postoperative pain are
relatively safe, noninvasive, and devoid of the
systemic side effects seen with other analgesic
treatment options
Non – Pharmacological techniques

31. 