Postoperative pain management is an essential component of surgical patient care. About 75% of surgical patients experience pain after a procedure. Effective pain control allows for early mobilization, reduced complications, and faster recovery. Postoperative pain arises from tissue damage during surgery and the subsequent inflammatory response. Both pharmacological and non-pharmacological methods can be used to treat postoperative pain, including opioids, NSAIDs, local anesthetics, and physical therapy. Proper assessment and an individualized treatment plan that utilizes a stepwise multimodal approach can provide pain relief and optimize patient outcomes.

1. Postoperative Pain
Management
Presented by
Tanjina Yeasmin Eva
Intern Doctor,Surgery unit 1,SOMCH

2.  Pain is the most common postoperative complaint
of surgical patients .About 75% patients complain
of pain in postoperative period.
 Clinicians attending to these patients need to have
better understanding about Effective postoperative
pain control as an essential component of the care
of the surgical patients.

3. Patient has to be
completely pain free
Target:

4. What is pain?
• Pain is an unpleasant sensory or emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage
Ref: The InternationalAssociation for the Study of
Pain (IASP)

5. HOW DOES
POSTOPERATIVE PAIN
ARISE?

6. Transduction
Transmission
Modulation
Perception
2
1
3
• Pain involves four physiological processes
4

7. Pain begins when..
Local tissue damage during surgery
Release of inflammatory substances
(PG,histamines,serotonin, bradykinin, substance P)
Electrical impulse generation ( transduction) at peripheral
nerve endings or niciceptors
Through A-delta or C fibers to spinal cord (Transmission)
Further relay to the higher brain centres can be modified
within the spinal cord (Modulation) before an individual
perceives a painful stimulus (perception)
Ref: Clinical surgery in general(RCS course manual):4th edition

9. Factors affecting postoperative pain
• The intensity, quality and duration of postoperative
pain is affected mainly by:
 Location, type, and duration of the surgical
procedure
 Extent of the incision and surgical trauma
 Physical and mental state of the patient
including the patient’s personal approach to pain
 Type of anesthesia

10. Cont..
 Incidence of surgical complications
 Quality of preoperative patient preparation
 Quality of postoperative care
Ref: Gerbershagen HJ, Aduckathil S, van Wijck AJ et al. Pain intensity on the first day after surgery: a prospective cohort study
comparing 179 surgical procedures. Anesthesiology. 2013

11. Why treating
postoperative pain is
important?

12. Why treating
postoperative pain is important?
Patient comfort & satisfaction
Early mobilization & rehabilitation
Prevention of pulmonary complications
 Atelectasis and Pneumonia,
Prevention of cardiac complications
 Increased risk of Myocardial Ischaemia in
patients with pre-existing cardiac disease

13. Cont…
• Reduced risk of DVT
• Faster recovery
• Reduced hospital stay & cost
• Good postoperative analgesia is related to reduced
clinical morbidity
Ref: Clinical surgery in general(RCS course manual):4th edition; Gerbershagen HJ, Aduckathil S, van Wijck AJ et al. Pain intensity on the first
day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology. 2013

14. ? Reasons behind
poor analgesia
Failure to provide good postoperative
analgesia is multifactorial
Insufficient knowledge & lack of
proper counselling
Fear of complications associated
with analgesic drugs
Poor pain assessment
Inadequate stuffing

15. Methods available to treat
post operative pain

16. Methods available to treat post operative
pain
Methods
Non-
pharmacological
Pharmacological

17. Non-pharmacological
Psychological methods:
 Pre-operative
counselling-maybe
beneficial for reducing
patient anxiety and
improve satisfaction with
treatment
 Hypnosis- it can help
reduce anxiety

18. Cont…
• Physical methods
i. TENS( Transcutanenous electrical nerve stimulation): reduces the
transmission of painful nerve impulses to the higher cortical centres,
thereby theoretically reducing the level of postoperative pain
ii. Acupuncture: number of studies that suggest that it reduces pain &
analgesic consumption after dental and abdominal surgery.
iii. Massage
iv. Application of superficial heat or cold
• **Although there is little evidence to support the effectiveness of unconventional
methods, certain patients do derive some benefit from them, so do not dismiss them
without consideration

19. Pharmacological
Paracetamol
NSAIDs: Diclofenac, Ibuprofen,Ketorolac
Opioids:
 Mild opioids: Codeine, Tramadol
 Strong opioids: morphine, diamorphine,
fentanyl,oxycodone,pethidine
Adjuvants : Local anesthesia, Epidural
Anesthesia, Patient controlled analgesia

20. Site of action of common analgesics

22. • Improving analgesia alone may not be
sufficient to reduce stress response to surgery.
• We must also influence other physiological
processes and restore homeostasis

23. Paracetamol
First line treatment if no
contraindicaton
Max dose: 4 g / 24 hrs
from all sources
More effective in
severe pain when
combined with other
opioids such as
codeine
Mechanism: thought to
inhibit prostaglandin
synthesis in CNS →
analgesia, antipyretic
Effective for mild to
moderate pain
Contraindicated in Acute
liver disease alcohol-
induced liver disease,
glucose-6-phosphate
dehydrogenase deficiency

24. NSAIDS
Use
• Moderate pain relief, reduces dose of opoids when
used combined
Adverse effects
• Gastric ulceration,nephrotoxicity,impaired
haemostasis,aspirin induced asthma,high cardiac
risk(COX-II inhibitor)
Contraindications
• Pre-existing PUD, Renal Failure,Asthma,Bleeding
disorder
Also, first-line treatment
 Mechanism -Block cyclooxygenase (COX)
enzyme → ↓ prostaglandin synthesis

25. Opioids
Route of
administration
• Oral,
• Intramascular
• Intravenous
• Centrally (epidural)
Side effects
• Itching, Sedation, Respiratory depression,
• Nausea and vomiting, Euphoria or dysphoria and
• bladder dysfunction, Dependency
Contraindications • Asthma, Shock, Hypotension
 Centrally acting on opioid receptors

26. Other…
Local
anesthetic
infiltration
Epidural
anesthesia
Patient
controlled
analgesia
 Local infiltration of
bupivacaine provides
pain relief for first 6
hours
postoperatively
 Affective for day
care surgery
 Extremely
satisfactory method
of ensuring a pain
free early
postoperative period
after major
abdominal or
thorasic surgery
without the sedation
o systemic opoids
 Administration of
intravenous opoids
at a bolus dose
controlled by the
patient where
overdose is
prevented by
lockout devices
Ref: Clinical surgery in general(RCS course manual):4th edition; Gerbershagen HJ, Aduckathil S, van Wijck AJ et al. Pain intensity on the
first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology. 2013,Frquhanson’s textbook
of Operative general surgery:11th edition;Essential surgical practice:higher surgical training in general surgery,5th edition

27. NSAIDs vs Opioids
NSAIDs Opioids
Weaker analgesic Strong analgesic
Acts peripherally Acts centrally
Does not Depress CNS depress CNS
No abuse liability High abuse potential
No dependence Can cause physical & mental
dependence
Ref:Ingredient Medical Pharmacology:4th edition

28. Single drug vs combination drugs

29. Benefits of using multimodal drugs
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)

30. Approach to a
postoperative patient
in pain

31. WHO Analgesic stepladder
• The WHO analgesic stepladder is the best known method
for approaching pain relief .
• it provides a strategy for titrating analgesia, starting with
simple analgesics & working upwards the ladder to strong
opioids.

33. Clinical assessment of pain
• Post-operative pain can be assessed subjectively &
objectively
Subjective: (history taking)
Ask the patient to grade their pain on a scale
of mild ,moderate or severe & use pain
scoring scales
Take history about the onset of pain, speed of
onset, location, radiation, quality of the pain,
and accompanying symptoms
causative factors – movement, sitting
position, cough, etc.

34. intensity of the pain at rest, during movement
Quality of sleep
Assessment of the patient’s expectations, personal
approach to pain, stress and pain coping strategies,
analgesic therapy preferences
History of any pre-existing pathology

35. Pain scoring tools

36. Cont..
Objective(physical examination):
 Pulse: Tachycardia
 BP: Hypertension
 Respiratory rate: Tachypnea
 Sweating or flushing
 Local area of tenderness

37. Monitoring
• Regular Assessment of the level of pain,
• Effectiveness & side effects of ongoing analgesic regimen
• Monitoring of sedation & respiration strictly for a patient on
opioids
• Observe patients behavior to assess the outcome of
treatment

38. Points to be noted
• After thorough assessment of patient create a
individual analgesic regimen for each patient
because pain is a subjective concept and patients’
experience of pain after a similar procedure varies
considerably.

39. “The good physician treats the
disease;the great physician treats
the patient who has the disease”
-Sir William Osler

40. Thank you