Dr. Tushar B. Munnoli emphasizes the importance of effective post-operative pain management, noting that despite its critical role, postoperative pain is often inadequately addressed due to factors like insufficient education and fears about analgesic side effects. The document outlines various pain assessment techniques and treatment modalities, including multimodal analgesia, aimed at improving patient outcomes and minimizing complications. It advocates for a comprehensive approach involving a multidisciplinary team to enhance communication, assessment, and pain management strategies.

1. Dr. Tushar B Munnoli, MD CIPS
Consultant Pain Specialist,
Apollo Hospitals, Jubilee Hills, Hyderabad.
POST-OPERATIVE PAIN
ASSESSMENT & MANAGEMENT
Fellowship in Chronic Pain Management.
Certified Interventional Pain Sonologist (CIPS), World Institute of Pain (USA).
Post-doctoral fellowship in Regional Anesthesia & Pain Management (AORA).
Diploma in Musculoskeletal Ultrasound.
GC Member - Indian Society for Study of Pain (ISSP).
Founding member - Musculoskeletal Pain & Ultrasound Society.

2. Vital signs?
• Pain is perceived as a consequence of Surgery and often the pain sufferers are
asked to live with it.
• Pain can be managed.

3. Introduction:
• Pain management is recognized as an important indicator of standards of
accreditation in health and quality of health care.
• Effective postoperative pain control is an essential & humanitarian need of
every surgical procedure.
• Postoperative pain is still undermanaged.
- due to insufficient education,
- fear of complications associated with available analgesic drugs,
- poor pain assessment,

4. What is Pain?
A vital function of the nervous system in providing the body with a warning of potential or actual injury.

5. PAIN PATHWAYS
• The pain pathway/nociceptive pathway - a
complex network of nerves and structures
responsible for transmitting and processing pain
signals throughout the body.
• Understanding of this is essential for
comprehending how pain is perceived and
managed.

6. PAIN PATHWAYS
• Sequence of events that are involved in the neural processing of noxious stimuli:
Transduction,
Transmission,
Perception.
Modulation.

7. PAIN PATHWAYS
Modulation
• Can either facilitate or inhibit pain.

8. PAIN PATHWAYS
Modulation
• The evidence for pain modulation was first recorded by a
physician serving the US Army during World War II
• “Strong emotions" block pain.
• Many variables interplay with the experience of pain, including
memory, mood, environment, attention, and expectation.

9. A strongly held misconception!
• “acute pain vanishes in a few days, and as long as the operation
was successful, the acute postoperative pain will soon be
forgotten”

10. The Pain Memory
• People may experience fear and anxiety if they have had a negative previous pain
experience, if effective pain management is not provided, if their pain is not relieved, or if
they have severe pain.
• On the other hand, if the pain the person experiences is effectively managed, the person
can cope better with the pain
(Acar et al., 2016).
PAIN PATHWAYS

11. PAIN PATHWAYS
Modulation
Mechanisms that act to inhibit pain transmission:
• Central Modulation
• Peripheral Modulation

12. PAIN PATHWAYS
Modulation
Gate control theory of Pain:

13. PAIN PATHWAYS
Modulation

14. TYPES OF PAIN
• Based on time
• Based on mechanism

15. TYPES OF PAIN
• Based on time

16. TYPES OF PAIN
• Based on mechanism

17. POST-OPERATIVE PAIN
• Postoperative pain is considered a form of acute pain due to surgical trauma with an
inflammatory reaction and initiation of an afferent neuronal barrage.
• It is a combined constellation of several unpleasant sensory, emotional and mental
experience precipitated by the surgical trauma and associated with autonomic, endocrine-
metabolic, physiological and behavioral responses.

18. POST-OPERATIVE PAIN - Incidence
• Every year, millions of people undergo surgery and experience postoperative pain at
various levels.
• Nearly three-quarters of patients undergoing surgical interventions have acute pain,
and 20% to 80% of postoperative patients experience pain.
(Gan, 2017; Meissner et al., 2018).

19. Biological responses to tissue injury
What happens after Surgery?

20. GOALS OF POST-OPERATIVE PAIN MANAGEMENT
• To provide continuous effective analgesia that is safe and free from
unwanted side effects.
- Facilitate rapid recovery and return to full function.
- Prevent complications and reduce morbidity.
- Allow early discharge from the hospital.
- Prevention of chronic pain.
- Improve the quality of life for the patient.

21. TEAM MEMBERS
Doctors
Nurses
Physiotherapists
POST-OPERATIVE PAIN MANAGEMENT
- Communicate effectively to keep the
team informed and organized.
- Make rapid decisions about appropriate
care interventions.
- Communicate with patients, families,
and other members of the healthcare
team to ensure seamless care delivery.

22. ASSESSMENT OF PAIN
Pain assessment should be ongoing, individualized, and documented.
Subjective and Objective methods are two different approaches to gather
information.
• Question the patient
• Use pain rating scales
• Evaluate behavior & physiologic signs
• Secure family’s involvement
• Take action and assess effectiveness

23. ASSESSMENT OF PAIN
PAIN HISTORY – OPQRSTU
• Onset: “Did your pain start suddenly or gradually get worse and worse?”
• Provokes or Palliates: “What makes your pain better or worse?”
• Quality: “What words would you use to describe your pain?” or “What does your pain feel like?”
• Radiates: “Point to where it hurts the most. Where does your pain go from there?”
• Severity: Pain is subjective and relative to each patient you treat. Have an open mind for any
response from 0 to 10.
• Time: Intermittent/continuous/time of the day

24. ASSESSMENT OF PAIN
Clinical examination:
- Pain diagram
- General physical examination
- Musculoskeletal examination
- Neurological examination
- Other systems

25. ASSESSMENT OF PAIN
PAIN ASSESSMENT

26. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Unidimensional tool
NUMERICAL RATING SCALE
≥ 4 out of 10 INTERVENTION IS REQUIRED
- A change in the NRS of 20% between two time-points of an assessment is regarded as being clinically
significant.
 Easy to use.
 Simple to describe.
 High rate of adherence.
 Flexible administration (including by
telephone)
Less reliable for some patients (very
young or old; patients with visual,
hearing, or cognitive impairment)

27. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Unidimensional tool
VISUAL ANALOG SCALE
 Efficient to administer.
 Valid in patients with chronic pain,
older than age 5 years, rheumatic
disease.
-Time-consuming scoring
-Controversial validity
-Can cause patient confusion
-Poor reproducibility with cognitive
dysfunction

28. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Unidimensional tool
WONG-BAKER FACES PAIN RATING SCALE
 Perceived as easier than NRS or VAS.
 Useful in individuals with difficulty
communicating (e.g., children, elderly,
individuals with limited language fluency or
education).
- Potential for distorted assessment (i.e., patients'
tendency to point to the center of such scales)
Ask the person to choose the face that best describes how he is feeling.

29. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Multidimensional tool
MCGILL PAIN QUESTIONNAIRE (MPQ)
 Extensively tested.
 Assesses sensory and affective dimensions of pain.
 Short form takes only 2-3 minutes.
- Total score, but not individual scale scores, is considered
valid measure of pain severity.

30. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Special Population
BEHAVIORAL PAIN SCALE (BPS)
 To assess pain in patients who are unable to
communicate verbally.
 Each category is scored on a scale from 1 to 4, with
higher scores indicating more severe pain-related
behaviors.
 The total score ranges from 3 to 12.
Painless (3), mild (4–6), moderate (7–9), or severe (10–12)
pain.
≥ 7 out of 12 INTERVENTION IS REQUIRED

31. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Special Population
FLACC Pain Scale
 An observational pain scale
 Was designed for neonates at 2 months, may be useful
up to 7 years of age. However, in adult settings may use
the FLACC pain scale for people who are unable to
communicate their pain..
≥ 4 out of 10 INTERVENTION IS REQUIRED

32. ASSESSMENT OF PAIN
PAIN ASSESSMENT – Special Population
NEONATAL INFANT PAIN SCALE (NIPS)
 Used in children less than one year of age.
 The scale typically assesses six behavioral and
physiological parameters.
≥ 4 out of 10 INTERVENTION IS REQUIRED

33. POST-OPERATIVE PAIN MANAGEMENT

34. POST-OPERATIVE PAIN MANAGEMENT

35. POST-OPERATIVE PAIN MANAGEMENT
Multimodal analgesia involves the use of a combination of analgesic medications with different mechanisms of
action to provide synergistic pain relief while minimizing side effects.

36. POST-OPERATIVE PAIN MANAGEMENT

37. POST-OPERATIVE PAIN MANAGEMENT
• OILS check: following a standardized procedure for
pump programming and checking of infusions. Orders,
Infusions, Lines and Securement (OILS).
• The position of the epidural catheter.
• The motor block (bromage).
Assessment of the effectiveness of the epidural catheter

38. POST-OPERATIVE PAIN MANAGEMENT
Complications related to epidural catheter insertion –
- Headache (post dural puncture headache).
- Back pain: This is usually at the insertion site; it is common and transient. Moderate to severe back pain
must be reported urgently for investigation.
Complications related to epidural drugs -
- Overdose/toxicity: Signs of LA toxicity are dizziness, blurred vision, decreased hearing, restlessness, tremor,
hypotension, bradycardia, arrhythmia, seizures, and sudden loss of consciousness.
- Cease the RA infusion. May require resuscitation and management of cardiac, neurological and respiratory
side effects.
Assessment of the effectiveness of the epidural catheter

39. POST-OPERATIVE PAIN MANAGEMENT
Complications related to pain
- Assess dermatomes, if there has been a receding block an epidural bolus may be required and the
infusion rate may need to be increased.
- The first line analgesia is an epidural bolus before administration of other analgesia.
- Check if the epidural catheter become disconnected, if the epidural catheter been dislodged, or if the
epidural infusion is leaking.
Assessment of the effectiveness of the epidural catheter

40. POST-OPERATIVE PAIN MANAGEMENT
Assessment of the effectiveness of the Peripheral nerve block catheter.

41. POST-OPERATIVE PAIN MANAGEMENT
Assessment of the effectiveness of the Peripheral nerve block catheter.

42. SUMMARY

43. You truly are the superhero for patients in pain!
THANK YOU!