3. COMMON COMPLICATIONS
POSTANESTHESIA
Nausea/vomiting 5%
Unexpected alterations in mental state 5%
Requirement for upper airway support 3.6%
Hypotension 3%
Dysrhythmias 2%
Hypertension, myocardial ischemia, or a major
cardiovascular complication <1%
4. ASA SUMMARY TREATMENT
RECOMMENDATIONS
Nausea and vomiting
ondansetron, droperidol,
dexamethasone, or metoclopramide
when indicated.
Supplemental oxygen for patients
at risk of hypoxemia.
Fluids
Postoperative fluids should be managed
in the PACU.
Certain procedures may require
additional fluid management.
Temperature
Normothermia should be maintained.
Forced-air warming systems are most
effective for treating hypothermia.
Pharmacologic agents for the reduction of
shivering
Meperidine is recommended.
Antagonism of the effects of
sedatives, analgesics, and NMB
Antagonism of benzodiazepines
Antagonists should be available.
Flumazenil should not be used routinely.
Flumazenil may be administered to
antagonize respiratory
depression and sedation.
Antagonism of opioids
Antagonists (e.g., naloxone) should be
available but should not be used routinely.
Naloxone may be administered to antagonize
respiratory
depression and sedation.
Reversal of neuromuscular blockade
Specific antagonists should be administered
for reversal of
residual neuromuscular blockade as
indicated.
After reversal, patients should be
observed to ensure that
cardiorespiratory depression does not
recur.
5. ROUTINE DISCHARGE CRITERIA
FROM PACU
Vital signs satisfactory and stable
Return to postoperative mental state
Adequate pain control
Immediate treatment of any complications
Adequate treatment of nausea/vomiting
Adequate function of all drains, tubes, catheters
Surgical bleeding controlled or treated
Postoperative orders reviewed and implemented
Laboratory studies needed immediately obtained and
results reviewed
8. “PAIN IS AN UNPLEASANT
SENSORY AND EMOTIONAL
EXPERIENCE ASSOCIATED WITH
ACTUAL AND POTENTIAL TISSUE
DAMAGE OR DESCRIBED IN
TERMS OF SUCH DAMAGE.”
International Association for the Study of Pain
9. POSTOPERATIVE PAIN
Acute pain is experienced immediately after surgery
(up to 7 days).
Chronic pain lasts more than 3 months after the
injury.
10. ACUTE POSTOPERATIVE PAIN
Pain present in a surgical patient because of
preexisting disease, the surgical procedure (with
associated drains, chest or nasogastric tubes, or
complications), or a combination of disease-related
and procedure-related sources.
11. GOALS OF EFFECTIVE AND APPROPRIATE PAIN
MANAGEMENT
lmprove quality of life for the patient
Facilitate rapid recovery and return to full function
Reduce morbidity
Allow early discharge from hospital
12. PRINCIPLES OF PAIN ASSESSMENT
Assess pain at rest and on
movement.
The effect of treatment is evaluated
by assessing pain before and after.
In the (PACU) or other
circumstances where pain is intense,
evaluate, treat, and re-evaluate
frequently (every 15 min initially,
then every 1-2 h as pain intensity
decreases).
In the surgical ward, evaluate, treat,
and re-evaluate regularly (every 4-8
h) the pain and the patient's
response to treatment.
Define the (intervention threshold).
For example, verbal rating score of 3
at rest and 4 on moving, on a 10-
point scale.
Document pain and response to
treatment, including adverse effects.
Patients who have difficulty
communicating their pain require
particular attention.
Unexpected intense pain,
particularly if associated with
(hypotension, tachycardia, or fever),
is immediately evaluated.
New diagnoses, e.g. wound
dehiscence, infection, or deep
venous thrombosis, should be
considered.
Immediate pain relief without
asking for a pain rating is given to
patients in obvious pain who are not
sufficiently focused to use a pain
rating scale.
Family members are involved when
appropriate.
14. THE OBJECTIVE PAIN SCALE
Blood Pressure/Heart Rate
+/- 10% of preoperative value 0
> 20% of preoperative value 1
>30% of preoperative value 2
Crying
Not Crying 0
Crying, responds to TLC 1
Crying, doesn't respond to TLC* 2
Movement
None 0
Restless 1
Thrashing around 2
Agitation
Asleep or calm 0
Mild Agitation 1
Hysterical 2
Verbalization of Pain
Asleep, states no pain 0
Vague, cannot localize pain 1
Localizes pain 2
For Pediatrics <3 years
For non-verbal who
cannot self-report
17. BALANCED (MULTIMODAL) ANALGESIA
Two or more analgesic agents act by different mechanisms to
achieve a superior analgesic effect without increasing
adverse events compared with increased doses of single
agents.
Examples:
Epidural opioids in combination with epidural local
anesthetics
Intravenous opioids in combination with NSAIDs (dose
sparing effect)
The method of choice wherever possible:
Paracetamol and NSAIDs for low intensity pain
Opioid analgesics and/or local analgesia techniques for
moderate and high intensity pain.
18. PARACETAMOL
Mechanisms:
Inhibition of a COX-2 in the
CNS
Inhibition of a COX-3
(selectively susceptible to
paracetamol)
Modulation of inhibitory
descending serotonergic
pathways
Prevents PG production at
the cellular transcriptional
level independent of COX
activity.
Efficacy:
Effective for acute pain.
Effective adjunct to opioids
reducing requirements by 20-
30%
Addition of NSAID further
improves efficacy
IV paracetamol as effective as
ketorolac
Valuable component of MMA
Adverse effects:
Fewer and can be used when
NSAIDS are contraindicated
Caution with liver disease and
G6PD deficiency
19. NSAIDS
Analgesic, anti-inflammatory, antipyretic
Inhibits prostaglandin synthesis in peripheral tissues, nerves and CNS
Non-selective COX inhibitors (inhibit both COX-1 and COX-2)
Efficacy:
Single doses effective for postoperative pain
Inadequate alone for severe postoperative pain
Useful adjuncts combined with opioids
Integral components of MMA.
NSAIDS given with paracetamol improves analgesia.
Adverse effects: more common with long-term use; risk and severity
increase in the elderly
Renal impairment
Interference with platelet function
Peptic ulceration
Bronchospasm
20. COX-2 INHIBITORS
Selectively inhibit the inducible COX-2 enzyme and spare the
constitutive COX-1(sparing physiological tissue PG production while
inhibiting inflammatory PG release)
Available:Meloxicam, Celecoxib, Etoricoxib, Valdecoxib and Parecoxib
(injectible precursor of valdecoxib)
Efficacy: Opioid-sparing in combination with opioids
Adverse effects:
Similar effects on renal function as NSAIDS
Do not impair platelet function
Short term results in gastric ulceration
Analgesic doses do not produce bronchospasm
21. TRAMADOL
Atypical centrally-acting due to combined effects as
opioid agonist and a serotonin and noradrenaline
reuptake inhibitor.
Has a lower risk of respiratory depression and impairs
GIT motor function less than other opioids at
equianalgesic doses.
Nausea and vomiting are the most common adverse
effects.
22. OPIOIDS
Morphine
The most widely used
opioid for the
management of pain and
the standard against
which others are
compared.
Fentanyl
Increasingly used for acute
pain due to lack of active
metabolites and fast onset.
Oxycodone
Commonly used for acute pain
management for patients able to
take opioids orally
Immediate-release and controlled-
release formulations have been used
as “step-down” analgesia following
PCA
Pethidine
Synthetic opioid still widely used
despite multiple disadvantages
Induces more nausea and vomiting
Accumulation of active metabolite
associated with neuroexcitatory
effects
Discouraged in favor of other
opioids
23. ADVERSE EFFECTS OF OPIOIDS Sedation
Assessment of sedation level is a more reliable way of detecting
early opioid-induced respiratory depression than a decreased RR.
Pruritus
Nausea
Vomiting
Slows gastrointestinal function
Urinary retention
Adverse effects are dose-related; once a threshold dose is reached,
every 3-4mg increase of morphine-equivalent dose per day is
associated with one additional adverse event or patient-day with such
an event.
24. ADJUVANTS
NMDA receptor antagonist:
KETAMINE
Reduces opioid requirements in
opioid-tolerant patient
Opioid-sparing effect in
postoperative pain
Best effects as continuous IV
infusion
Improves analgesia in patients with
severe pain poorly responsive to
opioids.
Alpha-2 agonists: CLONIDINE
and DEXMEDETOMIDINE
Decrease perioperative opioid
requirements
Higher doses of clonidine
significantly reduce opioid
requirements but cause greater
degree of sedation and hypotension.
Dexmedetomidine infusions to
sedate ventilated patients reduce
morphine requirements by 50%.
25. PATIENT CONTROLLED ANALGESIA
Allows to self-administer small doses of analgesic as
required.
Programmable PCA pump delivers opioid
medications IV or by other method and route of
delivery.
Bolus dose
Lockout interval
Continuous infusions
Dose limits
Loading dose
IV Opioid PCA
Provides better analgesia than conventional parenteral
regimens.
Patient preference is higher compared with conventional
regimens.
PCEA decreases doses of local anesthetic, lessens
motor block and fewer anesthetic interventions
compared with epidural infusions.
26. REGIONAL ANALGESIA
EPIDURAL ANALGESIA
- continuous administration of
analgesic into the epidural space via
an indwelling catheter
All techniques provide better
postoperative pain relief compared
with parenteral opioids.
Low concentrations of local
anesthetics and opioids provide
better analgesia than either
component alone.
Risk of permanent neurologic
damage is very low; higher when
delayed in diagnosis of an epidural
hematoma or abscess.
27. REGIONAL ANALGESIA
INTRATHECAL ANALGESIA
Local anesthetics intrathecally provide only short-term
postoperative analgesia.
Intrathecal opioids provide prolonged postoperative
analgesia following a single dose.
Combination of spinal opioids with local anesthetics
reduce dose requirements for either drug alone.
Intrathecal morphine 100-200mcg offers effective
analgesia with low risk of adverse effects.
28. OTHER REGIONAL AND LOCAL
ANALGESIC TECHNIQUES
Interscalene
Axillary
Femoral
Fascia iliaca block
Sciatic nerve
Lumbar plexus
Thoracic paravertebral blocks
Intercostal and interpleural blocks
29. WOUND INFILTRATION
Long-acting local anesthetics lengthen time until first
analgesic request, improve pain relief and decrease
opioid requirements after anterior cruciate ligament
reconstruction, shoulder surgery, spinal surgery and
median sternotomy after cardiac surgery.
30. TOPICAL APPLICATION OF LOCAL
ANESTHETICS
Topical EMLA (Eutectic Mixture of Local Anesthetic)
cream is effective in reducing the pain associated with
venous ulcer debridement
31. NON-PHARMACOLOGICAL METHODS OF
PAIN MANAGEMENT
Cold
Iced-water after knee-surgery.
Can be used both in the hospital and at home.
There are commercial systems easy to use.
Acupuncture
There are no documented effects of acupuncture in postoperative
pain management. However, there may be an effect in reducing
nausea and vomiting.
Relaxing therapy and distraction such as music, imagery or
hypnosis
These may have a positive effect in individual cases.
32. TREATMENT OPTIONS IN RELATION TO MAGNITUDE OF
POSTOPERATIVE PAIN EXPECTED AFTER SURGERY
33. FACTORS INFLUENCING ANALGESIC
REQUIREMENTS
Age: elderly patients require smaller doses.
Sex.
Pre-operative analgesic use.
Past history of poor pain management.
Coexisting medical conditions such as substance abuse or
withdrawal, hyperthyroidism, anxiety disorder, affective
disorder, hepatic or renal impairments.
Cultural factors and personality. (e.g.intolerant of any
discomfort - surprising self-control - pain as normal part of life).
Preoperative patient education (can improve expectations,
compliance and ability to effectively interact with pain
management techniques).
Site of operation: thoracic and upper abdominal operations are
associated with the most severe pain.
Individual variation in response and pain threshold.
Attitude of the ward staff.
