POST OPERATIVE PAIN

MANAGEMENT
Ignatius Riwanto
Dept of Surgery, Diponegoro Medical Faculty

P2B2 PABI, MAKASAR, 26 JULY 2023

INTRODUCTION

• Acute postoperative pain (APP) is still a major burden

• 70% of the 240 million postsurgical patients every year suffer
from moderate-to-severe pain
• Uncontrolled APP may result in significant clinical and
psychological changes
• Pain relief is fundamental in multimodal strategies to improve
surgical outcome, reduction of surgical stress, rapid
mobilization, and early oral nutrition.

Coccolini et al. World Journal of Emergency Surgery

(2022) 17:50
Uncontrolled pain syndrome:
• Sympathetic activation:
 tachycardia,
 arterial hypertension,
 increased rigidity of the muscles of the anterior abdominal wall and chest muscles:
 alteration of the ventilation and hypoxemia,
 difficulties in coughing  increased risk of respiratory infectious complications.
increases the tone of the smooth muscles of the intestine, inhibit peristalsis 
postoperative paresis.
• prevents early mobilization of patients
• emotional and physical suffering,
• sleep disturbances.

World Journal of Emergency Surgery (2022) 17:50

ENHANCE RECOVERY AFTER SURGERY
PRE ADMISION/
PREOPERATIVE COUNCELING
SHOULD INCLUDE POST
OPERATIVE PAIN

Telling patients
how a drug is chosen, its
properties and effects,
understanding
its side effects, and shared in the
decisions helps
reduce APP. A recent study proved
that a lower educational
level worsens pain

World Journal of Emergency Surgery (2022) 17:50

ENHANCE RECOVERY AFTER SURGERY

PAIN CONTROL IS
IMPORTANT PART
OF ENHANCE
RECOVERY AFTER
SURGERY
PAIN DEFINITION

https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
NOCICEPTORS
• Nociceptors can be defined as sensory receptors that
are activated by noxious stimuli that damage or
threaten the body's integrity.
• Nociceptors belong to the slowly conducting afferent
A delta and C fibres. They are classified according to
their responses to mechanical, thermal, and chemical
stimuli.
• In the skin, high-threshold mechano-nociceptors
(HTMs) and mechano-heat nociceptors of A and C
fibres (AMHs and CMHs) are frequently found.
• CMHs are usually called polymodal C fibres (CPMs) if
they also show chemo sensitive properties.
Sensations of sharp pain are evoked by intraneural
microsimulation of nociceptive A delta fibres, whereas
stimulation of C fibres causes dull pain sensations
NOCICEPTION AND PAIN
• Differentiating between the terms nociception and pain is worthwhile.
• Nociception refers to the detection of noxious stimuli by nociceptors,
followed by transduction and transmission of the sensory nervous
information from the periphery to the brain.
• Pain refers to the product of higher brain centre processing; it entails the
actual unpleasant emotional and sensory experience generated from nervous
signals.
• Pain are not merely a direct output of nociception, they involve interaction
with numerous inputs (attention, affective dimensions, autonomic variables,
immune variables and more), and may be considered more accurately from
the perspective of a neuromatrix
Chen 2022
 Pathogenesis and Mechanisms
of Inflammation and Pain

Botting, R.M., Botting, J.H. Pathogenesis and Mechanisms of Inflammation and Pain. Clin. Drug
Investig.19 (Suppl 2), 1–7 (2000). https://doi.org/10.2165/00044011-200019002-00001
 Transduction
Transmission
Modulation
Perception
Interpretation

Because this signal will be modulated at

different levels of the central nervous
system, pain is not the mere reflection of
nociception. Genetic, environmental,
societal, physiological, and psychological
factors will influence the perception of pain.

Marchand S (2021) Mechanisms Challenges of the Pain

Phenomenon. Front. Pain Res. 1:574370.
PAIN RELIEF LADDER ACCORDING WHO
 NSAID (Non Steroid Anti Inflammatory Drug)

NSAID BLOCK COX

SELECTIVE COX INHIBITOR: ONLY

BLOCK COX2

NON SELECTIVE COX INHIBITOR:

BLOCKBOTH COX  RISK OF
GASTRIC ULCER, SINCE PGI2
IMPORTANT FOR GASTRIC
PROTECTION

Fungsi ProteksiPembentukan
Nyeri Demam
trombosit tulang
Heide Huub, Koorevaar Rinco, Lemmens Albert, Kampen Albert, Schreurs Willem. Rofecoxib inhibits heterotopic ossification after total hip arthroplasty.
Archives of Orthopaedic and Trauma Surgery 2007. Chapter 5. Netherland; p.557-561.
https://www.vetscraft.com/nonsteroidal-anti-inflammatory-drugs-nsaid/
Clinical and Experimental Pharmacology & Physiology, 07 Aug 2020,
Front. Pharmacol. 11:580289. doi: 10.3389/fphar.2020.58028
Front. Pharmacol. 11:580289. doi: 10.3389/fphar.2020.58028
Single dose oral ibuprofen for acute
postoperative pain in adults
• Main results
• Seventy‐two studies compared ibuprofen and
placebo (9186 participants). Studies
were predominantly of high reporting quality, and the
bulk of the information concerned ibuprofen 200 mg
and 400 mg. For at least 50% pain relief compared
with placebo the NNT for ibuprofen 200 mg (2690
participants) was 2.7 (2.5 to 3.0) and for ibuprofen
400 mg (6475 participants) it was 2.5 (2.4 to 2.6).
The proportion with at least 50% pain relief was 46%
with 200 mg and 54% with 400 mg. Remedication
within 6 hours was less frequent with higher doses,
with 48% remedicating with 200 mg and 42% with
400 mg. The median time to remedication was 4.7
hours with 200 mg and 5.4 hours with 400 mg.
PLOS ONE | DOI:10.1371/journal.pone.0154004 May 6, 2016 1 /
16
COMBINATION OF
ACETAMINOPHEN
&
IBUPROFEN
 USEFULNESS OF COMBINATION OF PARACETAMOL-
IBUPROFEN

Daniels SE et al. Clin Ther. 2019;41(10):1982-95.e8.

DIFFERENCE TARGET:
ACETAMINOPHEN : TARGET CENTRAL (BLOCK VANILLOID AND CANABINOID RECEPTORS)
TARGET PERIPHERY (MILD ANTI COX 1 AND COX 2, ALSO COX 3)
SHORT ACTING
IBUPROFEN : TARGET PERIPHERY (ANTI COX 1 AND COX 2
LONG ACTING

https://www.vetscraft.com/nonsteroidal-anti-inflammatory-drugs-nsaid/
ADVERSE EVENT
ADVERSE
EVENTS WERE
COMPARABLE
BETWEEN
FIXED DRUG
COMBINATION
OF
PARACETAMOL-
IBUPROFEN
AND
IBUPROFEN
AND
PARACETAMOL
ALONE AND
ALSO TO
PLACEBO
OPIOID IN POST OPERATIVE PAIN
• In the treatment of moderate-to-severe pain, unresponsive to other
medications and in which regional anaesthesia techniques are not
indicated, the use of major opiate is indicated (strong recommendation,
moderate quality evidence).
• Initial infusion of opioids using intravenous patient controlled
analgesia (PCA) should be avoided in opioid naïve patients (strong
recommendation, moderate quality evidence).
• Sedation levels, respiratory status, and the possible development of
adverse events in patients on systemic treatment with opioids must be
regularly assessed (strong recommendation, weak quality evidence)
Coccolini et al. World Journal of Emergency Surgery
(2022) 17:50
• If indicated, infusion of opiates using intravenous patient-controlled
analgesia should be preferred to spinal patient-controlled analgesia in
postoperative pain management whenever the intravenous route is
viable (strong recommendation, moderate quality evidence).
What opioid should be used
• Literature confirms the superiority of treatment for severe APP with
opiates PCA, there is no clear evidence about which opiate drug
should be preferred.
• Morphine, which is by far the most widely used drug, is not the ideal
molecule as it has high renal clearance with potential accumulation
and adverse effects.
• The alternatives are fentanyl, oxycodone, and sufentanil.
• In open abdominal surgery, sublingual sufentanil tablets (SST) 30mcg
is effective for the management of moderate-to-severe postoperative
pain
• If PCA is not available or cannot be administered due to due to clinical
or social barriers, transdermal fentanyl patch (25 μg/h) may be used.
These patches should be affixed 12–14 h before surgery and avoid the
continuous IV infusion of fentanyl after surger
• Epidural catheters have been found to provide better pain relief than IV analgesic
medications
• Thoracic epidural anaesthesia has been demonstrated to improve post-operative
pain in major abdominal surgeries and has also been associated with decreased rates
of post-operative pneumonia and even insulin resistance.
• Patient controlled analgesia (PCA), in which intravenous opioid therapy may be
administered based on patient preferences
• Intravenous infusion of lidocaine. In a systemic review of 8 trials, there was a
decrease in the duration of ileus, length of hospital stay, postoperative pain and
post-operative nausea and vomiting with intravenous lidocaine infusion compared
to PCA morphine
• Infusion of local anesthetic via the On-Q Pain Buster, which can continuously
deliver local anaesthetics for up to five days. M.E.J. ANESTH 23 (2), 2015
ACETAMINOPHEN AND IBUPROFEN DECREASE
USING FENTANYL, NAUSEA AND VOMITING,
SHOULDER PAIN, SEDATION AND PAIN SCORE
SIGNIFICANTLY COMPARE TO PLACEBO AND
BOTH THEM COMPARABLE

World J Plast Surg. 2022;11(1):117-124.

INF ROPIVACAINE VS NACL
PHYSIOLOGIST:
• Side-effects were similar
• VAS and i-VAS pain scores, morphine
consumption [11.5 (0.27) vs 21.8 (0.37)
mg; P<0.001],
• time to bowel recovery [21.8 (0.4) vs
33.6 (0.9) h; P<0.001],
• mean length of hospitalization [2.1 (0.03)
vs 3.2 (0.1) days; P<0.001] were
significantly reduced in the ON-Q group.
• Cost analysis revealed an overall
savings of approximately 273 euros per
patient in the ON-Q group.
 Comparing continuous wound infusion of a local anaesthetic versus a placebo or a sham

• Pain at rest day 1 and 2 better in local anesthetic infusion

• Pain on movement day 1 and 2 better in local anesthetic infusion
• Less using PCA opioid in infusion of local anesthesia
• Comparable in wound infection better in wound breakdown favor for local
anesthetic infusion
• Comparable for any serious complication
Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in
adults (Review) 1 Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pain at rest day 1
and 2 better in
local anesthetic
infusion
Pain on
movement day 1
and 2 better in
local anesthetic
infusion
Less using PCA opioid in infusion of local anesthesia
Comparable in
wound infection
better in wound
breakdown favor for
local anesthetic
infusion
POST HEMORRHOIDECTOMY PAIN
 PUDENDAL BLOCK+COMBINE
ACETAMINOPHEN AND IBUPROFEN INFUSE
PRE EMPTIVE

1 HOURS
BEFORE: 1
BOTLE
INFUSION

TARGET CLOSE TO TUBER ISCHIADICUM

TARGET CLOSE TO ISCHIAL SPINE 2 CASES

POSTOPERATIVE BUPIVACAIN 10 CC ( 50 MG) KANAN • NO OPIOID USED
DAN 10 CC KIRI • NO NAUSEA/ VOMITUS
3X 1 BOTLE • BOWEL MOVEMENT ON DAY 1
INFUSION • VAS 1-2
TAKE HOME MESSAGE
• Acute postoperative pain (APP) is still a major burden (70%), uncontrolled APP may result in
significant clinical and psychological changes
• Pain are not merely a direct output of nociception, they involve interaction with numerous inputs
(attention, affective dimensions, autonomic variables, immune variables and more) PPAIN
CONTROL
• Pain control is important part of ERAS
• Beside medication, education to the patients is very important and prove reduce the severity of pain
• Combination of acetaminophen and ibuprofen effective to decrease post operative pain and using
opioid, and should be given as pre-emptive and post operatively
• Opioid only used selectively in case of epidural analgesia is contra indicated and non opioid
management is fail.
• Lidocaine infusion, or local wound infusion with local analgesia are reported reduce post
operative pain and using opioid, can be another alternative to reduce opioid
• IS IMPORTANT PART OF ENHANCE RECOVERY AFTER SURGER