PRINCIPLES OF
PROVIDING POST-
OPERATIVE PAIN
MANAGEMENT
PRESENTED BY-
RANI P BHUSNOOR [142]
What is pain ?
• Pain is an unpleasant sensory or emotional
experience associated with actual or potential
tissue damage
• Pain is the most common postoperative complaint of
surgical patients. About 75% patients complain of pain
in postoperative period
Types of pain
• Somatic pain : Pain arises from skin, muscles, bones and joints.
Characteristics : sharp & localized
Example : incisional pain from surgical wound
• Visceral pain : Pain originates from internal organs.
Characteristics : dull & poorly localized
Example : Pain after abdominal surgery [Bowel manipulation]
• Neuropathic pain : Pain occurs due to nerve injury or dysfunction.
Characteristics : Burning , Shooting , Tingling.
Example : Pain following nerve damage during surgery.
• Referred pain : Pain felt at a site distant from actual surgical site.
- Caused due to shared neural pathway .
Example : Shoulder pain after laparoscopic surgery due to
diaphragmatic irritation.
HOW DOES POSTOPERATIVE
PAIN ARISE?
• Pain involve 4 physiological pathway
1. Transduction
2. Transmission
3. Modulation
4. Perception
FACTORS AFFECTING
POSTOPERATIVE PAIN
• Location
• Type and extent of surgery
• Duration of surgery
• Type of anesthesia
• Use of drains, catheters, and sutures
• Quality of preoperative and postoperative care
• Physical and mental state of patient
Principles of postoperative pain
relief
• Assessment based management
• Individualized treatment plan
• Multimodal analgesia
• Prevention over treatment
• Minimal side effects
• Regular monitoring and reassessment
.
• Most patient will experience pain after surgery
this is usually managed by a combination of
painkillers and local anesthesia technique called
Multimodal analgesia .
MOST COMMONLY USED
PAINKILLERS ARE
• Regular paracetamol
• NSAID’s
• Opioids
PARACETAMOL
• First synthesized in 1878 by Morse.
• Introduced for medical usage in 1883.
• Due to misinterpretation of its safety profile use was limited
till 1950.
• Paracetamol is now the most commonly used drug
worldwide, used in almost all the ages and forms Step 1 of
WHO analgesic ladder.
• It is first line treatment in pyrexia and pain.
• MECHANISM OF ACTION : Inhibits central prostaglandin synthesis.
( COX inhibition in CNS)
Used in mild to moderate pain.
• ROUTE OF ADMINISTRATION :
1.Oral
2.IV – for faster onset
3.Rectal – Alternative in pediatric or unconscious patients
DOSAGE
• ADULT DOSE –
ORAL/RECTAL - 500-1000mg every 4-6 hours.
-Maximum dose 4 grams per day.
INTRAVENOUS – 1 gram every 6 hours or
650 mg every 4 hours
maximum IV dose 4 grams per day.
DOSAGE ADJUSTMENT IS NEEDED IN HEPATIC IMPAIRMENT, CHRONIC
ALCOHOL USE OR LOW BODY WEIGHT (<50 Kg)
Maximum dose reduced to 2-3 grams per day.
• PEDIATRIC DOSE –
ORAL/RECTAL/IV - 10 to 15 mg/kg per dose every 4-6 hours.
Maximum – 60mg/kg/day (Without medical supervision)
- Up to 75mg/kg/day in hospital setting under
monitoring.
ADVANTAGES – 1. Well tolerated.
2. No significant gastric irritation.
3. Minimal CVS or renal effects.
NSAID’S
• Most commonly used drugs are :
• MECHANISM OF ACTION : Inhibit CYCLOOXYGENASE(COX1 & COX2)
enzymes.
- Reduce prostaglandin synthesis leading to
reduced pain, inflammation, and fever.
Effective in mild to moderate pain.
• RISK & CONTRAINDICATION : Gastric irritation or ulceration
Thrombotic events like MI & Stroke
Renal impairment
Increased bleeding risk
AVOID IN :Patient with renal dysfunction
Peptic ulcer disease
Uncontrolled hypertension
OPIOIDS
• MECHANISM OF ACTION : They bind to opioid receptors in CNS
(mu, delta, kappa) and inhibit transmission
of nociceptive signals.
• Used in moderate to severe pain.
Commonly used opioids
• ADVANTAGES :
1.Potent analgesia – effective for moderate to severe pain
particularly useful when paracetamol or NSAID’S
are inadequate.
2.Rapid onset of action – IV opioids act quickly & provide immediate
relief.
3.Useful in patient controlled analgesia – allow patient to self
administer safe doses, enhances patient comfort.
• SIDE EFFECTS :
1.Respiratory depression
2.Sedation, Nausea, Vomiting
3.Constipation
4.Urinary retention
5.Tolerance, dependance on prolonged use
• By combining opioids with other drugs ,dose of opioids can be
minimised, thus side effects can be reduced.
