POST OPERATIVE PAIN

MANAGEMENT
DR MUHAMMAD IQBAL A GHANI
MB MCH BAO (NUI)

An unpleasant sensory and

emotional experience
associated with actual or
potential tissue damage or
described in terms of such
damage.
IASP PAIN DEFINITION 1994, 2008)

POST OPERATIVE
PAIN

Acute pain
Nociceptive
Inflammatory

CONSEQUENCES OF UNRELIEVED PAIN

Acute Pain
Increased
sympathetic
activity

GI effects

Splinting,
shallow
breathing

Myocardial
O2
consumption

GI motility

Atelectasis,
hypoxemia,
hypercarbia

Myocardia
l
ischemia

Delayed
recovery

Pneumoni
a

Increased
catabolic
demands

Anxiety
and fear

Poor wound
Sleeplessness,
healing/muscle
helplessness
breakdown

Weakness
and impaired
rehabilitation

Peripheral/
central
sensitization

Available
drugs

Psychological
Chronic
pain

Courtesy of Sunil J Panchal, MD

Effective pain management may improve

outcomes1,2,3
Effective analgesia included in a comprehensive
postoperative rehabilitation programme 1,2
Improved patient comfort and satisfaction
Decreased postoperative morbidity
Faster recovery
Shorter hospital stay1,2,3
Very favourable
cost/benefit ratio2
Low cost of analgesic techniques
and drugs2
1. Kehlet H. Br J Anaesth 1994;72(4):375-8.
2. Jayr C. In Les Aspects Economiques de lAnesthsie. JEPU 2000:131-8.
3. DAmours RH et al. JOSPT 1996;24(4):227-36.

PREOPERATIVE EVALUATION
TYPE OF SURGERY
EXPECTED SEVERITY OF
POSTOPERATIVE PAIN
UNDERLYING MEDICAL CONDITION
(RESPIRATORY OR CARDIAC
DISEASE)

PAIN ASSESSMENT
VISUAL ANALOGUE SCALE

MANAGEMENT

PHARMACOLOGICAL
INTERVENTIONAL
MULTIMODAL

PARACETAML

DOSE:
500 TO 1000 MG
PO Q6H
15MG/KG PEADS
MAX DOSE: 4 G
/ 24 HRS

NSAIDS
Mechanism

Block cyclooxygenase (COX)

enzyme prostaglandin
synthesis

COX-2 Prostaglandins
pain, inflammation, fever

COX-1 Prostaglandins
gastric protection,
hemostasis

Warnings: dose / avoid if

GI ulceration

Bleeding disorders / Coagulopathy

Renal dysfunction

High cardiac risk COXII

inhibitors

Asthma

Allergy

Formulations And Dosage Of Commonly Used

Analgesics
DRUG
Paracetamol

FORMULATION AVAILABLE
Tablet 500mg,
Suspension 500mg/5ml,
Suppositories

DOSAGE
500 mg 1gm qid

Tablet 50mg & 25mg,

Suppositories 12.5mg, 25mg,
(50mg & 100mg)*
Gel
Capsule 250mg
Tablet 200mg & 400mg*
Tablet 250mg, 550mg

Oral: 50mg tds,

Sup: 50mg-100mg stat
Topical: PRN

NSAID
Diclofenac

Mefenamic Acid (Ponstan)

Ibuprofen ( Brufen)
Naproxen (Naprosyn,
Synflex)
Ketoprofen (Orudis,
Oruvail)

Ketorolac (Toradol)
Meloxicam ( Mobic)

250 mg 500mg tds

200 mg 400 mg tds
500mg-550 mg bd

Capsule 100mg *, Injection Oral: 100mg daily, IV:

100mg,
100mg bd
Patch 30mg, Gel
Patch: 30mg - 60mg bd,
Topical: PRN
Injection 30mg/ml
10mg - 20 mg bd max 3
days
Tab 7.5mg
Daily or bd

DRUG

FORMULATION
AVAILABLE

DOSAGE

Celecoxib

Capsule 200 mg

200 mg bd (max 1 week)

Etoricoxib

Tablet 90 mg & 120 mg

120 mg daily (max 1 week)

Parecoxib

Injection 20 mg/ml

40 mg bd ( 20 mg bd for elderly) max for 2 days

OPIOIDS

DRUG

FORMULATION
AVAILABLE

DOSAGE

Tramadol

Capsule 50mg, Injection

50mg/ml

50mg -100mg tds or qid (max 400mg/day)

Dihydrocodeine
(DF118)

Tablet 30 mg

30mg-60mg qid (max 360mg/day)

DRUG

FORMULATION
AVAILABLE

DOSAGE

Nalbuphine (Nubain) Injection 10mg/ml

Stat dose only: 10mg (equivalent to Morphine

10mg). Do not use in patients on regular
Morphine/ Pethidine/ Fentanyl.

Morphine

Tablet SR 10mg,30mg
Aqueous 10mg / 5ml
Injection 10 mg/ml,

SR and Aqueous to be used for cancer pain

IV and Subcut :
< 65yrs : 5mg -10mg 3-4hrly
> 65yrs : 2.5mg -5mg 3-4hrly
Reduce dose in renal and hepatic impairment

Fentanyl

Injection 50 mcg/ml,
Patch 25 mcg, 50 mcg

IV only to be prescribed by APS team.

Patch to be used in cancer pain; NOT in Acute Pain

Pethidine

Injection
50mg/ml,100mg/2ml

IV and Subcut :
< 65yrs : 50mg -100mg 3-4hrly
> 65yrs : 25mg -50mg 3-4hrly
Reduce dose in renal and hepatic impairment.
Use not encouraged because of Norpethidine
toxicity and high risk of addiction.

Oxycodone
(Oxycontin)

Tablet SR 10mg &

20mg

Mainly used for cancer pain

OPIOIDS PCA
Allows patient to
reach their own
minimum effective
analgesic
concentration
(MEAC)
Rapid titration
(Morphine 1mg IV
every 5 min)
Better analgesia and
less side effects than
IM prn

EPIDURAL ANALGESIA

Introduction of analgesic drugs into

epidural space via an indwelling
catheter

ADVANTAGES
Superior Pain Relief
Less Systemic Side Effects
More Rapid Recovery of Bowel
Function
Earlier Ambulation

Grass JA. The Role of Epidural Anesthesia and Analgesia in Postoperative

Outcome. Anesthesiol Clin North America 01-JUN-2000; 18(2): 407-28

COMPLICATIONS OF EPIDURAL
ANALGESIA

Hypotension Secondary to Sympathetic

Blockade
Intravascular Injection (Local Anesthetic
Toxicity)
Respiratory Depression
Bladder Distention
Difficulty in Ambulation

SPINAL
ANESTHESIA

Spinal Anesthesia is Induced by Injecting

Small Amount of Local Anesthetic
(Bupivacaine) in the CSF
Results in Rapid Onset of Block
More Rapid Onset and Requiring less
Medicine Compared to Epidural Analgesia
Can add opiod for longer analgesic
effects

SPINAL CORD SELECTIVITY OF

NEURAXIAL OPIOID IN THE TREATMENT OF
ACUTE POSTOPERATIVE PAIN

Morphine commonly used

intrathecal opioids for
caesarean section

MONITORING AFTER INTRATHECAL

OPIOIDS
minimum hourly observations of:

Respiratory rate
sedation & pain scores
for at least
24h for morphine

THE CONCEPT AND BENEFITS OF

BALANCED ANALGESIA
The rationale for multimodal analgesia is
achievement of sufficient analgesia due to
additive or synergistic effects between
different analgesics, with concomitant reduction
of side effects, due to resulting lower doses of
analgesics and differences in side -effect
profiles

1. Kehlet H et al. Anesth Analg 1993;77:104856.

REAL WORLD: MULTIMODAL

ANALGESIA
Reduced doses

Opioids

Improved pain relief

severity
Potentiation Reduce
of AEs

NSAIDs, coxibs,
paracetamol,
nerve blocks

Kehlet et al. Anesth Analg. 1993;77:1048-1056 (B).

Earlier discharge
Decreased costs

SUMMARY
ACCURATE PAIN ASSESSMENT
USE MULTIMODAL PAIN MANAGEMENT
SUPERIOR ANALGESIA, SIDE EFFECTS
MEANS:
IMPROVED PATIENT SATISFACTION
BETTER REHABILITATION
EARLIER FUNCTIONAL RETURN
EARLIER DISCHARGE FROM HOSPITAL
LIKELIHOOD OF CHRONIC PAIN
REDUCED HEALTH CARE COSTS