An Introduction to Anaesthesia 201

Postoperative Pain &

Regional Anaesthesia
Dr Martin Rooms
Consultant in Anaesthesia
The Royal Marsden NHS Foundation Trust

Learning Objectives

List 6 important reasons for postoperative pain

control
Choose appropriate analgesic regimes
Know when to call for senior advice

Why is it important to control pain?

Divinum sedare dolorem

Reduce sympathetic activity ( ACS)
Reduce respiratory complications
Reduced chronic pain syndromes
Improved mobilisation
Improved patient satisfaction

Divinum sedare dolorem

Reduce respiratory complications

Reduce Sympathetic activity ( ACS)

Improved mobilisation

Reduce Chronic Pain Syndromes

Improved patient satisfaction

Case 1

It is your first on call as a Gas person.

Bleeped about Mrs X
DSU laparoscopic cholecystectomy
Admitted overnight for uncontrolled pain
PONV

Put the following in the right order

A. D/W SpR
B. Management plan
C. History and pain assessment
D. Check notes, anaesthetic and drug charts

D, C, B ,A
D. Check notes, anaesthetic and drug charts
C. History and pain assessment
B. Management plan
A. D/w Spr

Pain Assessment

Management Options
A. Regular oral analgesia eg paracetamol, diclofenac, prn IM morphine
B. Regular IV paracetamol, prn IM morphine, IVF, antiemetic
C. Morphine PCA
D. Immediate IV morphine 0.5-1mg/kg titrate in 2mg aliquots
E. C +D+ IVF+ antiemetic.

WHO analgesic ladder....1, 2, 3

Analgesia

Simple(mil
d)

Moderat
e

Strong
Fentanyl
Morphine

Codeine
Paracetam
ol

Tramadol
NSAIDs
Adjuvants: Ketamine, Gabapentin

General points

Ladder - Breakthrough pain - strong analgesics as

per WHO pain ladder

Oral - Regular oral analgesia ASAP

Others - Treat co-existing symptoms; fluids,

antiemetic, laxatives , oxygen

CASE 2
57 yr old 3d post laparotomy, thoracic epidural, taking free
fluids
Excruciating pain last 2 h

A. Morphine PCA
B. Notes, drug chart
C. D/W SpR
D. Hx, examination ( epidural site)
E. Regular oral analgesia, breakthrough morphine
F. Bolus/ top up

B, D, F, E, A, C

B. Notes, drug chart

D. Hx, examination ( epidural site)
F. Bolus/ top up
E. Regular oral analgesia, breakthrough morphine
A. Morphine PCA
C. D/W SpR

Regional analgesia

Peripheral nerve block

Mainly extremities, particularly orthopaedics

Epidural
Used as both analgesia and anaesthetic, usually catheter
in situ for top ups

Spinal
Similar to epidural , but lower volumes required, rarely
catheter in situ, continuous prolonged analgesia not
appropriate

Peripheral Nerve Block

Consent, performance and post-block care

Peripheral Nerve Block

Techniques:
Ultrasound
Nerve stimulator
Landmark

Spinal (A) v Epidural (B)

Summary control of POP

General concepts pain treatment

General concepts pain treatment

L (ladder) WHO pain ladder ; stepwise increment of

strength of analgesia; start at appropriate level

O (oral) establish oral analgesics ASAP

O (other assoc. symptoms ) Treat N & V, dehydration,

constipation, anxiety.

Learning Objectives

List 6 important reasons for post operative pain

control
Choose appropriate analgesic regimes
Know when to call for senior advice

Further reading on the course website.

www.ucl.ac.uk/anaesthesia/education/AnaesthesiaIntroduction

Postoperative pain
Pain in children
Epidurals on the ward