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Post-Op Pain Management Low-Tech 20150601
Post-Op Pain Management Low-Tech 20150601
True or false?
Major body
systems are
negatively
affected by
acute pain
Why should acute pain be treated?
Although in most patients the pain resolves with time, some patients
(~1 in 10 - 20) will develop chronic pain after surgery
or injury
•treatment will be necessary in about 50% of these patients.
• It‘s a waste of time & the information is useless - one patient‘s ‘5‘ is
not the same as another patient‘s ‘5.‘
… Recognize pain
• No biological markers
• Discrepancy pain / injury
• Inter-individual variations
… Adapt treatment
• Choice of treatment and dose
• Efficacy
… Improve communication
• Patients communicate pain intensity
How to assess acute pain?
Numerical scale
1. no pain 0
2. mild pain +
3. moderate pain ++
4. severe pain +++
How to assess acute pain?
Ask:
(1) How much pain do you have when you are at rest?
AND
(2) How much pain do you have when you move in bed / sit
up / get out of bed (= orthopedic patients)
How much pain do you have when you take a deep breath
OR cough (= general surgery patients).
OR to swallow (= patients after tonsillectomy)-
i.e. ask the patient to carry out an activity which is related to
the surgery.
How to assess acute pain?
please remember …
No evaluation
=
No treatment of pain
How to assess acute pain?
How to treat
post-surgical pain?
How to treat post-surgical pain?
• Pre-operatively
– Discuss options with patients
– Teach about assessment, treatment options
– Pre medication with paracetamol
• Intra-operatively
– Wound infiltration with local anaesthetic (surgeon)
– Administer analgesics (IV or rectally)
How to treat post-surgical pain?
Which route?
• Oral (PO)
– route of choice: simple, effective, well tolerated.
– Suitable as soon as the patient is able to tolerate oral
fluids.
• Intra-muscular (IM)
– Injection painful and absorbtion un-reliable.
– Should be not be used as a route for giving analgesics.
How to treat post-surgical pain?
Which route?
• Sub-cutaneous (SC)
– Route of choice if oral route is not possible
– Avoid for long term, repetitive dosing
• Intra-venous (IV)
– Allows for rapid titration.
– Allows for continuous OR bolus administration
– requires monitoring!
How to treat post-surgical pain?
Analgesics for post-operative use
Drug Dose Route Frequency
Paracetamol 1g p.o., i.v., rectal q.i.d
NSAID’s
ibuprofen 50-100 mg p.o. q.i.d
diclofenac 75 mg i.m. b.i.d or t.i.d
ketorolac 50-100 mg i.m. or i.v.
Opioids
(codeine) * 30 mg p.o. q.i.d
tramadol 50-100 mg p.o. or i.v. t.i.d or q.i.d
(pethidine) * 25-150 mg i.m. t.i.d or q.i.d)
morphine 10 (IR), 30mg (SR) p.o. Every 4 hours
10 mg sc Every 4 hours
bupivacaine 1mg/kg Wound infiltration End of surgery
b.i.d. –X2 daily; t.i.d. X 3 daily; q.i.d. – X4 daily
Caution !
• Codeine
– Its metabolism is highly variable and might result in
severe overdosing.
– Use only when no other opioid is available.
• Pethidine
– Accumulation may cause CNS-related side effects.
– Use only when no other opioid is available.
How to treat post-surgical pain?
Paracetamol
• Provides a mild analgesic effect
• Low toxicity
• No difference in quality of analgesia when given IV vs PO
– but is more expensive
• For short surgical procedures possible to give 1gr PO with
a little water 1/2 hour before the surgery.
• After minor surgery:
– if given as sole analgesic and pain is not relieved –
after 30 – 45 minutes - combine with another non-
opioid or opioid.
How to treat post-surgical pain?
Opioids (overview)
Tramadol
• Step 2 analgesic
• Analgesic (opioid and monoaminergic)
• 5 to 10 times less potent than morphine
• Risk of respiratory depression negligible
• Easier to import than morphine
• Not in the WHO list of essential medicines
How to treat post-surgical pain?
feeding.
– Administer with caution for a short period at the lowest effective dose
Codeine
• Step 2 analgesic
• weak opioid: 5 – 10 times less effective than morphine
• No injectable formulations
• Remember
– Codeine’s metabolism is highly variable and
might result in severe overdosing.
– Use only when no other opioid is available.
How to treat post-surgical pain?
Neurologic
• abnormal drowsiness = warning sign of early respiratory
depression
Respiratory
• respiratory depression (bradypnea, apnea)
Onset of excessive drowsiness indicates an overdose and often precedes the
RR ≥ 10/min
Intermittently drowsy, easily
S1 R1 Snoring and RR ≥ 10/min
awakened
Irregular respiration,
Drowsy most of the time,
S2 R2 obstruction, chest indrawing,
Intervene
responds to voice
RR < 10/min
Drowsy most of the time,
Respiratory pauses,
S3 responds only to physical R3
apnoeas
stimulation
How to treat post-surgical pain?
Management of Sedation
Management of Sedation
Continue to monitor the sedation score and respiratory rate every half
Naloxone
•The half-life of naloxone is ~30 – 81 minutes;
•This is shorter than the half life of some opioids, e.g.
morphine for morphine ~ 2 -3 hours.
• When using naloxone to antagonize the respiratory
depression of morphine patients should be monitored for
at least 4 hours.
How to treat post-surgical pain?
Staff
•Participate in a course like prepared here.
Patients
Teach them:
• How to assess pain
• That they should inform the staff when they are in pain and
when they experience side effects.
• That dependence or tolerance to medications are rare when
treating acute pain.
How to organize pain management within
your hospital
How to teach?
•Verbal & written (e.g. pamphlet or poster).
– ~ 30% of patients forget the information given to them.
•Remind staff to repeat the information - patients remember
only a small part at any one time.
How to organize pain management within
your hospital
3. Standardization
3. Standardization – examples
example of
an audit
Summary 1
Paris, France
International Pain School
Talks in the International Pain School include the following:
Physiology and pathophysiology of pain Nilesh Patel, PhD, Kenya