Post-Operative Pain Control





Key Words

post-operative pain, multimodal analgesia, preventative analgesia, perioperative pain management, systemic analgesia, local anesthetic infiltration, peripheral regional anesthesia, neuraxial analgesia, cognitive-behavioral modalities

 




Synopsis


Adequate post-operative pain control minimizes suffering, improves patient satisfaction, promotes early mobilization, reduces the length of stay, and minimizes costs. Optimal pain control requires pre-operative education and perioperative pain management planning that encompasses a preventative analgesic approach that utilizes multimodal therapies such as systemic analgesia, local anesthetic infiltration, peripheral regional anesthesia, neuraxial analgesia, and cognitive-behavioral modalities. These principles can and should be applied for reconstructive surgery in the developing world.




Introduction


Inadequate post-operative pain control can lead to poor recovery, function, and quality of life and can increase the risk of persistent post-surgical pain and complications. With over 80% of surgical patients experiencing acute post-operative pain and approximately 75% of those with post-operative pain reporting the severity as moderate or higher, it is important to achieve adequate pain control to minimize suffering, improve patient satisfaction, promote early post-surgical mobilization, reduce the length of hospital stay, and minimize costs.


Optimal post-operative pain control requires pre-operative education and perioperative pain management planning that encompasses a preventative analgesic approach that utilizes multimodal therapies such as systemic analgesia, local anesthetic infiltration, peripheral regional anesthesia, neuraxial analgesia, and cognitive-behavioral modalities. These principles can be adapted for use in reconstructive surgery in the developing world.




Pre-operative Education, Perioperative Pain Management Planning, and Methods of Pain Assessment


Before surgery, it is beneficial for patients to receive information on treatment options as well as on the plan and goals for post-operative pain management. This includes individually tailored education on methods of pain assessment for patients (and/or caregivers) as well as instructions on administration of analgesic modalities. Patients receive better health outcomes when they are able to participate in the decision-making process and adjust their pain management in accordance with their pain level and the presence of adverse effects. Although this may be a challenge when working in developing countries where language and cultural differences exist, engaging patients through interpreters and/or written materials in the local language will provide better health outcomes.


Utilization of a validated pain assessment tool (e.g., visual analog scale, a numeric rating scale, or symbols) is important to track the responses to pain treatments and to allow for proper adjustments. The following assessments should be used to help guide the perioperative pain management plan: what interventions have been effective, how the pain affects function, type of pain (e.g., neuropathic, visceral, somatic, muscle spasms), cultural or language barriers, cognitive deficits and misconceptions, and side effects (e.g., sedation, delirium, nausea/vomiting, constipation).




Multimodal and Preventative Analgesia


Acute surgical pain occurs when inflammation is caused by tissue injury (e.g., surgical incision, dissection, burns) and/or direct nerve injury (e.g., nerve stretching, compression, transection). The patient senses pain through the afferent pain pathway ( Fig. 1.8.1 ), which can be targeted by various analgesic drugs. The multimodal analgesic approach utilizes several drugs, each acting at different sites of the pain pathway, to provide superior synergistic pain relief compared with a single drug. By relying less on a single drug class such as opioids, opioid-related adverse effects are minimized.




Fig. 1.8.1


Various analgesic drugs can reduce pain sensation by targeting the afferent pain pathway that is activated by inflammation caused by acute surgical tissue injury (e.g., incision, dissection, burns) and/or direct nerve injury (e.g., nerve stretching, compression, transection).

(From Porth CM. Pathophysiology: Concepts of Altered Health States, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2004.)


When tissue injury occurs, the release of local inflammatory mediators leads to hyperalgesia (i.e., an increased response to a painful stimulus) and allodynia (i.e., a painful response to a normally innocuous stimulus) ( Fig. 1.8.2 ). Once the pain pathway is activated, sensitization of the peripheral pain receptors (primary hyperalgesia) and increased excitability of central nervous system neurons (secondary hyperalgesia) also contribute to hyperalgesia and allodynia. Preventative analgesia is a strategy to augment peripheral and central nervous system processing of painful stimuli, thereby reducing central sensitization, hyperalgesia, and allodynia. Preventative administration of analgesic modalities throughout the perioperative period includes preemptively administrating analgesia before surgical tissue trauma. By minimizing sensitization, preventative analgesia effectively reduces post-operative pain and/or analgesic consumption beyond the duration of action of the treatment drug or technique. Evidence-based analgesic modalities available for post-operative pain control include opioids, acetaminophen/paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2-specific inhibitors, anti-convulsants, IV lidocaine infusion, steroids, ketamine, local anesthetic infiltration, peripheral regional anesthesia, and neuraxial analgesia ( Table 1.8.1 ) .




Fig. 1.8.2


Tissue injury causes the release of local inflammatory mediators that lead to hyperalgesia (i.e., an increased response to a painful stimulus) and allodynia (i.e., a painful response to a normally innocuous stimulus).

(From Bear MF, Connors BW, Parasido MA. Neuroscience—Exploring the Brain, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2001.)


TABLE 1.8.1

Analgesia Regimen for Common Reconstructive Surgeries
































Cleft Lip Cleft Palate Burn Skin Grafting Upper-Extremity Procedures Lower-Extremity Procedures
Pre-operative


  • PO acetaminophen (adults and cooperative infants/children) ± Anxiolytic




  • PO acetaminophen (adults and cooperative infants/children) ± Anxiolytic




  • PO acetaminophen (adults and cooperative infants/children)



  • Celecoxib (adults) ± Gabapentin ± Anxiolytic




  • PO acetaminophen (adults and cooperative infants/children)



  • Celecoxib (adults) ± Gabapentin ± Anxiolytic




  • PO acetaminophen (adults and cooperative infants/children)



  • Celecoxib (adults) ± Gabapentin ± Anxiolytic

Intra-operative


  • IV or PR acetaminophen (if not given pre-operatively)



  • IV dexamethasone



  • Surgical site local anesthetic infiltration



  • Infraorbital and external nasal nerve block



  • IV opiates ± ketorolac (after hemostasis)




  • IV or PR acetaminophen (if not given pre-operatively)



  • IV dexamethasone



  • Surgical site local anesthetic infiltration



  • Sphenopalatine block



  • IV opiates ± ketorolac (after hemostasis)




  • IV or PR acetaminophen (if not given pre-operatively)



  • IV dexamethasone



  • Surgical site local anesthetic infiltration



  • Peripheral nerve block if feasible



  • IV opiates ± ketorolac (after hemostasis)




  • IV or PR acetaminophen (if not given pre-operatively)



  • IV dexamethasone



  • Surgical site local anesthetic infiltration



  • Interscalene block for shoulder/upper arm



  • Supraclavicular or infraclavicular block for forearm



  • Axillary block for forearm or hand



  • IV opiates ± ketorolac (after hemostasis)




  • IV or PR acetaminophen (if not given pre-operatively)



  • IV dexamethasone



  • Surgical site local anesthetic infiltration



  • Femoral block for thigh



  • Femoral/sciatic for leg



  • Popliteal/saphenous block for ankle/foot



  • Ankle block for foot



  • IV opiates



  • ± ketorolac (after hemostasis)

Post-operative


  • IV opiates



  • Codeine



  • Ibuprofen and/or acetaminophen




  • IV opiates



  • Codeine



  • Ibuprofen and/or acetaminophen




  • IV opiates



  • Codeine



  • Ibuprofen and/or acetaminophen ± gabapentin




  • IV opiates



  • Codeine



  • Ibuprofen and/or acetaminophen ± gabapentin




  • IV opiates



  • Codeine



  • Ibuprofen and/or acetaminophen ± gabapentin

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Dec 24, 2019 | Posted by in Reconstructive surgery | Comments Off on Post-Operative Pain Control
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