This document discusses postoperative pain management. It begins by stating that pain is commonly experienced after surgery and has historically been under treated. It then discusses pain assessment and various methods for treating pain, including acetaminophen, NSAIDs, opioids, local anesthetics, and patient-controlled analgesia. The document emphasizes the importance of treating pain for patient wellbeing and recovery, and the need for a multimodal approach using different drug classes to provide effective pain relief with fewer side effects.

1. POSTOPERATIVE PAIN
MANAGEMENT
Rojan Adhikari
FCPS RESIDENT

2. OBJECTIVES
• Introduction
• Why Treat pain?
• Pain Assessment
• Methods to Treat Pain
• Advantages
• conclusion

3. • Pain is the most common symptoms
experienced by surgical patients.
• Is historically been poorly evaluated and
frequently under treated.
• It may be caused by tissue injury sustained as
a result of surgery.

4. Definition
• Pain may be defined as an unpleasant sensory
or emotional experience associated with
actual or potential tissue damage or described
in terms of such damage.

5. Pain pathway

6. Steps in transmission of pain
• Transduction
• Transmission
• Modulation
• Perception

7. Why to treat pain ?
• Basic human right!
• ↓ pain and suffering
• ↓ complications
• ↓ likelihood of chronic pain development
• ↑ patient satisfaction
• ↑ speed of recovery → ↓ length of stay →
↓ cost
• ↑ productivity and quality of life

8. Complications of poorly controlled
pain
CVS: MI, dysrhythmias
Respiratory: atelectasis, pneumonia
GI: ileus, anastomotic failure
Endocrine: “stress hormones”
Hypercoagulable state: DVT, PE
Psychological:
Anxiety, Depression, Fatigue
Musculoskeletal- musclewasting ,pressure
sores

9. Pain Assessment
Pain History
O – Onset
P – Provoking / Palliating factors
Q – Quality / Quantity
R – Radiation
S – Severity
T – Timing

10. Continue……
Origin of Pain
Acute Pain
• ie. Incisional pain, acute appendicitis
Chronic Pain
• ie. Chronic back pain
Acute on Chronic Pain
• Acute and chronic causes may or may not be
related to each other

13. Pain management
• The analgesic ladder is as follows:
• Paracetamol
• Non steroidal anti-inflammatory drugs
• Codeine phosphate
• Morphine –patient controlled analgesia
• Local anaesthesia-spinal ,epidural

14. WHO- STEPLADDER

15. Multimodal Analgesia
Using more than one drug for pain control
Different drugs with different mechanisms/sites
of action along pain pathway
Each with a lower dose than if used alone
Can provide additive or synergistic effects
Provides better analgesia with less side effects
(mainly opiate related S/E)

16. Acetaminophen
• First-line treatment if no contraindication
• Mechanism: thought to inhibit
prostaglandin synthesis in CNS →
analgesia, antipyretic
• Max dose: 4 g / 24 hrs from all sources
• Warning: ↓ dose / avoid in those with liver
damage

17. NSAIDs
Also, first-line treatment
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

18. Opioids
-Centrally acting on opioid receptors
-No ceiling effect
-High dose/response variability in non-opiate users
-Previous dependence creates a challenge in acute on
chronic pain management cases
-Balancing safety and efficacy can be difficult
-Side effects may limit reaching effective dose
Side Effects
– Nausea / Vomiting
– Sedation
– Respiratory Depression
– Pruritus
– Constipation
– Urinary Retention
– Ileus
– Tolerance

19. CONTINUE
• Morphine
Most commonly prescribed opioid in hospital
Metabolism:
Conjugation with glucuronic acid in liver and kidney
-Morphine-3-glucuronide (inactive)
-Morphine-6-glucuronide (active)
Impaired morphine glucuronide elimination in renal
failure
-Prolonged respiratory depression with small doses
-Due to metabolite build-up (morphine-6-glucuronide)

20. *Codeine
-1/10th Potency of morphine
-Metabolized into morphine by body
*Hydromorphone (Dilaudid)
-Better tolerated by elderly, better S/E profile
-Preferred over morphine for renal disease
patients
-Low cost, IV and PO forms available

21. Local anasthetic
• Locl anasthetic act by blocking conduction in
nerve fibres,the second step In process of
nociception.
• It can be provided by various techniques
-local infiltration
-topical application
-epidural infusion
-peripheral nerve infusion

22. PCA
• An increasingly popular and effective modality using the parenteral
route of administration.
• The modality minimises the steps involved in the delivery of
analgesia and increases patient control and autonomy.
• Patient obtain prompt analgesia,receive smaller dose of opoids at
more frequent intervals ,can maintain blood concentration of drug
in analgesic range and have a lower incidence of drug related side
effects.
• The preferred agents for IV PCA are opoids with morphine
sulphate.other opoids used for iv pca
hydromorphinre,fentanyl,meperidine.
.While using physican must specify the drug,drug
concentration,loading dose ,bolus dose, continuous infusion,locked
interval and dose limit.

23. American pain society

24. Sites of action of analgesics

25. Benefits of postoperative pain relief
• Improved comfort
• Enhanced breathing
• Increased mobility
• Patient coperation assured
• Prevention of gastrointestinal immotility

26. conclusion
• Assessment of the severity of pain and its
timely management with appropriate and
adequate analgesic play great role in
postoperative care .

27. Thank you