POSTSURGICAL PAIN MANAGEMENT
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Abstract : Post-surgical pain is a complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system. The result is pain in areas not directly affected by the surgical procedure. Post-operative pain may be experienced by an inpatient or outpatient. It can be felt after any surgical procedure, whether it is minor dental surgery or a triple-bypass heart operation.
Post-surgical pain is a complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system. The result is pain in areas not directly affected by the surgical procedure. Post-operative pain may be experienced by an inpatient or outpatient. It can be felt after any surgical procedure, whether it is minor dental surgery or a triple-bypass heart operation.
Post-operative pain increases the possibility of postsurgical complications, raises the cost of medical care, and most importantly, interferes with recovery and return to normal activities of daily living. Management of postsurgical pain is a basic patient right. When pain is controlled or removed, a patient is better able to participate in activities such as walking or eating, which will encourage his or her recovery. Patients will also sleep better, which aids the healing process.
Description
Pain is recognized in two different forms: physiologic pain and clinical pain. Physiologic pain comes and goes, and is the result of experiencing a high-intensity sensation. It often acts as a safety mechanism to warn individuals of danger (e.g., a burn, animal scratch, or broken glass). Clinical pain, in contrast, is marked by hypersensitivity to painful stimuli around a localized site, and also is felt in non-injured areas nearby. When a patient undergoes surgery, tissues and nerve endings are traumatized, resulting in incision pain. This trauma overloads the pain receptors that send messages to the spinal cord, which becomes overstimulated. The resultant central sensitization is a type of posttraumatic stress to the spinal cord, which interprets any stimulation - painful or otherwise - as unpleasant. That is why a patient may feel pain in movement or physical touch in locations far from the surgical site.
Patients handle post-operative pain in high individualized ways. Health care professionals have observed that some patients report that they are in extreme pain after surgery, demanding large doses of pain medications while others seem to do well with much less medication. Several theories have been put forth for this discrepancy. For example, differences in body size seemed to require differing amounts of medication, but this theory did not explain differences in pain perception among patients of the same build. Emotional well-being was considered a better indicator of the ability to tolerate pain. It has been theorized that patients with stronger support systems and better attitudes actually perceive less pain than others. Some health care professionals have even speculated that extreme pain was not real in many cases, but was a way to seek attention.
Clear biological evidence proving that individuals are born with varying thresholds of pain perception was only recently discovered. Psychiatrist and radiologist Jon- Kar Zubieta, from the Mental Health Research Institute at the University of Michigan, found that variations in an amino acid in a newly discovered gene, which codes for an enzyme that accesses neurotransmitters in the brain, produce different levels of pain perception. Only three combinations produce the variation.
One individual may be able to fully access and metabolize the opioid neurotransmitters that reduce the sensation of pain. This person would have a higher threshold of pain tolerance and a lower level of pain perception. Another might not be able to do so at all, and that individual would experience more intense pain from the same stimulus. A third person might be able to tolerate a moderate amount of pain. This variation in genes not only shows that individuals do indeed experience pain at different levels, but it also points to differences in how people behave toward other stressors. Genetic variation may be a factor in the impact of long-term illness and depression that often accompanies chronic pain.
Since pain perception is highly subjective, it is important for the health care team to be aware of pain sensitivity differences in patients, and to value patient self-report as a reliable tool for pain assessment. The most common selfreport system in use is the pain intensity scale. The patient is asked to identify where the pain falls on a scale of 0 no pain at all to 10 the worst pain in the world. This scale, however, does have limitations. The Short-Form McGill Questionnaire, which uses sensory words or synonyms, may allow the patient to communicate more accurate, descriptive information about pain and may be a better tool in planning pain management strategies.
It is clear that there is a real need for providing different approaches to post-surgical pain management. A variety of interventions may be used before, during, and after surgery. Most of these methods involve medications given orally, intravenously, intramuscularly, or topically (via the skin). Some must be administered by a health care professional; others by the patient.
Pain management methods
Pre-surgery pain management
The goal of post-surgical pain management is to reduce the amount pain a patient experiences after surgery. New research has suggested that preventing the nervous system from being overtaxed by pain from the trauma of surgery may lead to a less painful postoperative experience. Pretreated patients may require less post-surgical medications, and they may recover more quickly, possibly experiencing pain-free days far sooner than patients who have used traditional post-surgical pain methods.
Also, in view of improved, less-invasive surgical techniques and the insurance industrys trend after the turn of the twenty-first century to trim rising medical costs by reducing the length of hospital stays, many patients have no longer been required to remain overnight in a hospital. Recently, outpatient (also called ambulatory) surgery has become a procedure of choice for many complex surgeries, such as hysterectomy and prostatectomy.
The patient must now be made comfortable enough to return home and manage his or her own pain. Preemptive analgesia introduces anesthetic drugs near the spinal cord or, sometimes, in nerve blocks in specific regions of the body. An epidural catheter, a thin plastic tube through which pain medication is delivered, is inserted into the patients back before surgery. The patient may also receive general anesthesia and post-surgical pain medications as needed. Sometimes, the epidural catheter remains in place for several hours or days after surgery, and is attached to a pump so the patient can administer medication on demand.
In other cases, peripheral nerve blocks are used to limit sensation in specific regions of the body. By injecting local anesthetic near a nerve or nerve plexus that supplies the area where the surgery will be performed, all sensation is blunted and the affected area is numbed and feels asleep. Some patients remain awake, but sedated, during surgery; others are given general anesthesia. Two important advantages to the use of peripheral nerve blocks in patients who are awake during surgery is the avoidance of the side effects of general anesthesia (nausea and vomiting) and complications that could occur during intubation, placing a tube in the patients airway. The use of peripheral nerve blocks alone may be best suited to surgical procedures involving the arms, legs, and shoulders.
Pain management during surgery General anesthesia has been the standard for pain management during surgery. Topical local anesthetics are also being used to numb the surgical site before any incisions are made. This has been the method used frequently with laparoscopic procedures. In a laparoscopy, the surgeon inserts a laparascope (an instrument that has a tiny video camera attached) through a small incision, often in the abdomen. Other small incisions are made for the surgeon to insert surgical instruments into, and to do repairs or remove diseased or damaged tissues. Local anesthetics minimize pain trauma to the surgical site and the central nervous system.
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