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Post-surgery pain management : In most hospitals during the past century, post-surgical pain management consisted only of the administration of analgesics and narcotics immediately after surgery. These drugs were usually given by intravenous or intramuscular injection, or by mouth. This is still a viable method for managing post-operative pain. Management of these drugs, nevertheless, has variant applications. Some hospitals insist on a routine of scheduled medications, rather than giving medications as needed. The health care staff in these instances state that when patients take medications before the pain appears, the body does not over-react to the pain stimulus. Therefore, staying ahead of the pain is critical.
Other hospitals advocate continuous around-theclock dosing through the use of a pump-type device that immediately delivers medication into the veins (intravenously, the most common method), under the skin (subcutaneously), or between the dura mater and the skull (epidurally). A health care provider programs the device with the specific dosage to deliver at each request made by the patient, as well as the total permitted during the time for which the device is set (commonly eight hours, sometimes 12, especially if the health care providers are working 12-hour shifts). Some of these devices are very sophisticated and even monitor themselves, ringing an alarm bell if there is an indication that they might be malfunctioning. The patient administers the dose by pushing a button, and is encouraged to keep a steady supply of medication within his or her system.
This is called patient-controlled analgesia (PCA). PCA provides pain medication at the patients need. However, because opium-like pain-relievers (opioids) are the medications these pumps deliver, there has been some concern about possible narcotic addiction. The pumps are calibrated to a maximum dosage, and are limited to a maximum dose every eight (or 12) hours. The health care staff checks the equipment regularly, and records the number of times the patient pushes the pump button. If the patient has pushed the button more times than allowed, the pump refuses to administer more medication. The patient should notify the health care staff if a specific medication is ineffective. In some cases, the patient needs encouragement to use the pump more, if necessary.
Nonsteroid anti-inflammatory analgesics (NSAIDs) are best used for continuous around-the-clock pain relief. This prevents the extremes in pain perception that occur with on-demand dosing; sometimes the patient feels no pain and extreme pain at other times. Opioids are best given on a schedule or in a computerized pump, which can prevent overdoses.
Another method used post-surgically is the On-Q or the pain relief ball. It is a balloon-type device that administers non-narcotic medication to the incision site through a small catheter. When the incision site is closed, the catheter is attached to the surgical site and the balloon or pump is either taped to the patients skin, carried in a pocket or pouch, or attached to the patients clothing. The pump numbs the incision site by flooding it with anesthetic. Recent tests show that On-Q reduces narcotic use by 40% in cesarean patients, and eliminates all narcotics in 43% of hysterectomy patients.
Alternative non-medical methods
Some non-medical methods can help reduce post-operative pain. Patient education about the surgical procedure and the aftermath can help reduce stress, which can affect the perception of pain. Education, like visualization, prepares the mind for surgery and recovery. The patient knows what to expect, thereby removing fear of the unknown. Education also enlists the patients cooperation and may encourage a feeling of control and empowerment, which reduces stress, fear, and helplessness. These factors can contribute to less perceived pain. Therefore, both education and visualization can be helpful in minimizing pain perception and encouraging a positive attitude after surgery, which can promote healing.
Meditation and deep breathing techniques also can reduce stress. These techniques can lower blood pressure and increase oxygen levels, which are critical to a healthy recovery. Hypnosis before and after surgery may calm the mind and emotions, and mute the perception of pain.
Multiple methods
Multimodal analgesia uses more than one method of pain management. Multiple methods can actually reduce the amount of medications necessary to relieve pain, and can minimize uncomfortable side-effects. Using pre-surgical, surgical, and post-surgical techniques allows the patient to arise from surgery with the pain already under control. He or she does not have to experience the shock of intense pain at the incision site or elsewhere in the body. Some pain is probable; however, a patient should not be in intense pain after surgery. Pain management should occur before pain appears rather than in reaction to pain. Further knowledge about multimodal pain management will be necessary as more outpatient and officebased surgery is done. Finding the right combination of methods for an individual patient will be the challenge and responsibility of the health care team.
Opioid-tolerant patients
Of great concern to health-care professionals is how to provide post-operative pain management to patients who are opioid tolerant. These patients require higher and more frequent doses of narcotics for pain relief. They may also need to stay on the narcotics longer, and gradually step back down to their pre-surgery levels. Patients who are opioid tolerant are not necessarily illegal drug users, but may be taking medications in combination with a narcotic, such as oxycodone/acetaminophen or acetaminophen/codeine. Patients who take opioid medications regularly may be treating pain for conditions like cancer, fibromyalgia, arthritis, or traumatic physical injuries.
It is important for anesthesiologists to aggressively treat pain for opioid-tolerant patients in the recovery room, where they can be closely monitored. Patient-controlled pain administration or continuous infusion, either in an IV or in an epidural catheter, has the best chance of controlling post-surgical pain together with the pain caused by preexisting conditions. When the patient is able to take medications orally, NSAIDs can supplement the use of opioid analgesia, sometimes reducing the total amount of opioids used. Newer, COX-2 inhibitors have proven effective in reducing pain without many of the side effects that NSAIDs possess (liver complications, kidney impairment, intestinal tract irritation, and bleeding), and seem to be a good fit for the opioid-tolerant patient.
Preparation
Before having any surgery, the patient should talk with the physician, surgeon, and if possible, the anesthesiologist in order to gain a full understanding of the procedure and what to expect immediately following surgery. It is important to develop a pain management plan with the health care team, and for the patient to be open about medication use, including opioids. Usually the patient will meet the anesthesiologist the day of the surgery to discuss pain management options for the operation. Being informed about the surgical procedure and anesthesia options will give the patient an opportunity to ask questions and respond accurately to those asked by the anesthesiologist.
The physician should take a complete medical history, and order tests to determine the patients current liver and kidney functions. Surgical patients should communicate their pain medication needs to the health care team. The patient should not eat or drink before surgery. This helps minimize the side effects of general anesthesia and pain medications, such as nausea and vomiting. If the patient cannot reach a comfort level with the prescribed medication regime, he or she should discuss this with the health-care staff and physician.
Normal results
After surgery, a patient should not have to endure severe pain. A reasonable comfort level can be reached in most cases. Prudent pain management will allow the patient to eat, sleep, move, and begin doing normal activities even while in the hospital, and especially when returning home. Recovery may take several weeks after surgery; however, the patient should be made comfortable with a regime of oral pain medications.
Risks
Pain medications may have unpleasant side effects. In many people, narcotics cause nausea, vomiting, and impaired mental functioning. NSAIDs can cause kidney failure, intestinal bleeding, and liver dysfunction, but this is not true for everyone. The NSAID ketorolac has been associated with acute renal (kidney) failure even when given for minor oral surgery in an outpatient setting.
Early screening for kidney problems and close monitoring for kidney failure or dehydration can prevent most of these problems. There are adequate safeguards in place, especially in patient-controlled analgesic pumps, to prevent addiction to narcotics; however, some patients do become addicted. In these cases, there usually is an underlying predisposition toward physical addiction that had not previously appeared.
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