SEMINAR PRESENTATION

SURGICAL PAIN AND IT’S MANEGEMENT

by: molalegn and
selamawit
 Presentation outline
• Introduction

• Etiology

• Epidemiology

• Clinical Presentation & Diagnosis

• Surgical Pain Mechanism

• Treatment

• Monitoring Parameter

• Evaluation of Therapeutic Outcomes

• Patient Education
2
 introduction
• pain is unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such
damage.However, as pain is subjective, many clinicians define pain as
“whatever the patient says it is.”

• pain’s impact on society is still great, and pain remains a primary reason
patients seek medical advice or health care.

3
 Cont….
• Pain can affect all areas of a persons life:
• Sleep, thought, emotions and activities of daily living
• Physical, mental, emotional, and spiritual aspect of
life

• Pain often is so highly personal and subjective

• The pt is the only person who can describe the
intensity and quality of their pain
The net effect of complicated interactions of ascending
and descending neural pathways with biochemical and
electrochemical processes
4
Epidemiology

• Relieving Pain in America” suggests that greater than 100 million

persons in the United States live with chronic pain.

• 25 million Americans will experience acute pain due to injury or

surgery, and one- third will experience severe chronic pain at some
point in their lives

5
CON..

• Economic burden: > 500 billion US dollars annually

• Unfortunately, despite much public attention, pain often remains

inadequately or inappropriately treated.

6
Etiology
Pain can occur from many causes, for example:

• Surgery
• Trauma

• Labor

• Medical procedures

• Illnesses
7
Classification of pain

• It is helpful in guiding assessment and treatment of pain to classify

or subdivide the presenting symptoms into types of pain
there are numerous ways of classifying pain, such as

-by type of pain/origin

nociceptive, neuropathic, inflammatory
- by pain intensity
mild, moderate, or severe, and
-most commonly by duration of pain
acute, subacute, or chronic pain

8
Acute Pain

Acute pain is a beneficial physiologic process, serving its adaptive

purpose by warning individuals of disease states and potentially
harmful situations
 Unfortunately, severe, unremitting, under-treated acute pain, when
it outlives its biologic usefulness, can produce many deleterious
effects.
Acute pain is typically short in duration, lasting less than 30 days.
 is usually nociceptive in nature with common causes, including
surgery, acute illness, trauma, labor, and medical procedures.

9
Chronic pain

•A pain which lasts beyond the average duration of time that an injury to
the body needs to heal, 4 to 6 weeks(pain persists for months to years)
• It can be nociceptive, neuropathic/functional, or both

Classified as:

• Cancer pain: caused by the disease itself (e.g., tumor invasion, organ
obstruction), treatment (e.g. chemotherapy, radiation, and surgical
incisions), or diagnostic procedures (e.g., biopsy)

10
• chronic Non-cancer:
 Non-cancer etiologies
 is often a result of changes to nerve function and transmission
 thus making treatment more challenging

11
Characteristics of Acute and
Chronic Pain

12
Clinical presentation and Diagnosis

13
Assessment of pain
Tools for Pain Assessment

• Verbal Numerical rating scale (VNRS)

• Visual analogue scale (VAS)

• Categorical rating scale

• Faces Pain Rating Scale

14
• Numeric scales are widely used and ask patients to rate their pain on
a scale of 0 to 10, with 0 indicating no pain and 10 being the worst
pain possible. Using this type of scale, 1 to 3 is considered mild pain,
4 to 7 is moderate pain, and 8 to 9 is severe pain
• The visual analog scale (VAS) is similar to the numerical scale in that it
requires patients to place a mark on a 10-cm line where one end is
no pain, and the worst possible pain is on the other end

15
• Rating scales provide a simple way to classify the intensity of pain,
and they should be selected based on the patient’s ability to
communicate.

16
Cont….

17
Cont….
• Faces Pain Rating Scale

Used for the assessment of pain in children

and non communicating patients

18
SURGICAL PAIN MECHANISM
• Surgical pain is due to inflammation from tissue trauma
(ie, surgical incision, dissection, burns) or direct nerve
injury (ie, nerve transaction, stretching, or
compression)

• The patient senses pain through the afferent pain

pathway which can be altered by various pharmacologic
agents. 19
Cont….
• Tissue trauma releases local inflammatory
mediators that can produce augmented sensitivity
to stimuli in the area surrounding an injury
(hyperalgesia) or misperception of pain to non-
noxious stimuli (allodynia)

20
treatment

21
Goals of treatment
Relieves suffering

Earlier mobilization

Shortened hospital stay

Reduced hospital costs and

Increased patient satisfaction

22
Non-pharmacologic Therapy
• Application of heat or cold

• Aerobic exercise

• Acupuncture

• Massage

• Biofeedback

• Cognitive behavioral therapy

23
 Principles of analgesic drug
administration
Type Description

Give Tx by “mouth” If possible analgesic are given by mouth.

Consider other routes when PO not suitable
Give Tx by “ by the clock” Pts with persistent pain should be given
analgesics regularly at a fixed interval of time
Give Tx “by the ladder” The sequential use of drugs in pain mgt

Adjust Tx “for the The right dose is the dose that relieves the pts
individual” pain. No std doses for opioids drugs. E.g.
morphine oral dose range 5 – 1000mg q 4 hrs
In planning pain Tx pay Provide full info on dose and schedule , need for
“attention to details” regular adminst. to pt & family

24
Dosing Principles in Pain Mgmt.
Type of dosing Description
approaches
PRN dosing Intermittent pains separated by pain free intervals.
Beneficial when dose escalation is needed. Pts who
have rapidly decreasing analgesic requirement
Around the clock For continuous or frequent pain. Provides
‘ATC’ dosing continuous relief preventing from recurrence.
Controlled Of opioids can lessen the inconvenience associated
Release drug with the use of ATC dosing with short duration of
formulation action
Patient A technique of parenteral administ. in w/c the pt
Controlled controls an infusion that may deliver a continuous
Analgesia ‘PCA’ infusion and a bolus of drug ‘on demand’ according
to parameters set by the physician

25
WHO ANALGESIC LADDER

26
PREEMPTIVE ANALGESIA

• Preemptive analgesia is the administration of

analgesics prior to onset of noxious stimuli.

• Preemptive analgesia modifies peripheral and

central nervous system processing of noxious
stimuli, thereby reducing hyperalgesia and allodynia.

27
Cont.…
• Preemptive analgesia reduces postoperative opioid
use and opioid side effects.

• Effective preemptive analgesic techniques use

multiple pharmacological agents to reduce nociceptor
(pain receptor) activation by blocking or decreasing
receptor activation, and inhibiting the production or
activity of pain neurotransmitters.
28
Cont….
• Local:- Local anesthetic can be injected prior to surgical
incision and may promote preemptive analgesia.

• Systemic:- For preemptive analgesia

Ibuprofen 800 mg, PO,

Ketorolac 30 mg, IV or

Gabapentin 600 mg, PO.

29
NEURAXIAL (REGIONAL)
ANALGESIA
• Intraoperative epidural/intrathecal opioid injection:
Reduces the need for systemic opioids
postoperatively.

• For major abdominal surgeries with extensive

incisions, epidural infusions with local anesthetic
provide superior pain relief as compared with
conventional parenteral narcotics. 30
Cont….
• With less extensive surgery, however, intrathecal
narcotics alone can be used for postoperative
analgesia.

• A single dose of intrathecally (spinal) administered

narcotic can provide substantial pain relief up to 18 to
24 hours postoperatively.

31
• for intratecal injection morphine at dose 0.1-0.2 mg or fentanyl at
dose 10-20 mcg can be used.

• Epidural injection — The dose of morphine by the epidural route is

about 5 to 10 times that of the intrathecal route. usually 3 mg of
epidural morphine for lumbar and low thoracic epidurals is used.

32
POSTOPERATIVE EPIDURAL
MEDICATIONS
• epidural analgesia with opoids and local anesthetics are used to
manage pain postoperatively .
• these medication are used intermittently mostly in patients who
already have an epidural catheter located at the lumbar or low
thoracic level for surgical anesthesia.
• most common combination includes bupivacaine (0.125 percent) or
ropivacaine (0.2 percent) plus fentanyl (2 mcg/mL) or
hydromorphone (20 mcg/mL).

33
POSTOPERATIVE IV MEDICATIONS
• Parenteral opioids:- Opiates provide swift and
potent analgesia when administered parenterally.

• The most commonly used intravenous opioids for

treatment of postoperative pain are morphine,
hydromorphone, and fentanyl.

• Meperidine is not recommended for postoperative

pain relief
34
CON....
• Bolus intravenous injections are often used for moderate pain for
morphine the loading dose is 0.1 to 0.3 mg/kg and for
hydromorphone it is 0.01 to 0.03 mg/kg to achieve adequate basal
plasma levels.
• Continuous intravenous infusions of opiates are used for moderate to
severe pain which is poorly controlled with repeated bolus injections.

35
Cont….
• Intravenous lidocaine:- Intravenous lidocaine can be
administered by infusion intra-operatively &/or post-
operatively for the management of pain.

• IV Acetaminophen & NSAIDs:- reducing the amount of

opiates requested by the patient and decreasing opioid
side effects

36
PATIENT CONTROLLED ANALGESIA
• PCA pump is the preferred mode of administering opioids for
moderate to severe postoperative pain.

• The benefits include easier patient access to pain medication,

reduced chance of medication error, and ready titration

• Morphine, hydromorphone, and fentanyl can be administered

via PCA pump.

• The pump is discontinued when the patient is able to tolerate

oral analgesics. 37
 Oral opioids
• When the patient is tolerating an oral diet, the
opioid regimen for patients with moderate to
severe pain can be switched from intravenous to
oral opioids such as oxycodone, hydromorphone,
or morphine

38
• oral dose of morphine 10-30 mg every 4 hours as needed.
• oxycodein -Regular or immediate release formulations: Initial: 5-15
mg every 4-6 hours as needed.
• hydromorphine - 2-4 mg every 4-6 hours as needed. but for more
severe pain we consider 4-8mg.

39
Non- opioid Agents
• Acetaminophen, acetylsalicylic acid, and NSAIDs

• Preferred over opiates for: mild-to-moderate pain

• Switch to another member of NSAIDs if there is inadequate

response after a sufficient therapeutic trial of any single

agent

• Use with opioid in severe pain for opioid –sparing effect →

40
 Cont….
• Acetaminophen : 325mg to 1000 mg every 4 to 6
hours to a maximum dose of 4000mg/day.

• Ibuprofen: Ibuprofen (300 to 800 mg orally three or

four times per day) (max. 3200mg/day).

• Diclofenac: 50 mg TID (max.150mg/day)

• Aspirin: 325mg to 650 mg every 4 to 6 hrs.

(max.4g/day) 41
 Major Side effects
• Inhibition of platelets (with potential promotion of
bleeding)

• Hepatotoxicity

• Gastrointestinal insult

• Renal insult and adverse cardiovascular effects

42
 opiates
• Used in the management of acute pain and cancer-
related chronic pain

• Opiate choice should be based on: patient

acceptance, analgesic effectiveness and
pharmacokinetic, pharmacodynamics , and side-
effect profiles
43
 Cont….
• Mild to moderate pain: parenteral is not superior to
oral

• Severe pain: parenteral route is preferred

• Chronic pain: oral or transdermal is preferred

44
Codeine
Used in mild to moderate pain
It is weak analgesic and used with NSAIDs,
aspirin, or acetaminophen, etc.
Doses:
PO 15–60 mg every 4–6 h;
IM 15–60 mg every 4–6 h
45
 Tramadol
• Synthetic opioid which is one-fifth as potent as
morphine

• 200 mg tramadol = 40 mg morphine daily

• Less constipation than morphine

• Lowers seizure threshold (caution of use with SSRIs

and TCAs)

• Usual maximum dose is 400 mg daily 46

 Common ADRs
Effect Manifestation
Mood changes Dysphoria, euphoria
Somnolence Sedation, inability to concentrate
Stimulation of CTZ Nausea, vomiting
Respiratory depression Decreased respiratory rate
Decreased GI Motility Constipation
Increase in sphincter tone Biliary spasm, urinary retention
Histamine release Urticaria, pruritus, rarely exacerbation
of asthma due to bronchospasm
47
 Cont….
Tolerance Larger doses for same effect

Dependence Withdrawal symptoms upon abrupt

discontinuation

Addiction Genetic predisposition leads to loss of control of

drug use, continued
use despite harm, compulsion to use, cravings

Hypogonadism Fatigue, depression, loss of analgesia, sexual

dysfunction, amenorrhea (women)

Sleep Disrupts sleep-wake cycle, causes dose-

dependent rapid eye movement (REM)
suppression 48
 Monitoring parameters
• NSAIDS:- CBC, stool guaiac ,Scr

• Acetaminophen : -Serum transaminases,

Acetaminophen serum conc.

• Opioids :- Respiratory rate, Fatigue ,sedation

scale, Depression, Sexual dysfunction, Bowel
movement, Urticaria & pruritus,BP ,temprature .
49
EVALUATION OF THERAPEUTIC
OUTCOMES

Consistent monitoring for:

• Effectiveness : Pain relief, adequate functionality

• Adverse effects is in optimizing therapeutic

outcomes.

• Validated scoring tools : rating scale, visual analog

scale
50
 Patient Education
• Patients should be counseled on the proper intake of fluids
and fiber

• Use of alcohol should be discouraged when possible.

• To monitor situational factors that trigger their pain/stress

• Practice of relaxation, such as doing deep breathing

exercises

51
REFERENCE

1. Joseph .T dipiro 11th Edition.

2. Uptodate 2021.

3. Pharmacotherapy principle and practice 4th Edition.

52
53