Pain: An unpleasant sensory and emotional

experience associated with actual or potential

tissue damage, or described in terms of such
damage.

Milton wrote in Paradise Lost: “Pain is perfect miserie, the

worst /Of evils, and excessive, overturns/All patience.”
“Pain is a more terrible lord of mankind than even death
itself”
- Schweitzer A ( On the edge of primeval forest)
PAIN

PAIN

Postoperative
PAIN

PAIN
PAIN
PAIN
 Magnitude !!!!!
• U.S.A
• Seventy-three million patients undergo
surgical procedures each year in the
United States.
• 80% experience acute post-operative pain,
• 50% inadequate relief
• 20% experience severe pain.
 Post-operative Pain
management

Dr. Ashok Jadon MD, DNB, MNAMS

Fellowship in Interventional Pain management
Sr consultant & H.O.D. Anaesthesia
TATA MOTORS HOSPITAL
Factors for poor pain control

Patients

Nurse Doctor
 Doctors & Nurse Factors
• Inadequate Knowledge
– Drug/ dose/ side effects
• Fear of Addiction
– False fear
– Tolerance is different
• Accountability
– No litigation- Mera Bharat Mahan
– Lack of sympathy/ empathy
 Patients Factors
• Age and Sex.
• Pre-operative analgesic use.
• Past history of poor pain management.
• Coexisting medical conditions
• Cultural factors and personality
• Preoperative patient education.
• Site of operation
• Individual variation in response and pain
threshold.
• Attitude of the ward staff
Mechanism of Postoperative Pain
 Systemic effects of Post-operative Pain
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Metabolic-endocrinal
• Chronic pain
• Psychological
Severe postoperative pain and stress response to surgery
causes increased morbidity and mortality
 Physiological effects of Pain
• Tachycardia and elevated blood pressure
• Increased catabolism : poor wound healing
• Decreased limb movement: increased risk
of DVT/PE
• Respiratory effects: shallow breathing,
cough suppression increasing risk of
atelectasis & pneumonia
• Decreased gastrointestinal mobility PONV
 Psychological effects of Pain

• Negative emotions: anxiety, depression

• Sleep deprivation

• Existential suffering:
– may lead to patients seeking active end of life.
 Immunological effects of Pain

• Decrease natural killer cell counts

• Patient become host of infection

 Evidence Based Benefits
of Pain control
Improving clinical outcome by reducing
complications such as:
• myocardial infarction or ischemia
• risk of tachycardia and dysrhythmia
• impaired wound healing
• risk of atelectasis
• thromboembolic events
 Objective assessment of subjective pain

• VAS
• VRS
• Picture scales
(facial expressions)
• Clinical observation
sighing, groaning,
sweating, ability to
move
 PROPHYLAXIS
IS
BETTER THAN CURE

• Identify High risk patients

• Preemptive approach
Pre-emptive Analgesic Therapy
Before surgery to attempt to decrease the
intensity and duration of postoperative pain.

Controlling the "wind-up" phenomenon

Non Pharmacological Strategy
• Health-care information
– Information in preparation for
surgery
– Timing of procedures
– Self-care actions
– Pain and discomfort information
 Psychosocial support
• Identifying and alleviating concerns

• Reassurance

• Problem-solving

• Encouraging questions, and increasing the

frequency of support
 Skills teaching
• Coughing, breathing and bed exercises,

• Relaxation, hypnosis, cognitive reappraisal

 Non Pharmaco Adjuvant

• Acupuncture

• Trans-cutaneous Nerve Stimulation

(TENS)
Trans-cutaneous Nerve Stimulation TENS
Trans-cutaneous Nerve Stimulation
TENS
 Pharmacological Treatment
• Type of Drugs

• Modes & Methods of administration

• Recent advances
 Drugs for Postoperative Pain
• Opioids
– Morphine, Codeine
– Pethidine
– Fentanyl, Sufentanyl, alfentanyl
– Pentazocin, Buprenorphine, Butrophanol
• Tramadol / Ketoralac
• NSAID’s ( COX-2 inhibitor)
• Local anaesthetics and adjuvant
• Anaesthetic drugs: Ketamine
 Route of administration
• Common
– Oral / Intramuscular / Intravenous
• Less common
– Rectal (suppositories)
– Sub mucosal (lolly pops)
– Trans- cutaneous
– Nasal ( drops and sprays)
• Local Anaesthetics
– Wound Infiltration / infusion / instillation
– Spinal: single shot & continuous infusion
Advantage & Disadvantage
• Oral Vs Intramuscular Vs Intravenous
• Rectal and Nasal
• Trans cutaneous and Transmucosal

• LOCAL ANAESTHETICS
– Less systemic effects
– Combination with Narcotics

Multimodal Approach
 Contraindications to the use of
NSAID’s
 History of peptic ulceration
gastrointestinal bleeding or bleeding
diathesis
 Operations with high blood loss
 Asthma, Heart diseases
 Renal impairment, dehydration
 History of hypersensitivity to NSAID’s or
aspirin.
 The World Federation of Societies of
Anaesthesiologists (WFSA) Analgesic Ladder
Patient Controlled Analgesia
(PCA)
PCA
 PCA

PCA

Plasma
Level
Therapeutic level

IV

IM

Time in Hours
Alternate novel drug delivery systems for
intravenous analgesics

• Transmucosal Passive patch
• Transdermal Passive patch 
• Iontophoretic patch 
• Nasal  (Inhaled drops, spray)
• Rectal
Trans-dermal patch
Trans-dermal patch
Lollypops
Rectal Suppository
Wound infiltration, Instillation,
Infusion & spray
Safe and effective
method
Long duration of
analgesia with
minimal systemic
effect
Antibacterial
activity of local
anaesthetics
Peripheral Opioid
receptor theory for
combination
 Catheter techniques
• Continuous infusion provides prolonged post-
operative analgesia as compared to single
injection

• Block can last up to ten times longer than single

injection

• Analgesic effect superior to conventional

treatment with IV PCA narcotics

• Higher patient satisfaction, earlier mobilization

 Catheter techniques
• first described in 1946,
gained popularity only in
the 1970s

• Continuous Plexus Block

• Intrapleural Catheter

• Continuous wound
infiltration
 Intrathecal and epidural
Local anaesthetics & opioids
 Epidural or Spinal
• Many medications that are normally given orally or
intravenously can be delivered directly into the spinal
canal.
• The advantage of this delivery is that a much smaller
dosages of medication can be used, thereby minimizing
many side effects associated with other oral or
intravenous use.
• Typically, the intraspinal administration is 300 times
more effective than the oral dose. Morphine (and other
opioids or narcotics) interacts with opioid receptors in the
spinal cord to decrease pain impulses to the brain,
thereby decreasing the brain's perception of painful
conditions.
 Epidural contd.
• Intraspinal delivery may allow the patient
to significantly decrease the amount of
oral medications ingested, thereby
decreasing side effects.
• Because the effectiveness of intraspinal
morphine is many-times the effectiveness
of oral morphine, the patient's pain relief
may allow resumption of a much more
active lifestyle.
 CAUTION
• It is particularly dangerous to
prescribe other opioids to patients
receiving intrathecal or epidural
opioids as this increases the
likelihood of clinically significant
respiratory depression.
 Current Modalities preferred for
management of the acute postoperative pain

Epidural/ intrathecal analgesia  25%

Intravenous PCA 25%
Oral analgesics  19%
Peripheral nerve block  13%
Intermittent IV bolus analgesics  8%
Continuous wound infusion  6%
Intramuscular analgesics  3%
At Tata Motors Hospital !!!!!
Continuous Wound Infiltration
Continuous Epidural Analgesia
 TAKE HOME MESSAGE
• Fears of post-surgical addiction to opioids
are generally groundless

• Giving medicine only "as needed" can result

in prolonged delays because patients may
delay asking for help.

• Aggressive prevention of pain is better than

treatment because, once established, pain is
more difficult to suppress.
 TAKE HOME MESSAGE

• Physicians need to develop pain control

plans before surgery and inform the
patient what to expect in terms of pain
during and after surgery.

• Patient-controlled medication via infusion

pumps is safe.