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Management of acute
pain
Kiran K Koneti
Martin Jones
Abstract
Acute pain is an important fear for most patients and inuences their
recovery and overall experience. Poorly treated, it could lead to undesirable effects and patient dissatisfaction. Hence, it is important to understand, assess and treat acute pain effectively. Pain is regarded as
the fth vital sign and should be addressed as important as other vital
parameters. Management of pain involves team work, including acute
pain services, especially in dealing with complex problems. Management of pain ideally starts at the pre-assessment visit or from rst presentation to the clinician. It is important to anticipate and treat acute
pain effectively, which may prevent the development of chronic pain
syndromes. Patients should be given information about analgesic options, the risk:benet ratio of the treatment options at the earliest opportunity and ideally have an individualized management plan.
Physiology of pain
The ability of the somatosensory system to detect noxious and
potentially tissue-damaging stimuli is an important protective
mechanism that involves multiple interacting peripheral and
central mechanisms. The neural processes underlying the
encoding and processing of noxious stimuli are defined as
nociception. The detection of noxious stimuli requires activation of peripheral sensory organs (nociceptors) and transduction
into action potentials for conduction to the central nervous
system. Nociceptors are stimulated by chemical, thermal or
mechanical damage and trigger the nociceptive impulses.
Nociceptive primary afferents are widely distributed throughout
the body (skin, muscle, joints, viscera, meninges) and comprise
both lightly myelinated A-delta fibres (diameter 2e5 mm) and
slow-conducting unmyelinated C-fibres (diameter <2 mm).
These fibres enter the dorsal horn of the spinal cord and synapse
at different sites (Ad at Rexed laminae II and V; C at Rexed
laminae II). The substantia gelatinosa (lamina II) integrates
these inputs and second-order neurons form the ascending
spinothalamic and spinoreticular pathways on the contralateral
side (Figure 1). The larger Ab fibres conducting touch and
descending pathways stimulate inhibitory interneurons within
the substantia gelatinosa and inhibit C fibre nociceptive inputs.
This is the basis of the gate theory of pain. Pain may be modified
by altering the neural pathway from its origin at the nociceptor
to its interpretation within the central nervous system by
various agents.
Psychological factors that influence the experience of pain
include the processes of attention, other cognitive processes (e.g.
memory/learning, thought processing, beliefs, mood), behavioural responses, and interactions with the persons
environment.
Introduction
By any reasonable code, freedom from pain should be a basic
human right, limited only by our knowledge to achieve it.
Ronald Melzack
It is the basic duty of all healthcare professionals to relieve
pain, and the most important indication for treating pain after
surgery is humanitarian. Pain is defined by the International
Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage.1 Since pain
is highly subjective, it may also be described as being what the
patient says it is. Pain is an individual, multifactorial experience
influenced, among other things, by culture, previous pain experience, belief, mood and ability to cope. Pain may be an indicator
of tissue damage but may also be experienced in the absence of
an identifiable cause. The degree of disability experienced in
relation to the experience of pain varies; similarly there is individual variation in response to methods to alleviate pain.1
Pain may be classified according to its presumed aetiology.
Nociceptive pain is due to the stimulation of nociceptors by
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PERIOPERATIVE MANAGEMENT
Physiology of pain
Substantia gelatinosa
Dorsal horn
Pain assessment
Ventral horn
Spinothalamic
and spinoreticular
tracts
Figure 1
Effects
Consequences
Clinical issues
Cardiovascular
Gastrointestinal
Respiratory
Metabolic
Other
Ileus
Atelectasis, ventilation-perfusion
mismatch and hypoxaemia
Delayed wound healing, reduced
immune function
Diminished muscle strength
Poor wound healing
Thromboembolism
Possible effects on tumour growth/
metastasis
Table 1
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PERIOPERATIVE MANAGEMENT
Treatment
Treatment of acute pain should be tailored to individual patients assessment and requirements prior to admission. It is
initiated usually by anaesthetists in the perioperative period
and carried on by the surgical team. It involves prior planning
with the acute pain service (APS), if necessary along with the
use of protocols for managing specific types of surgeries and to
identify at risk patients. The APS involves the multidisciplinary
team including medical, nursing, and pharmaceutical expertise. The APS plays a major role in day-to-day management of
acute pain after surgery along with provision of training for
medical nursing staff involved in the management of postoperative pain.6 It is important to use appropriate other services (e.g. physiotherapists) to facilitate early recovery and
mobilization.
Traditionally the analgesic ladder introduced for treatment of
cancer pain by the World Health Organization (WHO) ladder has
been adapted for the treatment of acute pain (Figure 3).
It is made up of three steps in the increasing intensity of pain.
The first step involves the use of non-opioid adjuncts (e.g.
paracetamol, aspirin or non-steroidal anti-inflammatory drugs
(NSAIDs)). If pain is still unsettled or there is increasing intensity, in addition to step 1 medication weak opioids (e.g. codeine, tramadol) can be added. In moderate to severe pain or
pain persisting or increasing in spite of step 2 treatment, stronger
opioids are considered in addition. All these involve the concept
known as multimodal analgesia. It is important to include the
analgesic ladder in individual patient analgesic plan along with
the adjunctive therapies, although it is used in reverse order in
acute pain. The analgesics act at different sites. Some may act at
the site of injury and decrease pain associated with inflammatory
reaction (e.g. NSAIDs), some may alter nerve conduction (e.g.
Box 1
10
Mild pain
Moderate pain
Severe pain
No pain
Step 3
Strong opioid
non-opioid
adjunct
Worst possible
pain
Step 2
0
No hurt
1
Hurts a
little bit
2
3
4
Hurts a
Hurts
Hurts a
little bit even more whole lot
more
Weak opioid
non-opioid
adjunct
5
Hurts
worst
Step 1
Non-opioid
adjunct
Figure 2
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Figure 3
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PERIOPERATIVE MANAGEMENT
Side effects: it is well tolerated with very few side effects and
contraindications. Since it is metabolized in liver, any form of
liver impairment would necessitate cautious administration.
NSAIDs
NSAIDs are widely used to treat mild to moderate pain and also
to reduce opioid consumption in the perioperative period. The
NNTs of various NSAIDs are as in Figure 4.
95% confidence interval of number needed to treat for at least 50% pain relief compared with placebo
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab.html
Figure 4
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PERIOPERATIVE MANAGEMENT
facilitates the inflammatory response. They also act as antipyretics due to inhibition of centrally produced prostaglandins.
Presentation e available in doses of 50/75/100 mg, sometimes in combination with paracetamol. Tramadol 100 mg has
NNT (95% CI) of 4.8 (3.8e6.1). It is well absorbed orally with
bio-availability of 70e90%.
Side effects: it has potential to interact with drugs that inhibit
central 5-HT or noradrenaline re-uptake (e.g. tricyclic antidepressants, selective serotonin re-uptake inhibitors) resulting in
seizures and hence should be avoided in epileptic patients.
Strong opioids
Strong opioids form the third step in the WHO analgesic ladder
for severe pain. These are common drugs used in the perioperative period for most intermediate and major surgeries. The
prototype and standard against which other drugs are compared
is morphine. Other commonly used strong opioids in the perioperative setting include oxycodone, diamorphine, fentanyl, and
alfentanil. The use of pethidine has decreased over the years due
to adverse central side effects.
Presentation: strong opioids are administered orally or parenterally as intermittent boluses or continuous infusions. It is vital
to provide supplemental oxygen and frequently monitor vital
signs, especially respiratory rate and oxygen saturations (SpO2)
for patients on strong opioid infusions or patient controlled
analgesia (PCA) systems. PCA is the preferred method of
administering strong opioids for most major surgeries for the
initial 48e72 hours with a step down to oral route when
tolerated.
Side effects: all opioids share a similar side effect profile such as
sedation, nausea and vomiting, constipation, itching commonly
and the more serious side effect of respiratory depression. It is
always important to prescribe regular medication for combating
the common side effects of opioids. Respiratory depression
should be diagnosed early and initial treatment will be according
to an ABC approach along with use of the opioid antagonist
naloxone. It is important to consider urinary catheterization for
patients with impaired mobility or major surgery.
Adjuvant drugs
Complex pain is fraught with challenges in the use of traditional
analgesia. Pain-modifying adjuvant medication has a role in these
situations. Adjuvants used in acute pain include nitrous oxide
(N2O), gabapentinoids, ketamine, magnesium, lignocaine, and
clonidine. N2O has been used as Entonox (50% mixture of oxygen
50% N2O) mainly for labour analgesia and procedural analgesia
(intravenous cannulation, ulcer care, sigmoidoscopy) in a ward or
emergency setting. It has modest analgesic and sedative properties
and causes minimal respiratory and cardiac depression. N2O diffuses more rapidly than nitrogen and can expand enclosed aircontaining spaces within the body. Its use is therefore contraindicated in the presence of a pneumothorax, obstruction of
middle ear and sinus cavities, recent vitreoretinal surgery, pneumocephalus, bowel obstruction and gas embolism.1
N-Methyl-D-aspartate receptor antagonists (e.g. ketamine,
dextromethorphan, amantadine, magnesium) have been used in
acute pain to modify central sensitization at spinal cord level. The
principal effect of low-dose ketamine is as an anti-hyperalgesic,
antiallodynic and antitolerance agent and not as a primary
Tramadol:
Mode of action e tramadol has affinity for opioid receptors
and also inhibits synaptic noradrenaline and serotonin (5-HT) reuptake, while stimulating presynaptic 5-HT release. This provides an alternative pathway for analgesia involving descending
inhibitory pathways within the spinal cord. It causes less respiratory depression and constipation in equianalgesic doses relative to morphine.
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PERIOPERATIVE MANAGEMENT
Local/regional anaesthesia
Commonly used local anaesthetics in the perioperative period are
lignocaine, bupivacaine and its L-isomer (levobupivacaine) and
ropivacaine. Local anaesthetics can provide good pain control
with minimal side effects, and are usually used as part of a
balanced multimodal approach. Recent studies have also shown
extended benefit with the use of local anaesthetics with regional
anaesthesia in decreasing the recurrent rate of breast and prostate cancers. Loco-regional techniques play a vital role in a
number of enhanced recovery programmes pertaining to
different surgeries.7
Local anaesthetics can be administered by different routes and
delivery methods. Care must be taken to avoid exceeding the
recommended maximum dose. Cardiovascular collapse is an
infrequent but a serious risk with inadvertent intravenous
administration. Resuscitation should proceed along life support
guidelines and treatment with lipid emulsion instituted following
local guidance.
The various techniques of local anaesthetic administration
include:
Local infiltration: infiltration of local anaesthetic reduced requirements for opioid analgesics after day surgery and leads to a
lower incidence of nausea and vomiting. After day-stay hernia
repair, wound infiltration with levobupivacaine provided analgesia for 24 hours. Local infiltration was superior to opioid and
tenoxicam after minor laparoscopic surgery. Infiltration of the
trocar site for day-case laparoscopic cholecystectomy was more
effective if done prior to incision than postoperatively.1
Continuous wound infusions with local anaesthetics: these
provide only limited analgesic benefit for the first postoperative
day after outpatient inguinal hernia repair.
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Summary/conclusion
Treatment of pain after surgery is central to the care of postoperative patients. Failure to relieve pain is morally and ethically unacceptable. Effective pain relief is an essential element of
good quality care. Early and regular pain assessment on par with
other vital parameters along with appropriate treatment by all
healthcare providers, if need be with the use of acute pain services, will lead to improved patient outcomes and satisfaction.
This can be achieved by education, use of departmental guidelines/protocols, regular audit of practice, and feedback to the
professionals involved.
A
REFERENCES
1 Australia and New Zealand College of Anaesthetists and Faculty
of Pain Medicine. Acute pain management: scientic evidence.
3rd edn. 2010. Melbourne: ANZCA, http://www.nhmrc.gov.au/
les.nhmrc/publications/attachments/cp104_3.pdf.
2 White P, Kehlet H. Improving post-operative pain management.
Anesthesiology 2010; 112: 220e5.
3 Niraj G, Rowbotham J. Persistent post-operative pain: where are
we now? Br J Anaesth 2011; 107: 25e9.
4 Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human
right. Pain 2004; 112: 1e4.
5 Kehlet H, Holte K. Effect of postoperative analgesia on surgical
outcome. Br J Anaesth 2001; 87: 62e72.
6 Commission on the provision of surgical services. Reports of the
working party on pain after surgery. London: RCS and RCoA,
1990.
7 Enhanced Recovery Programme. Quality and service improvement tools. NHS Institute for Innovation and Improvement. http://
www.institute.nhs.uk/quality_and_service_improvement_tools/
quality_and_service_improvement_tools/enhanced_recovery_
programme.html.
8 Cook T. Major complications of central neuraxial block in the UK.
Report and ndings from the 3rd national audit project (NAP3).
2009. London: RCoA, http://www.rcoa.ac.uk/node/1428.
9 Procedure specic post-operative pain management (PROSPECT) study group. http://www.postoppain.org/frameset.htm.
10 Searle RD, Simpson KH. Chronic post surgical pain. Cont Edu
Anaesth Crit Care Pain 2010; 10: 12e4. http://dx.doi.org/10.1093/
bjaceaccp/mkp041.
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