Post Surgical Pain

Pain that occurs after surgery (or post surgical pain) is a frequent problem facing the increased number of outpatient surgeries being performed in the United States. The planning for pain management starts even before the surgery occurs and is called perioperative pain management. Perioperative pain management are the steps taken before, during, and after a surgical procedure that aim to lessen, if not completely eliminate, post-operative pain.

A multimodal approach, i.e. employing several courses of action, to manage acute perioperative pain is the most ideal strategy to avoid the over prescription and abuse of opioids; also to reduce the increasing incidence of opioid dependence among patients. This strategy is also effective to achieve the following goals: relieve suffering, early mobilization after surgery, reduce length of hospital stay, and patient satisfaction. The kind of pain control regimen will depend on the patient’s medical, psychological, and physical condition; age; level of fear or anxiety; surgical procedure; personal preference; and response to prescribed drugs.

Mechanism of Perioperative Pain

Perioperative pain results from inflammation caused by tissue trauma, such as from a surgical incision, dissection, or burn; or from direct injury to the nerves. Such tissue trauma can then result in either hyperalgesia (enhanced sensitivity to pain) or allodynia (pain response to stimuli that does not usually cause pain).

Traditional treatment for these conditions through opioids only targets specific pain mechanisms. Multimodal analgesia, which is designed act on different sites of the pain pathway, is now considered the most ideal form of acute perioperative pain management. Through this multi-faceted approach, dependence on a single medication is reduced, the need for opioids is either reduced or eliminated, and overall opioid dose and related side effects are also significantly lessened.

Preventive Analgesia

Preventive analgesia is an encompassing approach to the reduction of acute and chronic postoperative pain. It has proven effective in reducing sensitization, or enhanced response to pain, to noxious stimuli (potential tissue damage) before, during, and after a surgical procedure. Preventive analgesic techniques use various combinations of medications and interventions.

The most common preventive analgesic approach is a combination of local anesthesia (administered prior to surgery) and systemic analgesics using nonopioid medications (administered during and after surgery). Nonopioid systemic analgesics include NSAIDs (nonsteroidal anti-inflammatory drugs), acetaminophen, and antidepressants; these can be used to replace opioids or can be combined with opioids as part of the multimodal approach to perioperative pain management. This treatment approach has been shown to reduce opioid consumption, pain intensity, nausea and vomiting, and sedation, compared to treatment with morphine alone.

Strategy for Perioperative Pain Control

An effective multimodal approach is different for every patient. It acts as a checklist to ensure that all applicable categories of pain medication are considered, selected, and dosed according to the individual patient’s needs. A primary goal of perioperative pain management is to have the patient comfortable when he or she awakens from anesthesia, with a smooth transition from post-anesthesia care to the surgical ward. When creating a specific multimodal approach, the following should be considered:

• Level and length of postoperative pain associated with the specific surgical procedure. 
• The location of the surgery and anticipated sites of pain.
• Patient factors, such as age, other pre-existing medical conditions, or prior surgery.
• Specific clinical scenarios:
  • Minor outpatient surgery
  • Extremity surgery
  • Minimally invasive abdominal surgery or abdominal wall surgery
  • Total knee replacement
  • Major open abdominal or thoracic surgery
  • Painful surgery, such as spinal fusion, wherein regional analgesia will not be adequate

Therapeutic Options

Parenteral analgesia, wherein analgesics are administered through intravenous (IV), intramuscular (IM), subcutaneous, transdermal, and transmucosal routes. The ideam multimodal analgesia strategy entails maximizing the use of nonopioid analgesics to reduce the patient’s dependence on opioids.

• Patient-controlled analgesia (PCA) is useful in patients who can cooperate and understand instructions for use of the PCA pump. This technique allows self-dosing with opioids up to a predetermined limit set by the clinician. 
• Common opioid side effects include sleepiness/drowsiness; poor respiratory control/difficulty breathing; urinary retention; and nausea and vomiting.  
• More serious opioid side effects include: tachycardia, hypotension, severe itching (pruritus), or constipation and intestinal obstruction.

Regional analgesia, wherein local anesthetics are administered around the nerves of the central nervous system, such as spinal anesthesia (also called subarachnoid anesthesia), and epidural anesthesia.

• Side effects are rarely life-threatening and include: systemic toxicity, hypotension, inadequate or failed block of pain mechanism, pruritus, nausea and vomiting, and respiratory depression. 
• The patient should be assessed regularly on the following: adequacy of ventilation; vital signs; level of sedation; motor function; and pain. Parenteral or oral opioids or sedatives should be avoided, unless specifically prescribed.

Epidural infusion combined with local anesthetics and opioids, administered via an epidural catheter.

• The patient receiving an epidural opioid infusion should not have standing orders for systemic opioids because of the risk of respiratory depression.
• The patient should be assessed daily on the following: vital signs; adequacy of pain relief and level of activity tolerated; degree of motor blockade/difficulty; nausea and pruritus; localized infection at the site of epidural catheter placement; and neurological changes. 

Peripheral nerve blocks target a specific nerve to block the pain mechanism. These are often used for surgical anesthesia, but may also be used for postoperative pain relief.
Oral analgesics.

Postoperative pain control for special populations. Postoperative pain control may be particularly challenging in some categories of patients, and an individualized multimodal strategy would be required per individual. These populations include:

• Morbidly obese
• Opioid-dependent patients
• Patients taking methadone 
• Patients taking buprenorphine
• Breastfeeding women

Persistent Postoperative Pain

Ten to 50 percent of patients may develop persistent pain, and two to ten percent of these patients may develop severe chronic pain. Increasing pain or persistent pain that lasts for months may be due to surgical factors, such as local scar formation, infection, hernia, foreign body reaction, or incisional neuroma (a benign tumor that arises in nerve cells). Patient factors and conditions unrelated to the surgery may also be the cause of persistent postoperative pain.

At Elite Pain Management, we understand that stress of facing a painful recovery from surgery. Contact our specialists to develop a plan before you undergo surgery as well as pain management afterwards. Our goals are to control pain so that you may return to regular active life as soon as possible. At the same time, we aim to help alleviate the stress of facing pain during your recovery period by developing a plan and coordinating with your surgeon.