Premedication

Analgesia can be given to patients prior to arrival in the theatre suite. The oral route is

preferred unless there is a clinical contraindication.

Pre-emptive analgesia

This term refers to the delivery of analgesic intervention(s) before the first surgical incision.

The rationale is to stop (or obtund) the transmission of the intense nociceptive barrage to the

brain that occurs with the onset of surgery. In theory this should prevent sensitization of the

neural pathways and reduce the requirement for subsequent postoperative analgesia. There is

good evidence from animal studies that this can be effective. However, it has not been

possible to unequivocally demonstrate that an analgesic intervention made before surgical

incision significantly improves postoperative analgesia.

Preventive analgesia

Preventative analgesia aims to provide a longer duration of effective analgesia in the

perioperative period (hours to several days). There is evidence that successful analgesic

interventions in this initial perioperative window have a beneficial effect on postoperative

pain or on analgesic consumption that exceeds the expected duration of action of the drug.

• NMDA receptor antagonist drugs show preventive analgesic effects. For some procedures

the use of ketamine at induction reduces postoperative morphine consumption.

• The severity of pre- and postoperative pain influences the development of chronic

postsurgical pain and there is evidence that early analgesic interventions reduce the incidence

of chronic pain after surgery. Pain management should therefore begin prior to surgery and

be continued throughout the patient’s hospital stay.

Intraoperative pain relief

Good intraoperative pain relief is often the key to success of postoperative pain control.

Analgesic drugs should be given early enough (determined by their pharmacokinetics) to

ensure suffi cient analgesia when the patient is waking from the procedure. A multimodal

strategy should be employed, including paracetamol +/– NSAIDs and either an opioid, LA

block, or regional blockade.

The World Federation of Societies of Anaesthesiologists (WFSA) analgesic ladder

The WHO analgesic ladder was introduced to improve pain control in patients with cancer by

employing a logical strategy to pain management (see b WHO analgesic ladder p.34). The

same principles have been adopted and modifi ed by acute pain teams in postoperative pain

management. One such scheme is the WFSA analgesic ladder (Fig. 3.1 ), which has been

developed to guide the treatment of postoperative pain. Early postoperative pain can be

expected to be severe and may need controlling with strong analgesics in combination with

LA blocks and peripherally-acting drugs. As pain is easier to prevent than to bring under

control once it has become entrenched then proactive early management is crucial to a good

outcome.

The dose of opioid should be increased until pain relief has been achieved or side effects

prevent increasing the dose further. There is a very large variation in amount of opioid

required between patients and because opioids have no ceiling effect they should provide

effective analgesia for most surgical procedures. The opioid prescription should allow for the

great variation in individual opioid requirements. If side effects prevent increasing the opioid

dose further, a different opioid drug should be considered. When increasing doses of opioids

are ineffective

in controlling pain, a prompt search for new or residual pathology is indicated — also

consider neuropathic pain.

Transition from parenteral to oral medication

As a general principle, oral analgesia should be favoured wherever possible. Parenteral

injections can cause pain and local trauma that may prevent patients requesting analgesia.

Further they increase infection risks for both patients and staff. However, in some instances,

the oral route

may not be possible because of the nature of the surgery. Rectal, IM, and SC administration

all have a time delay and considerable variability in absorption to the circulation and the IV

route is usually the most appropriate in the initial perioperative period, allowing rapid loading

and titration against effect.

Typically, postoperative pain will decrease with time and the need for drugs to be given by

injection should diminish. The second rung on the postoperative pain ladder is the restoration

of the use of the oral route to deliver analgesia. Initially, strong IV analgesia may need to be

replaced with strong oral opioid analgesia (e.g. morphine sulphate solution R and morphine

sulphate (modifi ed release)). The previous parenteral dose in 24h should be calculated and

this dose should be given orally in divided doses of a long-acting opioid. A fast-acting opioid

should be prescribed for breakthrough pain. This can subsequently be stepped down to

combination preparations of weak opioids or smaller doses of strong opioids. Finally, as

healing continues, pain may be controlled with simple analgesics such as paracetamol and

NSAIDs.