PAIN MANAGEMENT IN SURGERY

BY

DR OGBUDU HENRYPAT UCHE

CONTENTS
DEFINITION OF PAIN
TYPES OF PAIN
CATEGORIES OF PAIN BY ANATOMICAL ORIGIN
PAIN ASSESSMENT
MEASURING PAIN INTENSITY
GOALS OF PAIN MANAGEMENT
GENERAL PRINCIPLES OF PAIN MANAGEMENT
PAIN MANAGEMENT APPROACH
MODALITIES FOR PAIN MANAGEMENT
INTERVENTIONAL PAIN MANAGEMENT
ADJUVANT MEDICATIONS
MODIFIED WHO ANALGESIC LADDER
REFRACTORY PAIN
PATIENT AND FAMILY EDUCATION
Summary

References

DEFINITION OF PAIN
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.
International Association for the Study of Pain
(Merskey, 1979)
Pain is always subjective. Cannot be measured
objectively
The patients self-report of pain is the single most
reliable indicator of pain.

TYPES OF PAIN
ACUTE: lasts less than 6 months, May be sudden onset or
slow in onset, subsides once the healing process is
accomplished
CHRONIC: involves complex processes and pathology.
Pain has no predictable ending, difficult to find specific
cause, Often cant be cured, Frequently undertreated. It is
constant and prolonged, lasting longer than 6 months, and
sometimes, for life.
CANCER: Pain that is associated with cancer or cancer
treatment. May be attributed to Tumor location,
Chemotherapy, Radiation therapy, Surgical treatment.

CATEGORIES OF PAIN BY ANATOMICAL ORIGIN

Somatic
Source:

Skin, muscle, and connective tissue

Examples:

Sprains, headaches, arthritis

Description: Localized, sharp/dull, worse with movement

Visceral
Source:

Internal organs

Examples:

Bowel obstruction, gastritis, kidney stone,

peritonitis

Description: Cramping, diffuse, referred, colicky, constant,

or touch, aching, deep, dull, gnawing

Pain med:

NSAIDS, Acetaminophen, Opiates

dull, less affected with movement

Pain Med:

Bone Pain
Source:

Sensitive nerve fibers on the outer surface of

bone

Examples:

Cancer spread to bone, fracture, and

severe osteoporosis

Description: Tends to be constant, worse with movement

Pain Med:

Opiates with NSAIDS as adjunct

Opiates, analgesics

Neuropathic
Source:
Examples:

Nerves
Diabetic neuropathy, phantom limb pain,
cancer spread to nerve plexis
Description: Burning, stabbing, pins and needles, shocklike, shooting
Pain Meds: Opioates, Tricyclic antidepressants
nortriptaline), Anticonvulsants (Gabapentin,
Carbamazepine), Local anesthetics
(Lidocaine), Topical capsaicin.

PAIN ASSESSMENT
Asking about pain is an important part of ALL assessments!!
Pain assessment should involve a full history and examination.
The history should show:

Appropriate investigations is necessary to confirm the source of

the pain. Cancer patients may need re-staging of their disease.

PAIN ASSESSMENT IN NON-VERBAL PATIENTS

The following are non- verbal behaviors that can
indicate the experience of pain:
Facial expressions: slight frown, sad, frightened face,
grimacing, wrinkled forehead, closed or tightened
eyes, any distorted expression, rapid blinking

Verbalizations, vocalizations: sighing, moaning,

groaning, grunting, chanting, calling out, noisy
breathing, asking for help
Body movements: rigid, tense body posture,
guarding, fidgeting increased pacing, rocking,
restricted movement, gait, or mobility changes

MEASURING PAIN INTENSITY

There are several types of pain measurement scales

It was developed and validated in children. Visual scales may be

more suitable for people with communication difficulties such as
aphasia, illiteracy, or language barriers. The only caution would be
that occasionally older adults mistake the Faces Pain Scale for a
measure of depression or sadness rather than pain intensity.

GOALS OF PAIN MANAGEMENT

Fulfill the patients right to pain management
What does the patient family/ caregiver want?

Decrease pain experience and control pain

Improve function and quality of life for patient
Minimize side effects of pain management therapy

GENERAL PRINCIPLES OF PAIN MANAGEMENT

Set a goal of reduction of pain to tolerable
levels, not a goal of complete relief
Start low and go slow
Make sure patient and family are aware of goals
Frequent clinic visits at first for assurance,
validation, and monitoring of titration

PAIN MANAGEMENT APPROACH

Could be single or multi-disciplinary involving
anesthesiology, urology, nursing, pharmacy,
psychology, and neurology departments.
Care is individualized and may depend on:
Pain source and intensity
Patients age
Developmental, physical, emotional and cognitive
status
Cultural beliefs
Treatment preferences
Concurrent medical conditions

MODALITIES FOR PAIN MANAGEMENT

Non-pharmacologic
Methods

Pharmacologic
Methods

Hot/cold treatments

NSAIDS (Aspirin, ibuprofen, ketoprofen)

Resting /Relaxation

Acetaminophen (Tylenol, paracetamol)

Distraction
Acupressure/acupuncture

Anti-convulsants (Gabapentin,
Carbamazepine)

Repositioning

Anti-depressants (Tricyclics, SSRIs)

Hydrotherapy

TENS (Transcutaneous Electrical Nerve

Stimulation)

Opioid analgesics (Codeine, Fentanyl,

Hydrocodone, Hydormorphone,
Methadone, Morphine, Oxycodone,
Oxymorphone)

Therapeutic touch/ Massage

Local anesthetics (Lidocaine)

Guided Imagery

Neurolytics (phenol, glycerin)

Interventional Pain Management

Tranquilizers/ sedatives

(Surgery)

INTERVENTIONAL PAIN MANAGEMENT

It may be possible to call on Neurosurgeons, Interventional
Radiologists or Anaesthetists with procedural experience to
perform a variety of neurolytic procedures including:

Intercostal nerve blocks

Coeliac plexus block (pancreatic cancer);
Saddle block spinal (rectal cancer, sphincter loss)
Lateral cordotomy (resistant lateralised body pain)

Other forms of Surgical intervention in pain management

include:
Repair for herniated disk
Excision of mass compressing on nerves

ADJUVANT MEDICATIONS
Adjuvant medications are used when there is a suspicion that the
pain is neuropathic in nature or when there is a pain that is difficult
to control and there are significant opioid side effects. A high
proportion of pain in cancer has a mixed mechanism of causation
and there is often a hidden neuropathic component present.

Acetaminophen (NSAIDS)
Tylenol and Motrin

Steroids

Relieve swelling and inflammation

Anti-emetics

Treatment for nausea and vomiting

Stimulants

Combats opioid induced drowsiness

Pamidronate (Aredia)
Zoledronic acid (Zometa)
Strontium-89 (Metastron)
Calcitonin (Calcimar)
Capsaicin (Zostrix) scheduled in
neuropathic pain

Clonidine (Catapres) all forms

Decreases experience of agitation/restlessness Cannabinoid (Marinol)

Antianxiety medications

MODIFIED WHO ANALGESIC LADDER

Reevaluate and adjust medications at regular intervals and as necessary.

Do not stop pain medication in terminal patients. Chang the route if needed.

REFRACTORY PAIN
In the context of cancer pain and palliative care practice, this refers to
pain that fails to achieve acceptable control despite the optimal use
of the WHO analgesic ladder approach.
It can be due to:
poorly controlled or unrecognised neuropathic pain.
central sensitization (wind up phenomenon); refers to changes in
the nervous system as a result of constant nociceptive input leading to
a wind-up of pain despite increasing opioids. One of the main
pathways involved is thought to be mediated by the N-Methyl-DAspartate (NMDA) receptor.

opioid induced hyperalgesia: where the neurones become sensitised

to opioids and these drugs then generate pain signals (pronociception) or transmit sensations as pain.
The emergency management of this type of pain uses Triple Agent
regimens, using an NMDA pathway inhibitor (e.g. Ketamine) in
combination with a reduced level of opioid, together with a potent
anti-inflammatory agent.

PATIENT AND FAMILY EDUCATION

Patients and family are given specific
instructions prior to discharge
regarding
Pain control

Pain medications
Management of potential side effects

SUMMARY
An unpleasant sensory and emotional experience associated
with actual or potential tissue damage. It is the clinicians
responsibility to determine the nature and cause of the pain and
its appropriate treatment.

Patients often have more than one site and mechanism of pain
operating at any given time, and these may require different
treatments.
Pain management cannot be put on auto-pilot, continual
monitoring and reassessment are necessary. Pain can change its
cause, location and nature during the course of an illness.
The answer to pain is not always more medication. The
psychological and emotional dimensions of pain and suffering
require attention at all times.

REFERNCES
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Doyle, Hanks, Cherny, Calman. Oxford Textbook of Palliative
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Geller A, OConnor K. The Sickle Cell Crisis:A Dilemma in Pain
Relief.
www.mayoclinicproceedings.com/content/83/3/320.full
Allard P, Maunsell P, Labbe J, Dorval M. Educational
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WHO Pain Relief Ladder for Cancer Pain Relief. Available at:
www.who.int/cancer/medicinescomplete/painladder/en/
(accessed 7 February 2012)

THANK YOU