Whats Behind The

Pain?
A Critical Question For Better
Postoperative Pain Management
A. Husni Tanra
Dept. of Anesthesiology, Intensive Care and Pain
Management

Faculty of Medicine, Hasanuddin

University

What the patients want for

their surgery?
The answers always are:

1. They want the surgery to be

successful
2. They dont want any complications
3. They dont want it to hurt (no
pain)
4. They dont want any SE of
analgesic.

What the Patients say for

his/her anesthesiologists?
Before 1990, most patients say
IM WORRIED THAT I WONT WAKE UP
AFTER THE SURGERY
After 1990, Due to the safe of
anesthesia, now, most patients
concern about their pain
IM WORRIED TO HAVE PAIN AFTER
THE SURGERY

Unrelieved Pain May Lead

PHYSIOLOGICAL DISTURBANCE
to
Imunosupression

Cardiovascular overactivity
Respiratory dysfunction
Renal suppression
Gastrointestinal dysfunction
Muscle spasm
Thromboembolic

PSYCOLOGICAL DISTURBANCE
Fear, anxiety, depression and suffering

Increase Morbidity and Mortality

Under treatment of postop

pain
have serious
Postop pain
Inadequate
consequences
treatment
Induction of
chronic pain

Physiologic and
psychological changes

Decreased
mobilisation

Increased risk of
deep vein thrombosis, pulmonary embolism, myocardial
infarction and coronary ischaemia

Mortality/morbidity, longer hospital stay, re-admission, decreased quality of life,

decreased patient satisfaction and increased health costs
Ballantyne et al. Anesth Analg 1998;86:598;
Wu et al. Anesth Analg 2003;97:1078;
Pavlin et al. Anesth Analg 2002;95:627;
Anesthesiology 2004;100:1573;
Perkins et al. Anesthesiology 2000;93:1123

CHRONIC PAIN IS A DISEASE

ENTITY
- Is a major problem of public health
- lead to emotional distress and suffering
(insomnia, anxiety, depression,can not work, etc)
-

Is really a killer for quality of life

What Does Pain Mean to

Patients?
Poor diagnosis and impending death
Particularly when pain worsens

Decreased autonomy
Impaired physical and social function

Decreased enjoyment and quality of

life
Challenges of dignity
Threat of increased physical suffering

Why postop pain continue

to be undermanaged ?
Some Bariers

1. Confusion about who is responsible for

postoperative pain management ?
2. Inadequate knowledge of analgesics (opioid &
non-opioid analgesics).
3. Administration of analgesic is too late, when the
patient complain of pain.
4. Using single modality and similar to every
surgery.
5. etc

Pain Relief is HUMAN RIGHT

Recently, pain relief is being viewed as
BASIC HUMAN RIGHT (ethical as well as
morally)
Unrelieved pain may adversely affect the
outcome of surgery ( morbidity and
mortality)
May lead to chronic pain ( financial and
social cost)
Pain should be viewed as the FIFTH VITAL
SIGN (recorded, assessed and managed
regularly)

Pain: The Fifth Vital Sign

Pulse
Blood
pressure
Temperature
Respiratory
rate

Pain:
The Fifth
Vital Sign

American Pain Society (APS) has redefined PAIN as the 5th

vital sign
Health care professional has to assess patients for pain
every time
June 2005

Pain Management
Pain management is so important
It is not appropriate to withhold pain
management until the investigations and
treatment of the underlying disease are
complete or other criteria are met
Unmanaged pain may lead to changes of
the NS (wind-up)
Reduce responsiveness to treatment
Devastating physiological and psychological

Several Technique for

Postoperative Pain
Management
PCA (Patient Controlled Analgesia)
Epidural / Intratechal with opioid
Epidural / Intratechal with local anesthetic
Nerve block (infiltration, intercostals,
intrapleural, etc).
NSAIDs (COX1, COX 2 and COX3)
MULTIMODAL ANALGESIA
etc.

Why Multimodal is the

best
for Postoperative
Pain?

Benefits of Multimodal
Analgesia
Opioids

Reduced doses of each

analgesic

Potentiation

Improved pain relief due

to synergistic or additive
effects
May reduce severity of
side effects of each drug

NSAIDs,
acetaminophe
n,
nerve blocks
1

Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

Multimodal Analgesia
PERCEPTION

Ketamin,
Tramadol
COX-2, COX-3

Pain

Descending
modulation
Ascending
input

OPIOID
- Systemic
- Epidural
- Subarach

MODULATION
Dorsal
Horn

LOCAL ANESTHETIC
- Epidural
-Subarachnoid
-Peripheral nerve
block
Dorsal
root
ganglion

TRANSMISSI
ON
Spinothalami
c
tract

Peripheral
nerve

LA
COX1
TRANSDUCTION
COX2

Peripheral
nociceptors

No single drug can produce optimal analgesia without adverse effect

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.

Trauma

Multimodal Analgesia
Parecoxib
Ibuprofen
iv

iv

Cox-2 agents

Ketamine

NMDA
antagonists

iv

NSAIDs

Better analgesia
Multimodal

Synergy
Additivity

Reduce side effects

Paracetamol
iv

iv

Opioids

NorAdr & iv
5HT antagonists

Local Anaesthesia
Tramadol

Jin et al. J Clin Anesth;13:524, 2001

Kehlet et al. Anesth Analg;77:1048. 1998
Woolf CJ, Science, 288:1765-1768, 2000

Role of Parecoxib (Dynastat)

The existence of COX2 injection brought a new era
of
Multimodal analgesia
Pre-emptive analgesia
Complete nerve block can not prevent central
sensitization
Tissue damage or inflammation may induce COX2
PG (via humoral) to induce central sensitization
Only parecoxib can inhibit COX2-isoenzyme both
peripherally and centrally

THANK YOU
Very Much
For Your
Attention