Current issues in

postoperative pain
management
HELLO!
I am Nabila Vika

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INTRODUCTION

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THIS IS A SLIDE TITLE

▰Pain relief after surgery continues to be a major medical

challenge.
▰Poorly managed postoperative pain may delay discharge and
recovery  patient’s inability to participate in rehabilitation
programmes  poor outcomes.
▰Recent advances are available in pain management.

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Problem
▰ Advances in pain managements have not led to any major
improvements, and undertreatment of postoperative pain
continues as a considerable problem worldwide.
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 POSTOPERATIVE PAIN
Prevalence of postoperative pain
▰Worldwide survey concluded that
the management of postoperative
pain was suboptimal.
▰Certain categories of patients are
at a greater risk of being
undertreated including the
pregnant, the paediatric, the elderly,
the opioid tolerant and the patient
undergoing ambulatory surgery.
Persistent postoperative pain
▰Persistent postoperative pain (PPP) is
a major cause of chronic pain and
therefore an important public health
problem
▰Given the very high prevalence, it is
time to include the risk of PPP in
preoperative information routines,
particularly for patients at high risk.
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 PHARMACOLOGICAL MANAGEMENT

Opioid therapy
Multimodal analgesia
▰Opioids are widely used because they are
▰the main aim is to reduce or eliminate
highly effective for relieving moderate-to-
the use of strong opioids which are
severe postoperative pain, do not have a
recognised to have many disadvantages
ceiling effect and are available in a wide
and unacceptable side-effects.
variety of formulations, thus remains the
foundation of postsurgical pain therapy. ▰the benefits of combining other
nonopioids is overrated, the side-effects
▰However, opioids have many dose limiting
generally ignored and the role of
side-effects that range from bothersome to
combining more than two nonopioids
life-threatening.
largely unknown.
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 REGIONAL ANAESTHESIA TECHNIQUES
Epidural techniques
▰the advantages of epidural
analgesia are not as impressive as
formerly believed and the risks are
greater than estimated in the past.
▰Epidural analgesia can no longer
be considered the ‘gold standard’ as
a routine method for the
management of postoperative pain.
Perineural techniques
▰there is convincing evidence about the
efficacy and feasibility of peripheral
nerve blocks to manage pain, and using
catheter techniques prolong the
duration of analgesia for an unlimited
time.
▰routine use of these techniques still
remains restricted to a relatively small
percentage of institutions.
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 INFILTRATIVE TECHNIQUES
Wound infiltration
▰Direct application of local
anaesthetics to the surgical site is a
rational approach to block pain
transmission from afferent
nociceptive barrage.
▰Surgeon-administered wound
infiltration at the end of surgery is a
simple and effective technique, and
is used routinely in many hospitals.
catheter infusion techniques
▰The technique involves catheters placed in
a number of sites including subcutaneous,
subfascial, preperitoneal, intraperitoneal,
subacromial, intraosseous, intra-articular
and others
▰Wound catheter infusions was effective
across a variety of surgical procedures
(abdominal, cardiothoracic, orthopaedic
and others).
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 INFILTRATIVE TECHNIQUES
Local infiltration analgesia (LIA)
▰LIA is a major recent development
in lower extremity joint replacement
surgery.
▰controlled trials are necessary to
address the many unanswered
questions such as the role of intra-
articular catheters and the most
appropriate drug combinations, the
technique is here to stay.
catheter infusion techniques
▰The technique involves catheters placed in
a number of sites including subcutaneous,
subfascial, preperitoneal, intraperitoneal,
subacromial, intraosseous, intra-articular
and others
▰Wound catheter infusions was effective
across a variety of surgical procedures
(abdominal, cardiothoracic, orthopaedic
and others).
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 INFILTRATIVE TECHNIQUES

Intraperitoneal local anaesthetics Transversus abdominis plane blocks

▰intraperitoneal use of local ▰TAP infiltration has been used
anaesthetic in laparoscopic successfully in bowel surgery,
cholecystectomy was shown to appendicectomy, hernia repair, umbilical
reduce pain, opioid use and the surgery and gynaecological surgery.
need for rescue.
▰The technique has been
demonstrated to be superior to
epidural analgesia in terms of
analgesia and reduction of hospital
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 CURRENT MANAGEMENT GUIDELINES
▰All pain management guidelines
advocate generalised ‘one size fits
all’ recommendations for the use of
analgesic drugs and techniques.
▰Procedure-specific Postoperative Pain
Management (PROSPECT) group
guidelines are such a source of evidence
based, procedure-specific
recommendations from an international
group of anaesthesiologists and
surgeons.
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ACUTE PAIN SERVICES
▰APS with a multidisciplinary
team approach has received
widespread formal acceptance
from national and international
organisations.
▰Worldwide, the number of
hospitals with an APS seems to
be increasing.
▰most APSs worldwide did not
meet basic quality criteria,
defined as regular recording of
pain scores at least once a day,
written protocols, dedicated
personnel and policies for pain
management during nights and
weekends
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 CONCLUSION
▰decades-old problem of undertreated postoperative pain is not
because of lack of effective drugs or techniques but to a lack of an
organised, multidisciplinary approach (APS) which uses existing
treatments.
▰Irrespective of the APS model, teaching programmes to upgrade
the role of ward nurses, standardised protocols and regular audits
are necessary to address the problem.
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THANKS!
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