Postoperative pain management

Although scientific interest in the field of pain research is unremitting and the understanding of acute pain mechanisms has eminently advanced, it is evident that clinical practice of postoperative pain management still has major deficits. Indeed, the use of regional analgesia via a catheter, e.g. epidural analgesia (EDA), or patient controlled intravenous analgesia (PCIA) has become very popular. These methods require special equipment, adequate nursing skills and professional expertise as well as the establishment of clinical procedures and an appropriate logistic setup. However, the majority of patients are not managed by EDA or PCIA and cannot be ignored due to lack of knowledge of the proper use of basic analgesic treatment. Therefore, it makes sense to establish a standardized step-concept of postoperative pain management with regular quality control integrated into a multimodal perioperative rehabilitation program.     

Postoperative pain management

Postoperative pain can be effectively managed, even in the most complex oncologic procedures. Although the primary agents for treatment of severe pain continue to be opioids, routes of administration and dosing regimen have undergone a dramatic metamorphosis in the past 10 years. The intramuscular injection given every 4 hours has been replaced by patient-controlled analgesia and epidural techniques. Management of ancillary issues that contribute to an increased perception of pain (i.e., stress, depression, anxiety, and inflammation) must be included in an effective multimodal plan. Closer attention to the treatment of pain can obviate the consequences of poorly managed pain, which we are only beginning to understand. In this day of active consumerism in medicine, patients have come to expect improved pain management. Early outcome studies are beginning to confirm the belief that improved pain management translates into between outcomes and earlier dismissals. In the first century BC, Publilius Syrus, a Latin mime, wrote, "There are some remedies worse than the disease." For centuries, pain was inextricably linked to treatment. We may now be approaching a time in the development of medical care when this is no longer true.     

Postoperative delirium: risk factors and management: Continuing Professional Development

Purpose

Postoperative delirium often remains undiagnosed and therefore untreated. The purpose of this continuing professional development module is to identify patients at high risk of developing delirium following non-cardiac surgery and to provide tools to aid in the diagnosis of delirium at the bedside. Optimal prevention and treatment strategies are recommended.

Principal findings

Delirium is characterized by an acute onset and a fluctuating course, inattention, disorganized thinking and an altered level of consciousness, and occurs in up to 40% of patients in the perioperative period. The pathophysiology of delirium is multifactorial, but it is believed to be related to inflammation, altered neurotransmission, and stress in the patient who has had surgery. Acetylcholine and dopamine appear to play a significant role. There is an increased risk of a poor outcome in patients who develop delirium, including a longer hospital stay and death. Surgical and patient factors play a significant role in predicting who will subsequently develop delirium. Prevention is much more effective than treatment in the management of delirium. The most effective prevention strategies include proactive geriatric assessment and care of the patient on a geriatrics surgical ward as well as prophylactic low-dose antipsychotic agents. From an anesthetic perspective, evidence in some surgical populations would support the use of regional techniques and minimal sedation. If delirium develops, treatment with low-dose oral antipsychotics appears to be most effective.

Conclusions

Delirium is a serious condition that must be recognized early and treated promptly to minimize deleterious outcomes. In order to institute prevention strategies and treat the condition effectively when it occurs, the anesthesiologist must be vigilant in identifying patients at risk and in screening for this condition.     

Postoperative pain management: epidural analgesia

BACKGROUND: Epidural analgesia is one of the most effective regimens for postoperative pain relief after abdominal surgery. The use of epidural analgesia in high risk patients has been associated with significant decrease in surgical stress response, in cardiac and pulmonary morbidity, in recovery of gastrointestinal function and in thromboembolic events. The aim of this paper is to describe pain relief, side effects and recovery of gastrointestinal function during epidural analgesia. METHODS: During the period January 1999 to September 2001, 590 patients undergoing elective major abdominal surgery received epidural analgesia. Epidural catheters were inserted at T8-T9 (upper abdominal surgery) or T9-T11 (lower abdominal surgery) and ropivacaine 0.5% ml 7-12 combined with sufentanil 30 microg or with morphine 2 mg was injected. General anesthesia was induced and a continuous epidural infusion of ropivacaine 0.5% 5-10 ml/h was begun. Postoperatively, continuous epidural administration of ropivacaine 0.2% plus sufentanil 0.5 microg/ml or ropivacaine 0.2% plus morphine 0.02 mg/ml was continued. Data on the quality of analgesia, recovery of gastrointestinal function and all side effects were recorded for 4 days. RESULTS: Resting and incident pain scores were <4 and <5; 20% of patients received a rescue dose; the incidence of nausea was 6%, pruritus 5%; all patients also recovered from postoperative ileus. CONCLUSIONS: Continuous epidural analgesia resulted in good pain relief, provided the best balance of analgesia and side effects and improved postoperative outcome.     

Postoperative complications: delirium

Delirium is a common feature of the postoperative period, leading to increased morbidity and mortality and significant costs. Multiple factors predispose a patient to delirium in its hypoactive, hyperactive, or mixed forms. Tools have been validated for its quick and accurate identification to ensure timely and effective multidisciplinary intervention and treatment. A significant percentage of patients may require placement in skilled nursing facilities or similar care environments because of the long-lasting effects. The physician must be vigilant in the search for and identification of all forms of delirium and must effectively treat the underlying medical condition and symptoms.     

Postoperative delirium

Delirium is a common complication during the postoperative period. Because of its significant associations with physical and cognitive morbidity, clinicians should be aware of the evidence-based practices relating to its diagnosis, treatment, and prevention. Here, we review select recent literature pertaining to the epidemiology and impact of postoperative delirium, the perioperative risk factors for its development and/or exacerbation, and the strategies for its management, with additional attention paid to the population of patients in intensive care units.     

Postoperative pain management of the obese patient

In the obese patient, the goal of postoperative pain management is provision of comfort, early mobilisation and improved respiratory function without causing inadequate sedation and respiratory compromise. The pathophysiology of obesity, typical co-morbidities and the high prevalence of obstructive sleep apnoea (OSA) amongst obese patients make safe analgesic management difficult. In particular, pain control after bariatric surgery is a major challenge. Although several reviews covering anaesthesia and analgesia for obese patients are published, there is mainly expert opinion and a paucity of evidence-based recommendations. Advice on general management includes multimodal analgesic therapy, preference for regional techniques, avoidance of sedatives, non-invasive ventilation with supplemental oxygen, early mobilisation and elevation of the head of bed to 30 degrees. Finally, with regard to monitoring, sedation scoring is most relevant, but there should be a low threshold for continuous pulse oxymetry, arterial blood pressure measurement and placement in a high-dependency area for the postoperative period.     

Postoperative pain management in children

There is increased awareness of the need for effective postoperative analgesia in infants and young children. A multi-modal approach to preventing and treating pain usually is used. Mild analgesics, local and regional analgesia, and opioids when indicated, frequently are combined to minimize adverse effects of individual drugs or techniques.     

Postoperative pain management and outcome after surgery

Postoperative pain management aims not only to decrease pain intensity but also to increase patient comfort and to improve postoperative outcome. Better pain control is achieved through a multimodal combination of regional analgesic techniques and systemic administration of analgesic agents. To guarantee uneventful follow-up and unnecessary prolongation of hospital stay, it is important to avoid side-effects of analgesic agents, especially those of opioids which are dose-related, by decreasing opioid demand through combination with non-opioid agents. Epidural analgesia not only has the advantage of providing potent and effective analgesia but also of hastening recovery of bowel function and facilitating physiotherapy and rehabilitation. Unfortunately, a reduction in postoperative morbidity and mortality by epidural analgesia has not actually been demonstrated. Inclusion of postoperative pain treatment in a multimodal approach of patient rehabilitation may improve recovery and shorten hospital stay. Effective treatment of postoperative pain is also likely to prevent chronic pain syndrome after surgery, but further studies are needed to support this hypothesis.     

Postoperative transitory syndrome and delirium

In this review we discuss the symptoms, etiology and therapy of reversible organic mental disorders following surgery. Acute confusional states and delirium still pose difficult and unsolved problems in our operative wards and intensive care units. They are a major cause of morbidity and mortality following geriatric surgery. It is necessary to keep a watchful eye for signs of mild cerebral impairment. Slight disorientation, minor fear, depression or delusions can be the first step towards an aggressive or delirious restlessness. Changes in cognitive skills and a reduction in the operative level are useful guidelines. In most cases more than one etiological factor contributes to the psychopathology. The list of possible causes is long and the frequency and importance varies greatly. Preexisting dementia, unrecognized hypoxia, massive surgical procedures, extracorporeal circulation during cardiac surgery, drug and alcohol withdrawal, infections and the use of multiple medications with cerebral side effects can all interfere. A total, but reversible cerebral alteration or sometimes local damage with neurological dysfunction is thought to be part of the pathomechanism. Disorders of the blood-brain barrier, changes in transmitter turnover, disturbances in the circadian rhythm and REM sleep phases are also being considered. When attempting to make a diagnosis, one should look for signs of neurological damage, withdrawal reactions and exclude or verify major or menacing etiological factors. The therapeutic strategy consists of treatment of the underlying organic diseases, consistent and attentive care that provides orientation and support, and carefully selected medication. The change in pharmacokinetics during old age, and the anticholinergic or other confusion-inducing properties in drugs should be remembered. The administration of either minor or major tranquilizers should be in accordance with a clear treatment strategy.     

Postoperative pain management after supratentorial craniotomy

The aim of this study was to compare the analgesic efficacy of three different postoperative treatments after supratentorial craniotomy. Sixty-four patients were allocated prospectively and randomly into three groups: paracetamol (the P group, n = 8), paracetamol and tramadol (the PT group, n = 29), and paracetamol and nalbuphine (the PN group, n = 27). General anesthesia was standardized with propofol and remifentanil using atracurium as the muscle relaxant. One hour before the end of surgery, all patients received 30 mg/kg propacetamol intravenously then 30 mg/kg every 6 hours. Patients in the PT group received 1.5 mg/kg tramadol 1 hour before the end of surgery. For patients in the PN group, 0.15 mg/kg nalbuphine was injected after discontinuation of remifentanil, because of its mu-antagonist effect. Postoperative pain was assessed in the fully awake patient after extubation (hour 0) and at 1, 2, 4, 8, and 24 hours using a visual analog scale (VAS). Additional tramadol (1.5 mg/kg) or 0.15 mg/kg nalbuphine was administered when the VAS score was > or = 30 mm. Analgesia was compared using the Mantha and Kaplan-Meier methods. Adverse effects of the drugs were also measured. The three groups were similar with respect to the total dose of remifentanil received (0.27 +/- 0.1 mircog/kg/min). In all patients, extubation was obtained within 6 +/- 3 minutes after remifentanil administration. Postoperative analgesia was ineffective in the P group; therefore, inclusions in this group were stopped after the eighth patient. Postoperative analgesia was effective in the two remaining groups because VAS scores were similar, except at hour 1, when nalbuphine was more effective (P = .001). Nevertheless, acquiring such a result demanded significantly more tramadol than nalbuphine (P < .05). More cases of nausea and vomiting were observed in the PT group but the difference was not significant (P < .06). In conclusion, pain after supratentorial neurosurgery must be taken into account, and paracetamol alone is insufficient in bringing relief to the patient. Addition of either tramadol or nalbuphine to paracetamol seems necessary to achieve adequate analgesia, with, nevertheless, a larger dose of tramadol to fulfill this objective.