Post-operative pain analgesia ladder.

PAPER IV JUNE 2009
Q. Post-operative pain analgesia ladder.
Managing patients in the postoperative period is often challenging. The spectrum of challenges depends on:

1. Patient factors: age, comorbid conditions etc
2. Surgical factors: site and nature of surgery, fluid and blood loss, nil by mouth
status etc
3. Local factors: availability of resources, man power, drugs, equipments etc.

There is an endless list of problems that can be encountered in the postoperative period. This section will focus on some commonly occurring ones in the postoperative ward.

Management of postoperative pain:

The effective relief of pain is of paramount importance to anyone treating patients undergoing surgery. This should be achieved for humanitarian reasons, but there is evidence that pain relief has significant physiological benefit.

Clinical factors

The site of the surgery has a profound effect upon the degree of postoperative pain a patient may suffer. Operations on the thorax and upper abdomen are more painful than operations on the lower abdomen which, in turn, are more painful than peripheral operations on the limbs. However, any operation involving a body cavity, large joint surfaces or deep tissues should be regarded as painful. In particular, operations on the thorax or upper abdomen may produce widespread changes in pulmonary function. The result will be an inability to cough and clear secretions which may lead to lung atelectasis and pneumonia. Matters are made worse by postoperative bowel distension or tight dressings.

Effects of pain

Pain causes an increase in the sympathetic response of the body with subsequent rises in heart rate, cardiac work and oxygen consumption. Prolonged pain can reduce physical activity and lead to venous stasis and an increased risk of deep vein thrombosis and consequent pulmonary embolism. In addition, there can be widespread effects on gut and urinary tract motility which may lead, in turn, to postoperative ileus, nausea, vomiting and urinary retention. These problems are unpleasant for the patient and may prolong

hospital stay.