Controlling pain in the post-operative setting

• Published in: International journal of clinical pharmacology and therapeutics Vol. 49; no. 2; pp. 116 - 127
• Main Authors: Costantini, R, Affaitati, G, Fabrizio, A, Giamberardino, M A
• Format: Journal Article
• Language: English
• Published: Germany 01-02-2011
• Subjects: Analgesia; Analgesics, Opioid - therapeutic use; Anesthetics, Local - therapeutic use; Animals; Humans; Minimally Invasive Surgical Procedures; Pain, Postoperative - diagnosis; Pain, Postoperative - therapy
• ISSN: 0946-1965
• DOI: 10.5414/CP201401

Post-operative pain (POP) is a form of acute, intense pain experienced in the period following surgery, whose adequate control is often problematic. This paper reviews determinants and characteristics of POP, together with rationale and current protocols for its management.
Main determinants of POP are the type of intervention and the disease motivating surgery, though other factors related to patient (age, pain threshold, socio-cultural factors, personality) and setting (pre-operative information, relationship with medical staff) may also influence its perception. POP control is essential to relieve suffering but also to prevent dangerous consequences on organ systems, e.g., reduced cough, atelectasis, increased myocardial oxygen consumption and ischemia, constipation, urinary retention, reduced musculoskeletal mobility and increased risk of deep venous thrombosis.
Constant assessment of pain intensity is recommended for optimal POP control. This is mostly achieved pharmacologically with monitoring of side-effects. Multi-modal analgesia is recommended, combining different drug classes, e.g., an opioid (morphine, pethidine, fentanyl, tramadol, codeine) with a non-opioid (NSAID; Cox-2 inhibitor), delivered through various routes, and including neuraxial use of local anesthetics (bupivacaine, ropivacaine) alone or in combination with other drugs, nerve blocks, antihyperalgesics (ketamine, dextromethorphan) and techniques such as patient-controlled analgesia (PCA) and pre-emptive analgesia. An efficient organization of pain services is also recommended.
Acute post-surgical pain represents a crucial problem, but the multimodal therapeutic approach has enhanced the efficacy of pain-control while minimizing side-effects of each modality. Further improvement of POP control will necessarily involve better organization of pain services.