Indian J.
PG
340 ISSUE2006;
Anaesth. : PAIN50 (5) : 340 - 344
ACUTE POST OPERATIVE PAIN
Dr. Manimala Rao
Keywords : Acute, Post Operative, Pain.
Introduction
The relief of pain has been one of the primary reasons
for development of health care. Acute pain management
came into force as a speciality in 1988 in Seattle where
Brain Ready published his concept of acute pain services.1
Later in 1990 with joint colleges report that recommended
the setting up of acute pain services at all hospitals. Acute
pain teams are widespread in US, Australia and Europe.
The decade has been denoted as decade of pain management
and research. Pain has been introduced as the fifth vital
sign by Joint commission on health care organization
(JCAHO). They have published the standards for pain
management in hospital setting in 2001.2,3
Pain is omnipresent, is an intolerable sensation and
makes the patient vulnerable. There is a saying that there
is no gain with out pain. This may not be true in the acute
postoperative pain. It is well documented that pain
inadequately relieved is deleterious and can lead to a number
of complications in the post operative period Therefore the
pain of surgery must be relieved totally.
Acute pain services (APS)
Despite good understanding of its patho-physiology
and awareness regarding the beneficial effects of pain
relief in the post op period, many patients do not receive
adequate analgesia. This problem is international in
character. Patient controlled analgesia spinal opioids
regional analgesic techniques have provided better pain
relief than intermittent injections of opioids. Such of the
above techniques require special monitoring. Therefore one
may require an organization which will provide education
and policies that permit physicians and nurses to care safely
for the patients.
Number of times national guidelines have been
published in several countries but the impact of these
guidelines on the patient care was not clear. The key
recommendation was to introduce APS. The principle
obstacles were financial constrains and under educations of
physicians regarding its management.4 Similar problems
were envisaged in many countries.5 Further APS using a
multi disciplinary team approach received a wide spread
Professor Emeritus & Head of Anaesthesiology and
Critical Care Yashoda Hospital, Somaji Guda, Hyderabad
(Formerly Prof & Head NIMS Hydarabad)
E-mail : manimalarao@hotmail.com
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006
340
acceptance and financial support from the institutions and
organizations from many countries. The key recommendations
of United Kingdom working party are as follows.
1) Need for education and training and changing the
attitudes as well as provide adequate funding.
2) Systematic record of pain as the 5th vital sign.
3) A named member of staff should be responsible for
the hospital policy toward post operative analgesia
audit and appraisal.
4) All major hospitals per forming surgery should
implement APS with a team approach, with a physician,
nurse, pharmacist and psychological expertise.
Anaesthesiologist has the primary key role.
5) There is need for powerful but safe analgesics and
long acting nontoxic local anaesthetics.
With advent of APS the Anaesthesiologists are
offering new and powerful analgesia. However the bed
side nurses have to be trained and be responsible to deliver
the analgesics and monitor their adverse effects. The nurse
or the anaesthesia technician can be trained in this area in
our country. The protocols should be simple and could be
modified when necessary. Anaesthesiologists play a pivotal
role in acute pain services. APS is still not a very well
organized in our country, even though the anaethesiologist
takes care of post operative pain relief in major surgical
procedures as well as takes care of the surgical ICUs. It
has to go a long way to educate, train and implement APS
in all major hospitals.
Importance of post operative pain management and
mechanisims
The relief of pain has been one of the primary
reasons for development of health care, yet physicians
often do not understand the meaning of the complaint of
pain or how effectively they can assist the patient to regain
control over his or her life. Anesthesiologists should
understand the various concepts in generation of pain and
not allow their technological skills only to govern all their
interactions with pain. Although treatment of pain for its
own sake is considered a worthy duty in medicine, it has
not been vigorously pursued as it should have been. One of
the reasons for the invention of hypodermic syringe in
MANIMALA : ACUTE POST OPERATIVE PAIN
1840 was to deliver the analgesics Alexander Wood
produced relief of pain but perhaps not by morphine
conduction block but by systemic use.
Pain derived from Latin word Poena means
punishment. It has been defined with acute or potential
danger or described in terms of such danger very aptly by
International Association for study of pain. Understanding
of pain is very important. It should be viewed form 4
points. They are nociception, pain, suffering and pain
behaviour. The acute pain has meaning and the underlying
pathophysiology is obvious. Postoperative pain forms one of
the categories of acute pain. Anesthesiologists focus
their attention on the abolition of postoperative pain. It
would be nice if anaesthesiologists worried a bit more
about patients pain after his/her departure from the operating
theatre. This has led in many countries to manage acute
pain services by anaesthesiology team. A redefinition of the
role of anaesthesiologists, dedicated to manage the acute
pain of surgery will bring tremendous improvement in
health care delivery in the pain management services which
ultimately leads to patient satisfaction and reduces the dread
of surgical procedures.
Surgery activates the stress response post op pain
also has somewhat the same but not an identical effect.
Both are modified by nerve blocks and central neuraxial
blocks like the spinal and epidural anesthesia.
It is now well recognized that prolonged insult
to the body produces changes in the nervous system,
which alter the normal physiological response to a
noxious stimulus. Therefore pain is divided into two
entities, physiological and pathophysiological or clinical.
The process underlying both are totally different.
Physiological pain describes the situation where a noxious
stimulus activates peripheral receptors, which transmit
the information via several relays until it reaches the brain
and is recognized as harmful stimulus. This entity can
also be often referred as incissional pain. The latest
development is ON Q systems are simple pumps which can
deliver non narcotic medication at the incision site
with a multi lumen catheters inserted by the surgeon at
the time of surgery. They target the specific area and
prevent the sensitization of the receptors to nociception.
They deliver the set concentrations of local anaesthetic
solutions to the specified area.
The factors responsible for development of clinical
pain will result in a stimulus response system that has quite
different characteristics from those of physiological pain.
Inflammation or nerve damage gives rise to changes in
sensory processing at peripheral and central level with a
resultant sensitization. Once sensitization occurs the
341
stimulus, which normally do not produce pain, are perceived
as painful (allodynia) and there is an exaggerated response
to painful stimulus (hyperalgesia).
Fig. 1 : Physiological pain
Low intensity stimulus
Sensitized
Low threshold nocioceptor A
Mechanoreceptor delta & C
A beta PNS
CNS
Hyperexcitable
dorsal horn neuron
PAIN
Fig. 2 : Clinical pain
Surgery in particular, produces biphasic insult on
human body, which has implications for pain management.
First of all, during surgery there is trauma to tissue, which
produces noxious stimuli and great nociceptive input.
Secondly, after surgery there is inflammatory process at
the site, which is also responsible for noxious input. Both
these processes sensitize the pain pathways. They occur at
peripheral level where there is a reduction in threshold of
nocioceptive afferents and at a central level with an increase
in excitation of spinal neurons involved in pain transmission.
It has profound implication for management of acute pain
and provoked interest in the use of preemptive analgesics
and new methods of postoperative pain management with
new agents of non-opioid type and in combination with
opioid drugs.
Peripheral sensitization can be with different stimuli,
VIZ., thermal, tactile, mechanical, chemical and their first
relay is in the dorsal horn. In clinical situation this noxious
342 PG ISSUE : PAIN
stimuli is prolonged resulting in tissue damage and
inflammation. This leads to release of a soup of
inflammatory mediators such as K, serotonin, bradykinin
substance P, histamine etc. These substances act to sensitize
high threshold nociceptors. As the low threshold stimuli,
which would not normally cause pain, are now perceived
as painful.6 If one would like to reduce peripheral
sensitization rational approach is to prevent or reduce the
inflammatory soup, use of NSAIDS and peripherally acting
drugs, combination of opioids, local anaesthetic drugs.
Inflammatory response is part of complex injury. Therefore,
sensible modification of the injury response becomes part
of the strategy for pain management and acute rehabilitation.
Studies are confirming that such strategies reduce pain,
post surgical catabolism and early discharge from hospital.
Tissue damage Inflammation Sympathetic
terminals
SENSITIZING SOUP
Hydrogen ions Histamine Purines Leucotrienes
Noradrenaline Potassium ions Cytokines Nerve growth factor
Bradykinin Prostaglandins 5-HT Neuropeptides
High threshold nocioceptor
Transduction sensitivity
Low threshold nocioceptor
Fig. 3 :Peripheral sensitization
Central sensitization - Recent research has focused
on dorsal mechanisms. Following injury, there is an
increased response to normally innocuous mechanical
stimuli (allodynia) and a zone of secondary hyperalgesia in
uninjured tissue surrounding the site of injury. It is now
known that a secondary C fibre barrage in primary afferent
fibres leads to other morphological and biochemical
changes in dorsal horn which may be difficult to reverse.
Firstly, there could be expansion in receptor field size
Secondly, there is an increase in the magnitude and
duration of response to stimuli and finally there is a
reduction in threshold, so that stimuli, which are not
normally noxious, activate neurons, which usually transmit
nociceptive information. It appears, NMDA receptor
may mediate responses in the physiological processing of
sensory information, and is involved in central sensitization.7
Ketamine, which is NMDA receptor antagonist, has profound
analgesia. Nitric Oxide(NO) has a role in nociceptive
processing. NO is produced secondary to NMDA receptor
activation. Drugs, which may prevent production or block,
may have a role for reducing or abolishing pain.
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006
Nocioceptor input
Activity-dependent increase
in excitability of dorsal horn
neurons
Low threshold
Modified responsiveness
Mechanoreceptors
(A beta fibres) PAIN
(Mechanical allodynia)
Fig. 4 : Central Sensitization
(Figures are from Woolf CJ, Chong MS Anesth Analg
1993, 77: 362-379)
There are basically two approaches, one is to
investigate the agents, which act at spinal level on opioid,
a adrenoreceptors and NMDA receptors, and the other is
to prevent central sensitization. The concept of preemptive
analgesia has arisen as a result of these findings, to minimize
or prevent these changes.
Preemptive analgesia - while the concept of
peripheral sensitization has been well recognized, the central
sensitization component after surgery, despite convincing
animal data, failed to suggest it following surgery. Simple
analgesics such as morphine or nitrous oxide, given to
patients prior to surgery, may not act preemptively and
prevent significant central sensitization. Nerve blocks and
regional techniques may to certain extent modify the
sensitization.
Balanced analgesia has evolved under the direction
of Kehlet and Dahl. They propose that pain free state
should be utilized to the patients advantage with aggressive
regime of post operative mobilisation and early enteral
feeding. This may reduce deep vein thrombosis and amount
of protein wasting and making the patient more anabolic.8
Wound infiltration and nerve blocks - Local
anaesthetics reduce nociceptive pain at the site of operation
and also attenuate central sensitization. Nerve block provided
slightly superior analgesia, the later covers entire area
whereas infiltration may have the advantage of blocking the
peripheral sensitization. Despite the advantages one must
also keep the risks associated. Infection used to be the most
important concern. With the advent of ON Q systems which
have been used in post cardiac surgical patients as well as
in many other surgical procedures of herniorraphy and breast
surgery. Specialized pumps deliver non narcotic local
anesthetics at the area of incision, giving the medication
where it is needed. Specially designed catheters and simple
pumps which can be clipped on to the clothing are a novel
MANIMALA : ACUTE POST OPERATIVE PAIN
way to provide the post operative pain relief. The benefits
are reduced dosage of narcotics and their associated
complications.9
Non pharmocological methods
Though pharmacotherapy forms an integral part of
management of acute pain, one has to look at various other
methodologies to relieve post operative pain The non
pharmacological methods can be used as adjuvants to the
main method of pain relief. A holistic approach can cut
down costs and reduce the complications associated with
the opioid and non opioid drug usage and dosage. A
combination of pharmacotherapy and patient education in
the pre operative period may go a long way in treating acute
pain after surgery. lot of interest in complimentary and
alternative medicine (CAM) for chronic pain management
is in vogue which could be applied for acute pain.
With work on stress response system, a system
integrating body and mind has evolved is also goes by the
name of psycho neuro immunology.10 Disease is created
when there is discrepancy between autonomic and endocrine
systems, resulting in inappropriate fight and flight reactions.
Treatment focuses on balancing the sympathetic overdrive
by using body and mind techniques viz.
Bio feed back & Hypnosis These techniques can be
counter balancing the Meditation and Yoga relaxation
response.
But every thing can never be explained on the CAM
technique.
Common cam techniques for post op pain
Herbal medicine, Hypnosis, Homeopathy, Therapeutic
touch, Meditation, Trans cutaneous nerve stimulation
(TENS), Acupuncture, Heat application are a few to name.
Cognitive dysfunction
Occurs in 10-15% of patients in the post op period.
More common in the elderly alcoholics electrolyte imbalance
and usage of benzodiazipine and Pethidine were also
implicated. High levels of post op pain can cause delerium
and vice versa. It can impair cognition and worsen the
pain.
Herbal medicine
Many of the pain medications are derived from
plant extractions and are purified alkaloids. Modern pain
relieving extract from chlli pepper (capsicum) is commonly
used. The active ingredient in zofran crme is capsaician
which depletes substance P from nerve terminals. Is
beneficial in amputation phantom limb pain, and post
mastectomy syndrome.11,12
343
Hypnosis
Is a mind body technique creates focused attention.
It is self hypnosis where therapist functions as a guide to
help patient to focus attention as well as filter out unpleasant,
and negative sensation and receive positive sensation.
Currant research shows it is not a passive withdrawl of
awareness but rather an active suppression of somato
sensory cortex by frontal cortex.13 Anecdotal reports abound
but growing scientific literature on the role of suggestion
in preparing for surgery there by reducing the post op
pain.14
Homeopathy
Symptom is Considered as positive sign throwing off
the disease state. It has proved to be effective in allergy
and asthma, but not so effective in acute pain. Argument
against is that the methodology employed was not
effective.15,16
Therapeutic touch
IT is a nursing technique based on purported human
energy field that surround the body as magnetic field surround
a magnet. It involves three steps. First the nurse positions
and observes, second detects any abnormal movement, third
corrects them. By non contact movements of the hands over
the affected area. It has resemblance to an ancient technique
used in China and Europe for many years. It has shown to
relieve phantom limb pain.17 More work is required to
validate this form of energy.
Meditation
In many ancient cultures meditation could voluntarily
stop the heart, bring down the respiratory rate, prolong
suspended animation and relieve pain completely. Modern
research has also indicated that it is useful in chronic pain.
As against the common belief it does not require years of
training. Simple techniques like closing the eyes and
concentrating on breathing and slowly coming back to reality
is an useful tool which can be practiced before surgery and
would be useful to reduce the dose of pain medications in
the post operative period. Could be included in the holistic
approach in CAM therapy along with usage of conventional
methods of pain relief.
Tens in acute post op pain
It is accepted that use of TENS either at acu point
or dermatome corresponding to surgical incision decrease
the post op pain, opioid requirement, and related side
effects. The effect of frequency of electrical stimulation
was studied in 100 women undergoing gynecological
surgeries. Post op pain was controlled with patient
controlled analgesia with morphine, and sham tens without
344 PG ISSUE : PAIN
stimulation in one group, 2Hz, 10Hz, and mixed 2 and
10 Hz respectively. The last group showed better pain
relief and 53% decrease in morphine requirement, as well
as reduced itching nausea and vomiting.18
Acupuncture
Derived from Greek word Acus means needle and
punctura means puncture. This method was practiced in the
5th century B.C in China. The basic theory is that of Yin
and yang balance opposing influences in nature. The
evidence of release of endogenous peptide with AP and EP
derives from seminal work done by Pomeranz.19 Opiod
receptor antagonism has shown to abolish the analgesic
effects of acupuncture. The fascination for this ancient
medical modality increased when one of the press Corps
from presidents Nixons troupe received it for appendectomy.
IT can be used like TENS in reducing the requirement of
medications.
CAM interventions have become more and more
acceptable in public. Though one does not have a very clear
cut idea about the mode of action, one can never turn the
back on these methods They may form part of holistic
approach to pain management in the acute post op pain in
future, as they are already a part of chronic pain
management. More research and funding is being relegated
to this aspect, in view of public interest. In future it may
potentially transform the way pain management is practiced
even in the acute setting.
Inspite of great interest in understanding the pain
mechanisms and pain management, number of patients still
suffer unacceptable pain even today. Surveys show that
there is not much improvements in this area. So it is quite
clear that the solution to post operative pain is not just
developing a single technique.
Or a drug to relieve it but to implement simple
protocols that suit in different settings with strategies to
exploit the available expertise. Anaesthesiologists with their
expertise not only in understanding the pathophysiology,
but coupled with their technical and technological expertise
could with commitment make it safe as well as comfortable
to the individual patient needs. They could inturn play a
pivotal role in organize and manage pain sevices to the
entire hospital.
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