Post-operative pain: how to do better
With Dr Kristiina Kuusniemi | 9 Apr 2015 | Print
Dr Kuusniemi is Head Anesthetist in Terveystalo Hospitals, and Adjunct Professor of the Department of Anaesthesiology at Turku University Hospital in Finland.
Do you believe that post-operative pain is currently managed adequately?
No, I believe that it is under-treated. Studies have found that about 80% of patients report experiencing pain post-operatively and, even more worrying, 30% to 40% of these patients say their pain was severe during the post-operative period.[1-3]
What measures can be taken to improve post-operative pain care?
At Turku University, we ran an educational program over a 2-year period to improve our post-operative pain care. We educated nurses in the post-anesthetic care unit (PACU) and both nurses and doctors on the wards to make sure that pain care was optimal not just in the PACU, but also after transfer to the wards.
Patient education was also critical. We created a range of booklets and leaflets that we still give to every patient. These let patients know what to expect during their hospital stay and what modes of pain relief are available to them. This includes information on intravenous medications, patient-controlled analgesia (PCA), epidural pain treatment, peripheral nerve blocks, etc. All of this pre-operative work is an important part of the strategy for improving post-operative pain care.
What sort of approach do you employ to prevent post-operative pain?
We employ a multimodal pain management program and the first part of that is to provide appropriate pre-medication to the patients. Previously, we used sedatives to reduce patients’ anxiety before the operation. But nowadays, we use a combination of different pain medications in an effort to prevent post-operative pain so the treatment starts well before the procedure.
It is also essential to ensure the patients are well informed. This is also part of the pain management program, really. The patient needs to know what’s going to happen, know what analgesic techniques will be used, how to use them – in the case of PCA – and what to expect from the treatment.
Is sedation a concern during post-operative pain management?
The aim in Finland is to adopt a ‘fast-track’ surgery concept; get the patient up and moving as soon as possible. Sedation and side effects would work against this.
By using the multimodal pain management techniques, it’s possible to reduce or eliminate sedation, as this is dependent on the drug concentrations. By combining analgesic techniques, we can minimize the opioid dose, avoid sedation and side effects, and get the patient ambulatory as soon as feasible.
Is fear of opioid addiction something you have to address with patients in this setting?
In Finland, addiction fears aren’t really the major problem. Patients are more likely to be concerned about side effects such as nausea and vomiting and dizziness, especially if they have experienced these side effects before. We have to explain that we can minimize the risk of these side effects by careful dose titration to the appropriate opioid dose.
This is where the multimodal pain management comes in – by using a variety of complementary or even synergistic agents and modalities, we can optimize the doses of each agent, including the opioid analgesic. Thus, we obtain the required pain relief with a reduced risk of unpleasant side effects for the patient.
1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534-540.
2. McGrath B, Elgendy H, Chung F, Kamming D, Curti B, King S. Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth 2004;51:886-891.
3. Beauregard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery. Can J Anaesth 1998;45:304-311.
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