Managing Pain in the
Surgical Patient
LUCILLE LUTZ, RN, MSN, APRNBC
CLINICAL NURSE SPECIALIST
PAIN MANAGEMENT
Objectives
•Discuss preop pain assessment
•Discuss intraop pain management
•Discuss postop pain management
Background
Acute Pain
• Immediate
• Serves as a warning
• Easier to treat (generally)
• Has an end (generally)
Background
Chronic Pain
• Lasts longer than 3-6 months
• Serves no purpose
• Cannot identify a cause
• Can lead to pain behaviors
• Very difficult to treat
Pain Conduction
•Injury triggers release of bio-chemicals
•Inflammation takes place
•Stimulation of nerve fibers
•Bio-chemicals causes pain impulses to
begin
Pain Perception
•Impulse is sent to the brain via ascending
tracts in spinal cord
•Neurotransmitters released by C fibers
(substance P)
•Message to the brain (Thalamus)
•Sends message down descending
pathway= pain response
Why Pain Control
•Persistent acute postoperative pain:
•Decreases the body’s physiologic
reserves
•May exacerbate co-morbid conditions
(e.g.) increase risk of MI in patients with
CAD
•Contributes to pulmonary complications.
•Impairs rehabilitation and functional
outcome
• May lead to development of chronic pain
syndromes and long-term disability.
• Increases hospital stay and the cost of
patient care
• Decreases patient satisfaction.
Metabolic Stress Response
•Surgical insult results in post op pain
•Increased circulating catecholamines
•Resulting in tachycardia and hypertension
•Leading to increased cardiac work
•Resulting in increased myocardial oxygen
consumption
Cardiovascular
• ↑ HR, ↑ BP, ↑ SVR, altered regional blood
flow, ↑CMO2, ↑ DVT
Respiratory:
•– ↓ VL (atelectasis), ↓ cough (sputum
retention)
•– hypoxemia and infection
Gastrointestinal:
•– ↓ gastric and bowel motility, nausea,
vomiting
•• Genitourinary: urinary retention
•• Neuroendocrine: ↑ catabolic hormones
•– ↑ blood glucose, Na + H20 retention
Musculoskeletal: Muscle spasm,
immobility (↑ DVT)
Psychological: fear, anxiety, insomnia
•• Chronic pain
Pre Op Assessment
•Indication for surgical procedure
•Allergies and intolerances to medications,
anesthesia, or other agents
•Known medical problems
•Surgical history
•Trauma (major)
•Current medications (incl.OTC herbal &
dietary supplements,and illicit drugs)
Gayatri,P (2005). Post-op pain services. Indian J.
Anaesth. 49 (1) : 17-19
•Discuss History of Acute or Chronic Pain
•Identify history of pain control methods
•What has worked
•How long on pain meds
•Do they work
•True allergies, ask what happens
•Differentiate between tolerance and
physical dependence
•Discuss pain management problems
(ie) anxiolytic therapy with pain meds
Identify if there is a need to wean from any
pain medications prior to surgery
•Do not stop suddenly
•Consider Patients with:
•Multiple back operations
•Abdominal pain patients (ie) Crohn’s
disease
•Recurrent cancer
•Chronic joint pain, (ie) RA or DJD
•If with a history of chronic opioid use for
pain management may require higher
doses for pain control
•This will include using PCA and/or meds
for break through pain
•May not get adequate relief with
“standard” doses of “standard” post op
pain orders
• Do a directed pain history
• Type of pain
• Location, description, duration,
exacerbation and relieving factors
• Directed pain examination
• Discussion of post-op pain control plan
What about the Elderly
•Evaluate each patient individually
•Do not assume that aging is the same in
all patients
•Evaluate for side effects of narcotics
•Need complete list of meds to check for
interactions
•Dispel myths
• Concerns about opioids
• Concerns about addiction
• Fear of tolerance
• Age related expectation of pain
Pre Op Teaching
Educate patient/family/staff
• Pain plan
• How & when to evaluate
•Use of alternative methods of pain control
•Patient and/or Family education on use of
PCA
•Explain blocks !!!!!!
•Provide pre-anesthetic evaluation,
brochures, and videotapes to educate
patients about therapeutic options (music
and/or guided imagery, other)
Preoperative Preparation of the Patient
Instruct on bedside postoperative
evaluation
Include instruction in behavioral
modalities to control anxiety
 Distraction,
deep breathing,
visualization (etc)
Preoperative Preparation of the Patient
Instruct on pain ranking tools prior to
surgery
Use age appropriate tools, why, when
and how to be used.
 Instruct S.O., parents if needed.
May want to use personalized tool
(i.e.Randall)
•Generally there is decreased cardiac and
pulmonary reserve with increased age
•Opioids may produce confusion or cause
some delirium postoperatively in some
patients
•An elderly patient taking six medications
is likely to have adverse reactions 14 times
more than a younger person taking the
same number of medications.
•Consider additive respiratory depressant
effect of both opiates and anxiolytics
•Most elderly patients metabolize drugs at
a slower rate and may require lessfrequent dosing or a reduction in dosage
•Certain medications should be avoided in
elderly patients, based on their adverse
effects
•(Beers list)
•Sedative effects with an increased risk of
falls
•Constipation related to opiates & NSAIDS
• May have reduced gastrointestinal
motility
•Stool softener with stimulant
•Start pain meds at a lower dose and
increase to pain relief if opioid naive
Special Populations
Pediatrics
• Use pain scales specific to age
•
FLACC (pre-op instruction)
• Observe frequently
• Medication dose wt specific
• Guided Imagery
• Distraction
• Music/video
Special Populations
Pediatrics
• Allergies
• Sensitivities
• Comfort frequently
• If non verbal anticipate painful
procedures result in pain
• Be an advocate
Special Populations
Special needs:
• Identify what works for this patient
• Ask the family or caregiver
• Comfort frequently
• If non verbal anticipate painful
procedures result in pain
• Again be an advocate
Cultural Considerations
• Be aware of specific needs and
beliefs
• Respect the patient/family tradition
• Internalize (how would I feel if)
• Do not pre judge
• Explain need for pain control
Intra Op Consideration
•Therapy selected should reflect the
individual needs of the patient.
•Ability to recognize and treat adverse
effects during surgery
•Special caution during continuous
infusion modalities
•Drug accumulation may contribute to
adverse events
•Patients who are pretreated with pain
meds, anxiolytics or NSAIDS prior to
surgery
•Have a greater decrease in postoperative
pain
•Decrease in postoperative anxiety
•Olorunto,W & Galandiuk, S. 2006. Managing the Spectrum of Surgical Pain:
•Acute Management of the Chronic Pain Patient. American College of Surgeons
•Surgeries to upper abdominal and
thoracic areas associated with severe pain
can lead to:
• Restrictive lung defect
• Depressed diaphragmatic activity
Gayatri,P (2005). Post-op pain services. Indian J.
Anaesth. 49 (1) : 17-19
Study:
•Early and aggressive use of pain
medications after surgery results in
shorter hospital stays, fewer chronic pain
problems later, and use less pain
medication overall than people who avoid
pain medication.
Taylor, M. (2001).Managing postoperative pain. Hosp Med; 62: 560-563.
Intra Op Consideration
•Patient Advocate
•Continue to assess for anxiety/pain
•Provide comfort
 Positioning
 Guided
 Music
imagery
Adequately treating Post-surgical Pain
• Increased Comfort =quicker healing
• Increased activity=
increased strength
• Decreased complication=
improved post-op period
•The risk of addiction to pain medication is
low for patients using such medications for
post-surgical pain
•Addictive personality leads to addiction
•Dependency is another issue
Effective Pain Control
Listen to the patient
• Believe the patient’s pain ranking
Support the patient/family
• Answer questions
• Provide information
Instruct re: need for pain control
Sources of postoperative pain
•Acute nociceptive pain from incision.
• Musculoskeletal pain from abnormal
body positioning and immobility during and
after surgery
• Neuropathic pain from excessive
stretching or direct trauma to peripheral
nerves
Post Operative Pain Control
Decreases risk of
• Myocardial ischemia
• Tachycardia and dysrhythmia
• Impaired wound healing
• Atelectasis
• Thromboembolic events
• Peripheral vasoconstriction
Post Operative Pain
Near the surgical site.
•Acute exacerbation of pain may be added
to the basal pain
•Increases with activities such as
coughing, turning, dressing changes
•Generally self limiting
•Progressive improvement over a relatively
short period
With Special Populations
• Geriatric
• Be aware of renal/hepatic function
• Sensitivities/allergies
• Be pro-active with medication
• Opioids
• Combination meds
• Be aware of drugs to be avoided in the
elderly
ASSESS & RE-ASSESS
• Before and after pain medications
• Put it in the patient’s own words
• Assess for non verbal cues
• Be aware of special needs of the
cognitively impaired patient
• Use appropriate pain scale
• Document, Document, Document,
ASSESSMENT TOOLS
• VAS
• PAIN FACES
• PAINAD
• FLACC
Post Op of Special Populations
Geriatric
• If with Cognitive Impairment
• PAINAD scale
• Observe & re-assess frequently
• Guard/observe for delirium
• superimposed on dementia
• Know drug side effects
• Know method of elimination
Medication Use
• Review information gathered during pre
op assessment
• If something has not worked in the past
don’t use it.
• Explain what you are doing and what
you are giving
• When in doubt, follow the WHO
guidelines
World Health Organization (WHO)
3- Step Ladder approach to pain
management
• Step 1- Mild Pain (1-3/10)
• Nonopioid
• Add adjuvant analgesic agent
(i.e.) Ice, heat
WHO cont’d
• Step 2 Mild to moderate pain (4-7/10)
• This step builds on step 1
• Treat with opioid combination drug
•
(hydrocodone/acetaminophen)
• Watch ceiling effect of adjuvant drug
• Peds are dosed by weight
• Watch special needs patients/elderly
WHO cont’d
• Step 3- Severe pain (8-10/10)
• Use opioids
• Add adjuvant (i.e.)anti-anxiety,antiemetics, muscle relaxants
• Start with short acting opioids to
determine pain relief, breakthrough
needs and frequency.
• Switch to long acting use equianalgesic
dosing chart for conversion
POINTS TO REMEMBER
• The pain intensity determines the step
at which to begin.
• Opioids are the only group of analgesics
with no ceiling on dose with careful
titration.
• Most opioid side effects resolve within a
few days.
• Exception>>>>Constipation-- need to
write for this immediately
Commonly used first line opioids
• Codeine
• Morphine
• Hydromorphone
• Oxycodone
Share the following characteristics
• Half-life of immediate release
preparations is 2 to 4 hours
• Duration of analgesic effect between 4
to 5 hours when given at effective
doses.
• Sustained release formulations have
duration of analgesic effect of 8 to 12
hours
• Equianalgesic doses need to be
calculated when switching from one
drug to another
• when changing routes of administration
or both.
• An equianalgesic table should be used
as a guide in dose calculation
•
Due to incomplete cross-tolerance
clinicians should consider reducing the
dose by 20 to 25% when ordering.
Morphine
Onset: 15 to 60 minutes
Peak Effect: 30 minutes to 1 hr
Half Life: 1.5 to 2 hr
IV: 0.05 to 0.1 mg/kg
5 minutes prior to procedure; max: 15
mg/dose
Morphine
Sedation, somnolence, respiratory distress
or depression, pruritis
Reversal:
Naloxone: 5 to 10 mcg/kg/dose; Single
dose should not exceed max
recommended adult dose of 0.2 mg
Fentanyl
• Fentanyl is 80 to 100 times more potent
than morphine.
• Studies report less constipation and
somnolence in patients using
transdermal fentanyl compared to those
using SR morphine.
Fentanyl
• Fentanyl’s high lipophilic properties
provide a sufficient sublingual
bioavailability of 90%, thus making it a
suitable opioid for use sublingually.
• Conditions that may effect absorption, bl
levels & clinical effects if the drug
• Morbid obesity
• Ascites
• opioid-naïve patients
Fentanyl
Onset: 1 to 5 minutes
• Peak Effect: (no data available)
• Half Life: 1.5 to 6 hr
• IV: 0.5 to 3 mcg/kg/dose; may repeat
after 30 to 60 minutes; max: 50
mcg/dose
• Use lower doses (0.5 to 1 mcg/kg/dose)
when used in combination with other
agents, such as midazolam
Fentanyl
• Respiratory distress or depression,
apnea, seizures, shock, chest wall
rigidity (most likely to occur with rapid
infusion or high doses)
• Reversal:
• Naloxone: 5 to 10 mcg/kg/dose; Single
dose should not exceed max
recommended adult dose of 0.2 mg
Sufentanil
• 5 to 10 times more potent than fentanyl.
•
Injectable sufentanil (like fentanyl) is
readily absorbed through the mucous
membranes
• Early onset of action of about 5 to 10
minutes, when used sublingually
Sufentanil
• Good for incident pain control.
• Peak analgesic effect of 15 to 30
minutes
• Duration of the analgesic effect is 30 to
40 minutes.
• Use for incident pain control, dosing 10
to 15 minutes prior to the painful event.
Methadone
• Long half life of methadone prevent it
being a first-line opioid.
• When converting to methadone dose
reduction of 75 to 90% should be
considered
• Initiation for pain management is 5mg
bid or tid depending on age
Dilaudid
10mg IV morphine is equivalent to 1.32mg Hydromorphone
IV Dilaudid has a half life of 2.5 hours,
duration of effect varies
Administering 1 mg or more of IV Dilaudid
every 1 - 2 hours leads to a build up of
the drug (stacking) and can increase
adverse effects like respiratory
depression. Know elimination
Stacking from delayed peak effect
Occurs when additional doses are given
prior to peak effect leads to multiple
doses, resulting in over dosage.
Caution:
Administration of a benzodiazepine with
narcotic analgesics increases the risk of
respiratory depression. (ie: Xanax,
Lorazepam, Versed, Valium)
Midazolam: CNS Depressant
Onset: 1 to 5 minutes (short acting)
• Peak Effect: 3 to 5 minutes (IV)
• Half Life: 1.5 to 12 hr
• Oral: 0.2 to 1 mg/kg; 30 to 45 minutes
before procedure; max: 20 mg
• IV: 0.05 mg/kg 3 minutes before
procedure (may repeat dose X 2); max:
2 mg/dose
Midazolam: CNS Depressant
• Respiratory distress, depression,
apnea, PVC's, amnesia, blurred vision,
or hyperexcitibility
Reversal:
• Flumazenil:(Romazacon) 0.2 mg/dose q
1 minute; max cumulative = 1 mg
POINTS TO REMEMBER
• Dosing intervals are determined by the
duration of action as well as the half-life
of the drug
• Know the route of elimination
• Adjust dose and frequency for special
populations.
• Be aware of prior surgeries involving
bowel, stomach, liver, kidneys
Opioid-induced Neurotoxicity (OIN)
• Hyperalgesia (heightened sensitivity to
the existing pain)
• Allodynia (a normally non-noxious
stimuli resulting in a painful sensation),
• Agitation/delirium with hallucinations
and possibly seizures.
• Due to the accumulation of toxic
metabolites and impaired renal
Post Op Documentation
• Document response to medication
• Pain relief
• Increased agitation
• Be pro-active if patient unable to
verbalize
• Painful procedures result in pain
(Treat as you would a family member)
GOAL
• Promote optimal pain management
• Reduce anxiety
• Support the patient
• Improve post op outcomes
• Promote patient satisfaction
QUESTIONS????
THANK YOU