Physician
Nurse in Chief
Assistant
Information
Preoperative
Assessment

Preanesthetic assessment.

Informs the patient and his/her family about the pain clinical pathway.

Delivers the patient or his/her family information sheet about pain clinical pathway.
1. ASSESSMENT AND CARE
Surgery
Recovery

Clinical assessment.

Prescribes immediate analgesia and rescues.

Evolution of analgesia, adverse effects, and recovery discharge.

Formulates analgesia plan for the next 72 hours.

Reviews clinical pathway warnings of drugs.

Monitors execution of clinical pathway.

Evaluates intensity of pain from 0 to 10 and writes details in case history every 4 hours.

Provides rescue analgesia and writes observations.

Checks vital signs.

Antalgic status of patient.

Reviews compressive bandages.

Checks adverse effects of analgesia:
Nausea, vomiting, epigastric pain, sedation, urine retention.
Postoperative
1st Day

Clinical assessment.

Evolution of analgesia and adverse effects.

Reviews prescription of analgesia.

Reviews clinical pathway warnings of drugs.

Monitors execution of clinical pathway.

Evaluates intensity of pain and writes details in case history every 4 hours.

Rescue analgesia and records vital signs every 4 hours.

Reviews compressive bandages.

Checks adverse effects of analgesia:
Nausea, vomiting, epigastric pain, sedation, urine retention.


Orally.
Delivery of information
2. ACTIONS

Orally and written.

Orally and written.

Satisfaction
Postoperative
2nd, 3rd Day

Clinical assessment.

Evolution of analgesia and adverse effects.

Reviews prescription of oral analgesia.

Reviews clinical pathway warnings of drugs.

Monitors execution of clinical pathway.

Evaluates intensity of pain and writes details in case history every 4 hours.

Rescue analgesia and record vital signs every 4 hours.

Reviews compressive bandages.

Checks adverse effects of analgesia:
Nausea, vomiting, epigastric pain, sedation, urine retention.

Satisfaction questionnaire.

Objectives
Performance
Criteria
Inclusion Criteria sheet to patient or his/her family.
To reduce anxiety caused for fear to pain.
Education about pain management.
To assure that patient or his/her family has received relevant information.
Preoperative patients.
To determine pain intensity.
To control pain.
To control adverse effects.
To inform treating physician immediately about the following signs of alarm:
1.
Intense pain which does not improve after 3 rescues.
2.
Deep sedation
(Grade 3).
3.
Respiratory rate lower than 10/min.
4.
Systolic blood pressure below 90 mm/Hg.
*In cases 2 , 3 and
4 , to apply oxygen through nasal cannula, 3 liters per minute.
-To request Narcan
1 ampule.
Adult patients with moderate to severe postoperative pain. questionnaire.
To manage pain control and other adverse effects.
To inform treating physician immediately about the following signs of alarm:
1.
Intense pain which does not improve after 3 rescues.
2.
Deep sedation
(Grade 3).
3.
Respiratory rate lower than 10/min.
4.
Systolic blood pressure below 90 mm/Hg.
*In cases 2 , 3 and
4 , to apply oxygen through nasal cannula, 3 liters per minute.
-To request Narcan
1 ampule.
Adult patients with moderate to severe postoperative pain.
To manage pain control and other adverse effects.
To inform treating physician immediately about the following signs of alarm:
1.
Intense pain which does not improve after 3 rescues.
2.
Deep sedation
(Grade 3).
3.
Respiratory rate lower than 10/min.
4.
Systolic blood pressure below 90 mm/Hg.
*In cases 2 , 3 and
4 , to apply oxygen through nasal cannula, 3 liters per minute.
-To request Narcan
1 ampule.
Controlled pain until third day after surgery.
Exclusion Criteria Major surgery requiring assistance at the Acute Pain
Service
3. PHARMACOLOGICAL RECOMMENDATIONS FOR ANALGESIA AND SIDE EFFECTS
RECOVERY:
ANESTHESIOLOGIST
Rescue analgesia:
Opioids:

Option 1:
Morphine 0.05 mg/Kg every 10 minutes until pain is relieved; or

Option 2:
Tramadol 2 mg/Kg. If severe pain persists, to change to morphine IV.
Adjuvant analgesia:

NSAID Option 1:
Diclofenac 75 mg IV,
POSTOPERATIVE 1ST TO
3RD DAY:
SURGEON
Analgesia by schedule:
Opioids:

Option 1:
Tramadol 1-2 mg/Kg every 6 hours, plus rescues with Tramadol
1 mg/Kg, between schedule dose, 4 rescues maximum in
24 hours; or

Option 2:
Morphine 0.05 – 0.1 mg/Kg every 4-6 hours, plus rescues with
Morphine 0.05 mg
PRECAUTIONS
NSAID’s contraindications:

History of ulcer.

Epigastric pain.

Coagulopathy.

Hypovolemia or mass transfusion.

Renal failure.

Heart failure.

Myocardial infarction.
 Allergy to NSAID’s.

diluted in 100 mL SSN
0.9% (see contraindications).

NSAID Option 2:
Dipyrone 1 gr IV, diluted in 100 ml SSN
0.9% (see contraindications).
Adverse Effects
Prophylaxis:

Dexamethasone 8 mg
IV. Only dose.

Haloperidol 1 mg IV

In case of active vomiting, rescue with
Metoclopramide 10 mg and Ranitidine 50 mg
IV. every hour.
Adjuvant analgesia:

NSAID Option 1:
Diclofenac 75 mg IV, diluted in 100 mL SSN
0.9% (see contraindications).

NSAID Option 2:
Dipyrone 1 gr IV, diluted in 100 ml SSN
0.9%, every 6 hours
(see contraindications), through pharmacological monitoring.

Acetaminophen 1 gr., orally every 6 hours, if patient tolerates oral consumption of solid food.

Omeprazole 20 mg orally every 24 hours, when NSAID’s are prescribed.

Haloperidol 1 mg IV every 12 hours, if still with no oral consumption; or
Haloperidol 2 mg, if oral consumption has started (20 drops).

If vomiting persists, rescue with metoclopramide 10 mg
IV every 6 hours and to pass haloperidol 2 mg
IV every 12 hours.
Prescription for adverse effects of analgesia:
Vomiting:

Rescue with metoclopramide 10 mg
IV every 6 hours.

Haloperidol 2 mg IV every 12 hours.

Ranitidine 50 mg IV every 8 hours.
Epigastric Pain:
 To stop NSAID’s.

Omeprazole 40 mg IV every 24 hours.