Optimising Postoperative Pain Management in the Ambulatory Patient

Abstract

Over 60% of surgery is now performed in an ambulatory setting. Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction. Effective postoperative pain management involves a multimodal approach and the use of various drugs with different mechanisms of action. Local anaesthetics are widely administered in the ambulatory setting using techniques such as local injection, field block, regional nerve block or neuraxial block. Continuous wound infusion pumps may have great potential in an ambulatory setting. Regional anaesthesia (involving anaesthetising regional areas of the body, including single extremities, multiple extremities, the torso, and the face or jaw) allows surgery to be performed in a specific location, usually an extremity, without the use of general anaesthesia, and potentially with little or no sedation. Opioids remain an important component of any analgesic regimen in treating moderate to severe acute postoperative pain. However, the incorporation of non-opioids, local anaesthetics and regional techniques will enhance current postoperative analgesic regimens. The development of new modalities of treatment, such as patient controlled analgesia, and newer drugs, such as cyclo-oxygenase-2 inhibitors, provide additional choices for the practitioner. While there are different routes of administration for analgesics (e.g. oral, parenteral, intramuscular, transmucosal, transdermal and sublingual), oral delivery of medications has remained the mainstay for postoperative pain control. The oral route is effective, the simplest to use and typically the least expensive. The intravenous route has the advantages of a rapid onset of action and easier titratibility, and so is recommended for the treatment of acute pain.Non-pharmacological methods for the management of postoperative pain include acupuncture, electromagnetic millimetre waves, hypnosis and the use of music during surgery. However, further research of these techniques is warranted to elucidate their effectiveness in this indication. Pain is a multifactorial experience, not just a sensation. Emotion, perception and past experience all affect an individual's response to noxious stimuli. Improved postoperative pain control through innovation and creativity may improve compliance, ease of delivery, reduce length of hospital stay and improve patient satisfaction. Patient education, early diagnosis of symptoms and aggressive treatment of pain using an integrative approach, combining pharmacotherapy as well as complementary technique, should serve us well in dealing with this complex problem.

Poderia a atividade física induzir analgesia em pacientes com dor crônica?

“…Os gastos associados a essa condição de saúde estimulam o sistema a investigar intervenções eficazes para o tratamento das dores em geral (7) . O tratamento clássico da dor (aguda) consiste em repouso e uso de fármacos para o alívio do sintoma, para favorecer a cicatrização da lesão (8) e a redução do processo inflamatório (9) . Ao contrário do tratamento da dor aguda, os agentes químicos analgésicos não se demonstram eficazes contra a dor crônica (10,11) .…”

Development and Validation of a Risk Score to Identify Patients at High Risk for Opioid-Related Adverse Drug Events

“…However, opioid use is frequently accompanied by opioid-related adverse drug events (ORADEs) and other negative consequences, including increased mortality. 6,7 Wheeler et al (2002) found that 29.0% of preventable adverse drug events (ADEs) were associated with analgesic use, the majority of which included opioids. 8 The most common of these ORADEs include gastrointestinal (GI) effects such as constipation, ileus, nausea, and vomiting; central nervous system effects including sedation, euphoria, and delirium; pruritus; urinary retention; and more serious adverse effects such as respiratory depression.…”

Auricular acupuncture for pain relief after ambulatory knee surgery: a randomized trial

“…4,5 To improve postoperative pain relief, an integrative approach combining pharmacologic methods and various complementary nonpharmacologic analgesic techniques has been recommended. 6 Auricular acupuncture holds promise, as it is an easily performed technique that might be effective for treatment of both preoperative anxiety and postoperative pain in patients undergoing ambulatory surgery. 7,8 However, there are reasonable doubts in the scientific community concerning the specificity of acupuncture, 9 because the large randomized trials on auricular acupuncture for treatment of cocaine and alcohol dependence have found no difference between treatment and invasive needle control.…”