Post-surgical pain





Definition

Post-surgical pain is a complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system. The result is pain in areas not directly affected by the surgical procedure. Post-operative pain may be experienced by an inpatient or outpatient. It can be felt after any surgical procedure, whether it is minor dental surgery or a triple-bypass heart operation.


Purpose

Post-operative pain increases the possibility of post-surgical complications, raises the cost of medical care, and most importantly, interferes with recovery and return to normal activities of daily living. Management of post-surgical pain is a basic patient right. When pain is controlled or removed, a patient is better able to participate in activities such as walking or eating, which will encourage his or her recovery. Patients will also sleep better, which aids the healing process.


Description

Pain is recognized in two different forms: physiologic pain and clinical pain. Physiologic pain comes and goes, and is the result of experiencing a high-intensity sensation. It often acts as a safety mechanism to warn individuals of danger (e.g., a burn, animal scratch, or broken glass). Clinical pain, in contrast, is marked by hypersensitivity to painful stimuli around a localized site, and also is felt in non-injured areas nearby. When a patient undergoes surgery, tissues and nerve endings are traumatized, resulting in incision pain. This trauma overloads the pain receptors that send messages to the spinal cord, which becomes overstimulated. The resultant central sensitization is a type of posttraumatic stress to the spinal cord, which interprets any stimulation—painful or otherwise—as unpleasant. That is why a patient may feel pain in movement or physical touch in locations far from the surgical site.

Patients handle post-operative pain in high individualized ways. Health care professionals have observed that some patients report that they are in extreme pain after surgery, demanding large doses of pain medications while others seem to do well with much less medication. Several theories have been put forth for this discrepancy. For example, differences in body size seemed to require differing amounts of medication, but this theory did not explain differences in pain perception among patients of the same build. Emotional well-being was considered a better indicator of the ability to tolerate pain. It has been theorized that patients with stronger support systems and better attitudes actually perceive less pain than others. Some health care professionals have even speculated that extreme pain was not real in many cases, but was a way to seek attention.

Clear biological evidence proving that individuals are born with varying thresholds of pain perception was only recently discovered. Psychiatrist and radiologist Jon-Kar Zubieta, from the Mental Health Research Institute at the University of Michigan, found that variations in an amino acid in a newly discovered gene, which codes for an enzyme that accesses neurotransmitters in the brain, produce different levels of pain perception. Only three combinations produce the variation. One individual may be able to fully access and metabolize the opioid neurotransmitters that reduce the sensation of pain. This person would have a higher threshold of pain tolerance and a lower level of pain perception. Another might not be able to do so at all, and that individual would experience more intense pain from the same stimulus. A third person might be able to tolerate a moderate amount of pain.

This variation in genes not only shows that individuals do indeed experience pain at different levels, but it also points to differences in how people behave toward other stressors. Genetic variation may be a factor in the impact of long-term illness and depression that often accompanies chronic pain.

Since pain perception is highly subjective, it is important for the health care team to be aware of pain sensitivity differences in patients, and to value patient self-report as a reliable tool for pain assessment. The most common self-report system in use is the pain intensity scale. The patient is asked to identify where the pain falls on a scale of 0 "no pain at all" to 10 "the worst pain in the world." This scale, however, does have limitations. The Short-Form McGill Questionnaire, which uses sensory words or synonyms, may allow the patient to communicate more accurate, descriptive information about pain and may be a better tool in planning pain management strategies.

It is clear that there is a real need for providing different approaches to post-surgical pain management. A variety of interventions may be used before, during, and after surgery. Most of these methods involve medications given orally, intravenously, intramuscularly, or topically (via the skin). Some must be administered by a health care professional; others by the patient.

Pain management methods

Pre-surgery pain management

The goal of post-surgical pain management is to reduce the amount pain a patient experiences after surgery. New research has suggested that preventing the nervous system from being overtaxed by pain from the trauma of surgery may lead to a less painful postoperative experience. Pretreated patients may require less post-surgical medications, and they may recover more quickly, possibly experiencing pain-free days far sooner than patients who have used traditional post-surgical pain methods.

Also, in view of improved, less-invasive surgical techniques and the insurance industry's trend after the turn of the twenty-first century to trim rising medical costs by reducing the length of hospital stays, many patients have no longer been required to remain overnight in a hospital. Recently, outpatient (also called ambulatory) surgery has become a procedure of choice for many complex surgeries, such as hysterectomy and prostatectomy. The patient must now be made comfortable enough to return home and manage his or her own pain.

Preemptive analgesia introduces anesthetic drugs near the spinal cord or, sometimes, in nerve blocks in specific regions of the body. An epidural catheter, a thin plastic tube through which pain medication is delivered, is inserted into the patient's back before surgery. The patient may also receive general anesthesia and post-surgical pain medications as needed. Sometimes, the epidural catheter remains in place for several hours or days after surgery, and is attached to a pump so the patient can administer medication on demand.

In other cases, peripheral nerve blocks are used to limit sensation in specific regions of the body. By injecting local anesthetic near a nerve or nerve plexus that supplies the area where the surgery will be performed, all sensation is blunted and the affected area is numbed and feels "asleep." Some patients remain awake, but sedated, during surgery; others are given general anesthesia. Two important advantages to the use of peripheral nerve blocks in patients who are awake during surgery is the avoidance of the side effects of general anesthesia (nausea and vomiting) and complications that could occur during intubation, placing a tube in the patient's airway. The use of peripheral nerve blocks alone may be best suited to surgical procedures involving the arms, legs, and shoulders.

Pain management during surgery

General anesthesia has been the standard for pain management during surgery. Topical local anesthetics are also being used to numb the surgical site before any incisions are made. This has been the method used frequently with laparoscopic procedures. In a laparoscopy , the surgeon inserts a laparascope (an instrument that has a tiny video camera attached) through a small incision, often in the abdomen. Other small incisions are made for the surgeon to insert surgical instruments into, and to do repairs or remove diseased or damaged tissues. Local anesthetics minimize pain trauma to the surgical site and the central nervous system.


Post-surgery pain management

In most hospitals during the past century, post-surgical pain management consisted only of the administration of analgesics and narcotics immediately after surgery. These drugs were usually given by intravenous or intramuscular injection, or by mouth. This is still a viable method for managing post-operative pain.

Management of these drugs, nevertheless, has variant applications. Some hospitals insist on a routine of scheduled medications, rather than giving medications as needed. The health care staff in these instances state that when patients take medications before the pain appears, the body does not over-react to the pain stimulus. Therefore, staying ahead of the pain is critical.

Other hospitals advocate continuous around-the-clock dosing through the use of a pump-type device that immediately delivers medication into the veins (intravenously, the most common method), under the skin (subcutaneously), or between the dura mater and the skull (epidurally). A health care provider programs the device with the specific dosage to deliver at each request made by the patient, as well as the total permitted during the time for which the device is set (commonly eight hours, sometimes 12, especially if the health care providers are working 12-hour shifts). Some of these devices are very sophisticated and even monitor themselves, ringing an alarm bell if there is an indication that they might be malfunctioning. The patient administers the dose by pushing a button, and is encouraged to keep a steady supply of medication within his or her system. This is called patient-controlled analgesia (PCA).

PCA provides pain medication at the patient's need. However, because opium-like pain-relievers (opioids) are the medications these pumps deliver, there has been some concern about possible narcotic addiction. The pumps are calibrated to a maximum dosage, and are limited to a maximum dose every eight (or 12) hours. The health care staff checks the equipment regularly, and records the number of times the patient pushes the pump button. If the patient has pushed the button more times than allowed, the pump refuses to administer more medication. The patient should notify the health care staff if a specific medication is ineffective. In some cases, the patient needs encouragement to use the pump more, if necessary.

Nonsteroid anti-inflammatory analgesics (NSAIDs) are best used for continuous around-the-clock pain relief. This prevents the extremes in pain perception that occur with on-demand dosing; sometimes the patient feels no pain and extreme pain at other times. Opioids are best given on a schedule or in a computerized pump, which can prevent overdoses.

Another method used post-surgically is the On-Q or the "pain relief ball." It is a balloon-type device that administers non-narcotic medication to the incision site through a small catheter. When the incision site is closed, the catheter is attached to the surgical site and the balloon or pump is either taped to the patient's skin, carried in a pocket or pouch, or attached to the patient's clothing. The pump numbs the incision site by flooding it with anesthetic. Recent tests show that On-Q reduces narcotic use by 40% in cesarean patients, and eliminates all narcotics in 43% of hysterectomy patients.


Alternative non-medical methods

Some non-medical methods can help reduce post-operative pain. Patient education about the surgical procedure and the aftermath can help reduce stress, which can affect the perception of pain. Education, like visualization, prepares the mind for surgery and recovery. The patient knows what to expect, thereby removing fear of the unknown. Education also enlists the patient's cooperation and may encourage a feeling of control and empowerment, which reduces stress, fear, and helplessness. These factors can contribute to less perceived pain. Therefore, both education and visualization can be helpful in minimizing pain perception and encouraging a positive attitude after surgery, which can promote healing.

Meditation and deep breathing techniques also can reduce stress. These techniques can lower blood pressure and increase oxygen levels, which are critical to a healthy recovery. Hypnosis before and after surgery may calm the mind and emotions, and mute the perception of pain.


Multiple methods

Multimodal analgesia uses more than one method of pain management. Multiple methods can actually reduce the amount of medications necessary to relieve pain, and can minimize uncomfortable side-effects. Using pre-surgical, surgical, and post-surgical techniques allows the patient to arise from surgery with the pain already under control. He or she does not have to experience the shock of intense pain at the incision site or elsewhere in the body. Some pain is probable; however, a patient should not be in intense pain after surgery. Pain management should occur before pain appears rather than in reaction to pain.

Further knowledge about multimodal pain management will be necessary as more outpatient and office-based surgery is done. Finding the right combination of methods for an individual patient will be the challenge and responsibility of the health care team.


Opioid-tolerant patients

Of great concern to health-care professionals is how to provide post-operative pain management to patients who are opioid tolerant. These patients require higher and more frequent doses of narcotics for pain relief. They may also need to stay on the narcotics longer, and gradually step back down to their pre-surgery levels.

Patients who are opioid tolerant are not necessarily illegal drug users, but may be taking medications in combination with a narcotic, such as oxycodone/acetaminophen or acetaminophen/codeine. Patients who take opioid medications regularly may be treating pain for conditions like cancer, fibromyalgia, arthritis, or traumatic physical injuries.

It is important for anesthesiologists to aggressively treat pain for opioid-tolerant patients in the recovery room , where they can be closely monitored. Patient-controlled pain administration or continuous infusion, either in an IV or in an epidural catheter, has the best chance of controlling post-surgical pain together with the pain caused by preexisting conditions. When the patient is able to take medications orally, NSAIDs can supplement the use of opioid analgesia, sometimes reducing the total amount of opioids used. Newer, COX-2 inhibitors have proven effective in reducing pain without many of the side effects that NSAIDs possess (liver complications, kidney impairment, intestinal tract irritation, and bleeding), and seem to be a good fit for the opioid-tolerant patient.


Preparation

Before having any surgery, the patient should talk with the physician, surgeon, and if possible, the anesthesiologist in order to gain a full understanding of the procedure and what to expect immediately following surgery. It is important to develop a pain management plan with the health care team, and for the patient to be open about medication use, including opioids. Usually the patient will meet the anesthesiologist the day of the surgery to discuss pain management options for the operation. Being informed about the surgical procedure and anesthesia options will give the patient an opportunity to ask questions and respond accurately to those asked by the anesthesiologist.

The physician should take a complete medical history, and order tests to determine the patient's current liver and kidney functions. Surgical patients should communicate their pain medication needs to the health care team.

The patient should not eat or drink before surgery. This helps minimize the side effects of general anesthesia and pain medications, such as nausea and vomiting. If the patient cannot reach a comfort level with the prescribed medication regime, he or she should discuss this with the health-care staff and physician.


Normal results

After surgery, a patient should not have to endure severe pain. A reasonable comfort level can be reached in most cases. Prudent pain management will allow the patient to eat, sleep, move, and begin doing normal activities even while in the hospital, and especially when returning home. Recovery may take several weeks after surgery; however, the patient should be made comfortable with a regime of oral pain medications.


Risks

Pain medications may have unpleasant side effects. In many people, narcotics cause nausea, vomiting, and impaired mental functioning. NSAIDs can cause kidney failure, intestinal bleeding, and liver dysfunction, but this is not true for everyone. The NSAID ketorolac has been associated with acute renal (kidney) failure even when given for minor oral surgery in an outpatient setting. Early screening for kidney problems and close monitoring for kidney failure or dehydration can prevent most of these problems.

There are adequate safeguards in place, especially in patient-controlled analgesic pumps, to prevent addiction to narcotics; however, some patients do become addicted. In these cases, there usually is an underlying predisposition toward physical addiction that had not previously appeared.

See also Pain management .


Resources

PERIODICALS

"Feel Better Faster with Pain Relief." Contemporary OB/GYN 47, no. 8 (August 2002): 102.

Hornsby, L. G. "Anesthesia's New Frontier: Ensuring Patient Safety in the Office Setting." Plastic Surgical Nursing 22, no.3 (Fall 2002): 112-15.

Ke, R. W. "A Preemptive Strike Against Surgical Pain." Contemporary OB/GYN 46, no. 4 (April 2001): 65.

Leff, D. N. "Probing Pain's 'Ouch' and 'Agony' Genes: Why Some Folks Shrug Off Painful Stimuli while Others Hurt Real Bad Discernible in Genetic Tea Leaves." Bioworld Today 14, no.35 (February 21, 2003): NA.

Murauski, J. D. and K. R. Gonzales. "Peripheral Nerve Blocks for Postoperative Analgesia." AORN Journal 75, no.1 (January 2002): 134-52

Wu, C. L. and Z. A. Casey. "Managing Postoperative Pain in the Opioid-tolerant Patient: Careful Planning Provides Optimal Pain Control, Minimizes Problems." Journal of Critical Illness 17, no.11 (November 2002): 426-33.


ORGANIZATIONS

American Association of Nurse Anesthetists (AANA). 222 S. Prospect Ave., Park Ridge, IL 60068-4001. (847) 692-7050. http://www.aana.com .

Association of Perioperative Registered Nurses (AORN). 2170 S. Parker Rd., Suite 300, Denver, CO 80231. (800) 755-2676 or (303) 755-6304. http://www.aorn.org .


Janie Franz



User Contributions:

Debbie Falgoust
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Jul 29, 2009 @ 1:13 pm
This article was very informative.
However, I was looking for information regarding post-surgical pain management for someone allergic to opioid medications such as codeine and morphine. The narcotics seem to just make me disoriented and nauseated without providing any pain relief at all. They actually make things worse by adding more miserable symptoms to the continuing pain.
Is there anything effective for surgical recovery that is non-narcotic, and contains no opioids?
S.B.
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Sep 10, 2009 @ 4:16 pm
I sure wish Ms. Falgoust's question could be answered publicly with a resounding "YES, today no one ever has to use narcotics or addictive substances for any reason", not even surgery.

I'm going in for surgery in 2 weeks. I've got who's purported to be the best surgeon in the state. My family are coming to my rescue for home care. I don't have to worry about my job or losing it. But, I'm having moments of complete TERROR.

I'm what's termed outside of the inner circle community as a recovered alcoholic/addict with 9 consecutive years of sobriety. Inside the rooms, no one counts themselves as trully recovered, as it's a medical condition that is only treatable with considerable vigilance.

I wish the medical community would push to develop non-narcotic non-addictive solutions to pain management as there are people BORN predisposed to addiction. Many of the "recovered" will put off needed medical treatment (as I have) out of fear that just the "taste" of an addictive substance will send them tail spinning.

I have related this to my physician and surgeon. I do believe they're sympathetic and very competent doctors. But wonder if there's a realization how extremely "life and death" this matter may seem from my perspective.

It's appalling that with today's technology medicine hasn't evolved completely away from addictive substances entirely already. I'm just praying they have an inkling of what this fear is like, and there is somewhere in the field of medicine some brilliance that will allay this fear forever.

No body WANTS to be an addict, strange as that may sound to society today. Addicts are not 'scum' to begin with, they're people (often very good people) who've fallen victim to substances that are actually poisons, that get trapped. Sometimes for good in spite of their most devout and earnest efforts to climb out. I'm one of the lucky ones who have climbed out...Are there ears to hear just how afraid I am of the "black hole pit" how terrifying the prospect is of falling back in? I wouldn't be the only one.

Medicine, thou art a GOD given divine gift and angel, given of all that are good...have mercy upon we who are the "least of these".
Deborah
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Oct 8, 2009 @ 12:00 am
how are things looking for the use of the marcaine pump and possible use in addicted pts.
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Apr 8, 2010 @ 8:20 pm
THEIS ATRICLE IS VERY USEFUL TO TO PROVIDE INSIGHT ON THE TEACHING AND PRACTICE OF PAIN MANAGEMENT OF SURGICAL PATIENTS
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Jun 25, 2010 @ 3:15 pm
I just had hardware removal surgery 7 days ago from L 3-4. I've been a pain management patient for 5 years. My preop meds were Oxycontin 80 mg 2-3 every 12 hours. I also took Roxicodone 30 mg 3 times a day for breakthrough. This was my 4th back surgery and by far the worst post-op pain. The surgeon also manages my pain so he knew how much I take. The problem was that the nurses gave me half my normal dosage for the 24 hours I spent in the hospital. The morphine pump gave minimal relief. My pain level was a 6-7 the first 4 post op days. I feel that a pain management Dr should be brought in for opioid tolerant patients. The nurses were afraid of giving me too much and couldn't believe that I could still carry on a conversation with the morphine pump. I believe all surgeons and nurses need to be well educated when dealing with a patient like me.
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Sep 9, 2010 @ 9:21 pm
Trying to locate a chart or graph which shows pain vs time after surgery.
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Apr 1, 2011 @ 11:11 am
This is very helpful. Just went through varicocele surgery and had a really sharp post surgical pain. I opted for oral pain reliever since it's somehow tolerable. Just avoid standing up or walking as much as I can coz I'm feeling dizzy and having black out visions.
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Apr 9, 2011 @ 3:03 am
This article has been very2x useful.Thanks to those people who uploaded this.
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Jul 27, 2011 @ 9:09 am
This is what I need to know very much.
I appreciate you to sharing this post with us.
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Aug 23, 2011 @ 1:01 am
this article is very important because all producers included. but now i need to clarify how about safeity mesuser means how to control by taking investigation 9( artial blood Gas and other samples please give me clarification.
Steve
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Jan 22, 2012 @ 8:08 am
I recently went through my 5th knee scope and was surprised at the options presented to me pre-operatively; Note; I worked in surgery for about 15 years and was an ambulance driver for 4 years and worked in the ER for the last three years of my Health care career (been away for about 6 years). I have even done my own paper on Peri-operative anxiety and outcomes; I am not a doctor or nurse, but was just a Certified Surgical Technician in Pre-Med- my knees kept me from going forward.

I can say this; Pain Perception is an individual thing; but good reporting post-operatively and the Dr's ability to listen is even more important. If no one asks about your pain, they can not measure that pain; if your Recovery room nurse etc. ask and just record it in a chart; again no one has really compared anything- till later.

My most recent surgery included Pre-op Block to the knee; I questioned the Anesthesiologist regarding why they would do it pre-operatively- versus post-op while I was asleep anyway; after some discussion, I felt I was being forced to make a decision- but it would be my call. I was very uncomfortable- just immediately before surgery is not the time to be deciding something.

For the second straight knee scope; I felt post-operative pain (about a 5)- The pre-op block does not help me in any way; in fact; if the pre-op injection caused the surgeon not to block me post-operatively, then the pre-op block is the main cause of my post-op pain. Add to the fact that I was put to sleep twice due to the pre-op block. 5 days later- no doctor has asked me how my pain is- in any scale- so much for the measuring of my individual pain.

I feel Post-op Catheters are the best treatment for pain control (if possible), if the patient is not above following all other post-op directions. But having your care givers learn along with you is the single greatest contributor to post-operative recovery with minimal discomfort.
Sherri
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Aug 19, 2013 @ 9:09 am
After suffering for 6 months with what I was sure to be cat scratch disease, I finally got my primary to order an ultrasound of the affected nodes in my armpit (injury and papule on same side at wrist). NOBODY, including ER staff at early stage ordered bloodwork to confirm and blindly treated with antibiotics. The tech immediatly found what they called lesions and I was promptly referred to a surgion who immediatly scheduled surgery. He ended up removing 3 lymph nodes that had resolved, resulting in the pain I felt in the area and down the inside of my arm. I am 48 and never have had an operation and opted for some meds via my iv to keep me under during the procedure. I dont like taking medications and that alone knocked me out for nearly 4 hours! I was given a script for pain meds which after day 2 I realized was constipating, so I stopped that, taking otc pain relief instead. I stopped having pain at the site after about a month, being completely healed...however, the lower half of my arm hurts really bad! During and shortly after the healing process I thought it was due to favoring my arm and the positioning as to reduce movement and pain at the site. Its 2 months post op now and it must be due to nerves but it really hurts. How long will this continue to be bothersome? It sometimes wakes me up during the night and I lose my grip in simple tasks. It isnt constant, so I forget, then try to go on with life as usual and end up in pain. When will this resolve or could it be something else?

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