Postoperative pain management – a surgeon’s view

Abstract

All surgical procedures are followed by pain, which may amplify metabolic, endocrine responses, autonomic reflexes, nausea, vomiting, acute muscular spasm, paralytic ileus, respiratory insufficiency, and may delay not only the restoration of functions, but greatly affect the psychological well being of the patients. Post operative hypoxemia, immunosuppression, muscle catabolism and wasting, thromboembolic complications, cardiac events, post operative infections, gastrointestinal and even sleep disturbance are directly related with post operative pain control ¹. Post operative fatigue, immobility, muscle wasting, nutritional impairments resulting from poorly managed post operative pain, adversely affect convalescence period and the speed of recovery ². The most recent systematic review of the pain literature by Liu and Wu examined the effect of the postoperative analgesic techniques on the incidence of complications after surgery. The authors reanalyzed 18 meta-analyses and 10 systematic reviews (in addition to 8 randomized clinical trials and 2 observational studies), and concluded that post operative morbidity has direct relationship with post operative pain control and convalescence³. Reviewing the available literature on Medline from the last two decade greatly emphasized the importance of efficient and timely post operative pain control to reduce the post operative morbidity and mortality⁴. Unrelieved pain control after surgery increases heart rate, systemic vascular resistance and circulating catecholamines, placing susceptible patients at risk for myocardial ischemia, stroke, bleeding and other complications. Unrelieved acute pain commonly elicits pathophysiologic neural alterations, including peripheral and central neuronal sensitization, that evolve into chronic pain syndromes. Apart from the above reasons medical text provides us exhaustive data and authorities are fully convinced to effectively and efficiently manage post operative pain due to ethical, political, cultural, and legal concerns⁵. Attitudes of the societies toward pain relief during surgery and childbirth illustrate the complex interactions between cultural concepts of pain, pain relief, and social behavior. The individuals rights in revolutionary France and the United States, and the rise of democratic states, has created an environment in which individual pursuit of better health care, including pain relief, became explicit goals in the civilized world⁶.

Knowingly, acute pain is a universal phenomenon. All emergency and elective surgery, severe medical illness, trauma, childbirth, burns, natural calamities, war and torture, all contribute to its burden. In many countries political conflict, social dislocation, and inadequate availability of analgesics conspire to make the relief of acute pain sporadic at best. It is believed that pain control, whether postoperative or in chronic painful conditions, is still not efficiently managed in the developed world⁷.

In the developing countries unfortunately many physicals fail to provide adequate pain relief because of a lack of concern and/or because of misconceptions regarding the use of analgesics in the management of pain. This could be partially attributed to the patient’s education and awareness regarding postoperative pain. Effective and efficient pain control, however, is an ethical responsibility and moral obligation of a caring physician, whether working in the developed or developing world. The ‘right to pain relief’ has a multidimensional foundations in law at the international (the ‘right to health’ in international human rights law), national and personal levels. The right to adequate pain management emerges from, and is directly founded upon, the duty of the doctor to act ethically. Failing to manage pain on the part of a physician is denying the basic ethical rights of the patient and all four main principles of bioethics (justice, autonomy, beneficence and onmaleficence) are evoked⁹.

Post operative pain management commences from the preoperative assessment and called pre-operative analgesia; it continues as adequate pain control during surgery and a well planed post operative pain control, both during early postoperative phase and in convalescence period, using appropriate analgesic techniques, customized and rationalized for every individual patient. Comprehensive pain management definitely relates positive impact on the out come of surgery¹⁰. The treating g physician must also understand and tailor his pain management strategy and tools according to the individual patient, his/her wishes, understandings, social and cultural beliefs; not merely essential understanding of pain phathophsiology, methods of pain control and their clinical implications. Patients counseling, taking into confidence and hypnosis aiming to relaxation therapy decreases the dose and overall analgesic requirements, thereby reducing pain medications, speedy recovery and early return to routine activities after major surgical undertaking¹¹ .There should be objective analysis of the post operative pain control techniques and patient’s right to remain pain free should not be compromised at any cost.