Page 281 Acute Pain Management
P. 281






9. SPECIFIC CLINICAL SITUATIONS




9.1 POSTOPERATIVE PAIN


One
of
the
most
common
sources
of
pain
is
postoperative
pain
and
a
large
amount
of
the

evidence
presented
so
far
in
this
document
is
based
on
studies
of
pain
relief
in
the

postoperative
setting.
However,
many
of
the
management
principles
derived
from
these

studies
can
be
applied
to
the
management
of
acute
pain
in
general,
as
outlined
in
this
and

other
sections
that
follow.

In
addition
to
this
approach,
there
is
also
a
need
for
information
on
postoperative
pain

management
that
relates
to
the
site
of
surgery
and
specific
surgical
procedures
(Rowlingson
&

Rawal,
2003).
The
development
of
such
procedure‐specific
guidelines
is
ongoing:
they
require

considerable
effort
and
resources
and
have
not
been
addressed
in
this
document.
An

ambitious
project
to
develop
such
evidence‐based
guidelines
for
the
management
of

postoperative
pain
was
initiated
by
the
PROSPECT
group
(Neugebauer
et
al,
2007;
Kehlet
et
al,

2007).
Guidelines
for
the
treatment
of
pain
after
a
number
of
specific
operations
can
be
found

at
the
PROSPECT
website
(PROSPECT
2009).


9.1.1 Risks of acute postoperative neuropathic pain
Neuropathic
pain
has
been
defined
as
‘pain
initiated
or
caused
by
a
primary
lesion
or

dysfunction
in
the
nervous
system’
(Merskey
&
Bogduk,
1994).
Acute
causes
of
neuropathic
pain

can
be
iatrogenic,
traumatic,
inflammatory
or
infective.
Nerve
injury
is
a
risk
in
many
surgical

procedures
and
may
present
as
acute
neuropathic
pain
in
the
postoperative
period.
The

incidence
of
acute
neuropathic
pain
has
been
reported
as
1%
to
3%,
based
on
patients

referred
to
an
acute
pain
service,
primarily
after
surgery
or
trauma
(Hayes
et
al,
2002
Level
IV).

The
majority
of
these
patients
had
persistent
pain
at
12
months,
suggesting
that
acute

neuropathic
pain
is
a
risk
factor
for
chronic
pain.
The
role
of
acute
neuropathic
pain
as
a

component
of
postoperative
pain
is
possibly
underestimated;
after
sternotomy
50%
of

patients
had
dysaesthesia
in
the
early
postoperative
period,
which
was
closely
associated
with

severity
of
postoperative
pain
(Alston
&
Pechon,
2005
Level
IV).
Similarly,
a
high
incidence
of

acute
neuropathic
pain
in
lower
limbs
due
to
lumbosacral
plexus
injury
has
been
reported
 CHAPTER
9

after
pelvic
trauma
(Chiodo,
2007
Level
IV).

There
is
some
evidence
that
specific
early
analgesic
interventions
may
reduce
the
incidence
of

chronic
pain
(often
neuropathic
pain)
after
some
operations
(eg
thoracotomy,
amputation).

For
more
details
see
Sections
1.3
and
9.1.2
and
9.1.3.
The
prompt
diagnosis
(Rasmussen
et
al,

2004)
of
acute
neuropathic
pain
is
therefore
important.
Management
is
based
on
extrapolation

of
data
from
the
chronic
pain
setting
(see
Sections
4.3.2
to
4.3.6).



Key
messages

1.
 Acute
neuropathic
pain
occurs
after
trauma
and
surgery
(U)
(Level
IV).

The
following
tick
box

represents
conclusions
based
on
clinical
experience
and
expert

opinion.


 Diagnosis
and
subsequent
appropriate
treatment
of
acute
neuropathic
pain
might
prevent

development
of
chronic
pain
(U).





 Acute
pain
management:
scientific
evidence
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