Page 286 Acute Pain Management

days (Fassoulaki et al, 2007 Level II). Spinal anaesthesia in comparison with general anaesthesia
reduced the risk of chronic postsurgical pain after hysterectomy (OR: 0.42; CI 0.21 to 0.85)
(Brandsborg et al, 2007 Level IV).

Key messages
1. Perioperative epidural analgesia reduces the incidence of post‐thoracotomy pain syndrome
(N) (Level II).
2. Cryoanalgesia for thoracotomy relieves postoperative pain but increases the risk of post‐
thoracotomy pain syndrome (N) (Level II).

3. Preincisional paravertebral block and perioperative use of gabapentin, mexiletine and/or
eutectic mixture of local anaesthetic reduce the incidence of postmastectomy pain (N)
(Level II).
4. Post‐thoracotomy, postmastectomy, postherniotomy and posthysterectomy pain
syndromes occur frequently (N) (Level IV).

9.1.4 Day-stay or short-stay surgery

Over 60% of surgery is now performed on a day‐stay basis. Adequate postoperative pain
management is often the limiting factor when determining whether a patient can have surgery
performed as a day procedure. Provision of analgesia after ambulatory surgery remains poor.
In two Swedish nationwide surveys of ambulatory surgery, pain was the most common
problem at follow‐up after discharge in a general (Segerdahl et al, 2008a Level IV) and a
paediatric population (Segerdahl et al, 2008b Level IV). Another survey from a single institution
found that even at 3 and 4 days after day‐stay surgery, 10% and 9% of patients respectively
reported moderate to severe pain (Greengrass & Nielsen, 2005 Level IV). The best predictive
factor was the presence of preoperative pain; other factors included preoperative high
expectations of postoperative pain, anticipation of pain by clinicians and younger age (Gramke
et al, 2009 Level IV).
Adverse effects of pain
CHAPTER 9 Phase 1 recovery delays affecting 24% of patients overall (Pavlin et al, 2002 Level IV).
Inadequate analgesia may delay patient discharge; pain was the most common cause of

Uncontrolled pain is also a major cause of nausea and vomiting, further extending the
patient’s stay in the recovery room (Eriksson et al, 1996; Michaloliakou et al, 1996). The most
common reason for unplanned hospital admission across 14 day‐surgery units in Finland
was unrelieved pain (Mattila & Hynynen, 2009 Level III‐2).
Inadequate pain management may cause sleep disturbance (Strassels et al, 2002 Level IV) and
limit early mobilisation, which may be crucial for early return to normal function and work
(Strassels et al, 2002 Level IV).
Analgesic drugs and techniques
More complex surgery continues to be performed on a day‐stay or short‐stay basis and
therefore the analgesic drugs and techniques required are similar to those used for inpatient
pain relief — see relevant sections of this document:
• systemically administered analgesic drugs (Section 4);
• regionally and locally administered analgesics drugs (Section 5); and
• regional and other local analgesia techniques (Section 7).

238 Acute Pain Management: Scientific Evidence