Page 47 Acute Pain Management
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Differences between different ethnic and cultural groups should not be used to
stereotype patients and lead to assumptions about responses to pain or pain therapies;
pain assessment and management should be done on an individual patient basis (N).
The patient with obstructive sleep apnoea
1. Patients with obstructive sleep apnoea may at higher risk of complications after some
types of surgery (Q).
2. Patients with obstructive sleep apnoea have an including an increased risk of obstructive
episodes and desaturations (N) (Level III‐2).
3. Morbidly obese patients undergoing bariatric surgery may be at increased risk of
postoperative hypoxaemia independent of a diagnosis of obstructive sleep apnoea (N)
(Level III‐2). SUMMARY
4. Continuous positive airway pressure does not increase the risk of anastomotic leak after
upper gastrointestinal surgery (U) (Level III‐2).
Management strategies that may increase the efficacy and safety of pain relief in patients
with obstructive sleep apnoea include the provision of appropriate multimodal opioid‐
sparing analgesia, continuous positive airway pressure, monitoring and supervision (in a
high‐dependency area if necessary) and supplemental oxygen (U).
The patient with concurrent hepatic or renal disease
Consideration should be given to choice and dose regimen of analgesic agents in patients
with hepatic and particularly renal impairment (U).
The opioid‐tolerant patient
1. Opioid‐tolerant patients report higher pain scores and have a lower incidence of opioid‐
induced nausea and vomiting (U) (Level III‐2).
2. Ketamine improves pain relief after surgery in opioid‐tolerant patients (N) (Level II).
3. Opioid‐tolerant patients may have significantly higher opioid requirements than opioid‐
naive patients and interpatient variation in the doses needed may be even greater (N)
(Level III‐2).
4. Ketamine may reduce opioid requirements in opioid‐tolerant patients (U) (Level IV).
Usual preadmission opioid regimens should be maintained where possible or appropriate
substitutions made (U).
Opioid‐tolerant patients are at risk of opioid withdrawal if non‐opioid analgesic regimens
or tramadol alone are used (U).
PCA settings may need to include a background infusion to replace the usual opioid dose
and a higher bolus dose (U).
Neuraxial opioids can be used effectively in opioid‐tolerant patients although higher
doses may be required and these doses may be inadequate to prevent withdrawal (U).
Liaison with all health care professionals involved in the treatment of the opioid‐tolerant
patient is important (U).
In patients with escalating opioid requirements the possibility of the development of
both tolerance and opioid‐induced hyperalgesia should be considered (N).
Acute pain management: scientific evidence xlvii
