Page 115 Guide to Pain Management in Low-Resource Settings

Chapter 14

Pain Management after Major Surgery

Frank Boni

What types of surgery infectious disease. The patient should be able to tol-

are we talking about? erate diagnostic and therapeutic procedures in the
postoperative period and have calm periods of wake-
Surgery can be grouped into four grades, as follows: fulness or sleep. The pain management should not
Grade 1: Minor: examples are excision of skin le- have any detrimental effect on the already compro-
sions and evacuation of the uterus; mised vital organs.
Grade 2: Intermediate: examples are inguinal hernia
What problems do we have to deal with during
repair and tonsillectomy;
the pain management plan?
Grade 3: Major: examples are thyroidectomy, hys-
terectomy, and bowel resections; and Th e patient may be unresponsive or confused and unco-
Grade 4: Very major: examples include cardiotho- operative because of his altered state of consciousness.
racic surgery and joint replacements. He was probably ill for about 2–3 weeks and has had
Th is grading depends on the extent and com- various kinds of treatment.
plexity of the surgical operation. Th ere may be some Septicemia comes with gastrointestinal tract,
problems with the classifi cation when endoscopies and cardiac, respiratory, renal, and other organ dysfunctions.
some newer surgical techniques are used. We will con- Th ere may be hypovolemic, cardiogenic, or septic shock
sider grades 3 and 4 for our discussions. with their associated problems. Fluid and electrolyte and
nutritional problems are very common in these patients.
Case report 1 Eff ect of the operation and anesthesia

An 18-year-old male had small-bowel resection for Th e sympathetic system might have been stimulated to
multiple typhoid perforations. He has not regained con- the extreme by the illness, and any further stress may
sciousness fully, 6 hours after the operation. cause the patient to decompensate. Th e patient may
therefore get worse temporarily in the postoperative pe-
Does he need pain relief? How would you riod as a result of the added stress of the surgery and
manage his pain, if any? What objectives do we anesthesia.
hope to achieve with our pain management?
Although communicating with the patient may be a Methods of pain relief options
problem, we still have to provide a pain-free period dur- Postoperative pain management must start with drugs
ing which the patient recovers from this multisystem given intraoperatively.
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 103
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.