Page 116 Guide to Pain Management in Low-Resource Settings

104 Frank Boni

Local anesthetic infi ltration of the wound, how- patient. Th e fact that the patient cannot complain does
ever, may not be advisable because of the generalized not mean there is no pain! Careful titration, use of mul-
systemic nature of the disease and the increased risk of tiple analgesics, and good monitoring hold the key to
wound infection, and the reduced eff ectiveness and in- safe and successful management.
creased chances of undesirable eff ects of the local anes-
thetic drugs. Case report 2
After the operation, intravenous, intramuscular,
or rectal paracetamol (acetaminophen) will be preferred A 75-year-old man is due for bilateral total knee replace-
to nonsteroidal anti-infl ammatory drugs (NSAIDs) or ment. How would you manage his pain perioperatively?
dipyrine for analgesia and antipyretic eff ects. Th is is be-
What objectives do we hope to achieve
cause of the high incidence of multiple organ failure.
with pain management in this patient?
Th ese patients will need to have small regular
Th is patient must be pain-free to mobilize quickly and
intermittent doses or continuous infusions of tramadol,
have physiotherapy in the perioperative period. Pre-
fentanyl, morphine, or any other suitable opioids that are
existing comorbidity should be considered at all times.
available in combination with the mild to moderate anal-
Complications from drug interactions and complica-
gesics mentioned above. Th ere is little evidence that one
tions from multiple drug usage should be avoided.
opioid is superior to another in the postoperative setting
as long as equipotent doses are used and application is What is the incidence and severity of
according to the specifi c drug kinetics. If the clinician is postoperative pain in joint replacement
very worried about hypotension and respiratory depres- patients?
sion, small doses of ketamine can be given intermittently, Joint replacements constitute some of the most destruc-
as a continuous infusion with a drip or infusion pumps. tive types of surgery and are usually very painful. Most
Small analgesic doses should limit the unwanted eff ects, of these patients have been in a lot of pain even before
and the sympathetic eff ects may actually be benefi cial. It surgery and are already on many drugs and other forms
must be stressed that all drugs have to be carefully titrat- of treatment. Th eir pain will be moderate (Grade 3) or
ed according to response. Many patients in low-resource severe (Grade 4), and bad enough to limit movement
countries have had limited exposure to opioids and can and normal activity. Th ere are other associated prob-
be very sensitive to them. Th is applies especially to very lems of old age and immobility. Many patients come for
ill patients like this one. Poor renal and liver function surgery as a last resort to get rid of their pain. We can
could lead to reduced metabolism and excretion, in- therefore assume that most will have unbearable pain
creasing the cumulative eff ects of drugs. after their surgery, especially when physiotherapists
start mobilizing them within one or two days after the
What other special actions should we take
regarding his pain? operation.
Very poor-risk patients like this one ideally will require What other problems do we have to consider
respiratory and cardiovascular support in a high-de- regarding pain management?
pendency or intensive care unit. Since most hospitals Th ese patients are usually on analgesics which may in-
in low-resource countries do not have these facilities, clude combinations of acetaminophen (paracetamol),
great caution must be exercised when using any drugs NSAIDs, and opioids. Some may be on steroids and
for pain relief, and careful monitoring of the cardiovas- other drugs for rheumatoid arthritis and other medi-
cular, respiratory, and urine output should be routine. cal conditions. Th ese drugs may have been taken for
Central nervous system manifestations such as agitation long periods, and side eff ects or drug interactions are
or coma may make it diffi cult to interpret the sedation not uncommon in the perioperative period. Th e el-
score. Th e delayed recovery of consciousness could also derly have considerable multisystem pathology, and
be due to the cumulative eff ects of sedatives and long- they may be on cardiovascular, respiratory, central
acting opioids used for sedation and ventilation. nervous system, and genitourinary drugs. Th ey may be
Th e take-home message would be: the general on blood-thinning drugs such as warfarin, aspirin, and
poor state of the patient and the fear of hypotension any of the heparins, which may aff ect our regional and
should not be reasons to avoid the use of opioids in this local anesthetic blocks.