Page 117 Guide to Pain Management in Low-Resource Settings

Pain Management after Major Surgery 105

The socioeconomic status of these patients be carefully conducted. In this situation, strong opioids
is very important. The patients may not have family combined with NSAIDs can provide good intraopera-
and financial support. If they have dementia and can- tive and postoperative analgesia.
not communicate very well, pain management can be Syringe and volumetric pumps are expensive
very difficult. and diffi cult to maintain, but large teaching hospi-
tals should have them for patient-controlled analgesia
What are the best pain management options (PCA) or continuous infusions in operations such as
for this patient?
joint replacement. Regular acetaminophen, either intra-
For pain relief during and immediately after the opera- venously or orally, should be given with other oral an-
tion, regional anesthesia is probably best for this group algesics such as codeine, tramadol, or NSAIDs as soon
of patients. Th e duration of the operation, patient co- as patients can take oral medications. Antiemetics, ant-
operation, and technical diffi culties, as well as antico- acids, and mild laxatives may be prescribed as required.
agulant therapy, may make general anesthesia manda- Intravenous acetaminophen is now more aff ordable and
tory. Spinal anesthesia with long-acting local anesthetic convenient than rectal acetaminophen and should be
drugs together with intrathecal opioids will provide a used more often, even in low-resource countries. It is
simple and eff ective anesthesia and good postopera- probably the safest multipurpose analgesic that we have
tive analgesia. Th is method is well suited for any low- at the moment.
resource country because patients receiving this type of
anesthesia require less resources and care than patients What roles should the patient, relatives,
who have general anesthesia. Small doses of diamor- and medical personnel play in the pain
management of this patient?
phine given intrathecally with the local anesthetic drugs
can provide good analgesia for up to 24 hours post- Perioperative pain management plans should be me-
operatively. Diamorphine may, however, not be freely ticulously put in place well in advance of operations like
available in low-resource countries. Morphine may be this one. Th e surgeon, anesthetist, and acute pain team
easier and cheaper to procure and can be an alternative. (if available) should involve the patient and the rela-
Th e clinician should, however, only use preservative- tives before the operation to discuss the options. Special
free morphine in the intrathecal or epidural space and forms, written instructions, and guidelines make things
should be aware of the problems associated with mor- easier for patients and hospital staff . Th e appropriate
phine use, which include delayed respiratory depres- scoring systems, and the use of equipment like PCA
sion, itching, nausea, vomiting, and urinary retention. pumps, should be practiced with the patient before the
Patients on aspirin and some prophylactic an- operation. In uncooperative or demented patients with
ticoagulation can have spinal anesthesia, provided that no family support, the safest and most appropriate tech-
hematological profi les are kept within normal ranges and niques should be used, and extra care should be taken in
that care is taken with timing and concurrent use of pro- monitoring them.
phylactic heparins. Clopidogrel and some newer drugs Th ese are just two examples of major surgery
used in richer countries cause more problems and have that one can come across in poorly resourced countries.
to be stopped at least 7 days before surgery and regional Th ere are many other operations, types of patients, and
anesthesia. Th e timing of the dural puncture should not issues that one will come across in managing pain after
be within 2 hours of giving low-molecular-weight hepa- major surgery in these countries. Some of these issues
rin (LMWH) such as enoxaparin. Unfractionated hepa- will now be discussed.
rin is more aff ordable but not as eff ective as LMWH in
preventing deep vein thrombosis in these patients. Why is postoperative analgesia
Th e single-shot spinal may, however, not be
an issue?
suitable for a bilateral knee replacement in this patient,
and so a combined spinal epidural (CSE) can be used. Major surgical operations normally cause considerable
Th is treatment is more expensive, and the incidences of tissue damage and pain. It only became possible to per-
complications with anticoagulants are higher. If the du- form major operations safely and painlessly after mod-
ration of the operation or the patient’s condition do not ern anesthesia was introduced about a century ago. In
favor a regional technique, general anesthesia should the perioperative period, certain pathophysiological