Page 119 Guide to Pain Management in Low-Resource Settings

Pain Management after Major Surgery 107

metabolic, and psychological responses to trauma. Ex- numeric analogue scales should not be diffi cult to use
amples include the neuroendocrine changes involving routinely in even the poorest environments. Th e assess-
hypophysis-adrenal responses, which can have pro- ment should tell us about the nature and severity of pain
found eff ects on the body. Some of these detrimental ef- and help us to initiate and evaluate treatment.
fects are summarized below. Quantifying pain may, however, be diffi cult be-
cause pain is subjective and unique to the individual.
Cardiovascular system One has to be able to communicate with patients and
Pain can cause a number of diff erent types of arrhyth- measure their responses. Assessor and patient factors
mias, hypertension leading to myocardial ischemia, and are therefore important. To improve the accuracy of
congestive cardiac failure, especially in the elderly and the various assessment methods available, we have to
those with cardiac disease. educate the patients as well as medical staff in their use.
Preferably, patient education and practice in using these
Respiratory system
methods should take place in the preoperative period.
Tachypnea and low tidal volume due to painful respira-
tory eff orts, reduced thoracic excursions, and sputum Is the assessment of pain with
retention can lead to atelectasis or chest infections.
an analogue scale suffi cient
Gastrointestinal system for all situations?
Delayed gastric emptying can lead to nausea, vomiting,
Sometimes one cannot use the most common assess-
and bowel distension. ment methods such as the visual analogue scale, or they
may not be suffi cient for certain situations. In babies,
Metabolic eff ects
and with uncooperative and unconscious patients, we
Sympathetic stimulation can lead to hyperglycemia and
cannot use the analogue scale. In preschool and older
acid-base abnormalities such as respiratory acidosis or
children, modifi ed scales can be used, but one may have
alkalosis, which can lead to electrolyte imbalances and
to rely on physiological parameters such as pulse rate,
fl uid retention.
respiration, crying, sweating, limitation of movement
CNS and socioeconomic eff ects and many others. Unfortunately, pain is not the only
cause of these changes, and they should be interpreted
Pain can lead to uncooperative patients and can cause
with caution.
anxiety, depression, or agitation. Prolonged stay in the
In settings like intensive care units, physiologi-
hospital can put stress on individuals, families, and
cal data may be the only methods that can be used. Th e
health institutions.
equipment required can be very expensive to purchase,
Secondary consequences of pain maintain, and operate.

Th ere are also some eff ects that may not initially ap-
pear to be linked to pain. Pain delays the mobilization What are our goals in postoperative
of patients out of bed and, therefore, increases the risk pain management?
of postoperative complications like thromboembolism,
Clinicians will want to treat pain in order to prevent the
bedsores, and many infections such as chest, gastroin-
detrimental eff ects mentioned earlier. We would like the
testinal tract, and wound infections. Th ese can be re-
patients to be able to mobilize quickly out of bed. Pa-
ferred to as secondary consequences.
tients should be able to tolerate physiotherapy, tracheal
suctioning and coughing, and other potentially painful
Do we have to measure pain therapeutic and diagnostic procedures.

postoperatively, and how do Patients want to breathe, talk, walk, and carry
we go about it? out other functions as quickly and comfortably as pos-
sible. Th ey also want peaceful uninterrupted periods of
It is very useful, but not always possible, to assess rest and sleep. When on pain treatment, they do not
pain in the postoperative period. Simple and reliable want to be unduly drowsy, or have any nausea and vom-
methods of pain assessment like the verbal, visual, or iting or inconveniences such as constipation.