Page 120 Guide to Pain Management in Low-Resource Settings

108 Frank Boni

Whatever the method of analgesia chosen, the How do we monitor the side eff ects
method must be: of the analgesics we are using?
• Eff ective,
• Safe, and When using systemic analgesia, we are particularly con-
• Aff ordable. cerned about the use of opioids. Th e side eff ects we should
One should try and initiate analgesia before be most concerned about are the respiratory eff ects. Re-
the pain becomes intolerable and established because spiratory depression can be diffi cult and unreliable to de-
the pain cycle is more diffi cult to break once it be- tect at the initial stages. Since excessive sedation usually
comes established. Once good analgesia is achieved, comes before respiratory depression, if we monitor seda-
it should be maintained as long as the patient needs tion carefully and regularly, we should be able to prevent
it. After major surgery, the fi rst 48 hours will be the respiratory depression. A simple sedation score like the
critical period, but some patients will need analgesia one below should be used for all patients on opioids:
for weeks. Analgesia can be started with intravenous Grade 0 patient wide awake
strong opiates, with or without regional and local an- Grade 1 mild drowsiness, easy to rouse
esthetic techniques, and gradually tapered to weaker Grade 2 moderate drowsiness, easy to rouse
drugs by the oral or rectal routes over several days. Grade 3 severe drowsiness, diffi cult to rouse
Th e intramuscular use of drugs immediately after op- Grade S asleep, but easy to rouse
erations is not advisable because the results are not Th e key to safe use of opioids in poorly resourced coun-
very predictable and they are diffi cult to control. It is tries is therefore to monitor the sedation score very close-
preferable to use more than one technique or drugs to ly and avoid Grade 3 sedation. Regular monitoring, e.g.,
achieve our goals. by a nurse, may be considered as safe as monitoring with
technical equipment!
Does good acute pain control have
any long-term eff ects? What other parameters
should we measure in wards
Although we still do not fully understand the develop- after major surgery?
ment of chronic pain after surgery, we now know a lot
about the incidence of chronic pain after surgery and All patients should have the following monitored after
about ways to prevent its occurrence. Although the all major surgery:
numbers tend to vary after most types of surgery, about • Level of consciousness
one out of every 10–20 patients will have long-term • Position and posture of the patient
pain after surgery, and for half of them, the pain will be • Rate and depth of respiration
severe enough to need treatment. We now know that • Blood pressure, pulse, and central venous pres-
good pain control, no matter how it is achieved, will sure, when indicated
reduce the number of patients experiencing long-term • Hydration state and urine output
pain after major surgery. • All medications being administered along with
We also know that only a negligible number of analgesics
patients who receive opioids for acute pain after sur- • Patient activity and satisfaction.
gery will become addicted or dependent on opioids if • History, examination, and good record-keeping
the drugs are used in a controlled manner. Th ere is, will reveal any problems.
therefore, no justifi cation for withholding strong opi- Complications such as nausea and vomiting
oids from patients because of the fear of addiction, can be troublesome and should be controlled with an-
as is done in many developing countries. Ironically, tiemetics. Constipation may be a problem after pro-
many patients in these countries can barely tolerate longed use of opioids, and mild laxatives like lactulose
the euphoria, drowsiness, and other eff ects caused by can be used.
the opioids. Some patients in poorly resourced coun- Renal, bleeding, and other problems can be
tries will not accept opioids postoperatively when giv- worsened by the use of nonsteroidal anti-infl ammato-
en the choice. ry drugs and other analgesics, and patients should be