Page 121 Guide to Pain Management in Low-Resource Settings

Pain Management after Major Surgery 109

monitored more closely if there is any cause of suspi- Invariably the following will determine the type
cion from the history and examination. of methods to choose
• Type and condition of the patient
What pain management options do • Type of the surgery and healing period

we have to choose from? • Th e training and experience of the anesthetist
and other staff
Peripheral analgesics • Th e resources available to treat and monitor the
patient
Peripheral analgesics are sometimes described as weak
to moderate analgesics, and they can be used intrave-
Which pharmacological alternatives may I
nously, intramuscularly, rectally or orally. Examples are choose from?
acetaminophen (paracetamol), ibuprofen, and diclof-
Th e drugs included in the table are mostly the drugs from
enac. Although they may not be able to control pain
the latest essential drug list proposed by the World Health
alone after major surgery, they are very useful in combi-
Organization (WHO). Th e drugs marked are not included
nations with one another or with opioids and other an-
in that list but can be very useful. Th is applies to diamor-
algesic techniques. One of the new major developments
phine and some other drugs mentioned in the text.
in postoperative pain management is the regular use of
peripheral analgesics after all grades of surgery.
Should very ill patients receive
Local and regional anesthetics strong analgesics postoperatively?
Th ese include wound infi ltrations during operations,
Many patients are not well resuscitated and may be
fi eld blocks, nerve blocks, and regional blocks of the
hypovolemic after major surgery. Severe pain causes
limbs and trunk. Th ese are particularly useful in the fi rst
a lot of adrenergic stimulation, which tends to tempo-
12 to 24 hours, when we are very worried about cardio-
rarily keep the blood pressure up. Th is occurs at great
vascular and respiratory postoperative complications.
cost to the patient because of the accompanying tachy-
cardia and increased oxygen consumption, and also pe-
“Central” analgesics
ripheral and renal shutdown. When pain is abolished,
Opioids are the most useful in this group, but in some these patients may reveal their “true” blood pressure
specifi c situations, general anesthetic drugs such as in- and become hypotensive. Some medical staff therefore
travenous ketamine in “subanesthetic” doses can be used avoid opioids in such patients. Th e hypotension should
for pain relief without making patients unconscious. prompt medical staff to treat the patient more aggres-

sively and correct the real causes. Morphine causes his-
“Coanalgesics”
tamine release, which may cause vasodilatation, but it is
Drugs such as antidepressants and anticonvulsants are usually mild and benefi cial to the heart.
frequently used in chronic pain, but they are not very Some hospital staff looking after very ill patients
useful in acute pain. Intravenous steroids such as dexa- prefer to see a patient struggling and showing signs of
methasone are becoming more popular for use as anti- life rather than pain free and sleeping quietly. Some tie
emetics after surgery, but they have not been proven to up such patients to their beds when they are struggling.
reduce postoperative pain signifi cantly. Others resort to sedatives and hypnotics, such as diaz-
epam or even chlorpromazine. Many patients are rest-
Nonpharmacological methods
less because they have pain or a full bladder. Sedating or
Tender loving care (“TLC”), heat and cold applica- restraining such patients may do more harm than good
tions, massage, and good positioning of the patient and should not replace adequate pain relief.
can all reduce pain after surgery and do not add much
to the costs of treatment. Th ese methods should be Is the pain threshold higher in
used more whenever possible. Transcutaneous electri- patients from poorer countries?
cal nerve stimulation (TENS), acupuncture, and other
methods are not currently considered clinically useful Th ere is no real evidence for this surmise. Although
after major surgery. expressions and the reactions to pain may diff er from