Page 123 Guide to Pain Management in Low-Resource Settings

Pain Management after Major Surgery 111

• Th e acute pain service should organize regular • Optimum monitoring of the patient should in-
ward rounds, run emergency services for com- clude equipment for respiratory monitoring, in-
plications, carry out research, and conduct audits cluding pulse oximetry and cardiovascular moni-
on pain management. toring, and fl uid input/output charts.
• It should, however, be emphasized that the best
Advanced pain management services in monitors are the doctors, nurses, and other
teaching hospitals and other specialized units
health personnel with the help of relatives and
• Th ese facilities should aim to have acute pain any other persons around. Simple sedation ob-
service with guidelines and protocols to cover servation charts and early warning charts for ad-
children and adults in accident and emergency verse events will help manage even the most dif-
wards, operating rooms, and recovery wards as fi cult patients in the least well-resourced areas.
well as general wards.
• At least one or two doctors and an identifi ed
What are pain considerations
pain nurse should be able to follow up diffi cult
and problematic postoperative cases and to man- after some specifi c major surgical
age any complications arising from postoperative operations?
pain or its treatment.
General surgery (e.g., thyroidectomy, gastric and bowel
• A recovery ward and a high-dependency unit and
resections, major burns, and abdominal trauma)
if possible an intensive care unit will be required
Patients will have moderate to severe pain
for some of the major operations or for very ill
(Score 2–3). It does not matter if they are emergency or
patients in order to treat pain eff ectively in the
elective cases. More care must be taken with emergency
immediate postoperative period. Relying on the
cases because systemic analgesic drugs may mask symp-
sympathetic responses caused by pain to artifi -
toms and signs of diseases.
cially prop up the patient’s blood pressure is not
• Antispasmodics such as hyoscine butylbromide
acceptable and may cause more harm than good.
are useful in colic pains.
• Th ere should be staff training programs to train
• General surgery covers a wide spectrum of opera-
personnel to manage pain safely at all levels and
tions and pain-relieving techniques. Local and re-
especially in high-risk patients after major sur-
gional anesthetic blocks are grossly underused.
gery.
Obstetrics and gynecology (e.g., abdominal hysterecto-
my, cesarean sections, pelvic clearance for cancer)
What equipment and what drugs Patients will have moderate to severe pain
are required for postoperative (Score 2–3). Considerations include:
pain management? • First trimester. Choose drugs carefully and avoid
those that aff ect the fetus.
• Simple hypodermic needles or preferably can- • Before delivery of the baby by cesarian section,
nulas and syringes and intravenous infusion lines opioid use should be avoided as it aff ects the fe-
may be all that is needed to treat most patients. tus.
Syringe and infusion pumps are being increas- • Deep vein thrombosis, bleeding, and other hema-
ingly used for continuous, patient-controlled, or tological problems aff ect pain management.
nurse-controlled analgesia. Th e prices and avail- • Women may seem to tolerate pain better than
ability of these pumps should improve sooner or men, but this is not a general rule.
later and make it possible for poorly resourced • Nausea and vomiting are very common and
countries to procure them. should be adequately treated.
• Th ere should be a wide range of drugs to refl ect Trauma and orthopedic operations (e.g., fractures of the
the range of patients and operations carried out. neck of the femur with moderate pain or shoulder, knee,
Th e WHO essential drug list may not be ade- or hip reconstruction with very severe pain)
quate for managing pain after major operations, • Head injuries. Some clinicians are reluctant to
even in poorly resourced countries. use opioids, but they can be used safely.