Page 124 Guide to Pain Management in Low-Resource Settings

112 Frank Boni

• Acute abdomen. Analgesics may mask acute ab- • Scalp and other head and neck nerve blocks can
domen signs perioperatively. be very useful.
• Regional and nerve blocks can be used in many • Nausea and vomiting may be a problem.
clinical situations. • Dihydrocodeine or other “weak” opioids are pre-
• Multi-organ failure must be considered when ferred by some health workers to stronger opi-
choosing and titrating drug doses. oids, because of the view that they causes less
Major pediatric operations (e.g., cleft palate repair with respiratory depression. However, if doses are
severe pain, pyloric and bowel surgery with moderate titrated carefully to the desired eff ect and ade-
to severe pain, anal and genitourinary malformation quately monitored, any opioid may be used safely.
repair with severe pain, exomphalus and gastroschi- Ear, nose, throat, dental, and maxillofacial operations
sis with severe pain, and thoracic surgery such as dia- (e.g., jaw fracture fi xation with moderate pain, tonsillec-
phragmatic hernia and tracheoesophageal fi stulae with tomies with moderate but sometimes severe pain)
very severe pain) Common problems include:
Problems related to the management of pediat- • Airway concerns, especially with bleeding, in-
ric patients include: creased secretions, and opioids.
• Technical, physiological, and biochemical diff er- • Danger of sleep apnea, restlessness, or dimin-
ences from adult patients. ished states of consciousness.
• Drugs doses and drug delivery systems require • Nausea, vomiting, and retching are to be avoided
special training. as much as possible.
• Parents and staff role are more critical than in • Pethidine (meperidine) may have advantages of
adults. anticholinergic eff ects over other opioids.
• Th e view that newborns do not need pain relief is Genitourinary operations (e.g., prostatectomy, urethral
no longer valid. reconstruction, and nephrectomy, which can all be very
Cardiothoracic operations (facilities for cardiopulmo- painful, but fortunately these are easy to manage with
nary bypass are not usually found in poorly resourced regional techniques)
countries, but one may still need to do thoracotomies • Th e patients are usually elderly with geriatric and
and lung resection for tuberculosis and chest tumors. major medical problems.
Chest trauma, repair of aneurysms, esophageal surgery, • Intrathecal and epidural local anesthetics with
and some valve repairs and closure of congenital mal- opioids are commonly used.
formations can all be very painful, especially when the • Some theoretical problems, such as spasm of
sternum and ribs are split). sphincters caused by morphine, are rarely en-
Special problems include: countered.
• Use of anticoagulants and problems with regional
Septicemia
and local anesthetic blocks.
• Heavy sedation and ventilation ideally will re- Septic patients are common in poor countries. Many of
quire intensive care units. these patients may not be suitable for regional and local
• Heart and lung function may be compromised, anesthesia and analgesia if there is frank septicemia.
but good pain management can prevent or control Th ere may also be unpredictable drug eff ects
major complications and help with physiotherapy. from opioids, nonsteroidal anti-infl ammatory and
Neurosurgical operations (e.g., major spinal surgery with other potent drugs because of multiorgan failure. Ac-
severe pain, craniotomy and resection of brain tumors etaminophen and dipyrine, if they are not contraindi-
with moderate pain, trauma and skull fractures with cated, will help with the pain and the pyrexia seen in
moderate pain) septic patients.
• Care should be taken in interpreting the Glasgow
Coma Scale with opioids. Pearls of wisdom
• Large doses of opioids can cause hypoventilation
and increase intracranial pressure. • Acute pain after major operations provides few
• It may be advisable to avoid nonsteroidal anti- benefi ts and numerous problems for patients and
infl ammatory drugs. should be treated whenever possible.