Page 132 Guide to Pain Management in Low-Resource Settings

120 Andrew Amata

earlier presentation of patients, and the increasing avail- • The fear among health care providers of the
ability and accessibility of health care resources. Gen- respiratory depressant and sedative effects of
erally, more than half or even two-thirds of all surgical opioid drugs outside of immediate supervised
cases in health care facilities are usually considered mi- medical care.
nor and are often done as “same-day” or “day-case” or as • The presumption that patients or guardians
“outpatient” or “ambulatory” surgery, where the patient may be ignorant of the risks of medications and
comes into the health care facility, has the procedure may abuse them, with significant consequences
done, and goes home the same day. Th is trend has been at home.
increasing recently and is mainly driven by economic • Legislative and restrictive policies in some re-
factors, patients’ preferences, improved anesthetic and gions that make it diffi cult to have access to po-
surgical techniques, and the increasing availability of tent analgesics.
minimally invasive surgical procedures.
Strategies for ensuring eff ective
What is the prevalence of pain after postoperative analgesia
minor surgery?
Be proactive
Th e general assumption is that minor surgery is as- Eff ective postoperative pain management begins pre-
sociated with less pain than major surgery. One of the operatively. Patients are often very anxious and dis-
criteria for selection for outpatient surgery is that pain tressed by the hospital and procedure experience, and
should be minimal or easily treatable. However, it may this distress may exacerbate pain postoperatively. Pre-
be diffi cult to accurately predict pain intensity in a par- operative information and education regarding pain
ticular individual as some seemingly minor surgery control has been shown to signifi cantly reduce pa-
may elicit moderate to severe pain for various reasons, tients’ and guardians’ anxiety and analgesic consump-
including interindividual variability in pain perception tion. Education improves understanding and com-
and response. For the same type of surgical procedure, pliance with the analgesic administration regimen.
two similar individuals may perceive and experience Important information may need to be repeated or
pain very diff erently, and even for the same individual, provided in written form as patients or their guardians
the intensity of pain of a procedure may vary with time may not remember everything they had been told dur-
and activity. Several studies have shown that more than ing the perioperative period.
50% of children and a similar proportion of adults who Most patients recovering from anesthesia in the re-
undergo outpatient surgery experience clinically signifi - covery room are comfortable because of the proactive
cant pain after discharge. and aggressive pain management by the anesthesia care
provider. Unfortunately, when the patient is discharged,
What factors lead to poor pain the intensity or continuity of pain care is disrupted. Th e
control after minor surgery? pain of surgery often outlasts the pain medication or lo-
cal anesthetic administered in the perioperative period.
Contributory factors to poor postoperative pain control To avoid this problem, administer the fi rst postoperative
in minor surgery include: analgesic dose before the eff ects of the intraoperative
• Th e assumption that minor surgery is associated analgesics wear off completely.
with little or no pain, so that little or no analge-
sics are given in the postoperative period. Use preemptive or preventive analgesia
• Th e pressures of current ambulatory surgical Preemptive analgesia implies that giving analgesia be-
practices, which emphasize rapid recovery and fore the noxious stimulus is more eff ective than giving
return to “street fi tness” and early discharge, re- the same analgesia after the stimulus. While this con-
sulting in anesthesia care givers and surgeons cept has not been convincingly proven in all clinical
avoiding or minimizing the perioperative use of studies, what is clear is that more analgesia is often re-
potent and longer-lasting analgesics and sedatives quired to treat pain that is already established than to
that may delay recovery and discharge. prevent or attenuate pain that is still developing. One