Page 133 Guide to Pain Management in Low-Resource Settings

Pain Management in Ambulatory/Day Surgery 121

should therefore aim to preempt or prevent pain if pos- An often forgotten or neglected part of the
sible or proactively treat pain as early as possible. multimodal approach is the use of nonpharmacological
therapies. Psychological and physical therapies comple-
Avoid analgesic gaps ment medications and should be used whenever possi-

Analgesic gaps subject the patient to recurring pain and ble. Physical therapies include splinting and immobiliz-
unsatisfactory analgesia. Such gaps tend to occur when ing painful areas, application of cold or hot compresses,
the eff ect of a prior analgesic dose or technique is al- acupuncture, massage, and transcutaneous electrical
lowed to wear off before the subsequent dose is given. nerve stimulation (TENS). Psychological therapies in-
An appropriate dosing interval based on knowledge of clude behavioral and cognitive coping strategies such
the pharmacology of the agent is important to minimize as psychological support and reassurance, guided imag-
this gap. ery, relaxation techniques, biofeedback, procedural and
sensory information, and music therapy. Studies suggest
Apply a multimodal analgesia strategy that these nonpharmacological therapies improve pain
Multimodal analgesia implies the use of several analge- scores and reduce analgesic consumption.
sics or modalities that act by diff erent mechanisms in
combination to maximize analgesic effi cacy and mini- Pearls of wisdom
mize side eff ects. Th is strategy allows the total doses
and side eff ects of analgesics to be reduced. • Discuss the options and plan the method of post-
Paracetamol, a nonsteroidal anti-infl ammatory operative pain management with the patient and/
drug (NSAID), and local analgesia should be routinely or guardian preoperatively.
used as components of a multimodal analgesic strat- • Be proactive; begin postoperative pain manage-
egy, unless there is a specifi c reason not to use one of ment preoperatively. Th is strategy will reduce
these agents, as they are synergistic or additive. In other intraoperative anesthetic requirements and facili-
words, the combination provides better analgesia than tate earlier recovery and discharge.
one of the individual drugs alone. Potent opioids, espe- • Give preemptive or preventive analgesia. Preven-
cially the long-acting ones like morphine and metha- tion is better than cure. Much larger amounts of
done, should preferably be avoided or used sparingly as an analgesic are required to treat established pain
postoperative analgesics for minor surgery because of than to prevent it.
their associated side eff ects, especially nausea and vom- • Use a multimodal approach to pain management,
iting, respiratory depression, and sedation. Postopera- incorporating both pharmacological and non-
tive nausea and vomiting (PONV) can be quite distress- pharmacological methods.
ing, and some patients may prefer to tolerate the pain • Provide a supply of eff ective analgesics and infor-
rather than use opioids. PONV and pain are the two mation on their use before discharge.
most common causes of delayed discharge and also for • Give appropriate and eff ective analgesics regular-
unanticipated admission in day-case surgery. However, ly (around-the-clock) rather than p.r.n. or “as re-
if the severity of pain warrants the use of opioids, the quired” for the fi rst 24 to 48 hours postoperative-
shorter-acting agents such as fentanyl should preferably ly, when the pain intensity is likely to be highest.
be used by careful titration to eff ect in the immediate Make provision for management of breakthrough
postoperative period. pain (rescue analgesics).
Alternatively, the “weaker” opioids such as tra- • Always provide a contact number that a patient
madol or codeine should be used. Th e “weaker” opi- or guardian can call if necessary.
oids have the advantages of minimal sedative and re-
spiratory depressant eff ects, a low potential for abuse, References
and not being subject to stringent opioid restrictions,
and thus they may be more easily dispensed to appro- [1] Finley GA, McGrath PJ. Parents’ management of children’s pain follow-
ing minor surgery. Pain 1996;64:83–7.
priate patients. Th ey therefore fi ll an important gap [2] Rawal N. Analgesia for day-case surgery. Br. J Anaesth 2001;87:73–87
in the analgesic ladder between the mild non-opioid [3] Shnaider I, Chung F. Outcomes in day surgery. Current Opinion in An-
esthesiology. 2006;19:622–629.
analgesics and the more potent opioids, especially for [4] Wolf AR. Tears at bedtime: a pitfall of extending paediatric day-case
day-cases. surgery without extending analgesia. Br J Anaesth 1999;82:319–20.