Management of Acute Post-Surgical Pain 2

By Dr. Vasanthi Pinto and Dr. Ravi Weerakoon


Analgesic Plan

Different drugs and techniques can be used for each level of pain pathway. (Fig 1)The use of this is termed Multimodal Analgesic Technique. This has always proved to be better since no single analgesic drug or technique is found to be perfect. Thus, it is better to use a combination of drugs or a drug cocktail that is specific to different sites of action. This offers better and more improved efficacy and helps to keep side effects to a minimum and offers optimum patient comfort.


Figure 2: WHO Analgesic Ladder

















1. Paracetamol + NSAID +/- adjuvants; 2. Weak opioids + non-opioids +/- adjuvants; 3. Strong opioids + non-opioids +/- adjuvants


Is there any particular guide that can be used in this context?

The Analgesic Ladder had been described by the World Health Organization (WHO) as a concept that employs a logical strategy for acute pain management (Fig 2).


The Descending Analgesic Ladder has been formulated by the World Federation of Societies of Anesthesiologists (WFSA) for the treatment of acute pain in minor and major surgery (Fig 3 and 4).


Figure 3: The descending ladder of acute pain of the World Federation of Societies of Anesthesiologists (WFSA) for major surgery




















Figure 4: The descending ladder of acute pain of the World Federation of Societies of Anesthesiologists (WFSA) for minor surgery













Management of Post-Surgical Pain



The management and relief of post-operative pain is of such great importance to the patient that it needs to be planned and introduced in the preoperative period. It should be continued in Per-Operative (During operative procedure) and Post-Operative periods as well.


What is pre-emptive analgesia?

The administration of analgesics prior to the infliction of pain or surgery is termed as Pre-emptive analgesia. Techniques like the use of non-steroidal anti-inflammatory drugs (NSAID) 24 hours to 1hr preoperatively, the use of opioids preoperatively or the administration of local anesthesia to the site prior to the first incision could be considered as the available treatment options.


Per-operative pain management

Preoperatively analgesics like NSAID, opioids, epidural analgesia, local anesthetic nerve blocks, nerve plexus blocks, field blocks or skin infiltrations could be used.


Post-operative pain management

Postoperative management should include daily assessment of postoperative pain and the prompt use of the appropriate treatment modalities described above for the relief of pain.


Epidural analgesia

Local anesthetic drugs can be deposited in the epidural space. Epidural analgesia with the use of local anesthetic and opioid (0.125% bupivacaine with 2g/ml fentanyl or morphine) will provide analgesia without a motor block.


Figure 5: Epidural Analgesia (including caudal)


















By placing a catheter in place, analgesics can be used as infusions and for a longer durations, and a better quality of pain relief can be achieved.


Benefits of epidural analgesia are

superior analgesia

lower incidence of pulmonary complications

preservation of GI function (shorter duration of post-operative ileus)

attenuation of stress response

reduction in thromboembolic phenomena (orthopedics)

some evidence for

lower incidence of graft occlusion in major vascular surgery

lower incidence of arrhythmias (major vascular/cardiac surgery)

reduced blood loss (orthopedics)



Spinal local anesthetics

Local anesthetics can also be deposited intrathecally and by this the analgesia can be achieved according to dermatomal distribution. But there will be a motor blockade along with sensory blockade and autonomic blockade, which can lead to hypotension and other effects. Opioids can also be used in this route.


Paravertebral block

Since the block is localized as unilateral, this technique is mostly used during thoracotomy, breast surgery, cholecystectomy, and renal surgery. There will a low incidence of adverse effects.


Special Patient Groups

The elderly patients, children, sedated or unconscious patients and drug-dependents or patients addicted to drugs pose difficulties in assessment of pain. Thus, the treatment methods for these patients have to be modified accordingly.


Pain relief in children

A greater difficulty is associated with the assessment of pain. Children over four are better able to report pain and are able to use color scales, pictorial scales. As the emotional component of pain is very strong in children, psychological support is very important. Minimal separation from parents, holding and distraction are all important modalities.


Pain relief in the elderly

As a general rule, the elderly report pain less frequently and require smaller doses of analgesic drugs to achieve adequate pain relief.


Do We Manage Post-operative Pain Relief Well Enough?

Many reasons result in the failure to provide proper post-operative analgesia. The common reasons that can be deduced for these include insufficient education on the alleviation of pain, the fear of complications associated with analgesic drug administration, poor pain assessment, and inadequate staffing. Good patient communication with effective analgesia management is the cornerstone of a successful pain management program.


Acute pain service

This service has to be provided by a multidisciplinary team which should include the medical staff, nursing staff, pharmacy services and secretarial support. There should be daily ward rounds to review post-operative patients and attention should be focused on the management of pain. This should involve pre-operative patient education and screening as well.



Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. J Pain and Symptom Manage. 1999; 18 (6): 438-445.

Carr DB. Pain control: the new "whys" and "hows". Pain Clinical Updates. 1993; 1 (1): 1-4.

Mogil J, editor. Pain 2010- An Updated Review: Refresher Course Syllabus. Seattle: IASP Press; 2010.

Sri Lanka Association for the Study of Pain

The Sri Lankan Chapter of the International Association for the Study of Pain

January 2014. Sri Lanka Association for the Study of Pain (SLASP). All Rights Reserved.

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 Pain: An Overview

 Physiology of Pain

 Pharmacological Management of Pain

 Neuropathic Pain

 Abdominal Pain

 Orofacial Pain: An Overview

 Pain: Psychological Correlates

 Assessment of Pain

 Management of Acute Post-Surgical Pain

 Management of Pain in Obstetrics

 Management of Musculoskeletal Pain and Chronic Pain Syndromes

 Management of Pain in Children

 Management of Pain in Neonates

 Management of Acute Pain in Trauma

 Management of Cancer Pain

 Management of Headache




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