Post-Surgical Pain - Essay Example

Post-surgical pain can be defined as a complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system. As a result, pain is felt in areas not directly affected by the surgical procedure. Post-operative pain mat affect both inpatients and outpatients and may occur after any surgical procedure, whether it is minor dental surgery or a triple-bypass heart operation. Post-operative pain makes the patient more susceptible to post-surgical complications, raises the cost of medical care, and most importantly, interferes with recovery and return to normal activities of daily living. Therefore, management of post-surgical pain becomes a basic patient right. When pain is controlled or alleviated, a patient is better able to resume day to day tasks such as walking or eating that promote his or her recovery by aiding the healing process. Post –surgical pain can be categorized into two different forms: physiologic pain and clinical pain. Physiologic pain is transient, and is caused by experiencing a high-intensity sensation. Its basic function is that of a safety mechanism to warn individuals of dangers and injury (e.g., a burn, animal scratch, or broken glass). Clinical pain on the other hand, is marked by hypersensitivity to painful stimuli around a localized site and surrounding areas. When surgery is performed, tissues and nerve endings are traumatized, resulting in incision pain. This trauma overloads the pain receptors that send messages to the spinal cord, which becomes over stimulated. The resultant central sensitization is a type of posttraumatic stress to the spinal cord, which interprets any stimulation, painful or otherwise, as unpleasant and the patient, may feel pain in movement or physical touch in locations far from the surgical site. Patients handle post-operative pain in high individualized ways. Health care professionals have observed that some patients report that they are in extreme pain after surgery, demanding large doses of pain medications while others seem to do well with much less medication (Leff, 2003). Several theories have been put forth for this discrepancy. For example, differences in body size seemed to require differing amounts of medication, but this theory did not explain differences in pain perception among patients of the same build. Emotional well-being was considered a better indicator of the ability to tolerate pain. It has been theorized that patients with stronger support systems and better attitudes actually perceive less pain than others. Some health care professionals have even speculated that extreme pain was not real in many cases, but was a way to seek attention. Pain perception is a highly subjective sensation and hence it is important for the health care team to be aware of pain sensitivity differences in patients and to value patient self-report as a reliable tool for pain assessment. The most common self-report system in use is the pain intensity scale in which patient is asked to rate the intensity of pain on a scale of 1 to 10. Sensory words or synonyms may also be used that allow the patient to communicate more accurate, descriptive information about pain (Ex: Short-Form McGill Questionnaire) and may be a better tool in planning pain management strategies. However, most health practitioners agree that “pain is what the patient says it is”. A variety of interventions may be used before, during, and after surgery that involve medications given orally, intravenously, intramuscularly, or topically. Some may be administered by a health care professional and others by the patient. Pre-surgery pain management The purpose of post-surgical pain management is to reduce the amount pain a patient experiences after surgery. New research has suggested that preventing the nervous system from being overtaxed by pain from the trauma of surgery may lead to a less painful postoperative experience. Pretreated patients may require less post-surgical medications, may recover sooner than patients who have used traditional post-surgical pain methods. Recently, outpatient (also called ambulatory) surgery has become a procedure of choice for many complex surgeries, such as hysterectomy and prostatectomy that reduces the hospital stay thus cutting down the cost of treatment for the patient as well as the hospital. Preemptive analgesia introduces anesthetic drugs near the spinal cord or, sometimes, in nerve blocks in specific regions of the body. Pain management during surgery General anesthesia has been the standard for pain management during surgery. Topical local anesthetics are also being used to numb the surgical site before any incisions are made. Local anesthetics minimize pain trauma to the surgical site and the central nervous system. Post-surgery pain management Most hospitals make use of analgesics and narcotics immediately after surgery. These drugs may be administered intravenously, intramuscularly or orally and are considered one of the most viable methods. Many health practitioners prefer administering these drugs on a scheduled basis, even before the pain occurs. Other hospitals advocate continuous administration through the use of a pump-type device that immediately delivers medication into the veins (intravenously, the most common method), under the skin (subcutaneously), or between the dura mater and the skull (epidurally) (Liu S, 1995). Sometimes, the patient administers the dose by pushing a button, and is encouraged to keep a steady supply of medication within his or her system. This method of administration is called patient-controlled analgesia (PCA). Usually opium-like pain-relievers (opioids) are delivered through these pumps which has raised some concern about possible narcotic addiction. Opioids are best given on a schedule or in a computerized pump, which can prevent overdoses. Of great concern to health-care professionals is how to provide post-operative pain management to patients who are opioid tolerant because these patients require higher and more frequent doses of narcotics for pain relief. It is important for anesthesiologists to aggressively treat pain for opioid-tolerant patients in the recovery room under close monitoring (Wu and Casey, 2002). Nonsteroid anti-inflammatory analgesics (NSAIDs) are the treatment of choice for continuous around-the-clock pain relief and prevent the extremes in pain perception that occur with on-demand dosing; sometimes the patient feels no pain and extreme pain at other times (Murauski. 2002). Another pain management strategy is the On-Q or the “pain relief ball” which is a balloon-type device that administers non-narcotic medication to the incision site through a small catheter. When the incision site is closed, the catheter is attached to the surgical site and the balloon or pump is either taped to the patients skin, carried in a pocket or pouch, or attached to the patients clothing. The pump numbs the incision site by continuous flow of anesthetic into the wound site. Alternative non-medical methods Some non-medical aspects are proven to be effective in reducing post-operative pain. Providing accurate information ahead of time about the surgery and recovery gives the individual a realistic idea of what to expect during the hospital stay (for example, how much pain one is likely to experience) and can help to relieve anxiety and fear, both of which are known to aggravate symptoms of pain. Understanding the factors that are associated with intense pain after surgery can be helpful in preventing or pre-empting post surgical pain. Education also enlists the patients cooperation and may encourage a feeling of control and empowerment, which reduces stress, fear, and helplessness which in turn may contribute to less perceived pain. Psychologists’ help patients cope with postoperative pain through a variety of means. ‘Tools’ used by psychologists that have been shown to be effective in reducing intensity of postoperative pain include hypnosis and self-hypnosis, relaxation training, and cognitive behavioral therapy which includes education/instruction, relaxation, imagery, music, biofeedback. Meditation and deep breathing techniques also can reduce stress. These techniques can lower blood pressure and increase oxygen levels, which are critical to a healthy recovery. Physical agents include heat or cold; massage, exercise; transcutaneous electrical nerve stimulation (TENS). In most case a multi – modal strategy is implemented wherein use of pre-surgical, surgical, and post-surgical techniques allows the patient to arise from surgery with the pain already under control. However, some pain is probable but a patient should not be in intense pain after surgery. Pain management should occur before pain appears rather than in reaction to pain (Ke R W, 2001). Adequate knowledge about multimodal pain management is necessary as more outpatient and office-based surgery is done. Finding the right combination of methods for an individual patient will be the challenge and responsibility of the health care team. After surgery, a patient should not have to endure severe pain. Prudent pain management will allow the patient to eat, sleep, move, and perform routine activities even while in the hospital and on returning home. Recovery may take several weeks after surgery; however, the patient should be made comfortable with a regime of oral pain medications. Multi disciplinary team: Nowadays, most hospitals have an Acute Pain Service (APS) consisting of a team anesthesiologists and nurses whose main objective is to ensure that postoperative pain is properly managed through the use of powerful pain medications (AHCPR, 1992). Some hospitals also have a psychologist on the APS team whose role is to help determine the best pain management plan for each patient. Some patients become afraid, anxious or depressed after surgery which can affect the amount of pain they experience. By helping the patient deal with these problems, the psychologist contributes to improved postoperative pain management.  Meeting special needs: Dealing with elderly patients can be especially challenging because they often have multi-system disease in conjunction with physiologic changes associated with aging (Ferrell, 1996). Commonly, mental impairment and polypharmacy render these patients susceptible to adverse effects of analgesic medications used in pain control. Some common problems encountered in caring for the elderly include misconceptions, inadequate assessment, patients with cognitive impairment, dementia, aphasia and lack of education. Frail, debilitated patients and cognitively impaired patients benefit from frequent assessments. Co-operation and help of a family member in order to try and "understand" the patient is indicated many a time. It may be helpful to note the patients posture (rigid, not moving), facial expressions, verbal cues such as moaning. In a confused patient (who is previously not confused) rule out hypoxia, drug interaction, night time confusion, and pain. A history of alcohol abuse warrants preventive measures against withdrawal (May L Chin, 1996).   References: Primary source: Post-Surgical Pain forum, Encyclopedia of Surgery: A Guide for Patients and Caregivers :: Pa-St Pain in the Elderly, Ferrell BR, Ferrell BA, eds.; IASP Press, Seattle, 1996 Chin ML. Postoperative pain management of the adult patient. IARS review Course Lectures, 1996 Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia, role in postoperative outcome. Anesthesiology 1995;82:1474-1506 Acute Pain Management: Operative or Medical Procedures and Trauma; Agency for Health Care Policy and Research (AHCPR), 1992  "Feel Better Faster with Pain Relief." Contemporary OB/GYN 47, no. 8 (August 2002): 102. Hornsby, L. G. "Anesthesias New Frontier: Ensuring Patient Safety in the Office Setting." Plastic Surgical Nursing 22, no.3 (Fall 2002): 112-15. Ke, R. W. "A Preemptive Strike Against Surgical Pain." Contemporary OB/GYN 46, no. 4 (April 2001): 65. Leff, D. N. "Probing Pains Ouch and Agony Genes: Why Some Folks Shrug Off Painful Stimuli while Others Hurt Real Bad Discernible in Genetic Tea Leaves." Bioworld Today 14, no.35 (February 21, 2003): NA. Murauski, J. D. and K. R. Gonzales. "Peripheral Nerve Blocks for Postoperative Analgesia." AORN Journal 75, no.1 (January 2002): 134-52 Wu, C. L. and Z. A. Casey. "Managing Postoperative Pain in the Opioid-tolerant Patient: Careful Planning Provides Optimal Pain Control, Minimizes Problems." Journal of Critical Illness 17, no.11 (November 2002): 426-33. Read More