Medicosnext
Dr. Para Ghimire
Dr. Para Ghimire is an anesthesiologist specializing in Anesthesia and Critical Care. She earned both her MBBS and MD in Anesthesia and Critical Care from Kathmandu Medical College. Currently, she serves as a Lecturer in the Department of Anesthesia and Critical Care at KMC, where she plays an instrumental role in training the next generation of medical professionals. With a deep commitment to enhancing patient care, Dr. Ghimire has a particular interest in acute pain management in the perioperative setting.
Pain is a highly variable and subjective experience. Various factors affect an individual’s perception of pain. Individual variations in pain are contributable to biological, psychosocial, demographic and genetic factors. Complex interaction between a person’s genetic makeup and psychosocial status including factors like stress and anxiety play an important role in their feeling of pain. Only when we understand that the feeling of pain warrants individualization, can we be capable of managing such pain. Hence, for any person involved in pain management, it is of utmost important to not trivialize anybody’s experience of pain and understand everybody’s perception is unique. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage.” Any pain that arises suddenly and lasts for a short duration lasting from a few hours to a few weeks is often classified as acute pain.
PAIN MEASUREMENT
In order to manage pain, we need to first be aware about a patient’s pain severity. In our clinical setting, be it in operation theatre (OT), Intensive Care Unit (ICU) or the Post anaesthetic care unit (PACU), patients are often connected to a monitor for the purpose of monitoring their vitals like heart rate, respiratory rate, blood pressure. Any increases in heart rate, blood pressure may be an indication of pain in the patient and must be assessed for. Numerous self-evaluation tools are available for assessment of pain in the perioperative setting. Among those, sensitive, reliable and easy to use assessment tools that we commonly utilize for assessment of acute pain are Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS). These simple tools help us classify the severity of pain in the patient and allow us to identify, treat and monitor the severity of pain in a patient.
IMPORTANCE OF PAIN MANAGEMENT
Pain management is important. Untreated pain may lead to a range of negative consequences. Acute pain, if left unmanaged, progresses to chronic pain. Persistent pain has negative impacts on many of the body’s systems. It may lead to sustained tachycardia and hypertension. It also affects the endocrine system leading to excess catecholamine production eventually impairing insulin and lipid metabolism. These in turn promote crippling physical complications like obesity, diabetes, osteoporosis, etc. Acute pain complications are not only limited to physical but result in mental disturbances too. Patients with unmanaged acute pain may develop anxiety, depression and may even fall victims to suicide because of the nature of unbearable suffering. Hence, it is a topmost priority for us, as a perioperative physician, to avoid all these consequences from ever arising by early recognition and management of pain in its acute stage.
MANAGEMENT OF ACUTE PAIN
Pain management requires early recognition and intervention. Depending on the nature of the surgery, pain intensities may be different. As previously mentioned, pain is a subjective feeling. Hence, the best means to identify a patient’s pain is by simply asking them about it.
Various options are available for management of a patient’s pain perioperatively. Drugs that are used for relieving pain are called analgesics. Analgesics may widely be classified into opioid and non – opioid analgesics.
The mostly commonly used analgesics in the perioperative settings at our centre are:
– Opioid analgesics : Fentanyl , Morphine , Pethidine, Tramadol
– Non Opioid analgesics : Paracetamol , Ketamine, Dexmedetomidine, Ketorolac, Diclofenac
The drugs like Tramadol, Paracetamol , Ketorolac are available in both injectable and oral forms whereas others are available as injections at our centre. For management of acute pain, we usually give these drugs at regular intervals post operatively as well as bolus doses may be given as and when required keeping in mind the toxic doses.
Pain management may also be done via regional anesthesia techniques like subarachnoid block (SAB), nerve blocks or epidural anesthesia. Local anesthetic agents are given as a bolus in SAB whereas they may be used in continuous infusions via epidural. These techniques are usually performed prior to the start of surgery and help in management of pain in the intraoperative as well as postoperative ward. Commonly used local anesthetic agents at our centre are:
– For subarachnoid blocks: 0.5% heavy Bupivacaine
– For nerve block and epidural anesthesia : Plain Bupivacaine, Plain Ropivacaine
Local anesthetic agents may also be infiltrated at the site of surgery in order to avoid pain. Along with this, drugs like fentanyl, morphine, dexmeditomidine may be added as adjuvants to the local anesthetic agents to increase either their potency or duration of action. No single drug or technique is superior to the other in management of all types of pain. Just like sensation of pain, management of pain must also be individualised.
MULTIMODAL PAIN MANAGEMENT TECHNIQUE
We often utilize a multimodal approach for management of acute pain. Individual drugs, their efficacy and more importantly their side effect profiles warrant the adoption of a multimodal strategy. This strategy involves combination of multiple analgesic drugs and techniques. These different classes of drugs used in combination, act through various mechanisms of actions and on different receptors to bring about pain relief. This strategy is specifically helpful in reducing the consumption of opioids thereby avoiding their numerous side effects like nausea/vomiting, constipation, respiratory depression, etc. It is thus imperative that we use a multimodal approach for management of acute pain providing patients with maximum benefit from a wide array of drugs and analgesic techniques and at the same time avoiding toxicities resulting from use of large doses of a single group of drugs.
CONCLUSION
In conclusion, drugs and their frequencies need to be modified to fit individual choices. Proper pain management ensures early recovery and discharge from the hospital. Pain management is a continuous process and does not end after the surgery. Thus, regular follow up with the patient is important and their expectations regarding a pain free hospital stay must be met as far as possible.
REFERENCES
1. Fillingim RB. Individual differences in pain: understanding the mosaic that makes pain personal. Pain. 2017 Apr;158 Suppl 1(Suppl 1):S11-S18. doi: 10.1097/j.pain.0000000000000775. PMID: 27902569; PMCID: PMC5350021.
2. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, Keefe FJ, Mogil JS, Ringkamp M, Sluka KA, Song XJ, Stevens B, Sullivan MD, Tutelman PR, Ushida T, Vader K. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387; PMCID: PMC7680716.
3. T Bendinger, N Plunkett, Measurement in pain medicine, BJA Education, Volume 16, Issue 9, September 2016, Pages 310–315, https://doi.org/10.1093/bjaed/mkw014
4. Tennant F. Complications of Uncontrolled, Persistent Pain. Pract Pain Manag. 2004;4(1).
5. Kianian et al. Anesthesiology and Perioperative Science (2024) 2:9 https://doi.org/10.1007/s44254-023-00043-1
