Other Measures to Avert Postoperative Pain
Mechanisms underlying severe postoperative pain may include sociodemographic influences, previous postoperative pain experiences, surgery-related variables (some procedures are more painful than others) and psychological factors. Patients with better coping mechanisms with preoperative pain, usually experience less postoperative pain. In this regard, adequate preoperative analgesia and CBT m
Mechanisms underlying severe postoperative pain may include sociodemographic influences, previous postoperative pain experiences, surgery-related variables (some procedures are more painful than others) and psychological factors. Patients with better coping mechanisms with preoperative pain, usually experience less postoperative pain. In this regard, adequate preoperative analgesia and CBT may be useful. It has been demonstrated in patients undergoing lower limb amputation, that preoperative anxiety is associated with more postoperative acute phantom limb pain. Preoperative anxiety affects the patients’ ability to cope with pain. Catastrophising may aggravate postoperative pain experiences. These patients may benefit from anxiolytics.
The discharge prescription
The aim of the discharge prescription is to bridge the in-hospital moderate to severe pain to minor to moderate pain that justifies discharge. The former requires high doses of potent analgesics, while the latter should be managed with a time-limited multimodal analgesic prescription, usually consisting of paracetamol, an NSAID and a limited number of opioids for breakthrough pain. The discharge prescription should not turn into a long-term abuse of analgesics. It is not uncommon to find patients who remain on opioids and sedatives for years postoperatively.
A higher in-hospital total dose of opioids predicts the number of MMEs prescribed on the discharge prescription and use after discharge. Opioid use after discharge is predicted by younger age, men, lower socio-economic status, baseline preoperative substance abuse, admission to ICU, and the number of MMEs on the discharge prescription. Opioid use after discharge can be limited by limiting the number of MMEs prescribed postoperatively. Inhospital strategies can be used to achieve this goal, namely multimodal analgesia, decreasing the daily MMEs while in hospital, and physical interventions to decrease swelling (limb elevation and cold therapy).
The number of opioid tablets should be limited. It has been demonstrated that for patients who received paracetamol and ibuprofen, 5 tablets oxycodone 5 mg (7.5 mg MME) were enough to manage breakthrough pain after laparoscopic cholecystectomy and appendicectomy. It has also been demonstrated that patients discharged from the emergency department, took a median of < 10 tablets of morphine sulphate 5 mg MME and that 15 tablets of MME 5 mg were enough in 95% of patients for the first three days. Physicians should prescribe smaller quantities of opioids and ask the pharmacist to supply the total number of tablets in portions. This may minimise the number of unused units. If surgery was of a palliative nature, opioids should not be limited.
South African Society of Anaesthesiologists (SASA) Guidelines for the Management of Acute Pain in Specific Scenarios 2022