Postoperative Pain

Management in Ambulatory
patients
Arif H.M. Marsaban
Dept of Anesteshesilogy & Intensive Care
Univ of Indonesia, Dr Cipto Mangunkusuma Hospital

Introduction
Incidence of PAIN in ambulatory patient:
30 40% mod to severe pain (24 48 hr)
50% in pediatric
Postop PAIN is still inadequately managed

Postop PAIN management for ambulatory
patient is IMPORTANT
Ambulatory Discharge criteria
Tanda Vital
TD 20 mmHg dari nilai pra-anestesia
TD 20-50 mmHg dari nilai pra-anestesia
TD 50 mmHg dari nilai pra-anestesia

Aktivitas, status mental
Orientasi & berjalan stabil
Orientasi atau berjalan stabil
Tidak dua-duanya

NYERI, mual, muntah
Minimal
Sedang
Berat

Perdarahan surgical
Minimal
Sedang
Berat

Intake dan output
Minum dan BAK
Minum atau BAK
Tidak keduanya
PAIN causes :
> 50% becomes chronic pain
47% pediatric : problematical behavioural
changes
PONV
Delayed discharge
Unanticipated readmission
Increased costs
Severity of postop pain :
Type of surgery (orthop, urol, ENT,
cosmetic etc))
Complexity of surgery (lap chol,
hernia,tonsill etc)
Type of anesthetic techniques (RA, GA +
LA infiltration)
Analgesics perioperative (RA, NSAID)
Pain control for ambulatory surgery
Should be :
Effective
Minimal side effects
Facilitate recovery
Easily managed by patients at home
Should permit normal activities
Started intra-operatively (GA with short-
acting opioids, NSAID or RA)
Assessment of pain
Assess pain
at rest in early recovery
at rest and during activity at and after
discharge
Type of anesthetic techniques(1)

GENERAL ANESTHESIA :
Avoid opioid because of PONV
The choice : alfentanil or fentanyl
Add wound infiltration single shot or
continuous with bupivacain or ropivavain
Type of anesthetic techniques
(2)
REGIONAL ANESTHESIA (RA) & LOCAL
ANESTHESIA (LA):
Epidural
Spinal / CSE
Caudal (in pediatric)
Peripheral nerve block (one shot or continuous)
Intra-articular
Field block
Wound infiltration (one shot or continuous)
LA or RA can be used alone or combined with
GA /sedation



RA / LA
Reduced pain score
Prolonged postoperative analgesia
Less analgesics in PACU

Strategies for postop pain management
after ambulatory surgery (1)
Continuation from intraoperative with :
Short-acting opioids i.v
NSAID oral / i.v
RA
= balanced or multimodal techniques using
combination of short-acting opioids,
NSAID, & LA

Strategies for postop pain management
after ambulatory surgery (2)
Oral analgesic after discharge
Mild pain : paracetamol
Mild to moderate pain : combination
NSAID & weak opioids in addition to RA or
LA

Should provide rescue analgesia or
instruction if still have pain (weak opioids)
Paracetamol
First line analgetic
Effective
Cheap
Safe
Ceiling effect
For mild to moderate pain
For mod to severe pain combine with NSAID and
weak opioid
For pediatric loading dose 40 mg/kg, regular dose 90
mg/kg/day oral
Now only oral preparation, coming soon intravanous
preparation
NSAID
Mild to moderate pain
Sole analgesic or Combined with
paracetamol, weak opioids
COX-2 fewer side effects
Celecoxib etoricoxib, meloxicam,
rofecoxib, parecoxib
Choice of drug : availability, route of
administration, duration, cost
NSAID
Some NSAID & aspirin increased risk of
post-tonsillectomy bleeding
Weak opioid

Codeine : devoid of analgesic activity but
because metabolism of codein to
morphine
Dextropropoxyphene : renally excreted,
accumulation cause CNS, resp, cardiac
depression
Tramadol :opioid agonist & serotonin
noradrenalin reuptake inhibitor, potency =
petidine, s.e : nausea-vomiting
Strategies for postop pain management
after ambulatory surgery (3)
Continuous RA at home
Continous Peripheral nerve blocks
Reduced analgesic consumption & reduce
sleep disturbance
Complications :
nerve injury
Catheter migration LA toxicity,
unintentional spinal / epidural spread


Strategies for postop pain management
after ambulatory surgery (4)
Continuous RA at home

Infusion dose :
Bupivacaine 0.5 % or ropivacaine 0.5
0.75 % 20 40 mL
5 mL / hr
Strategies for postop pain management
after ambulatory surgery (5)
LA infiltration
Incisional & intra-articular LA drugs
Is more preferred because simple, safe,
low cost
Single shot or continuous infiltration

Strategies for postop pain management
after ambulatory surgery (6)
Continuous LA at home
Continuous wound infiltration several days of
analgesia , not as potent as continuous
peripheral nerve blocks
Can be combined with single-injection peripheral
nerve blocks or with oral non-opioid analgesics
Diposable pumps for continous infusion
available with variety preset rates with/without
patient-controlled boluses
Strategies for postop pain management
after ambulatory surgery (6)

Clear verbal & written instructions
Follow-up call next day
Take home message


treat Postop Pain according to the
intensity, start intraoperatively, continue
postoperatively
intens introperative PACU Home Rescue
mild LA + sedation
GA + infiltration
NSAID iv or
paracet iv
non-opiod
non-opiod
Weak
opioid
Mod to
Sev
Pain
GA + single
infiltration

GA


GA + single shot
RA

Single shot RA


Continous RA
NSAID iv or
paracet iv

Cont infilt +
NSAID iv

NSAID iv or
tramadol iv

NSAID iv or
tramadol iv

NSAID iv or
paracet iv
NSAID or weak
op + paracetamol

NSAID +
paracetamol

NSAID or weak
op + paracetamol

NSAID or weak
op + paracetamol

NSAID or weak
op /+ paracetamol


Weak
opioid
SUMMARY
THANK YOU