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Chapter 48: Perioperative Pain Management

Darin J. Correll

INTRODUCTION

Pain is the most common presenting symptom of disease. It is defined as an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. There are sound medical and legal reasons to treat pain aggressively in hospitalized patients. The Joint Commission, which certifies health care institutions in the United States, mandates that all patients have the right to adequate pain assessment and management (Table 48-1).

TABLE 48-1Joint Commission Pain Assessment and Management Standards for Hospitals
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TABLE 48-1 Joint Commission Pain Assessment and Management Standards for Hospitals

  1. The hospital respects the patient’s right to pain management.

  2. The hospital educates all licensed independent practitioners on assessing and managing pain.

  3. The hospital assesses and manages the patient’s pain. The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient’s condition.

  4. The hospital uses methods to assess pain that are consistent with the patient’s age, condition, and ability to understand.

  5. The hospital assesses and reassesses its patients. The hospital defines, in writing, criteria that identify when additional, specialized, or more in-depth assessments are performed for pain.

  6. Based on the patient’s condition and assessed needs, the education and training provided to the patient by the hospital include any of the following: discussion of pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management.

In the inpatient setting, patients may be more concerned about pain relief than the outcome of their underlying illness. Poor pain control has adverse physiologic consequences that lead to worse outcomes (Table 48-2).

TABLE 48-2Physiologic Consequences of Uncontrolled Pain
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TABLE 48-2 Physiologic Consequences of Uncontrolled Pain
Cardiovascular Tachycardia, hypertension, increased cardiac workload
Pulmonary Hypoxia, hypercarbia, atelectasis, decreased cough
Gastrointestinal Decreased gastric emptying, nausea/vomiting, ileus
Renal Urinary retention
Endocrine Increased adrenergic activity, catabolic state, sodium/water retention
Immunologic Impairment, slowed wound healing
Musculoskeletal Splinting, contractures, decreased mobility (deep vein thrombosis)
Hematological Increased coagulability
Neurological Anxiety, fear, anger, fatigue, delirium

In postoperative patients, better analgesia improves cardiovascular, respiratory, endocrine, immunologic, gastrointestinal, and hematologic status. Following many common surgeries, acute pain that is not satisfactorily treated may become persistent.

PATHOPHYSIOLOGY: NOCICEPTIVE AND ANTI-NOCICEPTIVE PATHWAYS

Nociception, the perception of noxious stimuli, is a preconscious neural activity that is normally necessary, but not sufficient, for pain. It is more accurate to refer to nociceptive pathways, rather than pain pathways. The peripheral nerve fibers acting as nociceptors are lightly myelinated A-delta and unmyelinated C fibers, which are triggered or sensitized (peripheral sensitization) by several substances, including adenosine triphosphate (ATP), prostanoids, bradykinin, serotonin, histamine, and hydrogen ions. Heat, pressure, or nerve damage also results in activation.

The primary nociceptors synapse in the ...

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