Pain Pointers: A+post-op pain management 
Francesca C. Levitt MSN, RN-BC 
Elizabeth V. Johnston Pharm.D., BCPS 

Nursing Made Incredibly Easy!
September/October 2011 
Volume 9 Number 5
Pages 49 - 52

Effective post-op pain management can make the difference between a rapid, uneventful recovery and a long, complicated post-op stay. Good post-op pain management benefits the patient by providing consistent care in a sometimes uncertain and frightening hospital environment. In addition to providing the best patient care, ensuring proper pain management may decrease hospital length of stay, and in these uncertain economic times, it also makes good business sense.

Unmet pain management needs during hospitalization may lead to decreased patient satisfaction and decreased likelihood to recommend the hospital to others. Some consequences of untreated acute pain are:

* decreased mobility

* increased risk of infection

* atelectasis and pneumonia

* increased risk of venous thromboem-bolism

* impaired bowel function

* chronic pain syndromes.

Treating acute or chronic pain presents unique challenges to care providers. Often, patients with chronic pain will be admitted to the hospital for a surgical procedure. Proactively planning for elective procedures can result in a smooth post-op course. For nonelective patients, a multidisciplinary approach and involvement of specialists early on is recommended.

First? Listen to your patient

The patient's self-report is the best source of information for treatment interventions. Many clinicians struggle with what they perceive as the incongruity between patients' actions and words, but you must rely on a patient's report of pain. Pain perception is subjective because of differences in neurochemical physiology, past experience, emotional makeup, and cultural -differences. Therefore, it's of no use to compare patients with one another; each person will rate the severity of pain -differently.

Several scales are available to assess pain intensity; examples are the FLACC (Face, Legs, Activity, Cry, Consolability) scale for 0 to 3 years old, the Wong-Baker FACES Pain Rating Scale, and the 0-to-10 numeric rating scale. Two factors to -consider when choosing a pain intensity scale are (1) validity and reliability and (2) appropriateness.

Be consistent with the scale used throughout the patient's hospitalization, unless there's a change in condition. Assess for pain at rest and with activity as part of a thorough post-op pain assessment. The goal of pain management is to optimize function and promote comfort. This will help to tailor the interventions to the planned activity; for example, administering pain medication before physical therapy and dressing changes.

One challenge in pain assessment is the nonverbal, cognitively intact patient. There are many valid and reliable assessment tools for cognitively impaired patients (such as the Pain Assessment in Advanced Dementia and the Checklist of Nonverbal Pain Indicators); however, tools for nonverbal, cognitively intact patients are still in the validation process (such as the Behavioral Pain Scale and the Critical-Care Pain Observation Tool). Pay attention to nonverbal cues that may reflect pain or discomfort, such as guarding, grimacing, and other body language.

Figure. Help your po... - Click to enlarge in new window Figure. Help your post-op patient stay pain free. Here's how!!

Pain management principles

When developing a post-op pain management care plan, communication is key. There should be one physician (such as a surgeon or anesthesiologist) in charge of prescribing the appropriate medical treatment. Involving patients in decisions about their care and treatment goals will improve communication and trust, and may increase patient satisfaction.

Opioids are the mainstay of treatment for moderate-to-severe pain. The three most common are morphine, hydromorphone, and fentanyl. These drugs differ with regard to onset, peak, and duration (see Common post-op opioids). The best medication for the situation should be chosen; for example, if a patient has extreme pain (writhing) upon arrival to the postanesthesia care unit, fentanyl would be the best choice because of its quick onset.

Morphine has an onset of action of 5 to 10 minutes in most patients, with a peak effect at 15 minutes. Doses that are given too frequently may lead to oversedation or respiratory depression due to a "stacking" effect. Meperidine has fallen out of favor due to poor efficacy, as well as central nervous system (CNS) toxicity. However, it's useful at low doses for post-op rigors (shivering).

The main route of administration for post-op pain medications is I.V., followed by a transition to oral medication. I.M. medications shouldn't be used unless absolutely nece-ssary because their route of administration is painful and they have poor and unpredictable absorption. Let's take a closer look.

Routes of administration

Epidural catheter placement and intrathecal injections are neuraxial methods of medication administration, performed by an anesthesiologist or certified RN anesthetist. Medication is injected into specific areas surrounding the spinal cord. Most often, an opioid and a local anesthetic are used -together to block sensory pain signals with the goal of maintaining motor nerve function. In other words, there's decreased incisional pain without inhibiting movement. Complications of epidural blocks can -include poor sensory blockade, catheter -dislodgement or migration, and excessive motor blockade.

Patient-controlled analgesia (PCA) is a method that allows the patient to self--administer a dose of pain medication through a pump to autonomously manage pain. The pump can be programmed to deliver both a basal (continuous) infusion and/or a demand (bolus) dose. I.V. basal (continuous) rates should be avoided in patients who are opioid naive. Patient selection and education are key. The patient shouldn't only be physically capable of pressing the button, but should also have the mental capacity to understand why, when, and how to press the button. The only time that PCA should be administered by someone other than the patient is during clinician boluses or in appropriate pediatric populations. The safety features incorporated into the pump help to prevent inadvertent overdose or adverse events. PCA can be administered I.V. or through an epidural catheter. With patient-controlled epidural analgesia, a continuous infusion is delivered, in addition to a demand dose.

Peripheral nerve blocks involve the injection of local anesthetics in or around the nerve plexus. They're used as part of a -preemptive and multimodal approach to provide effective pain management with minimal adverse reactions. Peripheral nerve blocks provide sensory and some motor blockade and are most often used for orthopedic procedures, such as shoulder or elbow surgery. Educate patients to protect the extremity by immobilization and proper positioning. Monitor patients for potential adverse reactions, complications, and efficacy. Assess patients for signs and symptoms of systemic toxicity, including tachycardia, hypertension, tinnitus, metallic taste, -circumoral numbness, CNS depression, and seizures.

Local anesthetic infusion provides a continuous infusion of local anesthetic directly or adjacent to the surgical site as one component of a multimodal approach to post-op pain management. Assess patients for signs and symptoms of local anesthetic toxicity.

Oral pain medication provides a conven-ient route of administration. Around-the-clock dosing provides more consistent pain control by maintaining consistent blood levels as compared with as-needed dosing. In preparation for discharge, the post-op patient should be transitioned to oral medications as early as possible to determine -efficacy and tolerability.

As part of a comprehensive treatment plan, nonsteroidal anti-inflammatory drugs for additional pain relief from inflammation caused by surgery may be beneficial in appropriate patients, with consideration of bleeding risks and cardiovascular adverse reactions. Acetaminophen may also be used as an adjunct to opioids. The advantage of acetaminophen is that it inhibits pain at a different point in the pain pathway. Combination products containing opioids and acetaminophen are available, but there's a limit on the number of doses per day. The maximum amount of acetaminophen is 4,000 mg/day to avoid serious liver toxicity. The FDA has recently recommended decreasing the amount of acetaminophen in combination products and may consider decreasing the maximum daily dose of -acetaminophen in the near future.

Other medications can be used in combination with opioids for the treatment of more complex or chronic pain conditions. Referred to as adjuvants, examples include antiepileptics, antidepressants, steroids, and the N-Methyl-D-aspartic acid antagonist ketamine.

Fentanyl is available as a long-acting transdermal patch and is approved for -opioid-tolerant patients only. Fentanyl patches are generally used in the management of chronic pain and can be encountered in the hospitalized surgical patient. Serious adverse reactions have resulted from improper prescribing, such as the use of fentanyl patches in opioid naive patients. Keep in mind that heat, either direct or indirect, can increase absorption to dangerous levels.

Be alert for complications

Prevention and management of adverse reactions are integral components of a good pain management plan. Pre-op screening of patients for obstructive sleep apnea (OSA) and other obstructive breathing conditions (such as chronic obstructive pulmonary disease and asthma) can identify those patients at risk for respiratory depression. Close monitoring of post-op ventilatory function should include respiratory rate, as well as depth and quality of respirations. End-tidal CO2 monitoring is an effective modality for assessing ventilation and should be used when appropriate. Oxygen saturation measures levels of oxygen in the blood and is a late marker for respiratory depression; a patient could have respiratory depression and still have an acceptable SpO2 level. For more information, refer to the American Society of Anesthesiologists OSA guidelines.

Sedation is an unintended adverse reaction of opioids and occurs all too often. Be aware of other medications that cause sedation such as antihistamines. An easy scale for quantifying the level of sedation in patients receiving opioids is the Pasero Opioid-induced Sedation Scale.

Common adverse reactions of opioids include itching, nausea, vomiting, delirium, hallucinations, and constipation. Constipation is the only adverse reaction that patients don't develop a tolerance to over time, and preventive therapy should be initiated for all patients on opioids. Laxative medications that contain both a stimulant and a stool softener are most effective.

Itching can be managed by giving antihistamines, low doses of mu-receptor antagonists, or mixed agonists/antagonists. Mu-receptor antagonists and mixed -agonists/antagonists should be used cautiously and at low doses to prevent loss of pain -control.

Post-op nausea and vomiting are unfortunate consequences of surgery and opioid therapy. Before surgery, risk factors for post-op nausea and vomiting should be assessed. For refra-ctory nausea and vomiting, medications with different mechanisms of action should be combined for the most effective prevention and treatment. In other words, if one medication isn't effective, more of the same medication isn't likely to be effective. For more information, refer to the American Society of PeriAnesthesia Nurses guidelines on postoperative and postdischarge nausea and vomiting.

Figure. No caption a... - Click to enlarge in new window Figure. No caption available.

In general, most opioid-induced adverse reactions can be managed by decreasing the dose of opioids and adding adjunctive therapy. Patient education should include information about constipation prevention, duration of therapy, and gradual weaning of opioids after discharge if the patient is on a prolonged course of therapy. Some patients are concerned about becoming addicted to opioids. Provide reassurance that true addiction in patients taking opioids for treatment of pain is extremely rare.

Freedom from pain

Take time to assess and reassess pain in the post-op setting. Treat patients using multiple modalities, including pharmacologic and nonpharmacologic interventions. Include your patient in the pain management care plan, and be aware that the mismanagement of post-op pain can lead to a life of chronic pain.


Adverse reactions to opioids include:

* sedation

* respiratory depression

* constipation

* nausea/vomiting

* itching

* confusion/delirium

* hallucinations.


Danger signs of oversedation include:

* falling asleep in the middle of a conversation

* unable to arouse

* hypoventilation (decreased respiratory rate)

* apnea

* unable to participate in activities of daily living.

cheat sheet

Take home points

* Obtain an accurate medication -history, including over-the-counter medications, herbals/supplements, -recreational drugs, and alcohol.

* Ask about medication allergies, including type of reaction and circumstances surrounding the reaction.

* Ask about average daily dosage of opioids. (For example, if the patient's prescription is for hydrocodone one to two tablets every 4 to 6 hours as needed, how many tablets does the patient normally take per day?)

* Include the patient in the care plan.

* Use a multimodal approach to pain -management.

* Have a nonjudgmental attitude.

Learn more about it

American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 6th ed. Glenview, IL: American Pain Society; 2008.

American Society of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team. ASPAN's evidence-based clinical practice guideline for the prevention and/or man-agement of PONV/PDNV. J PeriAnesth Nurs. 2006;21(4):230-250.

Chumbley G, Mountford L. Patient-controlled analgesia infusion pumps for adults. Nurs Stand. 2010;25(8):35-40.

FDA. FDA limits acetaminophen in prescription combination products; requires liver toxicity warnings.

Grinstein-Cohen O, Sarid O, Attar D, Pilpel D, Elhayany A. Improvements and difficulties in postoperative pain management. Orthop Nurs. 2009;28(5):232-239.

Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative man-agement of patients with obstructive sleep apnea: a report by the American Society of Anes-thesiologists Task Force on Perioperative Management of patients with obstructive sleep ap-nea. Anesthesiology. 2006;104(5):1081-1093.

Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manag Nurs. 2006;7(2):44-52.

Hutchison R, Rodriguez L. Capnography and respiratory depression. Am J Nurs. 2008;108(2):35-39.

Oderda GM, Said Q, Evans RS, et al. Opioid-related adverse drug events in surgical hospi-talizations: impact on costs and length of stay. Ann Pharmacother. 2007;41(3):400-406.

Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, MO: Mosby; 2010.

Taylor SA. Safety and satisfaction provided by patient-controlled analgesia. Dimens Crit Care Nurs. 2010;29(4):163-166.