POSTOPERATIVE ANALGESIA IN
SPECIAL POPULATIONS
This chapter has provided a general approach to the principles
and practice of acute postoperative pain management, but this approach may not be
applicable to certain populations that may have unique anatomic, physiologic, pharmacologic,
affective, and cognitive issues. The management of acute pain should be tailored
to the specific needs of a particular population. Although each topic by itself
could merit a separate chapter in some textbooks, the general principles and essence
of the issues associated with each population are outlined, and references are made
to other more extensive sources.
Ambulatory Surgical Patients
The percentage of surgical procedures being performed on an outpatient
basis continues to increase[367]
(see Chapter
68
). There is an increase in the number of outpatient surgical procedures
and in the complexity of operations being performed and comorbidities of the surgical
outpatients.[368]
Optimizing treatment of postoperative
and postdischarge pain is especially important in patients undergoing outpatient
surgery because inadequate control of postoperative pain is one of the leading causes
of prolonged stays or readmission after outpatient surgery.[369]
[370]
[371]
[372]
[373]
Although there has been much effort to minimize
symptoms such as pain and nausea in the postanesthesia care unit and subsequent (phase
II) recovery area to facilitate discharge after outpatient surgery, increasing data
suggest that postdischarge pain (i.e., pain that occurs after discharge) is common
and may interfere with patients' recovery and the overall health-related costs of
outpatient surgery.[370]
[371]
[374]
[375]
[376]
[377]
[378]
[379]
[380]
Despite the advances in surgical techniques
that minimize surgical trauma and postoperative pain, the incidence of moderate to
severe postdischarge pain is still approximately 25% to 35%[381]
[382]
and can be especially troublesome for certain
patients, such as those undergoing tubal ligation and orthopedic procedures.[372]
[378]
[383]
After
discharge, poorly controlled nausea and vomiting may interfere with the intake of
oral analgesics.
In light of these considerations, the traditional reliance on
opioid analgesia may not be appropriate for patients undergoing ambulatory surgery
because of the opioid-related side effects that may delay hospital discharge and
postdischarge recovery after outpatient surgery. A multimodal or "balanced" analgesic
approach using a combination of opioid and nonopioid analgesic techniques (i.e.,
NSAIDs or acetaminophen, local anesthetics, and other nonpharmacologic therapies)
may be more appropriate in this surgical population.[50]
[117]
[384]
Using
nonopioid analgesic techniques with different mechanisms of analgesia diminishes
opioid-related side effects, synergistically enhances postoperative analgesia, and
facilitates patient recovery. For instance, use of local anesthetics has decreased
postoperative pain, and the drugs can be administered as peripheral nerve blocks,
tissue infiltration, wound instillation, or topical analgesics.[118]
[317]
[326]
[327]
Similar results have been achieved using systemic NSAIDs and acetaminophen.
Although multimodal analgesia may be especially effective in the
immediate postoperative period, not all of the options may be routinely available
after the patient is discharged to home. For example, use of local anesthetics in
peripheral nerve blocks, tissue infiltration, or wound instillation may be effective
in the immediate postoperative period; however, a single dose of local anesthetic
rarely provides more than 24 hours of analgesia. Realistically, most outpatients
rely on a combination of short-acting analgesics (e.g., an opioid and acetaminophen)
for post-operative pain control after hospital discharge. However, there are several
strategies to optimize postdischarge pain, including the routine use of NSAIDs (if
there are no contraindications), which may improve global patient satisfaction ratings,
[385]
and use of small doses of sustained-release
opioids in certain surgical populations.[62]
Routine
use of acetaminophen, especially when an NSAID is added to the regimen, is recommended
to maximize postoperative analgesia,[386]
although
it is important to remember that acetaminophen is a coanalgesic agent in many combination
products that may limit the number of combination analgesic tablets that the patient
may consume. The future of postoperative pain control in ambulatory surgical patients
may include postdischarge (home) use of continuous infusion of local anesthetic solutions
[7]
or even use of long-acting, "sustained-release"
local anesthetics.[8]
[387]
 |
