Options to Prevent and Control Postoperative Pain

Patient education and reduction of any preexisting pain should occur before the operation. Because the goal of the treatment plan is to prevent significant postoperative pain from the outset, treatment alternatives, potential risks, dosage adjustments, and adjunctive therapies should be described to the patient and family. Teaching emphasizes what the patient is likely to experience postoperatively, including the specific method(s) of pain assessment, interventions the staff will employ, and the level of patient participation required. Staff also should inform patients that it is easier to prevent pain than to "chase" or treat it once it has become established, and that communication of unrelieved pain is essential to its relief.

Pain control options include:

• Cognitive–behavioral interventions such as relaxation, distraction, and imagery; these can be taught preoperatively and can reduce pain, anxiety, and the amount of drugs needed for pain control;
• Systemic administration of nonsteroidal anti–inflammatory drugs (NSAIDS) or opioids using the traditional "as needed" schedule or around–the–clock administration (American Pain Society, 1989);
• Patient controlled analgesia (PCA), usually meaning self–medication with intravenous doses of an opioid; this can include other classes of drugs administered orally or by other routes;
• Spinal analgesia, usually by means of an epidurat opioid and/or local anesthetic injected intermittently or infused continuously;
• Intermittent or continuous local neural blockade (examples of the former include intercostal nerve blockade with local anesthetic or cryoprobe; the latter includes infusion of local anesthetic through an interpleural catheter);
• Physical agents such as massage or application of heat or cold; and
• Electroanalgesia such as transcutaneous electrical nerve stimulation (TENS).

A postoperative pain management plan might include several of these options. A pamphlet, or "menu" of alternative strategies, can help focus discussion of these options between caregivers and the patient. The postoperative pain management plan should reflect coexisting and/or ongoing problems such as cancer–related pain or opioid tolerance. The plan should be consistent with the overall surgical and anesthetic plans. For example, an elixir form of analgesic is preferable to a tablet when painful or difficult swallowing is anticipated. Also, if the patient is to have an epidural catheter placed during surgery that could make postoperative pain control simpler or more effective, it should not be removed in the Post–Anesthesia Care Unit (PACU). Staff should note their plans for pre–, intra–, and postoperative pain management in the patient's chart so that other members of the care team can respond to patient questions and coordinate plans for rehabilitation and discharge.

Intraoperative management is often key to the success of postoperative pain control. If pain prevention and control are to be achieved through an epidural catheter, the catheter should be placed and its function verified preoperatively to assure its effective intra– and postoperative use. This is particularly true in patients whose position, body casts, or subsequent anticoagulation make postoperative catheter insertion problematic. The planned pre– and intraoperative use of opioids, and timing of the first postoperative opioid dose by the anesthesiologist, nurse anesthetist, surgeon, or PACU nurse are important in the postoperative care plan. Equally important are decisions during surgery on the concurrent use of local anesthetics (e.g., for intraoperative nerve blocks) and the nature of the surgical incision and placement of drains or tubes (e.g., chest and nasogastric). If TENS is to be used for postoperative pain management, the electrodes may need to be placed intraoperatively. Finally, intraoperative placement of casts and splints to provide support and restrict postoperative movement may enhance other pain management efforts.