Post-operative Pain management

Introduction

Persistent postsurgical pain that lasts beyond the healing period of 1 to 2 months, has become increasingly acknowledged as a substantial issue after the operation and may exceed 30% after some surgery, particularly amputations, thoracotomy, mastectomy, and inguinal hernia repairs. This assignment builds from the case study analysis. Our case study is Pasha (herein referred to as case study patient) 83 years of age grappling with persistent hip and joint pain due to severe osteoarthritis. Having undergone the right total hip replacement (ITR), the case study patient is undergoing pharmacological treatment and requires nursing care. In relation to this, the essay explores pharmacological processes, management and nursing care and the role of nurses in postoperative pain management.

Understanding postoperative pain

Our case study patient suffers from post-operative pain stemming from severe osteoarthritis that resulted in total right hip replacement (THR). Pasha had experienced chronic pains for over 5 years. This signifies that chronic pain is a common occurrence to patients following surgical operations. The nurse caring for him conducted a pain assessment based on the numerical rating scale tool. This tool rates pain on the scale of 1 to 10 with 1-3 being mild pain, and 7-10 being severe pain while any score in between is rated as moderate pain. Following the assessment, the case study patient recorded moderate pain, score of 5-6 when mobile and mild pain, score 2-3 when resting.

Acute postoperative pain is a normal occurrence of pain after surgical operation and is caused by delayed recovery or discharge from the surgical wound. This pain, if left untreated causes patients to be unsatisfied with the surgical operations. Increased morbidity and by extent mortality can also occur. The unmanaged condition may cause distress to the patient resulting in other pain-related conditions like depression (Grosu and de Kock 2011).

The combination of these pains, patient’s distress, and the prolonged recovery anxieties may result in mortality of patients. Acute pain that becomes obdurate and tenacious is referred to as chronic postsurgical pain (CPSP). CPSP can have a significant impact on the patient’s quality of life and daily activities, including disturbances of sleep and sentimental mood. Pain lasting for over 1 month after surgery occurs in 10% to 50% of individuals after common procedures, and 2% to 10% of these patients continue on to experience unadorned chronic pain (Khan et al 2011).

Acute post-surgical pain is ancillary to inflammation from tissue trauma or direct nerve injury and can be nociceptive or neuropathic. Tissue trauma can cause hyperalgesia (increased sensitivity to stimuli to the area surrounding the surgical injury) or allodynia (misperception of pain to nonnoxious stimuli).

Following the right total hip replacement surgical operation, care and management of the wound is imperative. Occasionally, patients are advised to dress their wound occasionally and monitor the dressing for any signs of infection. (Kodali and Oberoi 2014). The case study patient was had a small dressing on the hip wound which showed no signs of infection. Proper wound management is crucial in recovery from postoperative pain.

Postoperative impassiveness for osteoarthritis has conventionally been provided by administration of opioid analgesics. A multimodal approach distinguishing the pathophysiology of surgical pain uses several agents to diminish pain receptor activity and decrease the local hormonal response to injury. This approach moderates the dependence on a given medication and mechanism. For instance, local anesthetics can directly impede pain receptor activity, anti-inflammatory agents can decrease the hormonal reaction to injury, and medications like acetaminophen, ketamine, clonidine, dexmedetomidine, gabapentin, and pregabalin can yield analgesia by focusing on specific neurotransmitters (Laskowski et al 2011). However, excessive opioids administration is linked with a variety of side effects including ventilatory depression, urinary preservation, lethargy and sedation, pruritus, ileus, nausea and vomiting, and constipation.

Prescription of multi-modal analgesia plans contains non-opioid analgesics (e.g., local anesthetics, nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, acetaminophen, ketamine, clonidine, dexmedetomidine, gabapentin) as supplement of opioid analgesics can offer enhanced postoperative pain management consequence (De Oliveira et al 2011).

Pharmacological interventions

Pasha’s Intravenous (IV) morphine PCA dose is administered as 1ml (1mg) bolus with a lockout period of 5 minutes. The total dose is 12mg per hour as per the prescriptions of the hospital. This PCA medication is self-administered. The patient’s morphine controlled analgesia pump is in progress enabling him to gently mobilize short distances to the toilet and back, aided by a walking frame. This makes it prudent to understand available pharmacological interventions that can be accorded to patients suffering pain after operations.

Opioids

Opioid analgesics are part of the basic options for postoperative pain treatments following total hip replacement (THR) surgery with the theoretical benefit of no analgesic ceiling effects. Realistically, however, the analgesic efficacy of opioids is typically restricted by the evolvement of tolerance or opioid-related side effects. The principle of opioid administration is to obtain full analgesia without excruciating adverse effects. Most of the opioid-related hostile effects are dose-dependent, with nausea, vomiting, respiratory depression, and unwarranted sedation requiring more attention during the period. Appropriate monitoring and apt treatment for opioid-related side effects are essential. (Hurley et al, 2015).

Intravenous (IV) or intramuscular administration can be used for the treatment of moderate-to-severe pain. As compared with being imparted over the intact epidural space, 5 mg morphine (1 mg/mL) placed in the epidural space ominously reduced analgesic consumption and extended the postoperative analgesia after spine surgery (Kundra, et al. 2014). Pasha, our case study patient had been diagnosed with 1mg/ml of intravenous (IV) morphine PCA for pain relief. However, when handling postoperative analgesic failure, it was found that patients who did not respond to practical doses of opioids (morphine, 10 mg, IV) inclined to be unresponsive to supplementary opioids, and non-opioid analgesic techniques (such as regional anesthesia) should be considered for these patients (Heo, et al, 2016).

Innovative opioids are being established with retained analgesic effects but curtailed aggressive effects as compared to traditional opioids. Tapentadol is both a μ-opioid agonist and a norepinephrine reuptake inhibitor, indicated for the treatment of moderate-to-severe pain. Compared with oxycodone immediate release (IR), tapentadol IR had the analogous ability for pain after an arthroscopic shoulder operation, but with general improvement. A single dose of tapentadol administrated an hour before wide-ranging anesthesia induction was operative in tumbling perioperative analgesic requirements and pain without further side effects. Despite its improved gastrointestinal tolerability, the oral route of tapentadol may limit its usage, while the preemptive application can be an alternative with cautions in patients who have taken monoamine oxidase inhibitors. (Vorsanger et al, 2013).

Extended-release epidural morphine (EREM) is a single-dose extended-release morphine injection into the epidural space at lumbar level, which delivers good postoperative painkilling for a period of 48 hours, with no need for epidural catheterization. Combined with a femoral nerve block, EREM can provide similar analgesia to patient-controlled epidural analgesia (PCEA) and in patients enduring unilateral total knee replacement and be considered as a therapeutic equivalence to PCEA that may be more cost-effective. (Sugar et al, 2011).

Patient-controlled analgesia (PCA) provides better pain control, greater patient satisfaction, and fewer opioid side effects when compared with on-request opioids. The PCA is based on the idea of a negative response loop. When the patients experience pain, they self-administer medication, and once the pain is reduced, they stop giving themselves medication. Patients should be given a loading dose of opioid until a reported pain score of 4 out of 10 is attained or a breathing rate of fewer than 12 breaths per minute, before the PCA is begun (Sugar et al, 2011). The PCA is then encoded as a bolus dose, which the patients receive each time they press the button. The maximum number of doses is limited per hour. There is also a lockout interval of time, which confines how closely successive doses can be given. The PCA is usually used with morphine or hydromorphone. Fentanyl PCA is often circumscribed to hospital units with continuous observation, such as the ICU, secondary to the increased risk of respiratory depression. Sufentanil is another potent opioid that can be used for PCA.

Pharmacological interventions are crucial in the recovery of the patients from the pain associated with operations. The analgesics are prescribed to patients depending on their condition and the level of pain, according to physician’s prescriptions. Therefore, while the case study patient was accorded an Intravenous (IV) morphine PCA, other pharmacological interventions discussed above are available to patients with severe osteoarthritis and can be used to relieve the pain.

Medicines management

Medicines have been developed to manage post-operative pain and can be administered to patients suffering from different conditions related to their pains. It is important to emphasize that the dynamic nature of the conditions result in varieties in the medicines administered to handle the conditions. In addition to pharmacology intervention, the case study patient was prescribed with medicines to manage the condition. The dosage included paracetamol, enoxaparin sodium, diclofenac, ondansetron, and lactulose. It is important to understand the available medicine management options that can be accorded to patients with severe osteoarthritis and have undergone THR surgery.

Anti-inflammatory drugs

The American Society of Anesthesiologists (2012) endorses a multimodal tactic to postoperative analgesia which precisely states “unless contraindicated, all patients should receive an around-the-clock regimen of nonsteroidal anti-inflammatory drugs (NSAIDs), selective cyclooxygenase-2 inhibitors (coxibs) or paracetamol”. NSAIDs, coxibs, and paracetamol are specified for the relief of mild-to-moderate pain but given in permutation with opioids reduce the opioid consumption and the hostile effects associated with opioid use (Soltani et al 2015). Paracetamol (acetaminophen) drugs are administered to Pasha to reduce the inflammations associated with the postoperative pain at the dosage of 1 gram every 6 hours, with a maximum daily administration of 4 grams.

Anti-inflammatory drugs work by impeding the products of the cyclo-oxygenase pathway, both peripherally and centrally. The mechanism of paracetamol is less clearly understood and seems to work via obstruction of central cyclo-oxygenase enzymes, enhancing descending serotonergic pathways, stimulation of cannabinoid receptors, and inhibiting nitric oxide pathways.26-29

Dexamethasone given as a single circulatory dose at the initiation of surgery is meant to decrease acute postoperative pain. This is due to its inhibition of the cyclooxygenase and lipoxygenase pathways, as well as the suppression of expression of genes and release of pro-inflammatory enzymes. The ideal dose has not been established but appears to be 0.1mg/kg.

Alpha-2 agonists

Clonidine and the more discerning dexmedetomidine, have opioid-sparing, tranquilizing and analgesic properties. Regrettably, the analgesic doses of these drugs cause substantial side-effects in the form of sedation, hypotension, and bradycardia. They take time to react in the body and can cause delayed awakening after general anesthesia. The analgesic properties are very alluring though; a dose of 0.4 μg/kg dexmedetomidine was comparable with 60 μg/kg oxycodone to treat postoperative pain after laparoscopic sterilization (De Oliveira 2011).

Intramuscular dexmedetomidine (1-1.5 μg/kg), provides tremendous premedication and causes minimal hemodynamic changes. Peak plasma levels are reached 1.5 hours after administration, and analgesia effects keep on beyond six hours (De Oliveira et al 2011). When added to local anesthetics, alpha-2 agonists deliver analgesia which lasts longer than the effect of the local anesthetic. This makes regional methods much more effective postoperatively. Dexmedetomidine and clonidine can be used epidurally and intrathecally with local anesthetics, and have been shown to protract and improve the quality of neuraxial blocks.

Ketamine

Perioperative intravenous ketamine has been used as an adjuvant to treat postoperative pain for decades. A recent review of 70 studies with 4 701 patients, confirmed that perioperative opioid consumption was lower, postoperative nausea and vomiting were decreased, and that ketamine was specifically beneficial in very painful procedures such as thoracic and major orthopedic surgery (Laskowski et al 2011). The analgesic effect of ketamine was autonomous of the type of intra-operative opioid, the timing of ketamine administration, and ketamine dose.

Anesthetics

Peripheral regional anesthesia can be effective in the treatment of osteoarthritis postoperative pain, particularly when catheters are left in situ for the incessant infusion of local anesthetics. A significant decline in opioid consumption leads to less nausea and vomiting, less sedation and early mobilization. Perineural catheters and epidural catheters can be attached to patient-controlled devices for self-administration of local anesthetics. Interestingly, in a comparison exercise, patients’ preferred intravenous PCA analgesia to epidural PCA analgesia, even though the epidural group was linked with lower pain scores (Smith 2011).

Managing side effects

Postoperative pain interventions, both pharmacological and medicinal are accompanied with side effects. Pasha experienced persistent nausea, frequent vomiting, and mild dyspepsia. Additionally, his bowels had not been opened since the surgery resulting in mild pruritus to his trunk and back. Therefore, following post-surgery pain medication, care needs to be taken to monitor for side effects and interactions with concurrent medications.

Common side effects are nausea, vomiting, and sedation. Nausea and vomiting can be managed by anti-emetics. Knowing mechanisms of action of different anti-emetics is important. Ondansetron, which is commonly used in the hospital setting, is not always the most effective for opioid-induced nausea being a 5-HT3 serotonin antagonist in the chemoreceptor trigger zone (Kodali and Oberoi 2014). More appropriate choices may be dopamine antagonists such as Compazine, prochlorperazine or metoclopramide.

Sedation is a common side effect even with the most appropriate dosing. The standard prescription to control to reverse effects of opioids is 0.1–0.4 mg of naloxone depending on the clinical severity (Kodali and Oberoi, 2014). However, in patients on chronic opioids, it is also allowed to use lower than 0.1 mg of naloxone. This can be achieved by taking 0.1 mg and diluting in 10 ccs allowing for delivery as low as 0.01 mg when thorough reversal of opioid sedation is not mandatory. The case study patient recorded instances of sedation. The assessment from the nurse relying on the Alert, confusion, verbal, pain and unresponsive tool placed the patient at alert. This shows that Pasha was positively responding to the medication and the sedation level was not severe.

Other less common but well-known side effects are the neurotoxicities. Myoclonus, seizures and opioid-induced hyperalgesia can occur with high doses of opioids or if opioids are being used in patients with compromised renal or hepatic clearance (Grosu and de Kock, 2011). Hyperalgesia is the enigmatic increase in pain sensitivity despite the intensification of the treatment program. Though its contrivance is unknown, it is generally observed in patients with high doses of chronic opioids or when opioids are intensified too rapidly. Treatment of neurotoxicities includes lowering the dose, rotating or dissuading off of opioids altogether. Benzodiazepines can be used to treat myoclonus at times but care must be applied to avoid over sedation.

Nursing care, the role of nurses and self-practice

Care and management of postoperative pain are crucial in ensuring healthy living and prevention of the complications associated with the pain. This applies to patients with acute or minimal pain. Nurses play substantial care in THR post-surgery pain management. There are recommended practices to ensure pain relief and enhance postoperative pain management.

First, it is important that pain is controlled on oral medication, with ideally the lowest dose of opioid therapy necessary. Recovery from surgical operations creates an expectation of reduced medication as the patient progresses further from the post-operative date. (Khan et al 2011) Thus, oral medication is recommended for managing post-surgical pain. Nurses have a role of ensuring appropriate oral medication is administered to the patients to ensure pain relief and minimize additional therapies like an opioid. Patients and caregivers should adhere to the prescriptions by the doctor and follow through the oral medication dosage. Ignoring the dosage when pain reduces is tantamount to increased pains exposing patients to other medical conditions like depression. The presence of family members living with Pasha gives appropriate assistance and care to Pasha and helps in ensuring that Pasha takes medication as prescribed.

Quality nursing care is crucial to recovery from post-operative pain. The nurse should collaborate with the patient’s family to ensure that medications are accurately and completely adhered to. Any issues raising concerns should be resolved and patients should be subjected to the appropriate dosage prescriptions (Khan et al. 2011). Nurses should closely monitor the response of the patients to medications. The case study patient, Pasha was constantly under the nurse’s assessment with clinical observations recorded on a numerical rating scale. This helps in monitoring postoperative pain and recommending appropriate therapy.

Complete patient-friendly discharge instructions in clear age-appropriate language and with follow-up appointments scheduled with primary care, surgeon and pain management when necessary (Khan et al 2011). Patients with post-operative pain may exhibit temperament behavior and be aggressive to medical professionals in a health facility. Thus, the nurses are tasked with establishing rapport with the patients. This enables them to easily attend to the patients with post-surgical pain and increase the level of satisfaction of the patent. Effective postoperative pain management requires patience and commitment from the nurses who work resiliently.

It is a responsibility of the nurses to complete a discharge summary encompassing the postoperative pain course and plans for ongoing post-discharge pain management. Ensure that post-discharge providers receive a copy of the discharge summary in a timely manner (within 24–48 hours of discharge) so they can continue the plan for post-discharge pain management (Khan et al. 2011). Following the right total hip replacement operation, Pasha was equipped with discharge summary and education on how to manage the pains. This encompassed dressing the wound as manifested by the condition of the dressing which was well taken care of. Additionally, Pasha relied on anti-embolism stockings. The establishment of close working ties between the nurse and the patient ensures effective collaboration between the nurse and the patient in the management of the severe osteoarthritis pain. Following a THR surgery, discharge summary provides instructions to caregivers for the management of the patients upon their discharge.

Where possible, the nurse should conduct a follow-up to ensure that the patient’s treatment is strictly adhered to and that the caregivers are providing quality care to the patients (Khan et al 2011). This approach enables patients to easily recover from post-operative pain. In the case of Pasha, the nurse was closely monitoring the condition of the wound and the patient. The nurse played a significant role in the mobility of Pasha for short distances to destinations like the toilet and was also responsible for pain assessment and advising on the progress of the patient. This underscores the importance of nursing care to patients with severe osteoarthritis and total hip replacement postoperative pain.

Conclusion

Postoperative pain management is crucial in managing pain related to the aftermath of total hip replacement surgery. This recommends interventions, pharmacological and medical, that can be applied to alleviate the pain. People, especially with old age, occasionally develop pains after surgeries and if these pains aren’t managed, harmful health impacts may develop. This essay has presented an understanding of postsurgical pain management, examined pharmacological and medical interventions as well as the care for patients with this condition. The discussions have been linked to the case study of Pasha, an elderly man living with osteoarthritis and having manifestations of pains accompanying the operation. It can be concluded that postoperative pain management through pharmacological, medical and extensive care of the patients can help boost their health.

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