It is observed that over 230 million patients undergo surgical procedures every year globally, and this number is expected to increase (Pogatzki-Zahn, Segelcke, & Schug, 2017). Surgery is generally responsible for postoperative pain, which should be mitigated immediately and effectively to minimize suffering, improve healing processes, patient satisfaction and to avert health complications (Song, 2017). Pain after surgery is common in most patients (Glowacki, 2015). Pain can be classified as acute, chronic, or severe, and they generally occur due to tissue damage following surgeries.
Based on the type of surgery, it is estimated that between 10 percent and 68 percent of surgical patients may experience pain following their procedures. Further, it is also noted that about 2% to 10% of surgical patients may endure severe pain (Shahverdi & Khani, 2016). According to Shahverdi and Khani (2016), chronic pain following surgery lacks any precise definition, and variations in diagnostic processes and questionnaire used to assess pain following surgery could be responsible for the observed differences in most studies.
Buvanendran (2012) noted that the period of pain following surgery could last approximately two months for a reliable diagnosis to be done. It is also noted that pain following surgery is associated with some risk factors, which can be classified as factors before, during, and after surgical procedures. Within this context, past literature demonstrated that surgery was a risk factor for pain (Buvanendran, 2012). Given adverse health outcomes associated with pain following surgery, pain management following surgery is an issue that deserves more attention.
The Search for Evidence
Evidence for pain management following surgery were based on the key words and phrases: pain management, acute pain, chronic pain, severe pain, surgery and adverse outcomes. The search was conducted in major databases, including PubMed, OMICS International and others. A preference was given to open access publishers of peer reviewed journal articles. Notably, most recent literature published between 2012 and 2017 was considered for the research.
A Review of Literature
Research strives to determine potential mechanisms and pathophysiology for pain following surgery (Buvanendran, 2012). Consequently, three potential mechanisms and pathophysiology have been identified as sustained inflammatory reaction, neuropathic pain, or predisposition to pain attributed to genetic composition of a given patient (Buvanendran, 2012). Thus, it may be important to assess patients’ specific genetic makeup to inform them about potential exposure to pain.
Further, it is observed that factors, such as preoperative pain and cognitive traits, including catastrophizing, are indicators for chronic pain following surgical procedures (Buvanendran, 2012). Additionally, elevated postoperative pain is seen as a single factor for chronic pain after surgery. Considering postoperative pain, it is imperative to distinguish between association and casualty. It could be that patients who suffer severe acute postoperative pain could also experience increased spinal cord pain and, thus, they could have more prolonged postsurgical pain. Conversely, it may be claimed that patients with antecedents of sustained postsurgical pain could have severe acute postoperative surgical pain due to their already present and worsening conditions.
Pathophysiological activities that take place following tissue damage demonstrate that acute pain might turn into persistent pain. Irritation at the site of tissue insult results into massive afferent nociceptors action, which leads to peripheral and central nervous system sensitization (Shahverdi & Khani, 2016). This leads to functional adjustments in the spinal cord, peripheral nerves, routes prone to pain, and the sympathetic nervous system (Shahverdi & Khani, 2016). It appears that certain receptor sites, including N-methyl-D-aspartate receptor, is specifically significant in pain after an injury (Shahverdi & Khani, 2016). If chronic pain results from a sustained inflammatory or occurs due to neuropathic, then pain management could be used for interventions. In this case, anesthesiologists (perioperative physicians) should take the leadership position to comprehend and start interventions to management pain (Buvanendran, 2012).
While postoperative pain should be effectively managed immediately, Pogatzki-Zahn et al. (2017) note that clinical pain management following surgery is far from being effective notwithstanding intense increments in scientific empirical evidence in this field. Majorities of patients continue to endure severe pain following their surgical treatment. Even worse, many patients may develop chronic pain, which is poorly recognized. Chronic pain may be, at least in part, related to undertreatment of acute postoperative pain (Pogatzki-Zahn et al., 2017).
One major factor for undertreatment has been identified as the narrow translation of primary and clinical scientific results into evidence-based clinical practices. For instance, pain following surgery is an extremely distinct entity. It can be the outcome of an inflammatory activity independently or the outcome of a secluded insult to nerves. While irritation and neural tissue damage often take place, it is imperative to understand that the pathophysiology of postoperative pain is exceptional and the outcomes are distinct. Still, intervention approaches applied in actual clinical settings are still not driven by evidence-based results (Pogatzki-Zahn et al., 2017).
In addition, analgesics and interventions with longer adverse outcomes and/or with benefits directed at certain aspects of postoperative pain, such as movement-induced pain, are not available. On this note, Pogatzki-Zahn et al. (2017) insist on the relevance of acquiring novel insights into the activities of postoperative pain from both experimental and clinical environments to improve intervention options with enhanced efficacy and reduced risks of adverse outcomes relative to those used today. While comprehensive evidence-based findings from clinical studies are available, they need to be incorporated into clinical practice as well.
Evidence for the management of pain following surgery is now abundant, but postoperative pain is more complex than original thought (Shoar, Esmaeili, & Safari, 2012; Mishra, Kapoor, Mahajan, & Prabhakar, 2017). The multimodal analgesia is now applied in pain management after surgery because it shows that outcomes are better when analgesics are combined with various methods or sites of action (Zhou, Fan, Zhong, Wen, & Chen, 2017). Multimodal analgesia is used to enhance analgesia, lessen opioid needed and, thus, reduces adverse outcomes associated with opioids (Murphy et al., 2017). Nonsteroidal anti-inflammatory drugs are used for pain management after surgery. They are meant to control nociceptors peripheral sensitization and meet three important treatment needs, namely specifics for multimodal analgesia, lesser opioid requirements, and lesser adverse outcomes associated with opioids.
Corticosteroids, such as dexamethasone, are also administered for pain management after surgery. These drugs are anti-inflammatory corticosteroids important for lessening postoperative pain and opioid usages. They avert fatigue and enhance recovery.
Ketamine is used in subanaesthetic doses for the NMDA receptor. Studies support the administration of low-dose ketamine to ensure enhanced analgesia, an opioid-reduction requirement, and lessening of opioid side effects, including nausea and vomiting after a procedure. The advantages of ketamine are specifically demonstrated in patients who experience severe pain following their surgical procedures.
Pain can also be managed prior to surgery by administering Gabapentin to reduce pain following surgery. It also reduces the need for opioids and related side effects. It also imperative to recognize that chronic pain following surgery consists of neuropathic factors, even in its early state. Thus, drugs for managing chronic neuropathic pain are administered as enhancing drugs to control pain. Further, Pregabalin and Gabapentin are important for reducing pain severity after a procedure, lessening analgesic dose, and preventing chronic pain. These drugs may also enhance patient functional outcomes for a prolonged period (Buvanendran, 2012).
Pain management drugs are classified according to routes of administration. In this case, the classification accounts for “oral, intravenous (IV), intramuscular, subcutaneous, rectal, transdermal, intrathecal, and epidural routes, as well as neuronal blocks” (Shoar et al., 2012, p. 184). Another classification also accounts for the mechanism of action, and in this class, there are “analgesics (opioids and acetaminophen) or anti-inflammatory agents (nonsteroidal anti-inflammatory drugs [NSAIDs])” (Shoar et al., 2012, p. 184). Finally, the classification is also based on the type of drug. These drugs include conventional drugs, non-traditional drugs, and intravenous patient-controlled drugs.
Apart from the use of drugs to manage pain after surgery, research also shows that music therapy can reduce pain in patients (Mondanaro et al., 2017).
Conclusion
Evidence suggests that pain following surgery is a complex condition. As such, postoperative pain needs more than the use of opioids. In fact, now abundant scientific evidence is available to drive evidence-based practices in pain management following surgery. Present literature strives provide the best recommendations for pain management following surgery based on empirical evidence. As such, safe and effective pain management after surgery should planned to meet unique needs of a specific patient, surgical procedure used, and multimodal analgesia. It is noteworthy that research is ongoing to improve outcomes. For patients, they must understand that only healthcare providers can assist them to manage pain effectively. Thus, nurses must understand their responsibilities and decisions on pain management following surgery.
References
Buvanendran, A. (2012). Chronic postsurgical pain: Are we closer to understanding the puzzle? Anesthesia & Analgesia, 115(2), 231–232. doi:10.1213/ANE.0b013e318258b9f7
Glowacki, D. (2015). Effective pain management and improvements in patients’ outcomes and satisfaction. Critical Care Nurses, 35(3), 33-41. doi:10.4037/ccn2015440
Mishra, R. K., Kapoor, I., Mahajan, C., & Prabhakar, H. (2017). Enhanced recovery after surgery: Neuroanaesthetic perspective. Journal of Neuroanaesthesiology & Critical Care, 4(1), 17-22. doi:10.4103/2348-0548.197439
Mondanaro, J. F., Homel, P., Lonner, B., Shepp, J., Lichtensztejn, M., & Loewy, J. V. (2017). Music therapy increases comfort and reduces pain in patients recovering from spine surgery. American Journal of Orthopedics, 46(1), E13-E22.
Murphy, G. S., Szokol, J. W., Avram, M. J., Greenberg, S. B., Shear, T. D., Deshur, M. A.,… Newmark, R. L. (2017). Clinical effectiveness and safety of intraoperative methadone in patients undergoing posterior spinal fusion surgery. Anesthesiology, 126(5), 822. doi:10.1097/ALN.0000000000001609
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Song, S. J. (2017). Pain management and anesthesia in total knee arthroplasty. Knee Surgery & Related Research, 29(2), 77-79. doi:10.5792/ksrr.17.077
Zhou, J., Fan, Y., Zhong, J., Wen, X., & Chen, H. (2017). Efficacy and safety of multimodal analgesic techniques for preventing chronic postsurgery pain under different surgical categories: A meta-analysis. Scientific Reports, 7(1), 678. doi:10.1038/s41598-017-00813-5