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Discharge Analgesia

Objective

To maintain an acceptable level of analgesia with minimal side effects after discharge from the day surgical facility.

Drugs

Analgesia after discharge from ambulatory surgery is based upon
  • Paracetamol
  • NSAIDs
  • Opioids
  • Local analgesia
  • Topical analgesia

Paracetamol

Paracetamol is a mainstay due to safety profile and few side effects. The effect is limited, and frequently needs support by stronger acting drugs. Oral dosage is preferable when possible, as rectal doses are absorbed unpredictably.

NSAIDs

NSAIDs constitute the next step. Ibuprofen and naproxen have the most favourable cardiac risk profile. NSAIDs may be given as required or at fixed intervals according to needs. The rapid onset of ibuprofen is useful in as required use. Cox-2 selective drugs offer little or no platelet inhibition, but the risk of cardiac complications is larger.
In the frail or elderly patient renal function must be considered especially if the patient is on an ACE inhibitor, the NSAID dose and duration must be reduced accordingly and proton pump inhibitors prescribed liberally.

Opioids

When other measures fail to achieve adequate analgesia, the patient may need opioids after discharge. Oral morphine preparations and oxycodone are widely employed. Although codeine is still in regular use, 5% of caucasians lack the necessary enzyme converting codeine to morphine, while others are ultrafast metabolisers and risk increased side effects. For these reasons, many units do not use codeine in ambulatory surgery.
At discharge, patients may be given a limited dose of opioids and laxative for as required use at home.

Local Anaesthesia

Duration of local analgesia may be extended by connecting a disposable mechanical pump to an indwelling catheter, inserted along peripheral nerves or as a wound catheter. After instruction, the patient may remove the catheter at a set time.

Topical anaesthesia

Lidocaine formulations may be useful after ophthalmic surgery, circumcision and other operations with localized mucosal pain.

Supply of analgesic drugs

This will depend on the custom and practice of the local health service. If no drugs are to be supplied then the patient must receive information preoperatively about the need for analgesics, so he or she can stock the drugs before surgery. Where drugs are to be provided then the expected amount of analgesics and adjuvant drugs may be given to the patient at discharge. The amount handed out must be documented.

Information

Information at discharge must include recommended maximal daily doses of paracetamol and NSAIDs, the need for laxatives when taking opioids and possible need for proton pump inhibitors.