Prevention of Pain and PONV


Dr Jan Jakobsson. Adjunct Professor, Anaesthesia & Intensive Care, Institution for Physiology & Pharmacology, Karolinska Institutet, Stockholm. Sweden. Email: Jan.Jakobsson at ki.se

Pain Management

Preventive balanced multimodal opioid sparing pain management has become the Gold Standard in order to improve the perioperative management of postoperative pain. The strategy aims at reducing the need for opioid analgesic and so the opioid associated side-effects of sedation, nausea/vomiting and respiratory depression. All these are factors that can delay rapid and safe discharge.
The concept of combining drugs with different mode of actions aiming at an additive analgesic effect to a minimum of side effects has now been used almost for two decades.
Combining local anaesthesia, paracetamol, NSAIDs and lowest effective dose of opioid is well-established practice.
The ultra-sound guided block techniques have become increasingly popular among young anaesthetist and a variety of major and peripheral blocks are today used in conjunction with surgery for intra as well as postoperative pain management. Surgical site infiltration is a simple and safe alternative.
There are good evidence for providing local anaesthesia prior to incision even in patients having general anaesthesia in order to reduce the need for intraoperative analgesic and also facilitate the postoperative pain course. The standard dose of a long acting local anaesthetic e.g. bupivacaine or chirocaine are recommended in order to extend the duration.
If surgical site infiltration is used, combining pre-incisional and then further infiltration at wound closure will provide intra as well as postoperative analgesia.
Paracetamol is a safe analgesic and worth providing as base pain medication. Starting dose in a paracetamol naive patient can be increased to 30 mg/kg. In healthy adult 2 grams orally some 60 – 90 minutes prior to start of anaesthesia provide therapeutic plasma concentration in time for surgery.
Paracetamol 1 gram four times daily for postoperative pain management is a safe base medication.
Non steroidal analgesic drugs, NSAIDs have well known analgesic effects and their place as part of multi-modal/balanced analgesia is well documented. The oral route is cheap, safe and effective. Standard dose taken in combination with the paracetamol orally some 60 – 90 minutes prior to surgery provides preventive analgesia.
Ibuprofen 800 mg three times daily is an effective add on to paracetamol.
Coxibs are an attractive alternative. The Coxibs were developed in order to reduce the risk for GI-tract bleed and their effect on platelet function is minor. Coxibs minimise the risk for drug induced bleed. Oral Celecoxib 400 mg preoperative and 200 mg twice daily or Etoricoxib loading dose 120 mg followed by 90 mg once daily are 2 different alternatives to Ibuprofen.
Risk factors such as known NSAID/acetylsalycylicacide sensitivity, history of GI-bleed and or cardiovascular disease must of course be acknowledged. Coxib in combination with a proton pump inhibitor seems reasonable to minimise risk for GI-bleed. Naproxen has been shown to be associated to the lowest risk for cardiovascular/thromboembolic risk. As a general rule we should be prescribing these drugs for a short postoperative course and this should not cause major problems.
A single 4 mg intravenous dose of Dexamethasone has becoming increasingly used as part of PONV prevention and there is increasing support for additional analgesic properties if the dose is increased to 0.1 mg/kg. The steroid should be administered early but is best given once the patient is anaesthetised – if given to awake patients it can result in considerable perineal discomfort.
The risk associated to single iv. preoperative dose dexamethasone is low and recent guidelines suggest that steroids should not be withheld in patients with controlled diabetes and the short-lasting increase in blood glucose should be handled accordingly.
Rescue medication with opioids should be available. Oxycodone has in some countries become popular but choice of rescue opioid should be done on local traditions. Lowest effective dose should be suggested.

Prevention of Post Operative Nausea and Vomiting

So all of the above techniques can help contribute to the prevention of postoperative nausea and vomiting (PONV). If you use the techniques described then the rate of PONV will be low. However for those who experience PONV it seriously reduces the perceived quality of care and can delay discharge. It has become standard practice to risk score for PONV and to administer prophylaxis/prevention in accordance to the risk. There is a free online PONV Risk calculator for day cases provided by the British Association of Day Surgery that can be found at http://www.daysurgeryuk.net/en/resources/ponv-calculator/(external link)
There is also a free presentation on the background to the development of this tool http://videos.bads.101test1.co.uk/SWF/PONV/PONV.html(external link)
The use of routine administration of prophylactic antiemetics is something that each unit should consider – many like the unit described in the above presentation only use prophylaxis in those with high risk of PONV.

Table 1. Suggested postoperative analgesia regimen

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