####Introduction Traditionally, acute pain following surgery, although predictable, has not been prioritised as part of post-operative care with a resulting lack of education and understanding by staff leading to deficiencies in the quality of pain relief provided to patients. This has been highlighted in numerous national audits and reviews.[1] [2] [3] [4] The recognition of these deficiencies led to the development of acute pain services (APS) in the UK, and the presence of an APS is now seen as a prerequisite for all acute hospitals undergoing a significant volume of elective and emergency surgery. The introduction of an APS has been shown to improve the quality of analgesia provided and reduce analgesia-related side effects.[5] There is also growing evidence that good quality pain control can be associated with other significant benefits, including reduced post-operative morbidity and reduced length of hospital stay. The development of APS is supported by the Royal College of Anaesthetists. In addition, the provision of post-operative pain control is the subject of a [SIGN guideline](http://www.sign.ac.uk/pdf/sign77.pdf) in Scotland and is regularly assessed as part of the provision of anaesthetic services by each hospital during Quality Improvement Scotland (QIS) visits. ####The role of the acute pain service The APS is a truly multidisciplinary team with representation from nursing and medical staff, pharmacy and secretarial support if necessary. The standard model in the UK is a nurse-delivered service supervised by a doctor, usually an anaesthetist. The APS carries out daily ward rounds to review post-operative patients and deals with any new patient referrals. As well as reviewing post-operative patients, the APS is heavily involved in pre-operative patient education and screening. In addition, the APS is responsible for the education of all staff members involved in the management of post-operative pain. The APS develops evidence-based and standardised protocols for patient care to ensure continuity of practice and the optimum treatment of pain. In this way the APS hopes to facilitate and promote best practice. #####Multimodal or balanced analgesia The use of a range of drugs and techniques to optimise analgesia is now seen as standard. In particular, opiate-based analgesia regimes such as patient-controlled analgesia should always be augmented by other adjuvant analgesic drugs. These drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol, have a different mechanism of action to the opiate and can lead to improved pain control, which is usually achieved with less than total opiate use. This opiate-sparing effect is thought to reduce the incidence of troublesome opiate side effects, such as sedation and nausea and vomiting. ####Outcome Uncontrolled post-operative pain is associated with a number of adverse sequelae that can lead to post-operative morbidity. A greater understanding of these phenomena would help to motivate staff to provide better analgesia. #####Patient suffering and distress A long line of publications continue to highlight an ongoing inadequacy in modern acute pain management, with up to 30% of patients still suffering moderate to severe pain following surgery.[1] [4] #####Physiological derangement Severe pain produces a neurohumeral response with the release of catecholamines and activation of the sympathetic nervous system. This results in a number of physiological changes: **Cardiovascular** Tachycardia, hypertension, increased myocardial oxygen consumption, myocardial ischaemia. **Respiratory** Decreased lung volume, atelectasis, decreased cough, sputum retention, infection, hypoxia. **Gastrointestinal** Decreased gastric and bowel motility, ileus. **Genitourinary** Urinary retention. **Metabolic** Increased catabolic hormones, e.g. cortisol, glucagons, growth hormone etc.; reduced anabolic hormones, e.g. insulin, testosterone. **Psychological** Anxiety, fear, sleep disturbances. #####Chronic pain after surgery This phenomenon is still poorly recognised, but many patients following elective surgery can go on to develop prolonged and problematic pain as a direct result of the surgical intervention.[6] The incidence varies, with certain surgical procedures such as thoracotomy or hernia surgery having a particularly high incidence. Surgical, patient and anaesthetic factors are thought to be important in the development of this complication and often those who develop chronic pain have had particularly severe and poorly managed acute post-operative pain. It is thought that more aggressive acute pain management immediately following surgery can reduce the incidence of chronic pain even in high-risk patients and surgery. #####Post-operative morbidity and length of stay Deranged physiology as a result of uncontrolled post-operative pain can ultimately lead to patient morbidity and delay recovery. At the very least, patients who are sore are more likely to remain in bed and not be capable of following post-operative regimes such as chest physiotherapy or deep-breathing exercises. This can lead to complications such as chest infection, deep venous thrombosis or myocardial infarction. #####Outreach care The APS has long been recognised as an effective model of care for screening ‘at risk’ patients on surgical wards and identifying those patients who are developing difficulties post-operatively.[7] This is due in part to the fact that surgical complications can often present as an increase in intensity or character of pain, leading to APS review and further investigation. In addition, as APS are often run by anaesthetists, access to critical care expertise is often available to identify and manage patients who are failing to thrive in a general ward environment. #####Regional anaesthesia A number of review articles[8] [9] have shown that regional analgesic techniques are capable of providing good quality analgesia following surgery with a reduced side-effect profile, and that they can considerably enhance return to normal function after surgery. Both central neuraxial blocks and peripheral nerve blocks can also reduce post-operative morbidity and possibly mortality[10] and, as a result, these techniques are increasingly being used in the fight to control post-operative pain and distress. #####Evidence A number of online resources are now available to guide decision-making in modern acute pain management: [*Acute pain management: scientific evidence.* Second edition (2005)](http://www.anzca.edu.au/resources/books-and-publications/acutepain.pdf) This document was developed by the Australian and New Zealand College of Anaesthetists and Australian Faculty of Pain and has been endorsed by a number of governing bodies including the UK Royal College of Anaesthetists. It uses modern evidence-based medicine techniques to grade the quality of evidence for various interventions used within acute pain management. It is a comprehensive source of quality information that has been compiled by an international group of experts in the field of acute pain management. [Procedure specific postoperative pain management (Prospect)](http://www.postoppain.org/frameset.htm) Prospect is an online resource that has been developed by a group of interested surgeons and anaesthetists from around the world. The website uses the principles of the Cochrane Collaboration to assess evidence for interventions to relieve pain in specific clinical situations, and questions the appropriateness of generalising this information to other clinical circumstances. In this way the group has developed evidence-based guidelines for the management of post-operative pain related to a number of surgical procedures, including elective open colorectal surgery, total knee replacement and mastectomy. The guidelines and the evidence are published on the website and periodically reviewed and updated. [Bandolier: Oxford league table of analgesics](http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab.html) Among other things this online, peer-reviewed website has developed some of the strongest evidence currently available to guide the use of oral analgesics for the management of acute pain. By analysing initial pre-launch drug trials, the team has been able to generate a number needed to treat to indicate the efficacy of a range of oral analgesics. The list is not comprehensive and has some significant limitations, including a lack of information on the number needed to harm, but nonetheless provides useful clinical information to guide prescribing habits. ####Training #####National The Faculty of Pain has recently been formed within the Royal College of Anaesthetists and is committed to the development of greater training in all aspects of pain management at all levels of anaesthetic training. #####Local While a number of universities offer courses that focus particularly on chronic pain management, undergraduates in the West of Scotland now have some formal teaching in acute pain within their university syllabus and special study modules in pain management exist and have proven to be very popular. Foundation training incorporates modules in both acute and chronic pain management. It is hoped that these initiatives will lead to significant improvements in the management of post-operative pain in the future. ####Future Undoubtedly, new techniques and drugs will be developed that will prove to be significant advances in the management of acute post-operative pain. However, as there is still a significant lack of appreciation of the extent of the problem and its significance, it is likely that the greatest advances will come about by greater education of the staff dealing with these patients every day and with the greater use of simple multimodal analgesic strategies, as well as the standardisation and optimisation of current regimes embracing the principles and educational resources laid out in this article. ####Further reading PE Macintyre, SA Schug. *Acute pain management. A practical guide.* Third ed. Philadelphia: Saunders; 2007. 2009-03-05T11:30:00Z None declared. 104 2009-03-05T00:00:00Z 2009-03-12T09:58:07Z adult-post-operative-pain-management 2009-03-12T09:58:07Z

Acute post-operative pain continues to be poorly managed due to an ongoing lack of education and appreciation of the size and significance of the problem. Acute pain services have developed in many centres to improve this situation but are not always fully resourced and supported. Uncontrolled post-operative pain is harmful to patients, and optimal pain control can enhance recovery following surgery. This article seeks to highlight the importance of good quality pain management following surgery, as well as point out a number of resources available to guide patient care.

2009-03-12T09:58:07Z