Figure 13-3. Surgical procedures in which peripheral nerve blockade can provide postoperative pain relief.

Table 13-17 Differential Diagnosis of Delayed Emergence

The most common cause of delayed emergence is the residual effects of anesthesia. The differential

diagnosis of delayed emergence is best approached by ruling out physiologic, pharmacologic, and

neurologic cases, in this order (Table 13-17). There should be little confusion about the implication of

muscle relaxants because physical indications of ventilatory distress, combined with the readings of the

blockade monitor, should clearly indicate the role of these drugs. Where appropriate, opioids can be

reversed using titrated doses of naloxone. Flumazenil can be used for reversal of benzodiazepines.

ENHANCED RECOVERY PROTOCOLS

15 With the increasing adoption of minimally invasive surgical techniques and a realization that

postoperative complications may impact intraoperative management, nearly every surgical subspecialty

has begun efforts to establish enhanced recovery protocols. These comprehensive care management

plans dictate the preoperative preparation, intraoperative management, surgical technique, and

postoperative management choices made by all clinicians involved in the patient’s care: nurses,

anesthesiologists, surgeons, physical therapists, and consultants. While a consistent decrease in length of

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stay, complications, and costs has been observed across the many trials assessed in many surgical

specialties, there are very few consistent protocols.74,75 It appears that the process of collaboration and

standardization involved in creating a multidisciplinary and multispecialty protocol may be the most

causal attribute in the success of enhanced recovery protocols. While some recommend use of

controversial anesthesiology management techniques such as goal-directed colloid fluid therapy, others

do not make such recommendations. The evolution of enhanced recovery protocols and implementation

science is an active area in all perioperative specialties.

POSTOPERATIVE ACUTE PAIN MANAGEMENT

Postoperative pain is an inevitable consequence of surgery. Its severity is site dependent (Table 13-18),

but the magnitude of the pain experienced by individual patients after similar surgical procedures is

influenced by a multitude of factors. Variation in patient experience has been clearly demonstrated by

several authors and is reflected in deficiencies in postoperative pain control.76 The recognition of this

clinical problem has prompted interest in underlying pain mechanisms and in innovative ways to

alleviate postoperative suffering.

In 1965, the crucial role of nociceptive C fiber feedback behavior and its modulation by cells in the

substantia gelatinosa of the dorsal horn was recognized.77 Repetitive stimulation of these fibers by

cellular mediators, such as kinins and catecholamines, promotes neural excitation, prolongs repetitive

firing, and lowers the threshold to further excitation. As a result, C fibers do not show fatigue, and the

stage is set for continuous pain. Counterirritation of large afferent activity has been shown empirically

to have beneficial effects. The gate-control theory provides an explanation for the inhibition of C fiber–

mediated pain. Serotonergic and enkephalinergic descending inhibitory pathways modulate activity in

the dorsal horn before information is relayed to the somatosensory cortex through the spinothalamic

tract. The common observation that pain is worse at night, when less sensory information is processed,

and that it decreases with daytime activity is an example of how this complex neural system functions.

Superficial somatic pain is well localized and has a protective function. Superficial somatic pain is

readily treated by common analgesic techniques. Deep somatic pain may not be well localized; may

have some protective function, as in joint immobilization; and is fairly responsive to a variety of

analgesics. Visceral pain, served almost entirely by C fiber activity, is poorly localized, often referred,

and difficult to treat. In major operations, all modes can be activated, compounding the clinical

challenge of providing adequate pain management. These clinical observations direct the focus of

postoperative pain management to the treatment of somatic pain by attacking the nociceptor and the

subsequent transmission of the painful impulse by the nerve fiber. The use of nonsteroidal antiinflammatory drugs with or without the injection of local anesthetics into the wound is very effective. If

done pre-emptively at the time of surgery, this approach can significantly benefit the patient’s

postoperative experience.Examples of nerve blocks for various procedures are shown in Figure 13-4.

Table 13-18 Percentage of Patients Who Require Analgesic Injections

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Figure 13-4. Theoretical relation among dosing interval, analgesic drug concentration, and clinical effects when comparing a

patient-controlled analgesia system (solid line) to conventional intramuscular therapy (dashed line). (Reproduced with permission

from White PF. Patient-controlled analgesia: A new approach to the management of postoperative pain. Semin Anesth 1985;4:261.)

Table 13-19 Problems That Can Occur During Patient-Controlled Analgesia (PCA)

Therapy

Including potent opioids in the treatment of deep pain, both somatic and visceral, has been routine.

However, the responses to standard regimens have been notoriously unreliable, from inadequate pain

relief to narcosis, with complications at both ends of the scale. It was not until the 1980s that variations

in response were linked to variable serum concentrations of analgesic drugs. Interpatient variation in

serum levels to any standard dose can be fivefold, and interpatient therapeutic concentrations can vary

on a similar scale. When factored together, there is the potential for a 25-fold variation in patient

response to a standard drug prescription. Each patient has an individual therapeutic window. The

clinical implications are enormous.

In 1968, investigators demonstrated the virtue of small IV doses given on demand. As a result, the

patient experienced greater pain relief, yet used the same or less total narcotic. Although there was

significant patient variation, the demand from any individual patient, though cyclic, was constant.

Patient-controlled analgesia (PCA) and the technologic and administrative systems to provide it have

developed to a point of some sophistication, requiring servicing and a support structure with its own set

of problems (Table 13-19). PCA administration requires a receptive environment, education of all

personnel, and adequate patient instruction. PCA has received widespread acceptance by patients,

nursing staff, and physicians because it provides more prompt and painless analgesia that more closely

matches the patient’s need over time. PCA is as safe as conventional IM medication. Morphine and

meperidine are commonly used drugs, and an example of orders is shown in Table 13-20.

Transdermal narcotic delivery is receiving attention and may become available for postoperative

pain. The method is both practical and inexpensive and aims to maintain continuous delivery and

constant blood levels. Fentanyl has been the drug of choice and has been well received by patients. The

method appears to be safe, but there is a significant lag time between application and the attainment of

therapeutic blood levels.

The discovery of endorphins in the 1970s and recognition of their importance in modulating pain at

spinal sites led to the supposition that it would be possible to selectively apply opioids directly to

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receptors. This led to the development of epidural opiate analgesia, in which opioids are applied

directly to the receptors at spinal sites. The goal of epidural analgesia is to obtain maximal analgesia

while minimizing systemic side effects. For severe acute postoperative pain caused by major surgery,

epidural analgesia has proved to be a superior modality for pain control. In high-risk cases, there is

evidence that it has an overall beneficial effect on morbidity.43

Table 13-20 Example of Orders for Patient-Controlled Analgesia (PCA)

Table 13-21 Opioid Protocols in Epidural Opiate Analgesia

The effective use of this sophisticated modality requires education and the establishment of protocols

with rigorous attention to detail. The potential for respiratory depression demands adherence to

monitoring standards. Morphine and fentanyl, often in combination with a dilute local anesthetic

solution, are most often prescribed. A typical order form with monitored parameters is shown in Table

13-21.

A comprehensive postoperative pain management service demands resources and must use the

physical and pharmacologic modalities available while recognizing the significant subjective component

of any individual’s pain problem. The ability to recognize the impact of acute pain or an underlying

chronic pain disorder requires that experience be brought to bear on difficult problems. The active

involvement of nursing staff and surgeons is essential for the patient to achieve maximal benefit. It is

incumbent on the pain-management service to render efficient, continuous, and cost-effective care.

16 Postoperative acute pain management may require a multimodal approach that incorporates

opioids, PNB, and nonopioid analgesics. Chronic pain patients can be particularly difficult to manage

and may require preoperative optimization by an anesthesiologist. These patients require very large

doses of IV analgesics and need to be maintained orally. The best way to evaluate an appropriate

starting dose is to convert the preoperative opioid regimen to an IV morphine equivalent, then add what

would be required to treat the acute surgical pain (Table 13-4). The use of nonopioid and

nonpharmacologic treatments is essential in the management of acute postoperative pain in this patient

population. PNB, aggressive use of acetaminophen and nonsteroidal anti-inflammatory agents, and

novel agents such as dexmedetomidine may be necessary to minimize the adverse effects associated

with uncontrolled postoperative pain. As mentioned earlier, these patients may need to be evaluated by

an anesthesiologist prior to the day of surgery. This should be an institutional requirement for patients

on chronic buprenorphine therapy, as demonstrated in Algorithm 13-2.

Acknowledgements: The authors would like to thank Kevin K. Tremper and Timothy W. Rutter for

their contributions to earlier editions of this chapter.

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