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Cuirent interventions and approachesto postoperative pain managementMandy Layze

AbstractSome degreeofpain accom panies all surgical procedures. Current evidenceinformsusthat patients will expe rience significant physiological andpsychologicaleffects if this painis notadequately treated. These effects can cause serious harmdelay recovery fi-om surgery andin some cases lead topersistent post-surgicalchron ic pain . This article briefly d iscussestheimportance of assessing patientspreoperatively and highlightshowsom e patients will have risk factors which maylead them to experience severe postoperative pa in. Approaches topostoperativepain control arefocused onwaystoaddressthe inter-patient differences inresponseto painandtreatmentsandavoid periods of ineffective painrelief A review ofthecommonly used analgesics paracetamol non-steroidal anti-inflammatory drugsopioids and local anaesthetics and methods ofadministration is included. The finalsection providesashort review ofemerging trendsin acute pain therapyand theimplications for improving patient care.Key words: Acute painassessment

Analgesia Postoperative pain Preoperative

his year the NHScelebrates its 60thbirthday and no doubt those whohave worked in the NHS forsomeyears will have seen numerou s changesin health care. Over the past 15-2 0 years,healthcare professionals working in painmanagement have witnessed radical differencein themanagement ofpain, particularly acutepostoperative pain. Fortunately, thereis arangeof techniques for variety of surgical procedureswhich aim to minimize pain. Additionally,healthcare professionals have accesstovariousevidence bases which inform them of thetechniques effectiveness. However,in spite ofthese facts, under-treatment of postoperativepain continuesto be amajor problem both inthe United Kingdom (UK) and internationally(Wu etal, 2002; Ekstein etal, 2006).The reasons for this are complex and notquickly remedied as many barriers involvingthe patient, healthcare professional, theorganization, and in some cases, existing

Mandy Layzellis Lecturer Practitioner, Acute PainService, Poole Hospital NHSFoundation TrustandHealth andSocial Care, Bour nemo uth UniversityAccepted for publication: March 2008

Government policies,thuspreventing optimumpain management {Box 1 (Carr, 2007).Healthcare professionals working in theperioperative environment are well aware thatpain accompanies or follows virtually everysurgical procedure. The challengeis topreventand reduce pain where possible.To do thiseffectively may require approaches which areaimed at changing the organizational culturethat allows uncontrolled pain to persist. Thisculturemay bebased on the outdated notionthat exp eriencing pain is harmless and that painmedication is more dangerous than unrelievedpain.In theUnited states (US), lawsuits againsthospitals for the undertreatment ofp in are nolonger a rare occurrence (Pasero etal, 2007).Inresponse to this, national standards have beendeveloped to help provide fi-amework for goodquality pain management Qoint Commissionon Accreditation of Healthcare OrganizationsgCAHO] ,2001).The U K is yettofoUow.This article discusses how perioperativepain ismanaged in the 21stcentury. Initiallyit looks at the significance of preoperativeassessmentand theimportance of identifyingpatients with risk factors for experiencingsevere postoperative pain and developingpersistent pain. A brief review of thetechniques commonly used to control painintheperioperative and postoperative period.

and the available supporting evidencefortheeffectiveness, follows. Innovative researchecontinue to explore new and better ways delivering painrehef;these newtechnologiare discussedin thefinal section. By kno winwhat is available now, and in the future,cahelp ensure that patients benefit from thlatest pain-relief products.Preoperative assessmentAcute postoperative pain differs from chronor cancer pain because it is more transitorand any affective component relatestoanxieabout theoutcome of the surgical conditioand fear of pain. Indeed, many patients havpoor expectations about pain relief (Wickstroet al, 2005).

Assessment of patients preoperatively bnursing and medical staff is an importapart of the surgical experience to ensuthat appropriate interventions are used anrecovery from surgery is asquick aspossibTime spent preparing patients psychologicalfor surgery has been showntoshorten hospitstay and reduce the need for postoperatianalgesia (Carr and Goudas, 1999).Inadditioto psychological factors, anxiety is associatwith physiological effects which can influenthe level ofpain experience d (Vaughn et 2007). Research has also shown that anxielowers immun ity and can delay wound heali(Kiecolt-Glaser etal, 1995).

There is an increasing body of evidenlinking acute postoperative pain and tdevelopment of persistent (chronic) pain (Kehlet al 2006). Acute pain generally subsidwithin days to weeks,but in some instancpain following routine surgical procedurexists for longer periods than expected, anin some cases interferesin return towork aleisure activities{Table 1 .Acute to chronic painThe work of Henrik Kehlet and colleagu(2006) has provided evidence asserting ththis persistent postsurgical chronic pain is consequence of either ongoing inflammatior more commonly as a manifestation neuropathic pain, resulting from surgical inju

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ox1 Possible barrierstoeffective pain reiief Abelief that painis notharmful,orthatit is a normal consequenceofsurgery and injury Conc erns that pain relief will obs cure a surgical diagnosisormcisk thesigns ofsurgical

complications Atendency tounderestimateapatien t s painand notrecognise thevariability inpatients

perceptionsofpain Laci

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Table2.Adverse effe ctsofunder treated severe pain ypeo pain Adverse effectsCardiovascular

Respiratory

Gastrointestinai

GenitourinaryNeuroendocrine/metabolic

Muscuioskeietal

Psychoiogicai

Centrai nervous

Tachycardia, hypertension, increased peripheralvascular resistance, increased myocardial oxygenconsumption, myocardiai ischaemia, altered regionalblood flow, deep-vein thrombosis, pulmonary embolismReduced lung volumes, atelectasis, decrecised cough.sputum retention, infection, hypoxaemiaDecreased gastric and bowel motility, increased riskof bacterial transgressionofbowel wallUrinary retentionIncreased catabolic horm ones: glucagons, growth hormone.vasopressin, aldosterone, rennin and angiotensin.Reduced anabolic hormones: insulin, testosterone.This catabolic state leadsto hyperglycaemia, increasedprotein breakdown, negative nitrogen balance leadingto impaired wound heaiingMuscle spasm, immobility (increasing riskofdeep veinthrombosis), muscle Wcisting leadingtoprolongedrecoveryof functionAnxiety, fear, heipiessness, sleep deprivation.leadingto increased painChronic (persistent) pain dueto central sensitization

From: Macintyre and Schug (2007)

(e .g . pha nto m l imb) (Ho ckin g et al, 2007 ) .Fur ther s tudies are r equi red before it ispossible to r e c o m m e n d a specific dose orr e g i me n for adminis t ra t ion .Intraoperative treatmentsforpainPain managementin the perioperative periodis dependent on a num ber of factors, includingthe type of surgery to be performed andthe individual patient. Generally, opioidsarewidely used with the majority of surgicalprocedures either as intermittent boluses,inpatient-controlled analgesia PCA) pumps,or added to local anaesthetics in spinalsorepidurals.The following section discusses theseinterventions and highlights the evidenceof their effectiveness in postoperative painmanagement.OpioidsOpioids, also knownasopiatesandnarcotics,remain the mainstay of systemic analgesiafor moderate to severe acute pain (ANZCA,2005).There are a variety of drugs used inanaesthesia, with fentanyl, alfentanil, morphine,oxycodone anddiamorphine beingthemostcommonly ones used. Opioidsactas agoniststhrough mu, kappa and delta receptors

located on cells throughout the peripheraland central pain pathways and on cells inthe gastrointestinal tract (McLoughlin, 2004).They are involved in inhibition of nocice ption or sensing of pain in the dorsal rootganglia of the spinal cord,andactivation ofdescending pain pathways from the forebrainand midbrain therefore, modulating pain.Opioids are more effectiveforcontinuous anddull pain rather than sharp intermittent pain(Krenzischeketal, 2008).Itisworth noting that patients vary widelyin response to opioids,and doses need to betitrated to suit each patient s response; adultsage rather than weight is a better predictorof opioid requirem ents (Macintyre and Jarvis,1996).Titration for severe acute pain isbestachieved using intermittent intravenous IV)bolus doses asitallo ws more rapid titration ofeffect and avoids the uncertainty of absorption.The use of an algorithm based on age andpain score given at 35-minute intervalsasneeded is usefulin establishing rapid analgesiaand minimizing adverse effects (Macintyreand Schug, 2007). Common adverse effects,including sedation, itching, nausea, vomiting,slowing of gastrointestinal function andurinary retention, are dose-related, i.e. oncea

threshold dose is reached; small increasesinthopioids are associated with increasesinadverseffects (Zhaoetal, 2004).Patient-controlled analgesia PCA)For over three decades patients have beesafely using PCA, and they are routinely usefor many surgical procedures. Thereareclebenefits as patient satisfaction is improveand to some degree nursing time decrease(Kehlet and Holte, 2001).In addition,PCprovides better analgesia than conventionintramuscular or subcutaneous opioiregimens, and thereis also some evidenceoa decreased risk of postoperative pulmonarcomplications (Walderet al,2001). Therelimited data available on what the optimsized bolus shouldbe. In patients prescribemorphine 0.5 mg, mg and 2mg boldoses, mostofthose p rescribed 0.5 mg werunable to achieve adequate analgesia, whila high incidence of respiratory depressiowas reported in those who received 2m(ANZCA, 2005). The optimal dose wtherefore mg. Although rigid adherento this optimal dose may not lead to bepain relief for all patients, factors to take intaccount include history of prior opioid uandthepatient s age.

Background infusions and dose limitscabe programmed into PCAs; however, currenevidence suggests that there are no benefito painrelief, sleep orreduction in demand(Daletal, 2003). Auditsof adult patients havshown that the risk of respiratory depressionincreased when background infusion isaddetherefore, routine use is not recommendealthough may be useful in opioid-tolerapatients (Schug and Torrie, 1993; Sidebothaetal,1997; ANZCA , 2005).One of the moimportantandoften overlooked d eterminanof successful PCA is that the patient shoulbe reasonably comfortable when it isbegutherefore, pre-loading with opioids is necessa(Pasero etal, 2007).ParacetamolThe exact mode of action of paracetamremains to be confirmed. However, itisthougto act by selectively inhibiting the releaof prostaglandins within the central nervousystem as well as having some peripheranalgesic effect (Niklesetal, 2005).Paracetamol is widely used for pain reliand for its antipyretic effects, although only has a weak anti-infiamm atory effeand has few significant side-effects if takeat correct doses. Paracetamol is used asbasic building block of most postoperativ

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PAIN MANAGEMENTanalgesic regimens. It is well accepted thatadding paracetamol will resultin areductionof postoperative opioid requirement andtherefore a reductioninside-effects associatedwith opioids. Oral paracetamol is absorbedwell from the small intestine; it can alsobe given rectally, and more recently an IVpreparation has been introduced with anonset of action seen wit hin 510 min utesElectronic Medicines Compendium, 2007).NSAIDS and cyclooxygenase-2COX-2) inhibitorsNSAIDs and COX-2 inhibitors are usefulanalgesic adjuncts that can improve painrehef while reducing opioid requirementspostoperatively Myles and Power, 2007).They havea combination ofanalgesic, a nti-inflammatory and antipyretic effects. Theirprinciple therapeutic actions primarily inhibitthe synthesis of prostag landins, specificallytheactionofcyclooxygenase CO X)theinitialenzyme in the pathway of prostaglandinsynthesis. Prostaglandins sensitize nocicepto rsto mechanical and chemical stimuli bylowering the threshold of the nociceptor.In addition, NSAIDs exert their action onthe dorsal horn cells of the spinal cordto decrease reactive hyperalgesia thatmayoccurinresponsetoperipheral inflammationK renzischeketal, 2008).Prostaglandins are known to be involvedin numerous physiological functions,including gastric mucosal protection, renaltubular function and intrarenal vasodilation,bronchodilatation and platelet formation{ able 3 . Consequently, the potential side-effects bleedingandrenal failure restrictstheir use intraoperativelyinhigh-risk patients those with pre-existing gastric ulcerationand renal dysfunction) and certain surgicalprocedures tonsillectomy, cosmetic surgery,eye surgery, and following heparin duringcardiovascular proced ures) KehletandDahl,2003).It isworth noting that NSAID side-effects are more common with long-termusethan short-term postoperativeuse.COX-2 inhibitorsEvidence suggests that conventional NSAIDscould be replaced by CO X-2 inhibitorswhich selectively target the c yclooxygenase-2enzyme)insome situations where short-ter mtreatment is indicated Mc Crory and Lindahl,2002). These agents have d emonstratedefficacy in avariety of pain types andseemto have similar analgesic potencyandopioid-sparing benefitbuta better safety profile thanNSAIDs with respect to the gastrointestinal

Table3.Prostagiandins: their organ specificity and effectsOrgan speci f ic i tyPeripheral nervesGastrointestinal tractKidney

Peripheral issuesCoagulat ionUterus

EffectsSensit izat ion and hyperalgesiaMot i l i ty, mucosa protect ionMedul lary b lood f low, sodium ndpotassiumexchange, cort ical and glomerular biood f low ndregulat ion, sodium retent ion and water excret ioninf lammatory responseFibrlnoiysis, platelet aggre gationLabour onset, increase con tract i l i tyinlabour

From: Naesh 2006)

tract and platelet function, but their effectonrenal function is unclear Kehlet andHolte,2001). However, treatment with COX-2shasbeen associated with an increased incidenceof myocardial infarction and stroke, whichhasresultedin thewithdrawal ofrofecoxib fromthe market Krenzischek et al,2008). It isworth noting that all NSAIDs hold a potentialto aggravateanypreex isting h eart failureandhypertension due to fluid retention throughrenal effects Naesh , 200 6). This increa sedrisk hasled to recommendations that specificCOX-2 inhibitors should be used only inthe lowest possible dose in patients whomthere are no suitable alternatives. Potentialcardiovascular effects associated with short-term use of C O X -2 in the perioperativesetting havenotbeen well studied.Local anaestheticsThe use of local anaesthetics for pain reliefis increasingly being extended into thepostoperative per iod. These drugs do nothaveany specific analgesic effects,butworkby blocking the generation and conductionof nerve impulses in all sensory and motornerve fibres. The smaller unmyelinatednerve fibresareblocked first, which conductsensation for pain and temperature, beforeblocking the larger myelinated fibres whichconduct sensation for touch, pressure andmotor information Macintyre and Schug,2007).Local anaestheticsin theperioperativesetting can provide analgesia alone or incombination with opioids for epidurals,spinals, peripheral regional nerve blocksandwound infiltration.Epidural analgesiaEpidural analgesiais one ofth most effectivemethods available for the management ofsignificant acute pain, suchasmajor thoracicand abdominal surgery, and orthopaedicsurgery e.g. total kneeand hip replacements)

ANZ CA, 2005). Combined with activepostoperative and early enteral feedingepidural analgesia provided by locaanaesthetics with or without an additionof an opioid) may lead to a reductionin postoperative complications particularlyrespiratory andcardiac) and improve patienoutcome, especially in the high-risk patien MacintyreandSchug, 2007).

Combinat ions of low concentrationof local anaesthetic agents and opioidhave been shown to provide consistentlysuperior pain relief compared with eithedrug alone Curatolo et al, 1998).Theaddition of small amounts of adrenalineharesulted in improved analgesia Niem iandBreivik, 2002),and in some settings, addinclonidine has shown reduction in dose olocal anaesthetic and improvement in painrelief Macintyre andSchug, 2007). Resultfrom major prospective studies have shownthat postoperative epidural infusions aresafand effective andcanbemanagedongenerasurgical wards with few complicationsprovided that patients are observed andmonitored by staff trained in epiduramanagement KehletandDahl, 2003).Intrathecal analgesiaSpinal or intrathecal analgesia is usuallperformed prior to surgery to providanaesthesia for surgery and profound pairelief in the immediate postoperative periodThis technique involvesa single-shot injectioof opioids and local anaesthetic) into thcerebrospinal fluid avoiding absorption bepidural fat and blood vessels.The dose oopioid administered is much smaller thathose required for epidural analgesia and thduration of analgesia dependson the opioiused; generally, analgesia can be expectedfoupto 24hours{ able 4 Macintyre and Schu2007). Side-effects are similar to those thaoccur with epidural opioids.

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Table4 Intrathecal opioids: examplesofdose s usedOpioidMorph inePethidineDiamorphineFentanylSufentanil

Doseme)0.1-0.510-250.5-10.006-0.050.005-0.02

Onset min)15-305-10

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PAIN MANAGEMENTwound at the end of the operation.This is thenconnected to the pump which is filled withlocal anaesthetic. A continuous flow of localanaesthetic is infused into the wound over a48-hourperiod.Some systemsaOowthe patientto self-administer bolus doses as required ifbreakthrough pain occurs (D'Arcy, 2007).This new technique for pain management hasallowed early mobilization and discharge ofpatients, and, in some circumstances, dischargewith the system in place.Bupivacaine collagen sponge this spo nge isdesigned for implantation directly into thesurgical cavity and can be placed at differentlevels of the wound to provide pain relief toall affected areas. The collagen m atrix naturallybiodegrades overafewdaysand the bupivacaineis released to exactly where it is needed. Inaddition to pain relief the collagen matrixprovides haemostasis and promotes woundhealing after surgery. Clinical trials in patientsundergoing hysterectomy are ongoing. onclusionPostoperative pain management continues tobe challenging and should be a clinical priorityfor all healthcare professionals involved in thepatient's journey. Evidence is available of thedeleterious effects of poor postoperative painmanagement. Persistent postsurgical pain is amajor, largely unrecognized clinical problem,which is distressing and reduces the quality oflife ofpatientsand their carers.

There are a number of widely availablemedications and interventions available formanaging postoperative pain;somecarry risks ofside-effects and serious complications. Effectivepain management requires the coordinatedeffort ofaskilled and responsive interdisciplinaryteam, including medical and nursing staffphysiotherapists, pharmacists and managem ent.The NHS is driven by targets, in particularwaiting lists for surgery; the bed stay formany procedures has been drastically reducedover the last 20 years. Wit h shorter stays inhospital and early discharge there is a need formore innovative ways to reduce postoperativepain. Fortunately, there are new technologiesavailable and more on the horiz on. Thesetechnologies come at a price and the NHS,in this financially driven climate, have a short-sighted view to introducing new approaches topain management and many hospitals struggleto implement new interventions.The evidence informs that good pain relieffollowing surgery will improve the patientsoutcome and recovery and prevent thedevelopment of persistent pain, but if acute painmanagement is to be taken into the 21st

century, healthcare professionals have to bravelychallenge their organizations so that they canprovide appropriate multimodal therapy tailoredto the needs of the individual patient. Hw

Arns te in P (2002) Opt imiz ing per iopera t ive pa inmanagement .AORNJ 76(5): 812-8Australian and New Z ealand Co llege of Anaesthetists andFaculty of Pain Medicine (2005) Acute Pain Management:Sdentijic Evidence 2nd ed n. Austral ian and Ne w ZealandCollege of Anaesthetis ts, Me lbou rneCarr DB, Goudas LC (1999) Acute pain. Umcet 353(9169):2 0 5 1 - 8Carr E (2007) Barriers to effective pain management.JPerioper Pract17(5) : 200-8Curatolo M, Petersen-Felix S, Scaramozzino P, Zbin denAM (1998) Epidural fentanyl, adrenaline and clonidine asadjuncts to local anaesthetics for surgical analgesia: meta-analysis of analgesia and side-effects. cta naesthesioi Scand42(8): 910-2 0Dal D, Kanbak M, Caglar M,Ay par U (2003) A backg roundinfi js ion of morphine does not enhance postoperat iveanalgesia after caixliac surgery. CanJAnaesth 50(5): 476-9D'Arcy Y (2007) N ew pain managem ent op tions: deliverysystems and techniques.Nursing37(2): 26-27Ekstein P.SzoldA, SagieB,WerbinN,KlausnerJM,WeinbroumAA (2006) Laparoscopic surgery may be associatedwith severe pain and high analgesia requirements in theimmediate postoperativeperiod An n Surg243(1): 41-6Electronic Medicines Compendium (2007) PerfalganlOnig/ml solution for infusion. Available at : ht tp: / /e m c . m e d i c i n e s . o r g . u k / e m c / a s s e t s / c / h t m l / D i s p l a y D o c .asp?DocumentID=14288 (las t accessed 28 March 2008)Ho KY, Gan TJ, Hab ib AS (2006) Gabapentin andpostoperative pain - a systematic review of randomizedcontrolled trials.Pain126(1-3) : 91-101Hock ing Ci,Visser E, Schug S, Cousins M (2007) Ketam ine:does life begin at 40? International Association for theStudy on Pain. ClinicalUpdates XV(3) : 1-4Joint Commission on Accreditat ion of Health CareOrganizations (2001)Setting theStandard jointCommiss ion,I l linois . Ava il able a t : h t tp : / /ww w. jointc omm iss ion.o r g / N R / r d o n l y r e s / 6 C 3 3 F E D B - B B 5 0 - 4 C E E - 9 5 0 B . -A6246D A4911 E /O/sett ing_the_standard.pdf (last accessed20 March 2008)Katz J, Poleshuck E, And rus C et al (2005) Risk factors foracute pain and its persistence following breast cancersurgery.Pain119(1-3) : 16-25Kehlet H, Holte K (2001) Effect of postoperative analgesiaon surgical outcome. BrJAttaesth 87( 1): 6272Kehlet H , Dahl JB (200 3) Anaesthesia, surgery an d challengesin postoperative recovery.Lancet362(9399) : 1921-8Kehlet H Je n se nT S,Woolf C J (2006) Persistent postsurgicalpain: risk factors and prevention.Lancet367 (9522): 161825Kiecolt-Glaser JK, Marucha PT, Malarkey WB , MercadoAM, Glaser R (1995) Slowing of wound healing bypsychological stress.Lancet 346(8984) : 1194-6Krenzi schek DA, Dunwoody CJ , Polomano R C, R a thmel lJP (2008) Pharmacotherapy for acute pain: Implicat ionsfor practice.J Perianaesth Nurs23(1 Suppl): S2842

Macin tyre PE, Jarvis DA (1996) Age is best predicto r opostoperat ive of morphine requirements . Pain 64(23 5 7 - 6 4Macintyre PE, Schug SA (2007) Aaite Piiitt ManagemenA Practical Guide 3rd edn. Saunders Elsevier, ChinaMcLoughlin C (2004) Opioids .Prof Nurse19(10) : 51-2McCrory CR, Lindahl SGE (2002) Cyc looxygenasinhibition for postoperative analgesia. Attestli Anal^ 95(11 6 9 - 7 6Mo inich e S, Mikke lsen S, Wettersley J (1998) A qu.alitativsystematic review of incisional local anaesthesia fopostoperative pain relief after abdoniincil operations. BrAnacsth 81(3) : 377-83Mo inic he S, Kehlet H, Dah JB (2002) A qualitative anquantitative systematic review of pre-emptive analgesifor postoperative painrelief:the role of timing of analgesiAmsthcsiology 96(3): 725-41Myles PS, Power I (2007) Clinical upd ate: postoperativanalgesia. Uncet 369(9564) : 810-2Naesh O (2006) Back to the future: postoperative paimanagement beyond CO X-2 inhibitors. /\ ' Z MedJ 11(1242): 1-7Nikles CJ,Yelland M , Del Mar C, Wilkinson D (2005) Throle of paracetamol in chron ic pain: An evidence-baseappiroach.AniJTIier 12(1): 80-9 1Niemi G, Breivik H (2002) Adrenaline markedly improvethoracic epidural analgesia produced by a lo\v.-dosinfusion of bupivicain e, fentanyl and adrenaline aftmajor surgery. A random ised, double-blind , cross-ovestudy with and without adrenaline.Acta ttaesthesiol Sc42(8): 897-9 09Pasero C, Man worre n R C, McCaffery M (2007) PAINContro l: IV opioid range orders for acute pain m anagem enAmJ Nurs 107(2): 52-9Poloma no R, Rathm ell J , Krenzischek D, Dun woo dy (2008) Emerg ing trends and new approache.s to acute paim a n a g e m e n t . J Perianesth Nurs 23(Suppl 1): S43 -53Schu g SA,T orrie JJ (1993) Safety assessment of postoperativpain management by an acute pain service. Pain 55(33 8 7 - 9 1Sidebotham D, Dijkhuizen M R, Schug SA (1997) Thsafety and utilization of padent-controlled analgesia.J PaSymptom Manage14(4): 202 -9Vaughn F, Wich owsk i H, Bosworth G (2007) D oepreoperative anxiety level predict postoperative painAORNJ 85(3): 589-60 4Walder B, Schafer M, Henzi H, Tn ime r M R (2001) Efficacand safety of padent-controlled opioid analgesia for acutpostoperative pain.Acta naesthesioi Scand45(7): 795-8 0

Wall PD (1988) Th e prevention of postoperat ive pain.Pa33(3): 289-9 0Wickstrom K, Nord berg G,Johansson FG (2005) Predictoand barriers to adequate treatment of postoperat ive paafter radical prostatectomy.Acute Pain7(4): 16776Woolf CJ (1983) Evidence for a centrai component of posinjury pain hypersensidvity. Nature306(5944): 6868W u C Beren hol t z S , P ronovos t P,Fleisher L (2002) Systemareview and analysis of postdischarge symptoms aftoutpadent surgery. iiesthesiology96(4): 9941003Zhao S , Chun g F Hanna D, Ra tm undo A, Cheu ng R , CheC (2004) Dose-response relat ionship between opiouse and adverse effects after ambulatory surgery. J PaSymptom Manage28(1) : 35-46

KEY POINTS Moderate to seve re pain following surgery continues to be problematic for patients andremains a chaiienge for healthcare professionals w orking in the perioperative e nvironment.I Evidence is emerging w hich iinks a num ber of predisposing factors to th e develop ment

of persistent postsurgicai chronic pain. The aim of pain manag ement is to combine different treatmen t modalities, working atdifferent pain m echanisms, in order to improve analgesia and potentially re duce side-effects.I New technologies and less invasive techniques for pain management are becomingavailable; therefore, it is essential for nurses to be aware so that patients may benefitfrom the iatest pain relief products.

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