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Principles of analgesia for day surgery

Created: 26/6/2017
 
Postoperative pain management is a vital part of day surgery.

 

Preoperatively


Patient education is important, to ensure that patients know analgesic options and dosages, and improve compliance.

 

Intraoperatively


Regional techniques may be possible – simple blocks include ilioinguinal/penile/ankle/eye and ring blocks. In some units, brachial plexus blocks are used – depending on support/education. Caudal blocks are useful in children but parents should be warned of possible motor weakness.

 

Local anaesthesia infiltration


A multimodal approach should be used where possible: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) (if tolerated), short-acting opiates and long-acting opiates (where appropriate). Morphine may increase postoperative nausea and vomiting, length of stay and unplanned admission, but low doses (0.1 mg/kg) may be useful.
Bupivacaine has a longer duration of action than lignocaine, so is preferred.

Spinal blocks can be used successfully but mobilisation and recovery time should be considered; neither spinal opiates nor clonidine are recommended currently.

 

Postoperatively


Pain scores are useful – for example, the visual analogue or verbal rating scale. Oral analgesics are used predominantly – patients need to be able to eat and drink. It should be ensured that patients have taken the first doses before leaving the day surgery unit, prior to the local anaesthetic wearing off.

Analgesics used:
  • Paracetamol ± NSAIDs– most units will have preferred NSAID options – diclofenac/naproxen/ibuprofen. 
  • ±codeine – either separate or in combination (e.g. as co-codamol) 
  • Or tramadol 
  • Or oral morphine solution – warn patients of side effects, including constipation 
  • Or buprenorphine/ oxycodone.
But note that: 
 
  • Caution should be taken with codeine – 7% of patients do not have the enzyme responsible for O-demethylation, so they cannot metabolise codeine to morphine and may not derive analgesic benefit 
  • Oral morphine has high first-pass metabolism, so the dose may be variable from patient to patient 
  • Oxycodone has a higher bioavailability of 60%.

Advantages of protocol for day surgery unit:
  • Nurses can assist with information, and check the dosing regime and contraindications 
  • Easier to prescribe 
  • It is possible to audit outcome 
  • Reduces drug storage on the ward.
Patients and relatives should be given contact details and post-discharge follow-up details (? telephone call) to assess recovery.

 

Paediatrics

  • Consider topical local anaesthesia (e.g. EMLA/Instillagel) to wounds – parents can take these home 
  • Educate parents regarding paracetamol and NSAID dosing – higher than in conventional guidelines 
  • Codeine was recently removed from paediatric guidelines in some units because of risk of respiratory depression (fast acetylators).

Author: Dr Katharine Francis

ArticleDate:20170626
SiteSection: Article
 
   
    
                                            
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