24 04 2023
Effective postoperative pain management is a critical aspect of the ERAS (early and accelerated recovery program) protocol. Pain not only causes great discomfort to patients but also triggers the surgical stress response, which can increase the risk of postoperative complications, including wound infections, pneumonia, and elevated blood sugar levels. Therefore, providing adequate pain relief is crucial to reducing the surgical stress response and promoting recovery.
Multimodal therapy is now the preferred approach to managing postoperative pain. While opioids like morphine were previously used as the primary treatment for postoperative pain, their use is now limited due to their numerous side effects, such as constipation, delayed awakening, nausea, vomiting, and prolonged intestinal paresis. Instead, non-steroidal anti-inflammatory drugs (such as ketoprofen, diclofenac, and ketorolac) play a significant role in pain relief, although they should only be used for the first 24 hours after surgery due to their negative impact on platelet function and potential risk of acute kidney damage. On the other hand, paracetamol and metamizole are considered safe for use throughout the entire postoperative period.
The utilization of regional anaesthesia and analgesia techniques has become increasingly important for managing intraoperative and postoperative pain due to their effectiveness and safety. For most gastrointestinal surgeries, thoracic epidural anaesthesia/analgesia (TEA) is considered the gold standard. However, its use during liver resection is controversial due to potential impaired haemostasis and bleeding, although it can still be considered safe if the benefits are weighed against potential risks. Catheter removal is typically done before any transient hypocoagulability is expected. An alternative to TEA is the transverse abdominal block (TAP block) with a catheter in place, although it can cause side effects such as delayed wound healing or infection. A combination of regional techniques (TEA, TAP) and systemic analgesics can effectively manage postoperative pain with a low risk of complications.
Patient-controlled analgesia (PCA) is a widely used approach where patients can increase the dose of analgesics or local anaesthetics by pressing a button on a pump. This helps prevent breakthrough pain that may occur if the prescribed medication is not administered at regular intervals. With PCA, patients can move around and perform activities without pain, cough easily, and experience a reduced response to surgical stress as early as the first postoperative day.
