Pain should be assessed both at rest and with activity. Objective pain scores are usually used, such as a verbal pain score from 0 to 10. An objective score out of 10 can be related to the severity of pain, for example, as: 1-3 = mild pain, 4-7 = moderate pain, 8-10 = severe pain. Documenting characteristics of pain (sharp, dull, constant, intermittent, precipitating or alleviating factors) can aid therapy. To assess pain with activity, ask patients to rate pain with coughing, breathing deeply, or ambulating. For many patients, effective analgesia with activity is critical to recovery and discharge. For instance, a postoperative patient who stays bedridden and avoids coughing and breathing deeply due to postsurgical abdominal pain may have an increased risk of developing pulmonary complications.

Selection of pain medications by pain severity

Nonsteroidal anti-inflammatory drugs (NSAID’s) should be used for acute pain management in most patients without a specific contraindication to their use. Contraindications include peptic ulcer disease, GI bleeding, coagulopathy, and hepatic disease, renal insufficiency. Potent NSAID therapy, such as IV ketorolac or high-dose rofecoxib (50 mg/d), should be used for short durations (3-5 days). On such regimens, elderly patients may benefit from monitoring of the creatinine level.

Consider the effects of NSAID’s on platelet function and osteogenic activity in surgical patients. These effects and alteration of gastric mucosa homeostasis are less pronounced with the newer COX-2-selective agents, such as rofecoxib and celecoxib. Patients with ongoing postoperative bleeding, hypovolemia, or prerenal azotemia should not be given NSAID’s until these conditions resolve.

• Do not check "ROUTINE" for 1-Hour maximum amount. A "routine" protocol for the Hourly Maximum setting has not been established at UCLA, and this option will soon be removed from the PCA order sheet. The routine is at the discretion of the nurse who programs the pump. The patient’s age, recent history of opioid use, and response to recent doses of opioids should be considered in selecting the hourly maximum. The hourly maximum setting may not relate directly to the Dose and Lockout Interval.

• Basal infusion. An occasional patient may benefit from having a low-rate (e.g., 1mg/h morphine) basal infusion at night to prevent sleep interruption from pain or from receiving a constant basal infusion when opioid use is unusually high. However, the decision to use a basal infusion must be carefully considered, since little scientific evidence exists to support use of a basal infusion, and a basal rate lessens the intrinsic safety of the PCA system in avoiding opioid overdose.

• What to do for inadequate analgesia. Assess the history from the PCA pump. If the number of attempts is more than 3 times the number on injections and the patient is not bradypneic or oversedated, the demand dose may be increased or the lockout interval may be decreased. Often such changes do not require a change in the hourly maximum setting.

For opioid therapy, use IV or transdermal route of administration.

Use NSAID for all patients unless a specific contraindication exists. Use acetaminophen if NSAID is contraindicated. Give these medications scheduled, around-the-clock.

Give opioid regimen individualized for the patient. Confirm that discharge regimen is adequate before discharge by observing patient on the discharge regimen for at least six hours, preferably 24 hours. Vicodin alone does not work for everyone.

If patients are admitted on chronic opioid therapy, plan for discharge on appropriate opioid regimen, not simply Vicodin. Ensure each service’s ability to provide triplicate prescriptions when needed.

Patients undergoing abdominal surgery may benefit from epidural analgesia in two ways. Patients with upper abdominal incisions, including midline and subcostal incisions, can receive markedly better analgesia with epidural infusion of local anesthetic plus opioid than with systemic analgesics alone. This is especially true in the treatment of active pain. Some patients will not complain of severe pain when lying quietly in bed but will avoid breathing deeply, coughing, and getting out of bed due to intractable pain. Epidural analgesia usually provides better relief of active pain for these patients. Many patients with lower abdominal incisions do better with epidural analgesia as well.

The other major benefit of epidural analgesia after abdominal surgery is a quicker return of gastrointestinal motility. If patients with epidural analgesia are managed aggressively with early NG tube removal and early feeding, they demonstrate quicker return of normal bowel function and potentially quicker discharge to home than with systemic analgesia. The reasons for this effect are: 1) segmental sympathectomy from epidural local anesthetic increases peristalsis via enhanced parasympathetic outflow and 2) effects of systemic opioid on GI motility are reduced. Surgical patients with anticipated postoperative ileus are good candidates for epidural analgesia.

Patients undergoing thoracotomy incision often receive epidural analgesia because the excellent pain relief provided can be critical to early ambulation and to preserving the ability to cough effectively and breathe deeply. Patients undergoing thoracotomy are at risk for postsurgical pulmonary complications, and effective analgesia may reduce this risk. Epidural analgesia may reduce the long-term development of post-thoracotomy pain syndrome.

Most patients with epidural analgesia should receive concomitant NSAID therapy unless it is specifically contraindicated. Adjuvant NSAID use can improve analgesia compared to epidural infusion alone and can greatly reduce the shoulder or upper back pain that often follows thoracotomy without increasing sedation. If peripheral-acting NSAID’s are not indicated, intermittent IV opioid with or without acetaminophen can be used for this pain.

If epidural analgesia is contraindicated or impractical, intercostal nerve blockade can provide analgesia for patients undergoing abdominal or thoracic surgery. Unless repeated, intercostal blocks provide only 8-12 h of analgesia.

Epidural analgesia may also be used after lower extremity surgery, such as knee replacement, hip replacement, or lower extremity revascularization, and is also effective for many patients after major spine surgery. Use of epidural analgesia may reduce the risk of thromboembolic complications after major surgery of the lower extremities such as joint replacement. Patients with multiple rib fractures after blunt chest trauma often ambulate, breathe deeply, and cough better with epidural pain relief.