post-op analgesia

Question 1

You are asked by the nursing staff on the surgical ward to review a 78 year old woman with abdominal pain who underwent a small bowel section four days earlier. What are the considerations you need to take into account when you chart her analgesia?

Answer 1

Impression
2 main things I am cognisant of in approaching this situation

1 - Does this pain represent new pathology/surgical complication that needs further investigation and management
2 - What has already been charted/existing pain management plan for the patient

Goals

• take targeted Hx/Ex/Ix to further circumscribe these points, ascertain whether new pathology demanding further Ix and management
• liaise with treating team about appropriate non-pharm/ pharmacological escalation of pain management

Question 2

Post-op analgesia - History

Answer 2

History
Review patient notes for details of admission, operation report, and management plan as per treating team.

• Pain: site, onset, character, radiation, etc. Is this new or still post-operative - how has it changed across course of post-op period?
• identify life-threatening causes; chest pain, leg swelling, pleuritic pain,
• Opening bowels?
• Key post-op complications: (5Ws) ask about UTI/other infective sx, ask about DVT +/- PE or atelectasis, ask about whether mobilising
• Medications since post-op

Question 3

Post-op analgesia - Examination

Answer 3

Examination
Review nursing obs and general trajectory in past 24-48 hr period

• General appearance + vitals (Current) - signs of infection
• Abdo: peritonitis, assess wound site for evidence of infection, assess stoma for output and functioning (if relevant), assess any lines and drains in-situ if relevant
• Hydration status assessment: ins and outs, ?daily weights

Question 4

Post-op analgesia - Investigations

Answer 4

Investigations
Review and laboratory tests recently returned, add on additional according to clinical suspicion;

Bedside: UA, ECG
Bloods: FBC, UEC, LFT, CRP, cultures
Imaging: if indicated clinically - for CT Abdo if suspecting new bowel pathology

Question 5

Post-op analgesia - Management

Answer 5

Management
Pain
- liaise with treating team re pain, advise impression and ask for further management advice

Non-pharm

• mobilisation
• address any constipation (disimpaction, enema, etc)
• heat packs
• optimise positioning

Pharm

• Constipation: aperients (if appropriate)
• Paracetamol
• NSAIDs: consider alternative routes (PR, SC, IM)
• Then opioids (unlikely to be administered in GI surgery
• nerve blocks (may not be appropriate in this patient)

Otherwise
- treat reversible/causative pathology appropriately