Surgical Pain Management: Anesthesia & Analgesia PDF

Surgical pain management: anesthesia & analgesia Elizabeth Dee Winter 2025  Readings ADAMS – PHARMACOLOGY FOR NURSES 4th ED. CHAPTER 23 Analgesic drugs: Opioid analgesics, non-opioid analgesics, NSAIDs p. 336-349 (up to tension headaches)...

Surgical pain management: anesthesia & analgesia Elizabeth Dee Winter 2025  Readings ADAMS – PHARMACOLOGY FOR NURSES 4th ED. CHAPTER 23 Analgesic drugs: Opioid analgesics, non-opioid analgesics, NSAIDs p. 336-349 (up to tension headaches) CHAPTER 24 p. Local and General Anesthetics  Readings LEWIS-MEDICAL SURGICAL NURSING IN CANADA 5TH ED. CHAPTER 10 p. 154 CHAPTER 20 p.. 376-377 (common fears), p. 385 (table 20.8) CHAPTER 21 p. 399-404 CHAPTER 22 p. 416  Other resources https://www.youtube.com/watch?v=rM1aQC-HAX0&list=PLY0BzRkQur_QeuCL_hgGE1ylai4R6PJiJ EAQ-20G surgical pain management (under Chapter 22)  Student will have a basic understanding of: Causes of surgical pain and impact on client objectives Analgesia used in surgical pain management Advantages, disadvantages & adverse effects Assessment, plan and care of post-analgesic client  Student will have a basic understanding of: Anesthesia used in surgery/pain management objectives Advantages, disadvantages & adverse effects Assessment, plan and care of post- anesthetic client How is surgical pain different than other types of pain? Surgery is TRAUMATIC on the body How is surgical pain different than other types of pain? (Cont’d) It is multifactorial and can involve manipulating/cutting/tearing, then repairing: Skin Muscles, bones, tendons and/or ligaments Nerves Organs How is surgical pain different than other types of pain? Cont’d This leads to: Neuropathic pain Nociceptive pain Somatic Visceral What else can cause surgical pain? Positioning What else can cause surgical pain? retractors What else can cause surgical pain? Drains/tubes What else can cause surgical pain? incisions What else can cause surgical pain? Co2 gas from laparoscopy What else can cause Post-operative changes surgical pain? Mobilizing Dressing changes Lying in bed  Pre-operative assessment related to pain concerns and factors that influence pain Educating client on surgical pain and appropriate strategies to What is the nurse’s relieve it role in surgical pain management? Assessing using appropriate tools/observations Making sure appropriate pain relief measures are being used  Documenting on appropriate documentation tools What is the nurse’s role in pain Communicating to other health care team management? members Cont’d Monitoring ongoing pain relief strategies and their effectiveness  It starts pre-operatively: Pre-operative interview (related to pain) to What is the nurse’s determine: role in pain Client fears Medication/drug/alcohol use management? Past surgical experiences and pain strategies as Cont’d well as challenges Pain relief expectations History of chronic pain  It starts pre-operatively (cont’d): What is the nurse’s Client education/teaching: role in pain Analgesia used to include route, management? frequency etc.. PCA/epidural teaching if needed Cont’d Ask for medications as needed/regularly non-pharmacological pain strategies Complications of poor pain control: It is multifactorial and affects multiple systems Altered respiratory function Increased risk for chronic pain ↑ risk of pneumonia and atelectasis. Why? Increased stress response Altered cardiovascular function Delayed wound healing Altered GI/GU Decreased mobility  Increased stress response from pain Unmet needs this can lead to? Comfort Safety Activity Rest and sleep Nutrition Oxygenation Let’s compare Analgesia Anesthesia Analgesia is pain relief without loss of Anesthesia is a state achieved when there consciousness and without total loss of is a loss of touch, pain, and temperature feeling or movement sensations with or without loss of consciousness  Analgesics This is an addon (extension) to your 10D opioid class so please review  WHO pain laDder Common analgesics used for surgical pain Fentanyl Hydromorphone Morphine Oxycodone  Have MANY side effects, some are life threatening Opioids Affects multiple body systems including adverse effects GI: constipation, nausea, vomiting GU: urinary retention CV (cardiovascular): Hypotension (orthostatic), bradycardia Respiratory: respiratory depression CNS (central nervous system): confusion or over sedation  Opioids weakest to strongest oxycodone morphine hydromorphone Fentanyl Let’s compare Morphine administration Onset Peak Duration PO variable 60 min 4-5 hrs SC 15-20 min 50-90 min 4-5 hrs IM 30 min 30-60 min 4-5 hrs IV Immediate 20 min 4-5 hrs  Subcutaneous Oral (PO) Analgesia: Routes (SC) used for surgical pain Intramuscular Intravenous (IM) (IV)  Oral (PO) Analgesia: Routes Route of choice when client has functioning GI system used for surgical Higher doses needed pain Better for opioid naïve clients Slowest onset Analgesia: Routes used for surgical pain Subcutaneous (SC) Onset faster than PO but slower than IM or IV Used as a bridge between IV and PO PCA or Epidural (cont) Subcutaneous PO Also used for long term pain therapy/palliative  Intramuscular (IM) Analgesia: Routes Not recommended for pain control used for surgical medication-limited drugs pain Pain on injection unreliable absorption Needs to be repeated frequently  Intravenous (IV) Analgesia: Routes Quickest onset used for surgical Very effective for steady pain control Riskiest for overdose/requires MOST supervision pain Includes both single dose and continuous infusion via a PCA (patient-controlled analgesia) Patient controlled analgesia (PCA)  It is an infusion system that administers analgesia/anesthesia medication whose doses are “controlled” by the client. Client presses a button to receive medication (bolus). Patient controlled analgesia (PCA) Via intravenous route primarily, can be via epidural May have a continuous dose (basal rate) also.  Patient controlled analgesia (PCA) Set dose per hour Lockout interval (for bolus)  Medications used are: Patient controlled Morphine analgesia (PCA) Fentanyl Hydromorphone  Advantages Client has sense of control Patient controlled Allows client to self medicate safely and analgesia (PCA) effectively More stable levels of medication → better pain control Tendency to use less medication  Disadvantages Expensive/availability of pumps Patient controlled Client must understand how to use (they are analgesia (PCA) the only ones that can press the button) Client still needs to be monitored regularly (pain, side effects) Client needs continued education Pca monitoring/documentation related to infusion Client Pump Vital signs (RR & O2 sat more often) Lockout period (min)Bolus dose (mg) Pain level (0-10) Demands (# tries, # good) LOS (level of sedation) Total dosage (mg/mL) Pasero opioid-induced Sedation scale (POSs) S-sleeping, easily arousable 1-awake and alert 2-occasionally drowsy, easy to arouse 3-frequently drowsy, arousable, drifts off during conversation 4-Somnolent, minimal or no response to stimuli Anesthesia  Types of anesthesia  Types (Classifications) of anesthesia (definitions) General Local Regional an altered physiological state loss of sensation without reversible loss of characterized by: loss of consciousness sensation to a region of Loss of consciousness Skeletal muscle relaxation Can be induced topically, the body Amnesia intracutaneous or Nerve fibres are blocked Analgesia subcutaneous infiltration by localized anesthetic What determines which one is used? Type of procedure Length of procedure Patient’s: Physical and mental health Age Allergies Family history More serious potential complications include: hypotension respiratory depression allergic reactions. methods of administration of anesthesia Local Regional topical local infiltration peripheral nerve block spinal block epidural block  Local & regional: how does it work? Blocks the sodium channel Prevents nerve conduction Blocks sensory, motor and autonomic sensations  Regional: (Peripheral) nerve block  Regional: (Peripheral) nerve block Used for: Common areas include Injection of an anesthetic around a specific group of Intraoperative anesthesia Brachial plexus Post operative anesthesia Arms nerve or groups of nerves Chronic pain legs Spinal (intrathecal) anesthesia block  May be used for : Injection of anesthesia Intraabdominal and/or analgesia) into the Produces autonomic, surgeries (rarely) cerebral spinal fluid (below sensory and motor Procedures involving Lumbar 2) in the blockade lower extremities, subarachnoid space pelvis and groin (below the level of the hip) Spinal (intrathecal) anesthesia block Spinal anesthesia (intrathecal space) Single-injection epidural Epidural catheter Spinal (intrathecal) anesthesia block Most commonly used medications include: Anesthesia Analgesia Bupivacaine Fentanyl Lidocaine Morphine sulfate Hydromorphone (Dilaudid) Spinal (intrathecal) anesthesia block ADVANTAGES DISADVANTAGES Medication works quickly and effectively Limited to surgeries below hips (fast onset and peak) Potential ANS (autonomic nervous system Very little drug is absorbed systemically blockade) No catheter Hypotension Bradycardia Nausea/vomiting Cardiac/respiratory depression Spinal (intrathecal) anesthesia block Spinal Anaesthetic (Local) Potential Complications Postoperative Monitoring Bupivacaine (Marcaine) Hypotension Vital signs total spinal anaesthesia Motor and sensory block post–dural puncture headache Urinary output and bladder distension Headache assessment Spinal (intrathecal) anesthesia block Spinal Anaesthetic (Analgesia) Potential Complications Postoperative Monitoring Fentanyl Hypotension Vital signs Morphine sulphate (preservative-free) pruritus Motor and sensory block urinary retention Urinary output and bladder distension nausea, vomiting Headache assessment infection epidural hematoma oversedation post–dural puncture headache documentation related to spinal block Respiratory status LOS (level of sedation) Respiratory rate Pain level (0-10) rhythm Amplitude O2 sat Epidural anesthesia  May be used for : Injection of anesthesia (or childbirth analgesia) into the epidural Produces sensory As an adjunct space (lumbar or thoracic and motor blockade to general anesthesia Surgery on chest, approach) abdomen, pelvis or legs. Epidural anesthesia Epidural anesthesia Can be administered by either one dose, or continuous infusion Able to titrate a low concentration of anesthesia so that only sensory is blocked (motor is intact) in continuous infusions Spinal anesthesia (intrathecal space) Single-injection epidural Epidural catheter Epidural anesthesia block Most commonly used medications include: Anesthesia Analgesia Bupivacaine Fentanyl Lidocaine Morphine sulfate Hydromorphone (Dilaudid) Epidural anesthesia block ADVANTAGES DISADVANTAGES Easier to titrate dosage (compared to Risk for catheter displacement (continuous) spinal) Higher doses needed Less side effects than PO or parenteral Can have less sedation, so easier for mobilizing Epidural anesthesia block Epidural Anaesthetic (Local) Potential Complications Postoperative Monitoring Bupivacaine (Marcaine) Bupivacaine can be associated with Vital signs cardiac toxicity if injected intravascularly Respiratory assessment Sedation score Epidural anesthesia block Epidural Anaesthetic (Analgesia) Potential Complications Postoperative Monitoring Fentanyl Hypotension Dressing and insertion site (making sure catheter hasn’t moved) Morphine sulphate (preservative-free) Pruritus Vital signs Urinary retention Pruritis Nausea, vomiting Urinary output and bladder distension Infection Nausea, vomiting Epidural hematoma Pain assessment Oversedation Headache assessment  Continous Epidural anesthesia block Epidural anesthesia Continuous infusions: Infusions are either continuous (basal rate), intermittent (bolus) or a combination of both Maximum dosage per hour Documentation continuous epidural analgesia Client Pump Respiratory status (RR & O2 sat) Rate (mL/hr) Pain level (0-10) Bolus (mL) LOS (level of sedation) Total volume (mL) Documentation continuous epidural analgesia Client Motor & sensory block neurovascular signs insertion site L.A. toxicity Physician order sample Spinal vs epidural block Spinal block has faster onset but limited Epidural has slower onset but can be duration. prolonged with a catheter. Spinal produces dense motor blockade. Epidural allows more flexibility in motor Spinal requires a smaller anesthetic dose due blockade. to direct cerebrospinal fluid administration Epidural has a lower risk of post dural puncture headache compared to spinal. Less ANS (autonomic nervous system) blockade Less post anesthesia spinal headaches  When they arrive on the floor from PACU (post anesthetic care unit) Assessment of post Baseline vital signs Head to toe assessment (focus on post surgical client) anesthesia (& includes level of sedation (LOS) + pain analgesia) client Check any tubes that are attached to the client ( IV’s, PCA’s, epidurals etc..) Check equipment/program Check post operative order sheets for pain/protocols  Verify medical order VS and assess for (PRESSS) prior to administration guidelines for Pain level opioid monitoring Respiration rate Effects Sedation level Saturation Safety  Remain with patient during IV/epidural bolus guidelines for Assess (PRESSS) following opioid monitoring administration. Frequency and timing of assessment depends on the route, peak and duration of action of the opioid  PO Peak 90-120 minutes OIIQ guidelines for Duration of action 240 minutes. opioid monitoring Therefore LOS, RR, oxygen saturation and pain scale must be monitored at the peak of action of the administered opioid, 90 minutes later and then q1-2h intervals for the entire duration of action  IM Peak 30-60 minutes OIIQ guidelines for Duration of action 240 minutes. opioid monitoring Therefore LOS, RR, oxygen saturation and pain scale must be monitored at the peak of action of the administered opioid, 45 minutes later and then q1-2h intervals for the entire duration of action  Subcut Peak 30-90 minutes OIIQ guidelines for Duration of action 240 minutes. opioid monitoring Therefore LOS, RR, oxygen saturation and pain scale must be monitored at the peak of action of the administered opioid, 60 minutes later and then q1-2h intervals for the entire duration of action  IV Peak is 10-30 minutes OIIQ guidelines for Duration of action 120-180 minutes. opioid monitoring Therefore LOS, RR, oxygen saturation and pain scale must be monitored at the peak of action of the administered opioid, every 5 minutes x4 and the q15 minute intervals for the entire duration of action Ongoing monitoring of post analgesic/anesthetic client ALWAYS follow hospital protocols as they can vary Respiratory depression/oversedation Indications for following “collective prescription for naloxone”: Sedation scale (LOS) ≥ 3 OR RR≤ 8 min (sometimes it’s 10) OR O2 sat ≤ 90% 1. STOP opioids if in infusion 2. Administer oxygen 3. Make sure patent IV with NS (normal saline) or Dextrose 5% 4. Administer naloxone (if RR ≤ 8 min) Naloxone/narcan  Assess bowel function Opioids Stool softeners or laxatives prescribed concurrently nursing Antiemetics prescribed concurrently implications-GI Ondansetron (Zofran) is most common for post-op nausea Don’t give on an empty stomach  Opioids Nursing implications-GU Monitor urinary retention ( I & O)- check P.O.U.R protocol of unit Assess bladder distension Do a bladder scan Call physician if unable to void (order sheet will guide you)  Before client gets up, sits up Monitor dizziness, light headedness Opioids Nursing Ambulation with assistance as needed implications-CV Monitor for concurrent use of hypotensive medication  Opioids Nursing implications-Integ. Antihistamine prescribed concurrently for pruritis Benadryl (diphenhydramine)  Always do thorough pain assessment prior to administering. Why? Always take vital signs immediately Opioids before General Nursing implications/reminders Always check in on client during administration (watch peak effect) always check in on client during duration of effect  Always use least amount (or less strong) of medication to make pain at a tolerable Opioids level for client whenever possible General Nursing implications/reminders Always medicate before mobilizing & dressing changes References Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2023). Medical-Surgical Nursing in Canada: Assessment and management of clinical problems. (5th Canadian ed.). Elsevier Canada. Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (Eds.). (2024). Canadian fundamentals of nursing (7th Cdn. ed.). Elsevier Canada. Adams, M., Urban, C., Sutter R., El-Hussein, M., Osuji, J. (2024) Pharmacology for nurses: A pathophysiological approach. (4th Canadian ed.) Pearson Canada. References https://www.ezmedlearning.com/blog/general-anesthesia-sedation-drugs-definitions https://slideplayer.com/slide/14514237/ https://www.southlakepainrelief.com/peripheral-nerve-blocks/