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Surgery – Post Operative Nausea and Vomiting
One challenging and unpleasant side effect of anesthesia and surgery that can lengthen recovery is post-operative nausea and vomiting (PONV). The type of operation and case mix have an impact on the incidence of PONV. According to estimates, the incidence of PONV without prophylaxis is 30% when General Anesthesia is used with inhalational medicines. In addition to being a side effect of post-operative opioids, PONV is also caused by patient-specific variables, especially a history of PONV
Apfel PONV prediction system
Opioids used after surgery (1 point)
Gender - female (1 point) ♀
Non-smoker (1 point)
Motion sickness/PONV history (1 point)
The baseline risk of PONV can be decreased using a number of effective treatments. Among these are:
Steer clear of nitrous oxide (N2O)
avoiding anesthetics that are volatile
reduction of opioids used during and after surgery
Drink enough water.
Ondansetron, unless contraindicated, is one of two antiemetics with distinct mechanisms of action that should be administered to patients at risk for PONV. Usually administered orally (PO)
Preoperative antiemetics can also be administered intravenously. Ondansetron 8–16 mg PO is one preoperative antiemetic that can be administered as a single dosage. Prochlorperazine 3–6 mg buccal or 5 mg tablets PO; Cyclizine 50 mg PO. With the exception of dexamethasone, which is administered at induction.
Intraoperative antiemetics can be administered intravenously (IV) at the conclusion of the procedure: • Dexamethasone 3.3–6.6 mg IV (at induction). • 4 mg of ondansetron. Cyclizine (20–50 mg). • 625–1250 micrograms of droperidol.
Post-operative antiemetics: routinely evaluate patients to identify PONV.
Regular intravenous antiemetics should be administered to individuals who are vomiting.
Only mild to moderate nausea can be treated with oral and buccal antiemetics, such as ondansetron 4 mg 6 hours per day, cyclizine 50 mg 8 hours per day, and buccal pro-chlorperazine 12 hours per day.
One challenging and unpleasant side effect of anesthesia and surgery that can lengthen recovery is post-operative nausea and vomiting (PONV). The type of operation and case mix have an impact on the incidence of PONV. According to estimates, the incidence of PONV without prophylaxis is 30% when General Anesthesia is used with inhalational medicines. In addition to being a side effect of post-operative opioids, PONV is also caused by patient-specific variables, especially a history of PONV
Apfel PONV prediction system
Opioids used after surgery (1 point)
Gender - female (1 point) ♀
Non-smoker (1 point)
Motion sickness/PONV history (1 point)
The baseline risk of PONV can be decreased using a number of effective treatments. Among these are:
Steer clear of nitrous oxide (N2O)
avoiding anesthetics that are volatile
reduction of opioids used during and after surgery
Drink enough water.
Ondansetron, unless contraindicated, is one of two antiemetics with distinct mechanisms of action that should be administered to patients at risk for PONV. Usually administered orally (PO)
Preoperative antiemetics can also be administered intravenously. Ondansetron 8–16 mg PO is one preoperative antiemetic that can be administered as a single dosage. Prochlorperazine 3–6 mg buccal or 5 mg tablets PO; Cyclizine 50 mg PO. With the exception of dexamethasone, which is administered at induction.
Intraoperative antiemetics can be administered intravenously (IV) at the conclusion of the procedure: • Dexamethasone 3.3–6.6 mg IV (at induction). • 4 mg of ondansetron. Cyclizine (20–50 mg). • 625–1250 micrograms of droperidol.
Post-operative antiemetics: routinely evaluate patients to identify PONV.
Regular intravenous antiemetics should be administered to individuals who are vomiting.
Only mild to moderate nausea can be treated with oral and buccal antiemetics, such as ondansetron 4 mg 6 hours per day, cyclizine 50 mg 8 hours per day, and buccal pro-chlorperazine 12 hours per day.
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Surgery- Prevalent surgical manifestations
Discomfort Any pain should exhibit identical characteristics. This can be encapsulated by the acronym SOCRATES:
Sites - What is the location of the pain? Is it specific to a region or generalized?
Onset- Progressive, swift, or abrupt? Intermittent or continuous?
Character- Acute, penetrating, blunt, throbbing, constricted, painful?
Radiation. Does it disseminate to other regions? Ureteric pain radiates from the loin to the groin; diaphragmatic irritation extends to the shoulder tip; retroperitoneal pain manifests in the back; and myocardial discomfort is referred to the jaw and neck.
Associated symptom-. Nausea, emesis, dysuria, icterus?
Timing-. Does it transpire at a specific time? Factors that exacerbate or alleviate.
Exacerbation of symptoms with respiration, movement, or coughing indicates peritoneal or pleural irritation; alleviation through the application of hot water bottles implies deep inflammatory or infiltrative pain.
Surgical history- Is the pain associated with surgical procedures?
Dyspepsia refers to epigastric discomfort or soreness, typically occurring postprandially. What is the frequency? Is it triggered by eating or does it occur spontaneously? Do milky beverages or foods provide any relief? Is it determined by position?
Dysphagia (impairment in the swallowing process)
Is the symptom recent or chronic? Is it deteriorating rapidly or remaining reasonably stable? Is it more detrimental with solids or fluids? Increased severity with fluids indicates a motility issue rather than a stenosis. Can it be alleviated by any means, such as warm beverages? Can the patient indicate a certain 'level' of obstruction? This frequently corresponds to the degree of an obstructive lesion. Is it linked to 'spluttering' (indicating a tracheoesophageal fistula or aspiration of food/fluid)?
Gastroesophageal reflux
(bitter or acidic fluid in the pharynx or oral cavity). What is the frequency? Which color? Green indicates bile, while white signifies only stomach contents. When does it manifest (exclusively while supine, upon bending, or spontaneously in an upright position)? Is it linked to coughing?
Haematemesis refers to the presence of blood in vomit.
What is the color of blood? (Dark red-brown 'coffee grounds' indicates old or low-volume gastric bleeding; dark red may suggest venous bleeding from the esophagus; brilliant red signifies arterial bleeding, typically from significant gastric or duodenal arteries.) What volume has transpired throughout what duration? Did the blood manifest with the initial episodes of vomiting or only subsequent to a duration of extended vomiting? Indicates a traumatic esophageal etiology.
Abdominal distension
Symmetrical distension indicates one of the '5 Fs' (fluid ascites, flatus from ileus or blockage, fetal presence, adipose tissue, or a substantial mass). Asymmetrical distension indicates a confined bulk. What is the duration of the process? Does it fluctuate? Is it altered by vomiting? Defecation or flatulence?
Alteration in bowel habits
Alterations in frequency or consistency (i.e., increased frequency and looser stools are more likely attributable to a pathogenic etiology). Is it enduring or temporary? Prolonged alteration in bowel habits beyond six weeks necessitates additional examination. Defecation frequency and urgency The recent onset of urgency in feces is typically indicative of a medical condition. What is the level of urgency—how long can the patient postpone treatment? Is there accompanying discomfort? Is the stool normal?
Rectal hemorrhage
What is the color of blood? Pink-red coloration, observed solely on the paper during wiping or splashing in the pan, indicates a potential origin from the anal canal. The presence of bright crimson on the stool's surface indicates a lower rectal origin. Darkened blood with clots or marbled appearance in the stools indicates a colonic origin. Blood thoroughly integrated with the stool or modified indicates a proximal colonic origin.
Tenesmus is the need to defecate accompanied by either an absence of results or a sensation of incomplete evacuation. Indicates rectal pathology.
Jaundice (yellow pigmentation of the skin, sclera, or uvula resulting from hyperbilirubinemia;) What was the rate of jaundice development? Is there accompanying pruritus? Are there any indications of discomfort, fever, or malaise? Indicates infection
Haemoptysis (the presence of blood in sputum). What is the color of blood? Pale pink froth indicates pulmonary edema.) Are there clots or dark blood indicative of infection or an endobronchial lesion? What is the volume of blood? Moderate hemorrhages rapidly jeopardize airways—seek assistance promptly.
Dyspnea (difficulty in or awareness of breathing) When does dyspnea manifest? Assess the magnitude of exertion. Is it determined by position?
• Orthopnea. Assess the difficulty in breathing that arises when supine; quantify it by inquiring about the number of pillows the patient need at night to be asymptomatic.
• Paroxysmal nocturnal dyspnea. Nocturnal intermittent dyspnea. Orthopnoea and paroxysmal nocturnal dyspnoea indicate heart failure.
Claudication (muscle soreness in the calf, thigh, or buttock induced by physical activity and alleviated by rest). At what level of exercise does the pain manifest, considering both flat distances and inclines? What is the rate at which rest alleviates pain?
Rest pain (pain in a limb at rest without substantial exertion). What is the duration of the pain's presence? Is it sporadic? Does it primarily transpire during the nocturnal hours? Is it alleviated by the reliance of the affected limb?
Dysuria (discomfort during urination). At what point does the discomfort manifest (initially, at conclusion, or continuously along the process)? Is the sensation localized to the penis or the suprapubic region? Is it correlated with frequency? Is the pee discolored or does it contain particulate matter?
Hematuria (the presence of blood in urine). Does the hematuria manifest at the onset (indicating a bladder source), during, or at the conclusion (indicating a prostatic or penile source) of the urinary stream? Is there concomitant pain (indicative of infection or nephrolithiasis)?
Discomfort Any pain should exhibit identical characteristics. This can be encapsulated by the acronym SOCRATES:
Sites - What is the location of the pain? Is it specific to a region or generalized?
Onset- Progressive, swift, or abrupt? Intermittent or continuous?
Character- Acute, penetrating, blunt, throbbing, constricted, painful?
Radiation. Does it disseminate to other regions? Ureteric pain radiates from the loin to the groin; diaphragmatic irritation extends to the shoulder tip; retroperitoneal pain manifests in the back; and myocardial discomfort is referred to the jaw and neck.
Associated symptom-. Nausea, emesis, dysuria, icterus?
Timing-. Does it transpire at a specific time? Factors that exacerbate or alleviate.
Exacerbation of symptoms with respiration, movement, or coughing indicates peritoneal or pleural irritation; alleviation through the application of hot water bottles implies deep inflammatory or infiltrative pain.
Surgical history- Is the pain associated with surgical procedures?
Dyspepsia refers to epigastric discomfort or soreness, typically occurring postprandially. What is the frequency? Is it triggered by eating or does it occur spontaneously? Do milky beverages or foods provide any relief? Is it determined by position?
Dysphagia (impairment in the swallowing process)
Is the symptom recent or chronic? Is it deteriorating rapidly or remaining reasonably stable? Is it more detrimental with solids or fluids? Increased severity with fluids indicates a motility issue rather than a stenosis. Can it be alleviated by any means, such as warm beverages? Can the patient indicate a certain 'level' of obstruction? This frequently corresponds to the degree of an obstructive lesion. Is it linked to 'spluttering' (indicating a tracheoesophageal fistula or aspiration of food/fluid)?
Gastroesophageal reflux
(bitter or acidic fluid in the pharynx or oral cavity). What is the frequency? Which color? Green indicates bile, while white signifies only stomach contents. When does it manifest (exclusively while supine, upon bending, or spontaneously in an upright position)? Is it linked to coughing?
Haematemesis refers to the presence of blood in vomit.
What is the color of blood? (Dark red-brown 'coffee grounds' indicates old or low-volume gastric bleeding; dark red may suggest venous bleeding from the esophagus; brilliant red signifies arterial bleeding, typically from significant gastric or duodenal arteries.) What volume has transpired throughout what duration? Did the blood manifest with the initial episodes of vomiting or only subsequent to a duration of extended vomiting? Indicates a traumatic esophageal etiology.
Abdominal distension
Symmetrical distension indicates one of the '5 Fs' (fluid ascites, flatus from ileus or blockage, fetal presence, adipose tissue, or a substantial mass). Asymmetrical distension indicates a confined bulk. What is the duration of the process? Does it fluctuate? Is it altered by vomiting? Defecation or flatulence?
Alteration in bowel habits
Alterations in frequency or consistency (i.e., increased frequency and looser stools are more likely attributable to a pathogenic etiology). Is it enduring or temporary? Prolonged alteration in bowel habits beyond six weeks necessitates additional examination. Defecation frequency and urgency The recent onset of urgency in feces is typically indicative of a medical condition. What is the level of urgency—how long can the patient postpone treatment? Is there accompanying discomfort? Is the stool normal?
Rectal hemorrhage
What is the color of blood? Pink-red coloration, observed solely on the paper during wiping or splashing in the pan, indicates a potential origin from the anal canal. The presence of bright crimson on the stool's surface indicates a lower rectal origin. Darkened blood with clots or marbled appearance in the stools indicates a colonic origin. Blood thoroughly integrated with the stool or modified indicates a proximal colonic origin.
Tenesmus is the need to defecate accompanied by either an absence of results or a sensation of incomplete evacuation. Indicates rectal pathology.
Jaundice (yellow pigmentation of the skin, sclera, or uvula resulting from hyperbilirubinemia;) What was the rate of jaundice development? Is there accompanying pruritus? Are there any indications of discomfort, fever, or malaise? Indicates infection
Haemoptysis (the presence of blood in sputum). What is the color of blood? Pale pink froth indicates pulmonary edema.) Are there clots or dark blood indicative of infection or an endobronchial lesion? What is the volume of blood? Moderate hemorrhages rapidly jeopardize airways—seek assistance promptly.
Dyspnea (difficulty in or awareness of breathing) When does dyspnea manifest? Assess the magnitude of exertion. Is it determined by position?
• Orthopnea. Assess the difficulty in breathing that arises when supine; quantify it by inquiring about the number of pillows the patient need at night to be asymptomatic.
• Paroxysmal nocturnal dyspnea. Nocturnal intermittent dyspnea. Orthopnoea and paroxysmal nocturnal dyspnoea indicate heart failure.
Claudication (muscle soreness in the calf, thigh, or buttock induced by physical activity and alleviated by rest). At what level of exercise does the pain manifest, considering both flat distances and inclines? What is the rate at which rest alleviates pain?
Rest pain (pain in a limb at rest without substantial exertion). What is the duration of the pain's presence? Is it sporadic? Does it primarily transpire during the nocturnal hours? Is it alleviated by the reliance of the affected limb?
Dysuria (discomfort during urination). At what point does the discomfort manifest (initially, at conclusion, or continuously along the process)? Is the sensation localized to the penis or the suprapubic region? Is it correlated with frequency? Is the pee discolored or does it contain particulate matter?
Hematuria (the presence of blood in urine). Does the hematuria manifest at the onset (indicating a bladder source), during, or at the conclusion (indicating a prostatic or penile source) of the urinary stream? Is there concomitant pain (indicative of infection or nephrolithiasis)?
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Medical Terms - Atrophy
Atrophy is the reduction in size or quantity of cells, leading to the shrinkage or degeneration of a tissue or organ. The etiology may be physiological, evident in atrophy of the ovary, brain, and skin, or pathological, as observed in atrophy frequently linked to neurological illnesses or abnormalities of the spleen, liver, and thyroid. This symptom is typically identified through inspection and palpation methods.
Atrophy is the reduction in size or quantity of cells, leading to the shrinkage or degeneration of a tissue or organ. The etiology may be physiological, evident in atrophy of the ovary, brain, and skin, or pathological, as observed in atrophy frequently linked to neurological illnesses or abnormalities of the spleen, liver, and thyroid. This symptom is typically identified through inspection and palpation methods.
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Medical Terms - Asynergy
Disrupted coordination of muscles or organs that typically operate in unison. This extrapyramidal ailment arises from dysfunctions of the basal ganglia and cerebellum.
Disrupted coordination of muscles or organs that typically operate in unison. This extrapyramidal ailment arises from dysfunctions of the basal ganglia and cerebellum.
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Medical Terms - Attention span decreased
Inability to concentrate selectively on a task while disregarding irrelevant stimuli. Anxiety, emotional distress, and any disorder of the central nervous system may diminish attention span.
Inability to concentrate selectively on a task while disregarding irrelevant stimuli. Anxiety, emotional distress, and any disorder of the central nervous system may diminish attention span.
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Medical Terms -Autistic Behaviour
Amplified egocentric conduct characterized by an absence of receptivity to others. It is defined by highly individualized speech and acts that lack significance to an observer. For instance, the patient may sway their body or repeatedly strike their head on the floor or wall. Autistic behaviors may manifest in children and adults with schizophrenia.
Amplified egocentric conduct characterized by an absence of receptivity to others. It is defined by highly individualized speech and acts that lack significance to an observer. For instance, the patient may sway their body or repeatedly strike their head on the floor or wall. Autistic behaviors may manifest in children and adults with schizophrenia.
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Medical Terms - Barlow's sign
A sign of congenital hip dislocation identified within the initial 6 weeks of life. To elicit this sign, position the newborn supine with the hips flexed at 90 degrees and the knees fully flexed. Position your palm over the infant's knee, placing your thumb in the femoral triangle adjacent to the lesser trochanter and your index finger over the larger trochanter. Position the hip in midabduction while applying gentle posterior and lateral pressure with your thumb and posterior and medial pressure with your palm. Upon detecting a click of the femoral head as it dislocates along the posterior rim of the acetabular socket, you have elicited this indication.
A sign of congenital hip dislocation identified within the initial 6 weeks of life. To elicit this sign, position the newborn supine with the hips flexed at 90 degrees and the knees fully flexed. Position your palm over the infant's knee, placing your thumb in the femoral triangle adjacent to the lesser trochanter and your index finger over the larger trochanter. Position the hip in midabduction while applying gentle posterior and lateral pressure with your thumb and posterior and medial pressure with your palm. Upon detecting a click of the femoral head as it dislocates along the posterior rim of the acetabular socket, you have elicited this indication.
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Surgery - Fundamentals of effective prescribing
Optimal prescribing practices The UK GMC delineates the principles of effective prescribing practice (% Duties of a doctor): Stay informed on current laws and regulations. Operate within the boundaries of your expertise—administer treatment solely when you possess sufficient understanding of the patient's condition.
• Deliver effective treatment grounded in the most reliable evidence available. Ensure that the care or treatment you administer aligns with any other therapies the patient is undergoing. Utilize the resources at your disposal, such as the British National Formulary (BNF) app/book, hospital-wide policies (e.g., antibiotic prescribing policy), the ward pharmacist, and the ward intravenous (IV) drug guide. Collaboration In the hospital, numerous healthcare specialists are often consulted for specialized prescribing guidance. Key domains pertinent to surgery encompass the prescription of:
• Analgesics:
• Acute pain team—beneficial for complex pain management requirements following surgery.
Anaesthetists possess proficiency in patient-controlled analgesia (PCA), epidural treatment, and perioperative symptom management.
• Palliative care team— for terminal symptoms.
• Antiemetics (as already mentioned). Antibiotics: for infection care, adhere to hospital antibiotic guidelines as the primary approach; for complex infections, consult with microbiologists or infectious disease specialists.
• Anticoagulants—consult a haematologist for guidance on patients with bleeding issues and the administration of perioperative anticoagulation; utilize the local anticoagulation service for long-term anticoagulation recommendations.
• Intravenous medications—ward nurses (or intensive care unit nurses). General guidance, such as medication reconciliation and interaction advisories, is provided by the ward pharmacist.
• Additional specialty-specific guidance—senior colleagues, advanced nurse practitioners.
Optimal prescribing practices The UK GMC delineates the principles of effective prescribing practice (% Duties of a doctor): Stay informed on current laws and regulations. Operate within the boundaries of your expertise—administer treatment solely when you possess sufficient understanding of the patient's condition.
• Deliver effective treatment grounded in the most reliable evidence available. Ensure that the care or treatment you administer aligns with any other therapies the patient is undergoing. Utilize the resources at your disposal, such as the British National Formulary (BNF) app/book, hospital-wide policies (e.g., antibiotic prescribing policy), the ward pharmacist, and the ward intravenous (IV) drug guide. Collaboration In the hospital, numerous healthcare specialists are often consulted for specialized prescribing guidance. Key domains pertinent to surgery encompass the prescription of:
• Analgesics:
• Acute pain team—beneficial for complex pain management requirements following surgery.
Anaesthetists possess proficiency in patient-controlled analgesia (PCA), epidural treatment, and perioperative symptom management.
• Palliative care team— for terminal symptoms.
• Antiemetics (as already mentioned). Antibiotics: for infection care, adhere to hospital antibiotic guidelines as the primary approach; for complex infections, consult with microbiologists or infectious disease specialists.
• Anticoagulants—consult a haematologist for guidance on patients with bleeding issues and the administration of perioperative anticoagulation; utilize the local anticoagulation service for long-term anticoagulation recommendations.
• Intravenous medications—ward nurses (or intensive care unit nurses). General guidance, such as medication reconciliation and interaction advisories, is provided by the ward pharmacist.
• Additional specialty-specific guidance—senior colleagues, advanced nurse practitioners.
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Medical Terms – Ballet Sign
Sign of ballet Ophthalmoplegia, or the paralysis of the extraocular muscles. The patient exhibits an absence of voluntary eye movement control, however demonstrates typical reflexive movements and pupillary light reflexes. This indication signifies thyrotoxicosis.
Sign of ballet Ophthalmoplegia, or the paralysis of the extraocular muscles. The patient exhibits an absence of voluntary eye movement control, however demonstrates typical reflexive movements and pupillary light reflexes. This indication signifies thyrotoxicosis.
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Surgery -Analgesia
Effectively managing a patient's pain during the perioperative period is a fundamental obligation of a surgical student. The advantages of managing acute pain encompass: • Wound healing. • Mobility. • Patient contentment. • Premature hospital discharge. • Decrease in the likelihood of thromboembolic occurrences. In instances of acute pain resulting from trauma, surgery, delivery, or a medical condition, it is crucial to ascertain the location, temporal characteristics, and intensity of the pain. Various approaches are available for evaluating the patient's pain
Techniques for Evaluating Acute Pain
Visual analogue scale (VAS)
-Scored between ‘no pain’ and ‘pain as bad as it can be’
Verbal response score (VRS)
Pain scored as a number, e.g. 4 out of 10, or verbally, e.g.
mild, severe, excruciating
Autonomic response
Sweating, tachycardia, hypertension (HTN)
Dynamic pain scores
Pain on movement; ability to take a deep breath; ability
to cough
The objective of postoperative analgesia is to reduce the dosage of analgesic drugs, hence avoiding side effects, while ensuring sufficient and efficient pain relief. The World Health Organization analgesic ladder This was initially devised for the management of persistent pain associated with cancer. The ladder is being employed to address multiple forms of pain. The technique involves the immediate prescription of analgesics upon the onset of pain and the adjustment of the regimen until the patient achieves pain relief, utilizing the ladder system
Postoperatively, patients will necessitate potent and effective analgesia. The oral route is favored whenever feasible. In the acute postoperative phase or in cases of vomiting, intravenous administration may be necessary.
The intramuscular (IM) method is unpleasant and has inconsistent absorption; it should be avoided when feasible. The analgesic regimen can be titrated down utilizing the World Health Organization (WHO) ladder as the patient convalesces in the days subsequent to the procedure. To guarantee that patients receive consistent and extended analgesia, these should be supplied routinely rather than on an as-needed basis. Adjuvant medicines are agents that augment the efficacy of analgesics, such as anticonvulsants like gabapentin utilized for neuropathic pain.
WHO Pain Relief Ladder
Mild pain
Non-opioid (e.g. aspirin, paracetamol or NSAID) +/− adjuvant
Mild to moderate pain
Weak opioid (e.g. codeine)
+/− non-opioid
+/− adjuvant
Moderate to severe pain
Strong opioid
(e.g. morphine)
+/− non-opioid
+/− adjuvant
Effectively managing a patient's pain during the perioperative period is a fundamental obligation of a surgical student. The advantages of managing acute pain encompass: • Wound healing. • Mobility. • Patient contentment. • Premature hospital discharge. • Decrease in the likelihood of thromboembolic occurrences. In instances of acute pain resulting from trauma, surgery, delivery, or a medical condition, it is crucial to ascertain the location, temporal characteristics, and intensity of the pain. Various approaches are available for evaluating the patient's pain
Techniques for Evaluating Acute Pain
Visual analogue scale (VAS)
-Scored between ‘no pain’ and ‘pain as bad as it can be’
Verbal response score (VRS)
Pain scored as a number, e.g. 4 out of 10, or verbally, e.g.
mild, severe, excruciating
Autonomic response
Sweating, tachycardia, hypertension (HTN)
Dynamic pain scores
Pain on movement; ability to take a deep breath; ability
to cough
The objective of postoperative analgesia is to reduce the dosage of analgesic drugs, hence avoiding side effects, while ensuring sufficient and efficient pain relief. The World Health Organization analgesic ladder This was initially devised for the management of persistent pain associated with cancer. The ladder is being employed to address multiple forms of pain. The technique involves the immediate prescription of analgesics upon the onset of pain and the adjustment of the regimen until the patient achieves pain relief, utilizing the ladder system
Postoperatively, patients will necessitate potent and effective analgesia. The oral route is favored whenever feasible. In the acute postoperative phase or in cases of vomiting, intravenous administration may be necessary.
The intramuscular (IM) method is unpleasant and has inconsistent absorption; it should be avoided when feasible. The analgesic regimen can be titrated down utilizing the World Health Organization (WHO) ladder as the patient convalesces in the days subsequent to the procedure. To guarantee that patients receive consistent and extended analgesia, these should be supplied routinely rather than on an as-needed basis. Adjuvant medicines are agents that augment the efficacy of analgesics, such as anticonvulsants like gabapentin utilized for neuropathic pain.
WHO Pain Relief Ladder
Mild pain
Non-opioid (e.g. aspirin, paracetamol or NSAID) +/− adjuvant
Mild to moderate pain
Weak opioid (e.g. codeine)
+/− non-opioid
+/− adjuvant
Moderate to severe pain
Strong opioid
(e.g. morphine)
+/− non-opioid
+/− adjuvant
