Pain Management

Pain is a sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain perception involves multiple interacting central and peripheral mechanisms. In addition, pain is multifactorial and involves physical, psychological and environmental aspects in every individual. Pain fibers are carried in spinothalamic tracts which transmit sensations of pain and temperature of the contralateral side. Effective pain management is fundamental to the quality of care. A multidisciplinary approach to the management of acute pain, particularly in a formal acute pain service, leads to improved pain relief and better patient outcomes . Opioid analgesics are the cornerstone of the management of moderate to severe pain. Opioids should be administered by the safest and most effective route available. The patient's need for pain relief should be seen as more important than strict adherence to a dose interval. 'Patient-controlled analgesia' overcomes the wide variation in patients' analgesic requirements and allows patients to adjust the level of analgesia to their own level of comfort and tolerance of side effects. While PCA is usually associated with intravenous administration, it may be used to deliver opioids subcutaneously or epidurally . The advantage of tramadol is that it is analgesic with minimal sedation, respiratory depression, gastro-intestinal stasis, or abuse potential. Tramadol is a weak mu opioid agonist but also has important non-opioid spinal and central nervous system effects via noradrenergic and serotoninergic pathways. Tolerance may develop during chronic administration of drugs, and it may be due to both pharmacokinetic and pharmacodynamic changes. Tolerance to opioids can develop rapidly, especially under experimental conditions. Physical and psychological dependence can also develop.

NSAIDs can be very useful for managing mild to moderate pain. When NSAIDs alone cannot control pain, they have a significant opioid dose-sparing effect and can be useful in reducing opioid side effects . Recently, the roles of the N-methyl-D-aspartate (NMDA) receptor and nitric oxide in the production of 'wind-up' and morphine tolerance have been investigated. 

Non Medical interventions are appropriate for patients who wish to use them, who may benefit from reducing drug therapy, or who are likely to experience a prolonged interval of pain. Cognitive-behavioral approaches include preparatory information, simple relaxation, imagery, hypnosis and biofeedback The advent and increasing use of laparoscopic surgery, liposuction and other day care surgeries has had a marked impact on the length of hospital stay of surgical patients and on their postoperative management, including pain management