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Managing the Spectrum of Surgical Pain: Acute Management of the Chronic Pain Patient

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Preoperative evaluation

In evaluating the chronic pain patient preoperatively, it is important to differentiate between tolerance, which is a pharmacologic effect with which increasing doses of analgesic are required to maintain the same level of analgesia and physical dependence, in which withdrawal symptoms will develop if medication is abruptly stopped or an antagonist given.

Preoperative warnings of potential pain management problems include the patient who is on an anxiolytic therapy and patients with any type of

Different types of pain

There are obviously different types of pain. Nociceptive pain is pain that is caused by an injury that stimulates pain receptors and may also be accompanied by inflammation. Nociceptive pain arises when nociceptors are stimulated by noxious stimuli. Nociceptors are present in all tissues and organs except the nervous system. Nociceptive pain can be visceral (eg, pain caused by small bowel obstruction or surgical injury) or it can be somatic (eg, associated with aching bones, joints, and

Pain management

Advantages of effective pain management include increased patient comfort and satisfaction.6, 7, 8 Because of this increased patient comfort, effective pain management is also associated with earlier patient mobilization,9 decreased hospital stay,8, 9 and decreased cost.9 Gastrointestinal and urinary effects of acute pain are primarily a result of sympathetic overactivity. This, in turn, leads to increased urinary sphincter activity, which then can result in urinary retention. Sympathetic

Time and mode of administration of analgesia

Perioperative pain control can occur at three specific intervals with respect to surgery: pre-, intra-, and postoperatively. Most surgeons are fairly adept at addressing pain-treatment needs of a patient postoperatively, but the first two opportunities continue to be largely ignored.

There are many different routes of administration of analgesia to improve perioperative pain control. These different routes of drug administration include epidural administration, continuous IV administration with

Two illustrative cases

To illustrate how difficult it can be to manage chronic pain patients, we describe two challenging patients we treated recently. The first is a 67-year-old woman with a longstanding partial small bowel obstruction, a 30-year history of Crohn’s disease, and 15 earlier laparotomies. Her personal physicians had placated her reports of abdominal pain with large quantities of oxycodone. She underwent an operation at our institution with an extensive lysis of adhesions, repair of an existing

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    Competing Interests Declared: None.

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