Analgesia should be prescribed according to the severity of pain anticipated from the surgery and the anticipated, appropriate, postoperative route of administration.
Pain should be assessed at regular intervals on the ward postoperatively. Pain scores should be recorded with other routine postoperative observations.
Respiratory rate should be monitored for opioid-induced respiratory depression.
EXAMPLES OF WARD PRESCRIPTIONS FOR POSTOPERATIVE ANALGESIA ACCORDING TO ANTICIPATED PAIN SEVERITY
R52.9
MILD PAIN:
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum dose: 4 g in 24 hours.
AND
- NSAIDs, oral, e.g.:
- Ibuprofen, oral, 400 mg 8 hourly after meals.
CAUTION
Concomitant use of more than one oral NSAID has no additional clinical benefit and only increases toxicity.
Use of all NSAIDs is associated with increased risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events (stroke and myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See section 26.1: Chronic pain.
Do not use NSAID in pregnancy or while breastfeeding.
AND
- Tramadol, oral, 50–100 mg, 4 - 6 hourly.
- Avoid in head injury and epilepsy.
- Improved effect when given with paracetamol.
MODERATE PAIN:
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum dose: 4 g in 24 hours.
AND
- NSAIDs, oral, e.g.:
- Ibuprofen, oral, 400 mg 8 hourly with meals.
CAUTION
Concomitant use of more than one oral NSAID has no additional clinical benefit and only increases toxicity.
Use of all NSAIDs is associated with increased risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular events (stroke and myocardial infarction).
NSAIDs should be used judiciously at the lowest effective dose for the shortest duration. Explore and manage exacerbating factors for pain. See section 26.1: Chronic pain.
Do not use NSAID in pregnancy or while breastfeeding.
AND
- Tramadol, oral, 50–100 mg, 4 - 6 hourly.
- Avoid in head injury and epilepsy.
- Improved effect when given with paracetamol.
OR
- Morphine, IM, 0.1–0.2 mg/kg, 4 hourly or IV via a patient controlled analgesia device (see below).
SEVERE PAIN:
- Morphine, IM, 0.1–0.2 mg/kg, 4 hourly or IV via a PCA device.
AND
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum dose: 4 g in 24 hours.
AND
- NSAID, e.g.:
- Ibuprofen, oral, 400 mg 8 hourly with meals.
NOTE
Patient controlled analgesia
If a device is available that will administer patient controlled analgesia:
- Morphine, IV, in boluses of 1 mg every 6-10 minutes, with a maximum dose of 0.1–0.2 mg/kg 4 hourly.
- In the elderly and frail, the dose of morphine should be reduced and the dosage interval increased.
If unable to take oral medication, stop oral ibuprofen and use:
- Diclofenac, deep IM, 75 mg 12 hourly, to upper, outer quadrant of buttock.
- Administer for a maximum of 2 days.
- Avoid the same injection site.
- Counsel patient prior to injection of adverse events (scarring) at injection site if applicable.