Modern advances in patient care have enabled surgeons to treat more challenging and complicated surgical problems. In addition, surgical treatment can be offered to more fragile patients, with successful outcomes. In order to achieve these good results, it is vital to master the scientific fundamentals of perioperative management. The organ system–based approach allows the surgeon to address the patient's pre- and postoperative needs, and ensures that these needs are part of the surgical plan.
The most common neuropsychiatric complications following abdominal surgery are pain and delirium. Moreover, uncontrolled pain and delirium prevent the patient from contributing to vital aspects of his or her care such as walking and coughing, and promote an unsafe environment that may lead to the unwanted dislodgment of drains and other supportive devices, with potentially life-threatening consequences. Pain and delirium frequently coexist, and each can contribute to the development of the other. Despite high reported rates of overall patient satisfaction, pain control is frequently inadequate in the perioperative setting1 with high rates of complications such as drowsiness and unacceptable levels of pain. Therefore, it is mandatory that the surgical plan for every patient include control of postoperative pain and delirium and regular monitoring of the efficacy of pain control.
Pain management, like all surgical planning, begins in the preoperative assessment. In the modern era, a large proportion of surgical patients will require special attention with respect to pain control. Patients with preexisting pain syndromes, such as sciatica or interspinal disc disease, or patients with a history of opioid use may have a high tolerance for opioid analgesics. Every patient's history should include a thorough investigation for chronic pain syndrome, addiction (active or in recovery), and adverse reactions to opioid, nonsteroidal, or epidural analgesia. The pain control strategy may include consultation with a pain control anesthesiology specialist, but it is the responsibility of the operating surgeon to identify complicated patients and construct an effective pain control plan.
Postoperative pain control using opioid medication has been in use for thousands of years. Hippocrates advocated the use of opium for pain control. The benefits of postoperative pain control are salutary, and include improved mobility and respiratory function, and earlier return to normal activities. The most effective strategy for pain control using opioid analgesia is patient-controlled analgesia (PCA), wherein the patient is instructed in the use of a preprogrammed intravenous pump that delivers measured doses of opioid (usually morphine or meperidine). In randomized trials, PCA has been shown to provide superior pain control and patient satisfaction compared to interval dosing,2 but PCA has not been shown to improve rates of pulmonary and cardiac complications3 or length of hospital stay,4 and there is evidence that PCA may contribute to postoperative ileus.5 In addition, PCA may be unsuitable for patients with a history of substance abuse, high opioid tolerance, or those with atypical reactions to opioids.